Midwifery 
G.Ernest Herman MANUALS 
FOR 
Students of Medicine. FIRST LINES 
IN 
MIDWIFERY: 
A Guide to Attendance on Natural Labour for 
Medical Students and Midwives. 
BY 
G. ERNEST HERMAN, 
M.B. (Lond.), F.R.C.P.; 
OBSTETRIC PHYSICIAN TO THE LONDON HOSPITAL, AND LECTURER ON 
MIDWIFERY J 
PHYSICIAN TO THE GENERAL LYING-IN HOSPITAL ; 
FORMERLY PHYSICIAN TO THE EASTERN DISTRICT OF THE ROYAL 
MATERNITY CHARITY; 
EXAMINER IN MIDWIFERY TO THE ROYAL COLLEGE OF SURGEONS; 
CONSULTING PHYSICIAN-ACCOUCHEUR TO THE TOWER HAMLETS DISPENSARY ; 
TREASURER OF, AND LATE EXAMINER TO, THE OBSTETRICAL 
SOCIETY OF LONDON. 
WITH 80 ILLUSTRATIONS. 
PHILADELPHIA : 
LEA BROTHERS & CO., 
[Late Henry C. Lea's Son <fc Co.] 
PUBLISHERS. 
Estab Its Heil 1785. flTo 
THE COLLEAGUES WITH WHOM I HAYE HAD THE HONOUR 
OF BEING ASSOCIATED IN THE 
MANAGEMENT OF THE GENERAL LYING-IN HOSPITAL, 
JOHN WILLIAMS, 
F. II. CHAMPNEYS, 
0. J. CULLINGWORTH, 
AND 
ROBERT BOX ALL, 
1 DEDICATE THIS BOOK. FACE. 
The duties of a student in attendance upon his 
first cases of labour are the same as those of a 
midwife. The design of this book is to give both 
such elementary knowledge as is needed for the safe 
management of natural labour. To meet the require- 
ments of the midwife, a chapter on anatomy has 
been prefixed; and in various places some elementary 
information has been given which a medical student 
does not need : these, it is hoped, the student will 
pardon. 
I have to thank Messrs. J. and A. Churchill, 
Smith, Elder and Co., and other publishers, for the 
use of blocks for illustrations. Figs. 13, 14, 72, 73, 
74, 75, 76, 77, and 79 have been drawn specially 
for this work by Mr. Berjeau. Figs. 51 to 58, and 
Fig. 60 have been copied on a reduced scale from the 
drawings by Farabeuf, in the " Introduction a 1'Etude 
des Accouchements," by Farabeuf and Varnier. For 
the convenience of the reader, some of the woodcuts 
appear more than once. 
I have to thank Dr. Cullingworth for kindly 
reading the proof-sheets, and for making some valu- 
able suggestions. CONTENTS. 
CHAPTER PAGE 
I.-Anatomical 1 
II.-Labour 21 
III. The Mechanism oe Labour 31 
IV. Attendance on Natural Labour .... 65 
V. - Diagnosis 80 
VI.-Management of Breech and Footling Cases . 96 
VII.-Delay in Labour 100 
VIII.-Transverse Presentations 109 
IX.-Descent, etc., of the Cord-Descent of the 
Hand 116 
X.-Twins 123 
XI.-Contracted Pelvis 125 
XII. Hemorrhage 136 
XIII. Other Complications of Labour .... 155 
XIV. How to Revive Still-born Children . . .158 
XV.-The Lying-in Period 160 
XVI.-On Germs, Disease, and Antiseptics . . .168 
XVII.-The Infant .176 
Index .187 LIST OF ILLUSTRATIONS. 
PAGE 
Position of the Uterus at the full Term of Pregnancy ... 2 
Showing the Difference between the Body and Neck of the Womb. 3 
Canals perforating the Pelvic Floor 4 
The Vulva 6 
Illustrating the Manner in which the Vagina is opened tip . . 7 
Pelvis, seen from above, showing the False Pelvis .... 8 
Sacrum and Coccyx 9 
Os Innominatum 10 
Os Innominatum as it is in the Child . 10 
Movement of the Pelvis on the Sacrum 11 
Brim of Pelvis and its Diameters . 12 
Outlet of Pelvis and its Diameters 14 
Bones and Measurements of Foet al Skull 16 
Measurements of the Foetal Skull 18 
Measurements of the Foetal Skull '. 20 
Arrangement of the Uterine Muscular Fibres 22 
Bag of Membranes bulging at the Os 23 
Genital Canal after full Dilatation of the Cervix .... 27 
The " Crowning " of the Head 28 
The Natural Mode of Expulsion of the Placenta .... 29 
Effect of pulling on the Cord 30 
Usual Attitude of Child 31 
Vertex presenting : First Position 32 
Showing how Flexion is promoted by the difference in slope of the 
front and back of the Child's Head 34 
Successive Positions occupied by the Head during Delivery in 
the First Position 36 
Showing the Extension of the Head in Delivery with the Occiput 
forwards 37 
Vertex presenting : Second Position 39 
Vertex presenting : Third Position 41 
Successive Positions of the Head in Delivery when th* Occiput 
remains behind 43 
Showing Delivery by Flexion when the Occiput is posterior . . 44 
Fourth Vertex Position . 45 
Showing how Uterine Contraction increases Flexion ... 46 
Showing how, when Extension of the Head has begun, Uterine 
Contraction increases it 47 
Attitude in Face Presentation 48 
Face presenting: Third Position 50 
Successive Positions occupied by Head in Face Delivery . . 51 
Face presenting : Fourth Position 52 
Face presenting : First Position 53 
Face presenting : Second Position 54 
Head at Outlet of Pelvis in Face Delivery 55 
Breech: First Position ... 57 
Breech Presentation with extended Legs . . . . . .58 
Lateral Flexion of Spine in Breech Delivery 60 XII 
Ml DIV IF ER 1 
PACE 
Delivery of Shoulders in Breech Labour 61 
Mode of Passage of Head in Breech Labour 62 
Douche Tin 66 
Mode of Expulsion of Placenta 76 
Surgical Instrument Maker's Binder 78 
Method of Abdominal Palpation 81 
The Membranes bulging at the Os Uteri 87 
First Vertex Position 88 
Second Vertex Position 89 
Third Vertex Position 90 
Fourth Vertex Position . 90 
First Face Position 91 
Second Face Position 92 
Third Face Position 93 
Fourth Face Position 94 
One Mode of Delivering the after-coming Head . . . .97 
How to bring down the Arms when they are up by the sides of 
the Head 99 
Transverse Presentation : Dorso-posterior ...... 109 
Transverse Presentation : Dorso-anterior ...... 110 
Spontaneous Evolution: its Commencement 112 
Spontaneous Evolution in Progress 113 
Spontaneous Evolution: its Termination 114 
Spontaneous Expulsion 115 
Prolapse of Cord with Head Presentation 117 
Prolapse of Cord with Hand and Foot presenting .... 118 
Postural Treatment of Prolapse of Cord ...... 119 
Twin Pregnancy 123 
The Obliquity of Naegele 126 
Mode of Measuring the Diagonal Conjugate 129 
Pelvimetry : Measurement four inches 130 
Pelvimetry : Measurement three inches and a half .... 131 
Pelvimetry : Measurement three inches and a quarter . . 132 
Pelvimetry : Measurement three inches133. 
Pelvimetry: Measurement two inches and a half .... 134 
Placenta preevia 142 
How to compress the Uterus to stop Postpartum Haemorrhage . 151 
Hydrocephalus 156 Midwifery. 
CHAPTER I. 
ANATOMICAL. 
Position of uterus.-At the full term of preg- 
nancy the womb reaches as high in the abdo- 
men as the ensiform cartilage (tip of the breast- 
bone). When the woman is lying on her back 
it forms an angle of about 30 degrees with the 
ground. When she is standing it slopes so that it 
forms an angle of about 60 degrees with the ground, 
and its weight chiefly rests on the anterior abdominal 
wall, without the support of which the uterus would 
fall forward (Fig. 1). When the abdominal walls are 
very relaxed it does fall forward, and this condition is 
called " pendulous belly." The stomach and bowels 
are above and behind the uterus. 
The membranes.-The uterus is lined by the 
membranes, which contain a fluid called the liquor 
amnii, or " the waters." There are three membranes : 
but the outer one,the decidua, is so thin and fragile that 
it is of little importance in labour, and you need not 
take the trouble to look for it. Of the two that are 
important, the inner is called the amnion, and is the 
stronger of the two. It passes over the placenta, from 
off which it can be quite stripped, and is firmly attached 
to the umbilical cord. The outer is the chorion, and 
with it the decidua is practically blended. It is at- 
tached to the edge of the placenta. It is softer than 
the amnion, and therefore it sometimes happens that a 
bit of it is torn off and retained in the uterus after' 2 
Midwifery. 
[Chap. I. 
Fig. 1.-Showing the Position of the Uterus at the full Term of 
Pregnancy. (From Tarnier.) Chap. I.] 
Body and Neck of Uterus. 
3 
labour. The bag of membranes usually contains 
enough fluid for the child to move about freely in it. 
Difference between body and neck of 
uterus.-The uterus consists of two parts: the body, 
and cervix or neck. The bag of membranes contain- 
ing the " waters " and the child is, during pregnancy, 
Fig. 2.-Showing the Difference between the Body and Neck of the 
Womb. The child is seen lying in the body of the womb. The 
neck of the womb is a canal leading to the body. 
entirely in the body of the womb. The neck of the 
womb throughout pregnancy is closed (Fig. 2). It 
forms a canal a little more than an inch long, the upper 
opening of which is called the internal os, the lower the 
external os. The placenta is never attached to the 
neck of the womb. The child is nourished by and 
breathes through the placenta. 4 
Midwifery. 
[Chap. I. 
The placenta.-The placenta is attached to the 
inside of the womb, and large arteries and veins 
bring to it and carry back from it the blood of 
Fig. 3.-Showing the Canals perforating the Pelvic Floor. 
1, Sacrum ; 2, pubes; 3, rectum ; 4, uterus, unimpregnated ; 8, neck of uterus ; 
10, vagina; 12, bladder (full); 13, urethra ; 14, clitoris. 
the mother. In the placenta the blood of the 
child and that of the mother are only separated 
from one another by a thin membrane formed of Chap. I.] 
The Pelvic Floor. 
5 
cells, which have the power of transferring the 
oxygen and the nutriment which the child needs, 
from the mother's blood to the child's blood. Pure 
blood passes from the placenta to the child by the 
umbilical vein, and impure blood passes from the 
child to the placenta by the .umbilical arteries. The 
umbilical cord, or navel string, consists of the umbili- 
cal vein and arteries, bound together by a jelly, and 
covered by the amnion. When the child has begun 
to breathe, the blood gets oxygen from the air in the 
lungs, and therefore the placenta is no longer needed. 
The pelvic floor.-The abdomen is closed in 
below by strong muscles and layers of fibrous tissue or 
fascia?. These muscles and fasciae, taken together, 
are known as the pelvic floor. The uterus is im- 
planted into it. Three canals perforate the pelvic floor : 
the urethra in front, by which urine is discharged, the 
rectum behind, and between them the vagina, which 
is the passage leading to the womb (Figs. 3 and 4). 
The vulva or private parts form a slit running from 
before backwards, between two thick folds of skin, or 
lips, called the labia majora, which cover and conceal 
the orifice of the urethra and that of the vagina. 
In front of the mouth of the urethra is the clitoris : 
the space between the clitoris and the mouth of the 
urethra is called the vestibule. Running back on 
each side from the clitoris is a fold of skin, and 
these folds are called the labia minora, or lesser lips. 
They are also called the nympho;. The vaginal 
orifice when the labia are separated appears round, 
and is bordered by a sort of frill of mucous mem- 
brane called the hymen. The hymen differs much 
in size and shape in different women, and in those 
who have had many children is destroyed. The 
vulva is bounded behind by a thin fold of skin called 
the fourchette. Between the fourchette and the 
vaginal orifice is a hollow called the fossa navicularis. 6 
Midwifery. 
[Chap. I. 
The part between the fourchette and the anus is the 
perineum. 
The vagina.-The vagina, when the woman is 
in the erect posture, runs upwards and backwards, 
Fig. 4.-The Vulva. 
2, Labia majora ; 3, clitoris: 4, labia minora ; 5, vestibule; 6, meatus urlnarius ; 
8, vaginal orifice ; 9, hymen ; 10, fourchette ; 11, anus. 
and although its orifice appears round, yet above the 
orifice it is a slit running from side to side, bounded 
by an anterior and a posterior wall, which under 
ordinary conditions are in close contact. The strong 
muscular and fibrous structures which form the pelvic Chap. I.] 
T//E IZlG/NA. 
7 
floor are attached to its posterior wall. Below and 
behind its posterior wall are the rectum, and a mass 
of tissue reaching about an inch upwards from the 
Fig. 5.-Illustrating the Manner in which the Vagina is opened up; the 
anterior wall pulled up, the posterior pushed down. (From 
w,Uterus; 6,bladder; sp, symphysis pubis; c,coccyx; a, anus; pv, perineum. 
perineum, and called the perineal body. In front of 
the anterior wall, and attached closely to it, are the 
bladder and urethra. During pregnancy the vagina 
becomes larger, softer, and looser than it was before. 8 
Midwifery. 
[Chap. I. 
In labour, the vagina is opened up to let the child pass 
in the following manner. The anterior wall, and with 
it the bladder and urethra, are pulled up, in front of 
and over the child's head, while the child's head pushes 
the posterior wall down and back (Fig. 5). 
The resistance which the neck of the. womb and 
the vagina offer to being stretched open to let the 
child pass is the chief obstacle to delivery; for when 
Fig. 6.-Pelvis, seen from above, showing the False Pelvis. 
the pelvis is well shaped, and the child not larger 
than ordinary, and in a suitable position, it will 
pass easily, with room enough and to spare, through 
the bony canal. 
The pelvis.-(In reading the following pages the 
pupil should have at hand a female pelvis and a foetal 
skull. The measurements will be moreeasily recollected 
if the learner verifies them with a pair of callipers.) 
The pelvis is a bony ring which rests upon the thigh 
bones and supports the spine. With the muscles and 
ligaments attached to it, it forms the floor of the 
abdomen. Hence, in order to be born the child has Chap. I.] 
The Pelvis. 
9 
to pass through this bony ring, and stretch open the 
soft parts which form the floor of the pelvis. 
The pelvis consists of two parts : the true and the 
false pelvis. The false pelvis is the expanded upper 
part, and is open in front. The inze pelvis forms, 
roughly speaking, a short curved cylinder : and through 
this the child has to pass (Fig. G). This cylinder is 
not the same width at 
every part ; its size 
varies something like 
the rifling of a gun, and 
therefore to get along it 
the child's head has to 
make certain turns; 
and the size and shape 
of the child's head are 
such that it can only 
get through the pelvis 
in a certain position, 
and by making certain 
movements. A know- 
ledge of these turns and 
movements constitutes 
what is called the me- 
chanism of labour. It 
is essential that anyone 
who professes to be more than a monthly nurse should 
understand this mechanism. 
Bones and joints in the pelvis.-The pelvis 
is formed by three bones : the sacrum, which is be- 
hind, in the middle, and is the lower end of the back- 
bone. Attached to the tip of the sacrum by a joint 
is a small bone, a continuation of it, called the coccyx 
(Fig. 7); at the sides, the two ossa innominata 
(Fig. 8). In the child, each os innominatum is com- 
posed of three bones : the ilium, the expanded upper 
part, which forms the false pelvis; the ischium, on 
Fig. 7.-Sacrum and Coccyx, 10 
Midwifery. 
[Chap. I. 
Fig. 8.-Os Innominatuin. 
Fig. 9.-Os lunominatum as it is' in the Child, divided into its three 
parts-Ilium, Ischium, and Pubes. The space between them is 
filled up> withjcartilage. Chap. I.] 
The Pelvic Bones. 
11 
which we sit; and the os pubis, which meets the 
bone of the other side in front. Bounded by these 
three bones is a large hole filled up with membrane 
during life, and called the obturator foramen 
or foramen ovale (Fig. 9). The joint by which the 
two pubic bones are united is called the symphysis 
pubis. The joint between the ilium on each side and 
the sacrum is called the sacro-iliac synchondrosis. In 
Fig. 10.-Showing the way in which, by Movement of the Pelvis on the 
Sacrum, the Measurement from before backwards is enlarged. 
ab, Symphysis pubis ; c, promontory of sacrum ; cl, coccyx. 
a woman who is not pregnant these joints allow very 
little movement; but at the end of pregnancy they 
become looser, so that the bony ring can move a 
little on the sacrum, in such a way as to make the 
measurement from before backwards a little larger, 
either at the brim or outlet, as may be required (Fig. 
10) ; and each os innominatum can also move a little 
in such a manner as to make the ischial tuberosities 
a little farther apart. 
Tl»e pelvic canal.-The curved cylinder which 
the true pelvis forms is shorter in front, which is the 
inside of the curve, than behind, the outside of the 12 
Midwifery. 
[Chap. I. 
curve. It measures in depth about an inch and a 
half in front, and about five and a half inches behind. 
The upper opening, by which the head enters the canal, 
is called the brim or inlet of the pelvis. The line 
bounding the brim is called the ilio-pectineal line, and 
on it, rather nearer the sacrum than the pubes, is a 
slight elevation, the ilio-pectineal eminence. The 
lower opening, by which the head leaves the canal, is 
Fig. 11.-Showing Brim of Pelvis and its Diameters. 
called the outlet. The brim is formed all round by 
bone ; it would be oval in shape were it not that the 
sacrum projects forward. The projection which the 
sacrum makes where it joins the spinal column is 
called the sacral j)romontory. 
Pelvic measurements.-The distance from the 
most prominent part of the sacral promontory to the 
nearest point of the symphysis pubis is called the con- 
jugate diameter (Fig. 11). It is the smallest measure- 
ment of the brim of the pelvis ; and therefore the one 
the size of which it is most important to know, for if this 
diameter is large enough to admit the child's bead, the Chap. I.] 
Pelvic Measurements. 
13 
others probably will do so too. This diameter should 
measure four inches or a little more. The longest dia- 
meter of the brim in the skeleton pelvis is that measured 
from side to side, between the most distant points 
of the pelvic inlet. It is called the transverse 
diameter, and should measure five inches or a little 
more. In life, when the bones are clothed with flesh, 
the oblique diameter is the longest. It is measured 
from one sacro-iliac synchondrosis to over the middle 
of the opposite obturator foramen, or rather more than 
a finger's breadth in front of the ilio-pectineal emin- 
ence. The oblique diameter should be about four and 
three-quarter inches. The oblique diameters are called 
right and left according to the sacro-iliac synchondrosis 
from which they start; thus the right oblique diameter 
is the measurement from the right sacro iliac synchon- 
drosis to the pelvic brim above the middle of the 
obturator foramen. The part of the pelvis between 
the brim and the outlet is called the cavity of the 
pelvis. There is more room here than either at 
the brim or the outlet. Owing to the hollowing 
out of the sacrum (both from above downwards 
and from side to side), the measurement from 
before backwards is larger here than at the brim, 
being about five inches, and the other measure- 
ments are about the same. Lower down, the sides of 
the pelvis slope so as slightly to approach one another, 
and hence the transverse diameter at the outlet is 
smaller than at the brim, being usually about four 
inches and a quarter. In consequence of the curving 
forward of the lower part of the sacrum, the diameter 
from before backwards at the outlet is less than in 
the pelvic cavity, though greater than at the brim• 
it is generally about four inches and a half (Fig. 12). 
This measurement is made from the lower border 
of the pubic arch to the tip of the sacrum. The 
distance from the pubic symphysis to the tip of 14 
Midwifery. 
[Chap. I. 
the coccyx is only about three and three-quarter 
inches; but this is unimportant, because as the 
child's head passes it can push the coccyx back- 
wards.* The pelvic outlet is bounded in front by the 
pubes and the ischium, and the masses of bone which 
limit it transversely are called the tuberosities of the 
Fig. 12.-Showing Outlet of Pelvis and its Diameters. 
ischium. Behind there is a deep gap left between 
the ischium and the sacrum : this is called the sacro- 
sciatic notch. During life it is bridged over by a 
strong ligament called the sacro-sciatic ligament. The 
pelvic outlet is therefore bounded partly by bone, 
* There is no fixed standard to which every pelvis conforms. 
The measurements given above are those which I believe most 
nearly represent the average of normal pelves. The following 
measurements, given by Dr. Barbour, are very near the average, 
and may be easier to remember :- 
Conjugate. Oblique. Transverse. 
Brim - 4 4| 5 
Cavity 4| 44 44 
Outlet 5 (4|) 4 Chap. I.] 
The Foetal Head. 
15 
partly by ligament. The sacro-sciatic notch is divided 
into two parts by a point of bone called the spine of 
the ischium. If the pelvis be looked down upon from 
above it will be seen that this spine projects slightly 
into the pelvic cavity. Some think that this spine 
is very useful in guiding the head in its proper course 
through the pelvis. It really, however, has little if 
any influence on the way in which the head turns. 
The foetal head.-The head is the largest and 
hardest part of the child, and where it can pass 
the rest of the child can follow, unless it be de- 
formed by disease. Hence the head is the part 
that we have to study to understand the mechanism 
of labour. Its size and shape must be well examined. 
The child's head is egg-shaped, the large end being 
behind. The skull consists, broadly speaking, of two 
parts, the base, and the vault. The brain rests on 
the base of the skull, and is covered in by the vault of 
the skull. The base of the skull is hard and firm. 
The vault of the skull is thin ; the bones which form it 
are not completely ossified at birth, so that there are 
spaces between them where bone does not exist, and 
they can ride over one another, and can bend, thus 
lessening the size of the head. The most vital part of 
the brain, that from which the nerves which control 
breathing proceed, is called the medulla oblongata ; it 
is a continuation of the spinal cord, and rests directly 
on the base of the skull. Nerves run out from the 
brain through holes in the base of the skull. Any 
injury to the medulla oblongata is necessarily fatal; 
the base of the skull is hard and firm, in order to pro- 
tect it. The part of the brain above, which is called 
the cerebrum, and which fills the vault of the skull, 
may be injured without killing the child, and may be 
compressed a good deal without harm. Hence it is not 
essential that the vault of the skull should be so strong 
as the base. 16 
Midwifery. 
[Chap. I- 
The vault of the skull is mainly composed in the 
adult of four bones, in the child of five (Fig. 13). In 
front is the frontal bone, which in the child consists 
of two pieces, one on each side. Behind is the occipital 
bone. Between the frontal and the occipital bone are 
Fig. 13.-Bones and Measurements of Foetal Skull. 
a, Sagittal suture; b, parietal eminence; c, posterior fonatanelle: <1, parietal 
bone ; e, occipital bone ; f, temporal bone, mastoid portion ; g, anterior fon- 
tanelle; h, coronal suture; i, frontal bone ; j, sphenoid bone: fc, temporal 
bone, squamous portion ; I, temporal bone, petrous portion. For explanation 
of capital letters see Fig. 14. 
the two parietal bones, meeting in the middle. The 
lines between these bones are called sutures. That be- 
tween the two pieces of the frontal bone is called the 
frontal suture. Its continuation backwards in the 
middle line of the head, between the two parietal bones, 
is called the sagittal suture. The line between the 
frontal bone and the two parietal bones is called the 
coronal suture. At the place where the two parietal Chap. I.] 
The Fcetal Head. 
17 
bones and the two halves of the frontal bone meet there 
is a four-sided gap in which no bone is to be felt; this 
is called the anterior fontanelle. During labour the 
bones are sometimes so pressed together that hardly 
any gap is to be felt; it becomes little more than 
a point at which four sutures meet. The line 
between the parietal bones and the occipital bone 
is called the lambdoidal suture. At the place where 
the two parietal bones and the occipital bone meet is a 
three-sided gap filled only by membrane, and called 
the posterior fontanelle. During labour, from the 
compression of the head, this is only to be felt as a 
point at which three sutures meet. These sutures and 
fontanelles are very important, because by feeling 
them we can make out the position of the head during 
labour. The base of the skull is formed in front by 
a small part of the frontal bone, called its orbital 
plates. The occipital bone in the child consists of two 
parts, the basilar, and the squamous, which are united 
in the adult. The squamous portion forms the back 
part of the vault of the skull. The basilar portion 
forms the hinder part of the base of the skull. It 
contains a large hole called the foramen magnum, 
through which the medulla oblongata joins the spinal 
cord ; and on each side of this, underneath, are two 
smooth surfaces called the occip>ital condyles, by which 
the skull is jointed to the spine. Between the frontal 
bone and the basilar part of the occipital bone is the 
sphenoid bone; in the middle and on each side of it 
are the temporal bones. Each temporal bone consists 
of three parts. Inside is the petrous portion, which is 
very hard and strong, and with the sphenoid makes 
the strongest part of the base of the skull. Above is 
the squamous portion, which joins the parietal bones, 
and forms a small part of the vault of the skull. Be- 
low and behind the squamous portion, and outside and 
behind the petrous portion, is the mastoid portion. 18 
Midwifery. 
[Chap. I. 
This is the point of bone that can be felt just behind 
the ear. In front of and below the temporal and 
sphenoid bones are the jaw bones. 
The bones of the vault of the skull are thickest in 
the middle, and get thinner towards the edges. These 
thick prominent parts are called the frontal eminences, 
Fig. 14.-Showing Measurements of the Foetal Skull. 
a b, Vertico-mental; c n, sub-occipito-frontal; k f, cervico-vertical; 
G H, occipito-frontal. 
the parietal eminences, and the occipital protuberance, 
respectively. It is well that the bones are thickest 
at these places, because these are the parts on which, 
when children fall, they are likely to strike them- 
selves. 
Measurements of foetal head. The longest 
measurement of the head is from the chin to a little 
above the occiput. This is called the vertico-mental 
diameter, and measures about five inches and a quarter Chap. I.] 
Measurements of Fetal Head. 
19 
(Fig. 14). Now, as the largest measurement of the 
pelvic cavity is about five inches, it will be clear 
that the child's head could not possibly pass if it 
were so placed that the vertico-mental diameter had 
to enter the pelvis. The measurement taken from the 
lower part of the forehead, at the root of the nose, 
to the most distant point of the occiput, is called 
the occijrito-frontal diameter, and measures about four 
inches and a half. If the child's head be in such a 
position that this diameter has to pass through the 
pelvis (and this sometimes happens) although it can be 
driven through, this can only be done with difficulty, 
and if the child be larger than usual it will not be 
able to pass, nor will it if the pelvis be smaller than 
usual. The measurement from the back of the neck 
where it joins the head to the part of the frontal bone 
opposite it and most distant from it, is called the 
sub-occA/pito-frontal, and amounts to about four 
inches.* It can be made less by squeezing. This 
is the largest diameter that has to pass through 
the pelvis when the head enters the pelvis in a 
favourable position, that is, in natural labour. These 
diameters are all taken from before backwards. The 
largest measurement across the head from one side 
to the other is that between the parietal eminences 
(Fig. 15) : it is called the bi-parietal measurement, and 
measures three and three-quarter inches. It is situated 
rather behind the middle of the head. The bi-temporal 
or measurement between the two temporal bones 
is about three inches and a half. This is the part 
which, if the head lies across the pelvis, the face 
looking towards one side, the occiput to the 
other, has to pass through the conjugate diameter 
* The sub-occipito-bregmatic and the cervico-bregmatic measure- 
ments are given in most text-books. But these are unimportant, 
the really important ones being the sub-oc2ipito-/ro»d«? and 
cervico-verticaZ, as given above. 20 
Midwifery. 
[Chap. I. 
of the pelvic brim. The measurement which in 
natural labour passes through the conjugate is 
that from a point about an inch in front of one 
parietal eminence to about half-an-inch behind the 
other. This diameter is only a trifle larger than the 
biparietal, and can be much diminished by squeezing. 
The measurement from the point where the head joins 
the neck in front to 
the most distant 
point of the vault of 
the skull, which is 
near the anterior fon- 
tanelle, is called the 
cervico-vertical. It 
measures about four 
and a half inches, but 
can be altered by 
compression. When 
the head is delivered 
naturally with the 
face presenting, this 
is the largest diame- 
ter that has to pass 
through the pelvis. 
The measurement 
from a little above one parietal eminence to a little 
below the opposite one is called the sub-parietal 
super-parietal measurement, and is rather less than 
the biparietal measurement. Hence if the pelvic 
inlet be contracted, the head will pass more easily 
if it be tilted so that the two parietal eminences 
do not pass on the same level. In the most common 
kind of pelvic contraction this is the way in which 
the head does pass ; one parietal bone (usually the one 
which is in front) sinks down a good deal lower than 
the other. 
Fig. 15.-Showing Measurements of the 
Fcetal Skull. 
vp, Bi parietal; t t, bi-temporal. 21 
CHAPTER II. 
LABOUR. 
Labour is the process of expulsion of the child 
from the womb into the world. It is effected chiefly 
by the contractions of the uterus, which is a hollow 
muscle; but these are aided by the expulsive or 
" bearing-down " efforts of the patient. During a con- 
traction the womb gets smaller and harder, and when 
the contraction is over it becomes a little larger and 
much softer. The uterus contracts regularly during 
pregnancy. During labour another quality comes into 
play, viz. retraction, which means that after each con- 
traction the womb does not return quite to the same 
state as before the contraction, but remains smaller 
than it was before the contraction began, so that it goes 
on becoming progressively smaller throughout labour. 
Stages of labour*-Labour is divided into three 
stages. 
The first is from the beginning of the pains to the 
full dilatation of the cervix. 
The second is from the full dilatation of the cervix 
to the delivery of the child. 
The third is from the delivery of the child to the 
expulsion of the placenta and membranes. 
At the very beginning of labour the parts become 
more moist; and the secretion from them is mixed 
with a little blood. This is called a " show," and is 
an indication, though not a constant or certain sign, 
that labour is at hand. 
The first stage of labour consists in the open- 
ing up of the cervix uteri. At the end of pregnancy 
this is a canal a little more than an inch long (see 
First Stage. 22 
Midwifery. 
[Chap. II. 
Fig. 2, page 3), the upper opening of which, is called 
the internal os, the lower the external os. In 
women who have had children, owing to the tear- 
ing of the cervix which has taken place in previous 
deliveries, the external os is often large enough to 
Fig. 16.-Showing the general arrangement of the Uterine Muscular 
Fibres, Circular Fibres surrounding the Orifices; and Longitudinal 
Fibres which pull up the Cervix. (After Murphy.) 
admit the tip of the finger, but the internal os re- 
mains closed till labour begins. It is kept closed by 
the tonic, that is, persistent, contraction of muscular 
fibres which surround it like a ring. The beginning 
of labour is that this muscular ring becomes relaxed. 
Other muscular fibres which run vertically from the 
fundus to the cervix of the uterus contract (Fig. 16). 
When labour has begun their contraction is not, as it 
was before, opposed by that of the circular ring which 
surrounds the internal os, and so they pull the os open. Chap. II.] 
F/rst Stage of Labour. 
23 
The uterus and cervix thus come to form one cavity, 
and the bag of membranes conies to lie upon the 
external os. If this be wide enough, the bag of mem- 
branes can be felt with the finger through it. The 
uterine contractions wdiich do this are not painful, 
Fig. 17.-Showing the Bag of Membranes bulging at the Os. 
except ill conditions of disease. This is the preliminary, 
or, as it has been called, the " secret " stage of labour. 
The contractions continue, and the bag of membranes 
is pressed upon by the contracting uterus at every point 
except at the os uteri, and so the bag bulges here 
(Fig. 17). The pressure of the bulging bag of membranes 
stretches open the os externum. When the os is small, 
and only a small portion of the bag of membranes can 24 
Midwifery. 
[Chap. II 
enter it, the dilating force exerted is small, and so the 
os dilates slowly j but the larger it becomes the more 
of the bag of membranes can be pressed into it, the 
more force is consequently exerted, and the faster the 
os is dilated. The first stage of labour is therefore 
slow at first, but when once begun, goes on with con- 
tinually increasing speed. This stretching open of the 
os uteri is painful, and the more it is stretched the 
greater the pain. Hence the patient feels the uterine 
contractions which accompany the first stage of labour, 
and calls them pains : and as the first stage advances, 
they go on getting worse and worse as the cervix is 
more and more stretched. But the os uteri is not 
nearly so sensitive as the parts at the orifice of the 
vagina, and therefore the pains of the first stage of 
labour are not so severe as those felt while the head 
is passing out of the vagina. As the bag of membranes 
advances through the os, the chorion and decidua are 
detached from the lower part of the uterus. 
Bursting of membranes.-When the os uteri 
is nearly fully dilated, the bag of membranes bursts. 
It does not always burst at the time it should do. 
Often it bursts too soon • and sometimes does not burst 
at all, the child being born in its membranes : but it 
ought to burst when the os uteri is nearly fully dilated. 
(It is seldom that the child is born literally in its mem- 
branes ; it is usually in the amnion. The chorion is 
comparatively soft and weak, and ruptures easily. 
Then the amnion, if it does not burst, becomes 
detached from the chorion and advances. If this 
happens, the chorion is likely to be imperfectly 
detached from the uterus). Then, in a natural labour, 
the head comes into the os and stretches it open in the 
same way as the bag of membranes did. But the 
head is harder, and its pressure not so gentle, and 
therefore the pain felt is greater. 
Duration.-The average duration of the first Chap. II.] 
Rupture of Membranes. 
25 
stage of labour is, in first labours, about 20 hours ; 
in labours not the first, about 12 hours. 
Disadvantages of too early rupture ol 
membranes.-The preservation of the bag of 
waters is essential for a safe and easy first stage of 
labour. (1) It is a mechanical law that fluid presses 
equally in all directions, and this applies to the bag 
of waters. The fluid in it presses equally on every 
part of the uterus and of the child, and therefore no 
part is pressed upon unduly. When the bag of waters 
is absent, from the membranes having ruptured too 
soon, or when there is too little liquor amnii, the labour 
is slow, because the child does not bulge into and 
stretch open the os like the bag of membranes. The 
os is then opened up only by the muscular fibres 
which pull it open from above, and it cannot be 
stretched open by the presenting part of the child 
until it has become open enough for some part of 
the child to enter it. Now as this stretching, first 
by the bag of membranes, then by the presenting part, 
is the chief agent in opening up the os, it is clear that 
when this bag is absent the first stage of labour 
must be slow, and so it is. (2) When the liquor 
amnii escapes too soon, or there is not enough of it, 
the projecting parts of the child, with each contraction 
of the uterus, are pressed time after time against the 
same spots of the uterine wall, and the pressure being 
concentrated on these points is much greater than it 
ought to be. Hence if the liquor amnii be absent, the 
first stage of labour is not only too long, but it is more 
painful; and if other causes combine to delay delivery 
the continued pressure on certain spots in the uterine 
wall may lead to inflammation, or rupture, or perfor- 
ation at these spots, thus putting the woman in 
great danger. And not only does the too early 
escape of the waters lead to slow dilatation and in- 
jurious pressure on the uterus, but (3) it is bad for the 26 
Midwifery. 
[Chap. II. 
child. While the child floats in the bag of waters, 
the liquor amnii presses on every part of the child and 
of the cord, equally and gently. But if there be no 
liquor amnii the cord may be so compressed between 
the child and the contracting uterus as to stop the 
circulation through it and so kill the child. Further, 
(4) while the child is floating freely in the liquor 
amnii, those conditions which have the effect of putting 
it in the best position for being born (elsewhere de- 
scribed) can act easily, while they cannot act if the 
child is embraced by the contracting uterus. There- 
fore if the child be in an unfavourable position at the 
time the membranes rupture, there it will probably 
stay. And if the dilatation of the os has to be per- 
formed by the head, the pressure upon the head 
is greater and more prolonged than in a natural labour, 
and this may have injurious consequences; and if by 
the breech, the pressure on the cord will be so great 
and continuous that the child is almost certain to be 
still-born. 
Too early escape of the waters is thus in many ways 
a great misfortune, leading always to a longer and 
more painful labour than the patient otherwise 
would have had, often to danger to the child, and some- 
times to danger to the mother. 
Second Stage. 
The second stage of labour is from the full 
dilatation of the os uteri to the birth of the child. 
The os uteri is now pulled up over the child's 
head. With it, the bladder and anterior vaginal wall 
are pulled up out of the way of the child (Fig. 18). 
The presenting part of the child, driven on by the 
action of the uterus and the bearing down efforts 
of the patient, forces down the posterior wall of 
the vagina and the parts behind it, and stretches 
them open. The perineum is stretched both from Chap. II.] 
Second Stage of Labour. 
27 
side to side and from before backwards. The anus is 
pressed down and pulled forwards. If the patient suffer 
from piles, these are made to protrude. If the rectum 
Fig. 18.-Showing the Genital Canal after full Dilatation of the Cervix 
lias not been emptied, and there are faeces in it, the 
head, as it descends, squeezes them out. 
In anatural labour, with a full-sized and well-shaped 
pelvis, and a child of not more than average dimen- 
sions, the sole work of the second stage of labour is to 
stretch open the vagina and vulva: there is no diffi- 
culty at all arising from the bony parts. Hence the 
child's head is not at all fixed in the pelvis. It moves 28 
Midwifer f. 
[Chap. II. 
on when the uterus contracts, and when the con- 
traction is over the elasticity of the soft parts pushes 
it up again. This alternate advance and recession of 
the head is a most important sign. So long as it is 
going on there is no danger whatever of the mother's 
parts suffering from pressure : nor is there danger, if 
complications be absent, from prolongation of the 
Fig. 19.-The "Crowning" of the Head. (From Galabin.) 
labour. If on the contrary the head is impacted, that 
is, wedged fast in the pelvis so that it neither advances 
nor recedes, then there is danger, and speedy help is 
needed. 
Just as theperineum is stretched to almost its fullest 
extent it is not uncommon for the head to remain 
stationary for a few seconds. This has been called the 
" crowning" of the head (Fig. 19). It is a good thing, 
because if it happens the perineum is stretched slowly 
and is less likely to tear. In first labours the perineum 
is very often a little torn. The larger the child, and Chap. II.] 
Third Stage of Labour. 
29 
the more quickly the stretching of the perineum takes 
place, the greater is the risk of tearing. When 
the head is born, if the shoulders are delivered 
too quickly the perineum may be torn by them. 
With the birth of the child the second stage is 
ended. During the first and second stages of labour 
the mother's pulse is about 100 per minute. After 
the birth of the child it should sink to about 70. 
Duration.-The average duration of the second 
stage of labour is, in first labours, about two hours; 
in labours not the first, about one hour. 
Tiiird Stage. 
The third stage of labour is the expulsion of the 
placenta and membranes. This is effected by the con- 
tractions of the womb. After 
expelling the child the womb 
contracts so that it closely grasps 
the placenta. The inner surface 
of the womb, which the mem- 
branes cover, is much smaller 
than it was while the child was 
in the womb, therefore the mem- 
branes, as they do not contract, 
get wrinkled up, and this wrink- 
ling separates them from the 
womb. Further uterine con- 
tractions separate the placenta 
from the womb and drive it 
downwards towards the os uteri. 
If the placenta and membranes 
are completely detached the 
placenta is squeezed out edge- 
wise, folded with its uterine sur- 
face outwards (Fig. 20). But often the lower edge of the 
placenta is the last part to be separated, and then this 
part is held back while the upper part is pressed 
Fig. 20. - The Natural 
Mode of Expulsion of 
the Placenta. 30 
Midwifery. 
[Chap. II. 
down. If this be the case the placenta will come down 
so folded that its smooth fcetal surface is in advance. 
But whichever way it comes down, in a natural 
labour the uterine contractions alone drive the 
placenta out of the uterus into the vagina, and drive 
it out so folded and compressed that hardly any blood 
is contained between the uterus and the placenta. If 
the delivery of the placenta in the 
natural manner be interfered with 
by dragging at the cord, it may be 
that the part to which the cord is 
attached is so pulled away from 
the uterus that blood is sucked 
from the uterus into the space be- 
tween the placenta and the uterus 
(Fig. 21), and then the patient 
loses more blood than she ought to 
do ; and the clotting of blood in 
the uterine vessels, which is the 
natural preventive of haemorrhage, 
is interfered with, and the danger 
of bleeding afterwards is increased. 
To pull at the cord is therefore 
bad practice. The amount of blood 
lost in the third stage of labour 
ought not to be more than a pound. 
When the placenta is in the vagina it is usual for the 
attendant to help it out. The vagina has not the power 
to expel it. It may be driven out by the coughing or 
bearing down efforts of the mother, but such effort is 
seldom sufficient, and if the delivery of the placenta be 
not assisted, it may be delayed for hours or even days. 
The membranes are very often still attached round the 
lower part of the uterus after the placenta is com- 
pletely outside the vulva; and therefore it is generally 
necessary for the attendant to make a point of ascer- 
taining that the membranes are completely delivered. 
Fig. 21.-Showing the 
Effect of pulling on 
the Cord.. 31 
CHAPTER III. 
THE MECHANISM OF LABOUR. 
Reasons for the common position of the 
child.-In three cases out of four the child lies in the 
womb withits head downwards, and its back forwards 
Fig. 22.-Usual Attitude of Child. 
and to the left. Its thighs are held up as close as 
possible to its belly, and its knees are bent. The 
arms are crossed over the chest. The spine is bent, 
and the chin»bent down on the chest (Fig. 22). Thus 
the back of the child has a convex outline, the front a 32 
Midwifery. 
["Chap. III. 
rather concave one. The child's back is in front because 
the concavity of the front of the child fits the projec- 
tion of the mother's spine better than the child's back. 
The child lies with its head down simply on account 
of its weight. It has been found by experiment that 
vdien a healthy, though stillborn, child is put in fluid 
of the same specific gravity as the liquor amnii it sinks 
in the fluid in exactly the same position that it occu- 
pies in the womb. Premature children, children that 
have been dead for some time, children with water on 
the brain, and other diseased conditions, when put in 
such fluid do not take this position, and therefore we 
find that abnormal positions of the child are common 
in pregnancy and labour with premature and dead 
children. The child lies with its back to the left, 
because the rectum is at the brim of the pelvis on the 
left side, and pushes the child's forehead over to the 
right side. Very little force is enough to move the 
child when it is floating in the liquor amnii. 
Fig. 23.-Vertex presenting: First Position. (After Farabeuf.) Chap. III.J 
Movements of Head. 
33 
The first position.-The child ought to be born 
not only with the head first, but with the top of the 
head or vertex in advance. This is the part which 
ought to enter the bony canal first, and which does so 
in nineteen cases out of twenty. There are four 
different ways in which the child may lie with the 
vertex presenting, and they are called the four vertex 
positions, and are numbered. The most common one- 
that in which three-fourths of children are born-is 
called the first position (Fig. 23). In it the back of 
the head lies to the left and in front, the forehead to 
the right and behind. As this is the usual way in 
which children are born, the mechanism of labour 
with the child in this position will now be described. 
Movements of the head.-It is usual to divide 
the movements into five, which are the following 
(1) Obliquity.* 
(2) Flexion. 
(3) Rotation 
(4) Extension. 
(5) Restitution and external rotation. 
But remember that these are not stages distinct 
from one another; that steady descent into the pelvis 
and advance through it goes on along with these move- 
ments ; and that these five movements pass into one 
another, the transition from one to another being so 
gradual as to be imperceptible. 
1. Obliquity means that the head as it presents 
in the brim lies in the oblique diameter of the pelvis. 
It does this because there is more room in this 
diameter than in any other: as has been said in the 
description of the pelvis. In some cases of difficult 
* Some authorities omit " obliquity,'' as not being, strictly 
speaking, a ' ' movement. " But it is an essential part of the 
mechanism, and is therefore here enumera-ted among the move- 
ments. 34 
Midwifery. 
[Chap. HI. 
labour there is another kind of obliquity, which is 
called the obliquity of Naeyele. This will be described 
farther on. 
2. Flexion.- The head is bent so that the chin 
is near the sternum. The head is generally held bent 
in the womb before labour, and when the head is 
Fig. 24.-Showing how Flexion is promoted hy the difference in slope 
(indicated hy the lines b c, ac) of the front and back of the Child's 
Head. 
pressed down during labour the effect of the pressure 
is to bend it more and more. This is so for two 
reasons : first, the part of the top of the head that is 
forced into the ring of the os uteri by the pains is 
so shaped that the back slopes more than the front, 
and thus the back of the head slijis down more easily 
than the front (Fig. 24). Second, the head is jointed 
to the spine nearer the back than the front (the part in 
front of the joint being to that behind as 6 to 5), and 
therefore the resistance to its progress acts more Chap. in.j 
Movements of Head. 
35 
powerfully on the front than on the back, and so 
forces the forehead up and bends the head. 
Advantage of flexion.-The effect of the bend- 
ing of the head is that instead of the occipito-frontal 
diameter, which measures four inches and a half, 
having to pass through the pelvis, the sub-occipito- 
frontal, which measures oidy four inches, and by the 
pressure on it is made less than that, is the largest 
diameter that has to pass through the pelvis. The 
flexion of the head is therefore an important part of 
the mechanism of labour. 
3. Rotation.-It is only at the brim of the pelvis 
that the oblique diameter is the longest. In the 
cavity and at the outlet of the pelvis it is not larger 
than the others. Hence there is nothing in the shape 
of the bones to keep the head in the oblique diameter 
when once it has passed the brim. 
The great resistance to the birth of the child is 
from the muscular and fibrous structures which form 
the floor of the pelvis, and more especially from those 
which form the posterior part of this floor, because 
the anterior part of the pelvic floor is pulled up by the 
contracting uterus out of the way of the child. Now, 
these muscular and fibrous structures are attached to 
the back and sides of the pelvis, and the opening is in 
front and in the middle. Consequently, the part of 
the head which is in advance meets with the least 
resistance in front and in the middle, and as soon as 
it gets down to the floor of the pelvis moves in that 
direction. At this stage of the labour, therefore, the 
head turns, so that the occiput, instead of being to 
the left, comes to be in the middle, and the forehead, 
instead of being to the right, looks directly backwards. 
This change is called rotation. It often does not take 
place until just before the head is born (Fig. 25). 
4. Extension.-It has been pointed out already 
that the part of the pelvic floor which the head has to 36 
MIDWIFERY. 
[Chap. III. 
stretch open in order to be born is behind, and that 
in front, when the head has got down to the floor of 
the pelvis, there is hardly any resistance. Hence the 
Fig. 25.-Showing the successive Positions occupied by the Head 
dm irg Delivery in the First Position, (From Galabin.) 
advanced part of the head moves forwards. It can- 
not do this if the head remains bent, as a glance at the 
diagram will show. Therefore at this stage-that is, 
when it is emerging into the world-the head ceases Chap. III.] 
■Movements of Mead. 
37 
to be bent, the chin leaves the sternum, and the head 
is extended (Fig. 26). 
5. Kestitutiosi and external rotation.-- 
To understand this, the position of the shoulders 
must be remembered. Their longest measurement 
is in the opposite di- 
rection to the longest 
measurement of the 
head. When the 
head is in the right 
oblique diameter, the 
shoulders are in the 
left oblique diameter. 
It has been explained 
that the head is 
turned from the ob- 
lique into the antero- 
posterior diameter of 
the pelvis by the re- 
sistance of the pelvic 
floor. When this 
turn takes place the 
shoulders are too high 
up to meet with this 
resistance; there is 
nothing to turn them, 
and they do not turn ; the head turns, so that the 
chin, instead of being opposite the sternum, is to- 
wards one shoulder. Directly the head is born, it 
is liberated from the pressure of the pelvic floor 
which made it turn towards the shoulder, and is 
restored to its former position : that is, instead of 
looking straight back towards the mother's sacrum, 
it looks backwards and to the right. This is resti- 
tution. But when the head has emerged, the 
shoulders are able to come down to the floor of the 
pelvis, and they are turned into the antero-posterior 
Fig. 26.-Showing the Extension of the 
Head in Delivery with the Occiput 
forwards. 38 
Midwifery. 
[Chap. in. 
diameter of the pelvis, just as the head was. Therefore 
the head comes to lie in the opposite direction: that 
is, transversely, with the face towards the mother's 
right thigh. This is a continuation of the move- 
ment of restitution, and is called external rotation, 
because it is a rotation which takes place outside the 
pelvis. 
The shoulders are now expelled. If the woman 
has had children before, and the perineum is very 
short, the posterior shoulder is first seen, and then the 
anterior. If the perineum be long, then the posterior 
shoulder is covered by it until the child has been 
driven down so far that the anterior shoulder appears 
at the vulva. When the shoulders have been born 
the body and legs quickly follow. 
Second position.--In about one case in ten 
the child's head enters the pelvic brim in the second 
position (Fig. 27). In this the long diameter of the 
head lies in the left oblique diameter of the pelvis. The 
only difference between it and the first position is, that 
while in the first position the back of the head is to 
the left, in the second it is to the right ; the forehead 
to the right in the first position, to the left in the 
second. The mechanism is exactly the same, except 
that left and right are reversed. When the occiput 
meets the resistance of the pelvic floor it turns to the 
left to get to the middle line, instead of to the right, 
as in the first position, and the forehead moves 
towards the right. The shoulders enter the pelvis 
in the right oblique diameter, instead of in the left. 
When the head has emerged, the movement of resti- 
tution which it makes brings the face towards the 
mother's left thigh, instead of the right, as in the first 
position. 
These slight differences are of no practical import- 
ance. Labour is just as easy and safe when the head 
is in the second position as when it is in the first 
position. Chap. III.] 
Occipito-Posterior Positions. 
39 
Occipito-posterior positions.-But there is a 
great difference between the two positions that have 
been described and the two that come next to be con- 
sidered : viz. the third and fourth positions. In these 
two positions the occiput lies behind and the forehead 
in front. In the third position the occiput is to the 
right and the forehead to the left. The difference 
between the third and fourth positions is just like that 
Fig. 27.-Vertex pre3enting : Second Positron. (After Farabeuf.) 
between the first and second positions-merely one of 
left and right. In the fourth position the occiput is 
to the left, the forehead to the right. In the third 
position the long diameter of the head lies in the right 
oblique diameter of the pelvis, and in the fourth 
position in the left oblique. 
The head presents in the third position in about one 
case in every ten; in the fourth position not oftener than 
one case in twenty. Labours in which the head presents 
with the occiput behind, that is, in the third or fourth 40 
Midwifery. 
[Chap. in. 
positions, are sometimes, not always, long and difficult. 
The reason of this difficulty is that the mother's 
pelvis and the child's head are so shaped that when 
the occiput is behind there is resistance to its being 
flexed as it should be. Take the foetal skull and hold 
it in the pelvic brim in the first position, and you will 
see that the longest transverse diameter of the head- 
viz. the bi-parietal-lies exactly in the left oblique 
diameter of the pelvis, and that there is plenty of 
room for it. Now turn it round, and hold it still in 
the right oblique diameter of the pelvis, but with the 
occiput behind, instead of in front (i.e. the third 
position), and you will see that the bi-parietal diameter 
of the head is not in the left oblique diameter of the 
pelvis, but behind it, in a part of the pelvis much 
narrower than the left oblique diameter, and where 
there is only just room for it-none to spare. Con- 
sequently the occiput does not come down so easily in 
this position as it does in the first position. This is 
the reason why labours with the head presenting in 
this position are difficult. 
Third position.-Although in this position the 
descent of the occiput and the bending of the head 
take place with difficulty, yet they can take place. 
The first movements, therefore, are just as with the 
first position-(1) obliquity ; (2) flexion. If flexion 
takes place properly the occiput comes down, and is 
the first part which meets the resistance of the floor 
of the pelvis. It accordingly is turned forwards. It 
takes the shortest way to the front (Fig. 28). Being 
directed to the right, it moves along the right wall of 
the pelvis till it has got into the second position, and 
then it gets under the pubic arch, just as a head does 
which presents in the second position. Then all the 
rest of the labour goes on just as if the head had been 
from the beginning in the second position. It is ne- 
cessary, therefore, for the easy progress of labour with Chap, in.] 
O CC IF ITO-POST ER IOR POSITIONS. 
41 
the third position that it should be changed into the 
second. 
There are thus two reasons for delay when the 
head enters in the third position : first, that flexion 
is hindered ; second, that the head has to get into 
the second position. For these reasons delivery takes 
Fig. 28.-Vertex presenting: Third Position.* (After Farabeuf.) 
longer when the head is in the third position than 
when it is in the first. 
Division of occipito-posterior cases.-But 
in some cases in which the head presents with the 
occiput behind, the occiput meets with so much 
hindrance to its descent that flexion is incomplete. 
Cases with the occiput behind have been divided into 
two classes, according to whether flexion is complete 
or not. If flexion is complete, then the anterior 
* The longest transverse diameter of the head in this figure 
and in Fig. 31, seems to be nearer the front than the [back of 
the head because the head is represented flexed. 42 
Midwifery. 
[Chap. III. 
fontanelle is liigli up, near the acetabulum, and these 
cases are called bregmato-cotyloid. If flexion be in- 
complete, then the anterior fontanelle is lower down, 
and the frontal eminence is in contact with the back 
of the acetabulum; and these cases are called fronto- 
cotyloid. 
Delivery with occiput behind.-When the 
head enters the pelvis with the occiput behind, and 
flexion is incomplete, the first effect is that the occipito- 
frontal diameter, which is four inches and a half, lies 
across the pelvis, instead of the sub-occipito-frontal, 
which is only four inches. There is therefore much 
less room ; the head fits the pelvis more tightly, and 
advances slowly. When it gets down into the pelvis, 
the occiput not being lower down than the sinciput, 
the resistance of the pelvic floor does not affect the 
occiput more than the sinciput, and therefore does not 
turn it forwards. So the head remains with the fore- 
head in front, and as it is driven down the forehead 
is turned towards the middle line and becomes jammed 
against the back of the symphysis pubis (Fig. 29). In 
this position the face cannot possibly emerge under the 
symphysis, for if you will take the foetal skull, and put 
it in the pelvis, with the forehead against the back of 
the symphysis and the occiput in the hollow of the 
sacrum, you will see that for the face to pass out 
under the pubes the vertico-mental diameter must for 
a moment lie across the pelvis. Now, as the vertico- 
mental diameter usually measures more than five 
inches, while the pelvis measures five inches, this 
cannot possibly happen. The uterine force pushes 
down the child's spine, and this pushes down the occiput, 
which revolves round the symphysis pubis, having the 
forehead as its centre of movement, and thus is born 
(Fig. 30). The occipito-frontal diameter, which is 
four inches and a half, thus has to pass the antero- 
posterior diameter, which is four inches and a half, so chap. 111.j 
Delivery with Occiput Behind. 
43 
that there is no room to spare, and indeed, the head 
can only pass by yielding a little, being moulded as it 
is squeezed through. The perineum is also stretched 
Fig. 29.-Showing successive Positions of the Head in Delivery when 
the Occiput remains behind. (From Galdbin.') 
more than it should be, when the head passes in this 
position, for the diameter which should stretch the 
perineum, the sub-occipito-frontal, only measures four 
inches, while here it is stretched by the four and a 
half inches of the occipito-frontal diameter. Hence 44 
MlDW'IFER P. 
[Chap. in. 
the perineum is more likely to be torn when the head 
is delivered in this position. When the occiput has 
emerged, then the nape of the neck becomes fixed 
against the perineum, and the nose, mouth, and chin 
slip out from behind the symphysis pubis. The 
shoulders are now in the left oblique diameter of the 
brim. The head, after it has emerged, makes the 
Pig. 30.-Showing Delivery by flexion when the Occiput is posterior. 
movement of restitution to bring itself back into its 
original position with regard to the shoulders: that is, 
it turns to the mother's left thigh. Then the shoulders 
turn into the antero-posterior diameter of the outlet, 
and emerge as in the second position. Labour in 
which the head enters the brim with the occiput 
backwards is thus, if the occiput does not turn 
forwards, much more difficult and more dangerous. 
The fourth position (Fig. 31) is that in which 
the occiput is behind and to the left, the forehead in 
front and to the right. Just as the mechanism of the 
second position is the same as that of the first, except Chap. III.] 
Face Presentations. 
45 
that left and right are reversed, so the modes of 
delivery, and the mechanism of each, are the same in 
the fourth position as in the third, except that left and 
right are reversed. The occiput in the fourth position 
ought to turn forwards, and so the position of the head 
become changed into the first position. Sometimes it 
Fig. 31.-Fourth Vertex Position. (After Farabeuf.) 
does not, and then the forehead becomes jammed be- 
hind the pubes, and the occiput comes out over the 
perineum. 
Face presentations-their production.- 
It has already been mentioned that so long as the 
membranes are unruptured, and the waters not deficient 
in quantity, the fluid presses equally on every part of 
the inner surface of the uterus. But after the mem- 
branes are ruptured, the uterus, in contracting, em- 
braces the child more closely, and presses upon its 
prominent parts. This pressure tends to straighten 
the child's spine, and so to make the distance between 
the breech and the advancing head greater, so that, 46 
Midwifery. 
[Chap. III. 
the breech being pressed upon by the fundus uteri, 
the head must advance. 
The tendency of the pressure of the uterus on 
Fig. 32.-Showing how Uterine Contraction increases Flexion. 
{After Schatz.) 
n indicates the joint between the spine and the head, which is here behind the 
line ab, along which the pressure of the uterus in the head and breech is 
exerted. Such pressure, therefore, tends to make the angle B n c more 
acute ; that is, to increase/town. 
the breech, combined with the resistance the head 
meets to its advance is to press the head and the breech 
together. Now, if the child is in such an attitude 
that the joint between the spine and the head 
lies between the back of the child and the line along 
which such pressure is exerted, then the effect of the 
pressure is to increase, as far the uterus will allow, 
the bending of the back and the flexion of the chap, in.] 
Production of Face Presentations. 
47 
head (Fig. 32). But if the child is in such an attitude 
that the joint between the spine and the head lies 
on the abdominal side of the line along which the 
Fig. 33.-Showing how, when Extension of the Head has begun, 
Uterine Contraction increases it. {After Schatz.) 
n (the joint between the spine and the head) is here in front of the line An, 
along which the pressure of the uterus on the head and breech is exerted. 
Pressure which tends to make the angle bdc more acute, here increases 
extension. 
pressure is exerted (and a very little straightening out 
of the spine will bring this to pass), then the effect of 
such pressure is to more and more extend the spine and 
the head (Fig. 33). Thus, when the head is only a 
little extended, the effect of the uterine action will be 
to increase this until the head is as much extended as 
it possibly can be. When the child is lying in the 48 
Midwifery. 
[Chap. in. 
womb with its head downwards, the effect of the 
fullest possible extension of the head is to make the 
face look downwards and present at the brim ; in 
other words, to produce a face presentation (Fig. 34). 
There are various causes of face presenta- 
tions, some of which are of 
practical importance. One is 
obliquity of the uterus, by which 
the descent of the occiput is 
hindered; and if it be ever so 
little hindered, the action of the 
uterus may-, in the way that has 
been shown, bring about a face 
presentation. The importance 
of this fact is that the obliquity 
of the uterus may be corrected 
by making the patient lie on 
the side opposite to that to 
which the body of the uterus is 
deviated ; and if this correction 
be made early, the harm that 
the excessive obliquity has done 
will soon be undone. Another 
important cause of face present- 
ations is contraction of the pelvis. 
Remember that the greatest 
transverse diameter of the foetal 
head is the bi-parietal, which 
is situated behind the middle 
of the head. Consequently, if the pelvis be so con- 
tracted as not to admit easily the bi parietal diameter, 
the front part of the head will come down, and 
a face presentation will be produced. Recollect 
this, and if you meet with a face presentation high 
up, try and make out the size of the pelvis, and if it 
be contracted, or if you are in doubt whether it be 
contracted or not, send for assistance early. Face 
Fig. 3k-Attitude in Face 
Presentation, showing 
complete Extension of 
Head. (From Galabin.) 
AC, line along which expul- 
sive force is transmitted ; 
M F, Fronto-mental dia- 
meter of head. Chap. III.] 
Causes of Face Presentations. 
49 
presentation is also apt to occur when the child is 
larger than usual, or when the cranium is enlarged by 
hydrocephalus, for the same reason that makes it 
common in contracted pelves. Sometimes it is due 
to some deformity of the child, so that it cannot bend 
its head. It has been also attributed to excessive 
length of the child's head, so that the part behind the 
joint between the head and the spine is longer than 
the part in front of it. The child's head is always 
longer than usual when it has been born with the face 
presenting; but this is from squeezing during labour. 
There are other causes, but these are all that are 
practically important. There are causes that prevent 
the child from properly entering the pelvis, and these 
may cause the face to present, but they oftener lead 
to transverse presentation. Among these are: too 
much liquor amnii, so that the foetus floats about in 
the womb, instead of being kept with its head in the 
pelvic brim ; and then, when the membranes rupture, 
whatever part of the child happens to be nearest the 
os uteri comes to present. Hence it is important to 
see that the child is in a proper position before 
rupturing the membranes. When the child is pre- 
mature or dead, the relative weight of its different 
parts is not the same as in a living foetus at full term, 
and so the action of gravity no longer helps to make 
the head present ; and if dead, the maintenance in a 
proper position is no longer helped by the child's 
movements. Hence, abnormal presentations are com- 
mon with premature and dead children. There are 
other causes, which will be mentioned hereafter. 
Presentations of tlie face are divided into 
four positions. These are numbered as if they were 
formed out of the four vertex positions. Thus, take the 
first vertex position, with the forehead behind and to 
the right, the occiput forward and to the left, and 
extend the head. The chin will then be behind and 50 
Midwifery. 
[Chap. III. 
to the right, the forehead forward and to the left. 
The second face position is with the chin behind, and 
to the left, the forehead forward, and to the right. 
In the third and fourth positions the chin is in front; 
in the third position to the left, the forehead being 
behind and to the right. In the fourth position the 
Fig. 35.-Face presenting : Third Position. (After Farabeuf) 
chin is to the right, the forehead behind and to the 
left. 
The ease or difficulty of labour with the face pre- 
senting depends upon whether the chin is in front or 
behind. If the chin is in front the labour will not 
be very difficult. If the chin is behind, the labour 
may be very difficult. Therefore, in describing the 
mechanism, the more favourable cases will be first 
spoken of : viz. the third and fourth positions, in 
which the chin is forward. 
The movements of the head in passing through the 
pelvis with the face presenting are the same as those 
when the vertex is presenting, excepting that extension Chap. III.] 
Third Face Position. 
51 
takes the place of flexion, and later on flexion that of 
extension. Thus: (1) obliquity; (2) extension ; (3) 
rotation; (4) flexion; (5) restitution. 
Tn the third position (Fig. 35) the face lies in 
the right oblique diameter, the chin forward to the 
Fig. 36.-Showing successive Positions occupied by Head in Face 
Delivery. 
left, the forehead behind and to the right. The 
head is extended as much as it can possibly be. 
The effect of this great extension is to make the chin 
the most advanced part of the child's head. As the 
chin comes down and meets with the resistance of the 
soft parts forming the pelvic floor, it is turned for- 
wards. By this rotation the face comes to lie in the 
antero-posterior diameter of the pelvis. Then when 
the chin has got below the symphysis pubis, it moves 52 
Midwifery. 
[Chap. in. 
forward underneath it, and the front of the neck is 
fixed behind the symphysis pubis. Then flexion takes 
place, and the forehead, vertex, and occiput in succes- 
sion put the perineum on the stretch and are born 
(Fig. ,36). While this was taking place the shoulders 
were, in the left oblique diameter of the pelvis. There- 
fore directly the head gets free, the face turns to the 
Fig. 37.-Face presenting: Fourth Position. (After Farabeuf.) 
mother's left thigh, which is the movement of resti- 
tution. The anterior shoulder then turns under the 
symphysis pubis, and the birth of the rest of the body 
is completed as in the second vertex position. 
The mechanism of labour in the fourth face 
position (chin forwards and to the right) (Fig. 37) 
is just the same as that of the third, excepting that 
right and left are reversed. The chin turns towards 
the left to get into the antero-posterior diameter of 
the pelvis. After the head is born the movement 
of restitution turns it towards the mother's right 
thigh. Chap. HI.] 
First Face Position. 
53 
In the first and second face positions, 
those in which the chin is behind, the mode in which 
delivery should take place is the following :- 
First face position: (Fig. 38) Chin behind and 
to the right, forehead forward and to the left. The 
fronto mental diameter thus, at the beginning of 
labour, occupies the right oblique diameter of the 
Fig. 38.-Face'presentiug : First Position. (.After Farabeuf.) 
pelvis. The first movements, obliquity and exten- 
sion, are thus the same as in the positions in which 
the chin is in front. When the head has advanced 
so far that the chin meets with the resistance of 
the floor of the pelvis (and in order that the chin 
should be the part of the head which first meets 
with this resistance, it is necessary that the head 
should be well extended), it is by this resistance 
(which, it will be remembered, is greatest behind 
and least in front) turned round through three- 
eighths of the pelvic ring till the chin comes under 
the symphysis pubis. Then delivery takes place just 54 
Midwifer f. 
[Chap. III. 
as in the fourth face position. The mode of delivery 
in the second face position (Fig. 39) is the same 
as that in the first, except that right and left are 
reversed. 
The long rotation of the head which must take place 
if delivery is to be easy, when the chin is behind, is like 
that which has to take place when the occiput is 
Fig. 39.-Face presenting ; Second Position. (After" Farabeuf.) 
behind. Just as the third vertex position has to be 
changed into the second, and the fourth vertex position 
into the first, before delivery of a good-sized child can 
take place, so the first face position must be changed 
into the fourth, and the second face position into the 
third. 
When the face is delivered with the chin forwards 
(by a movement of flexion round the symphysis pubis 
as a centre, the front of the neck being closely pressed 
against the symphysis), the largest diameter of the 
head that has to stretch the perineum is one measured 
from the front of the neck, where it joins the head, to Chap. III.] 
Face Presentations. 
55 
the most distant point of the sagittal suture (Fig. 40). 
This is the cervico-vertical diameter. It measures about 
four inches and a half, or a little less, and can be 
reduced by squeezing. This is rather more than the 
sub-occipito-frental, which is the largest diameter that 
stretches the perineum when the vertex presents with 
Fig. 40.-Showing Head at Outlet of Pelvis in Face Delivery. 
the occiput forwards, Fig. 26.) Therefore labours 
with face presentations, even when the chin is in front, 
are a little longer than labours with the vertex present- 
ing in the first or second position. But besides this, face 
presentation is often caused by other conditions which 
make labour long or difficult; and therefore, taking 
all cases together, labours with face presentations are 
longer than labours with vertex presentations. 
In face presentations with the chin behind, laboui- 56 
Midwifery. 
[Chap. in. 
is longer than in the cases in which the chin is in 
front, because time is occupied in producing the long 
rotation which ought to take place. 
Difficult face presentations.-But in some 
cases this long rotation does not take place, and 
the head is driven down to the floor of the pelvis, 
with the chin behind. If you take the head, 
and hold it so that the face lies in the pelvic outlet, 
with the chin behind, you will see that the occipital 
condyles, by which the head is jointed to the spine, 
are so low down that when the head is in that position 
the neck and upper part of the chest must also be in 
the pelvis, and that the head cannot pass through the 
pelvis unless there is room both for the sub-occipito- 
bregmatic diameter of the head, which is about three 
and a half inches, and for the neck, which is about 
one inch and a half thick. These measurements, 
together amounting to about five inches, refer to a child 
of average size. Now, as the antero-posterioi- diameter 
of the outlet is only four inches and a half, it is 
clear that a child of average size cannot possibly pass 
through the pelvis in this position. It can only do so 
if the child be small or the pelvis unusually large. 
Except, therefore, in the case of very small children, 
delivery with the face presenting and the chin behind 
is impossible. 
Brow presentations.-Sometimes the head 
presents in a position which is intermediate between 
a face presentation and a vertex presentation. This 
is called a brow presentation, because in it the 
forehead of the child is the most advanced part. 
The diameter that is here engaged in the brim 
is one running from the chin to about midway 
between the two fontanelles. This diameter is the 
longest measurement of the head, so that a full- 
sized child cannot possibly pass through the pelvis in 
this position. If such cases are left alone they Chap. III.] 
Brow Presentations. 
57 
generally become changed into either face or vertex 
presentations, and are born in the manner which has 
been described in speaking of those presentations. 
Sometimes, though rarely, the head comes down in 
the brow position, the face turns towards the front, 
the jaw (not the forehead, as in occipito-posterior 
presentations) becomes fixed behind the symphysis 
pubis, and then the forehead, vertex, and occiput 
successively distend the perineum, and are born. Such 
labours are very long and difficult, and when the child 
is born its head is much deformed. 
Fig, 41.-Breech : First Position. (From GaJabin.) 
Pelvic presentations.- Those cases in which 
the child lies with j.ts breech downwards are 
grouped together as pelvic presentations. They were 
by some of the earliest writers on midwifery classed 58 
Midwifer f. 
[Chap. in. 
along with head presentations as " natural," because 
the child will generally be born alive if the foetus 
enters the pelvis by one end of the egg-shaped mass 
which it forms as it lies doubled-up in the womb. If 
the child lies across the pelvis, so that neither end can 
enter the pelvis, then it is seldom born alive without 
Fig. 42.-Breech Presentation with extended Legs. 
help, and therefore such labours were distinguished 
as not natural. 
When the child lies with the breech downward, 
the legs are generally in the same attitude as that 
which they assume when the head is presenting : that 
is, the thighs are bent up on the abdomen, and the 
knees bent, so that the feet are very near the breech 
(Fig. 41). Sometimes the knees are straightened out, 
so that the feet are near the head, and this attitude may Chap. III.] 
Breech Positions. 
59 
make the labour very difficult (Fig. 42). Sometimes 
(more especially in premature and dead children) one 
or both thighs, instead of being bent up to the abdo- 
men, hang down, so that a foot or a knee is much lower 
down than the breech, and is the part first felt by the 
examining hand. But wherever the feet may be, the 
mode in which the child passes through the pelvis 
when the head comes last is the same in all essential 
points. 
Positions of tlie breech.-The breech may 
present in one of four positions, which are numbered 
according to the position of the head, so that 
they correspond to the four vertex positions. Thus 
the first breech position is that in which the back 
of the child is to the left and forwards; the second 
position that in which it is to the right and forwards. 
The former position is the commonest, because 
before the parts of the feetus are pressed together by 
being driven down into the pelvis, the measurement 
from the sacrum to the front of the legs-the 
sacro-tibial measurement-is the longest measurement 
of this end of the foetus; and, therefore, this 
measurement takes the right oblique diameter, just 
as, when the head presents, the long diameter of the 
head goes into the right oblique diameter and for 
the same reason. But when the breech is driven 
down into the pelvis, the legs are pressed against the 
abdomen, and the bis-iliac diameter becomes the 
longest and, obstetrically, the most important. 
First breech position.-The mode of passage 
in the first position is the following : The long 
diameter of the breech is that which runs from side 
to side, between the two trochanters. In the first 
position this enters the pelvis in the left oblique 
diameter : the anterior trochanter being to the right, 
the posterior trochanter being to the left. As the 
breech descends, the pressure of the soft parts at the 60 
Midwifery. 
[Chap. III. 
back and sides of the pelvis causes the anterior 
trochanter, which is the one in advance, to move 
towards the middle line, and at the same time the child's 
spine is bent sideways so that the breech can advance 
forward in a curve like that which the head takes (Fig. 
43). This turn of the breech into the antero-posterior 
Fig. 43.-Showing Lateral Flexion of Spine in Breech Delivery. 
diameter of the pelvis is not often so complete as that 
which the head makes, because the breech is smaller 
and softer, and it is not therefore so necessary that it 
should take exactly the position in the pelvis in which 
there is most room. Then the anterior buttock 
appears at the vulval orifice, and stretches the Chap. HI.] 
Breech Labour. 
61 
perineum; and first it, and then the posterior buttock, 
pass over the perineum, and are born. When the 
breech is born, the legs, if they are in the position 
which they ought to occupy, escape immediately after- 
wards. Then, if no injudicious traction has been 
Fig. 44.-Delivery of Shoulders in Breech Labour. 
made, the shoulders come down, with the arms crossed 
over the front of the chest, and the anterior shoulder, 
which is in this position to the left, turns forwards, 
so that the long diameter of the shoulders shall be in 
the antero-posterior diameter of the outlet (Fig. 44) 
Whether the anterior or posterior shoulder be born first 
depends partly upon the length of the perineum, partly 
upon the conduct of the attendant. If there be a long 62 
Midwifery. 
[Chap. III. 
perineum, the anterior shoulder is usually born first; 
but if the perineum be very short-as is sometimes 
the case owing to rupture in previous labours-or if 
you draw the body of the child forward, the posterior 
shoulder may be born first. The turn of the shoulders 
Fig. -15.-Mode of Passage of Head in Breech Labour. 
into the antero-posterior diameter of the outlet, like 
that of the buttocks, is not always complete, and for 
the same reason. When the shoulders are born, they 
execute, if not prevented, a movement of restitution, 
and come again to lie in a position corresponding to 
the left oblique diameter of the pelvis. The head is 
now in the right oblique diameter, with the occiput 
forwards and to the left, the forehead backwards and Chap. III.] 
Breech Labour. 
63 
to the right. The contracting uterus has been, while 
the body was coming down, pressing on all parts of 
the head, and as the part in front of the joint between 
the head and the spine is larger than that behind it, 
the front part is pressed down-in other words, the 
head is flexed (Fig. 45). As it comes down, the mus- 
cular and fibrous structures forming the floor of the 
pelvis press the neck forwards and towards the middle 
line. Therefore, the occiput turns forward, and the face 
backwards, and the head comes to occupy the antero- 
posterior diameter instead of the right oblique. Then 
the nape of the neck is fixed behind the symphysis 
pubis, while first the chin, then the mouth, nose, and 
forehead successively pass over the perineum, and 
are born. The largest diameter which stretches the 
perineum is therefore the same as that in delivery 
with vertex presentations : viz. the sub-occipito- 
frontal. 
The second breech position is that which 
corresponds to the second vertex position, the back 
of the child being forwards and to the right, the 
abdomen behind and to the left. The long diameter 
of the buttocks is, therefore, in the right oblique 
diameter of the pelvis. Delivery takes place in 
the same manner as in the first position, except 
that left and right are reversed. 
In the third and fourth breech positions 
the back of the child is behind. The third breech 
2)osition is that which corresponds to the third vertex 
position. The back is behind and to the right, the 
abdomen forwards and to the left. The long (bis-iliac) 
diameter of the breech lies in the left oblique diameter 
of the pelvis. As it descends, the anterior buttock, 
which lies to the right, moves forward under the pubic 
arch, and the breech passes the pelvic outlet in, or 
nearly in, the antero-posterior diameter, and the chest 
and arms follow. As the head comes down and 64 
Midwifery. 
[Chap. in. 
enters the pelvis, it lies in the right oblique diameter, 
occiput behind, face forwards. Now the pressure of 
the pelvic floor presses the neck forwards under 
the pubic arch, and the occiput accordingly moves to 
the front by the shortest route: that is, it moves 
round the right side of the pelvis, over three-eighths 
of the pelvic ring, and thus the head comes to lie, first 
in the left oblique diameter, with the occiput forward, 
then in the antero-posterior diameter; and is born in 
the same manner as if the presentation had been at 
first in the second position. 
The mechanism of the fourth breech position-that 
is, with the back behind and to the left, the abdomen 
forwards and to the right-is exactly the same as that 
of the third, except that left and right are reversed. 
If the child be small, its head may be born, when 
the abdomen is in front, without making the turn that 
has been described. If the head is well flexed, the 
chin, mouth, nose, and forehead may successively pass 
down behind the symphysis, while the nape of the neck 
is pressing back the perineum. This cannot happen 
unless the head is well flexed. 65 
CHAPTER IV. 
ATTENDANCE ON NATURAL LABOUR. 
Midwifery practice in most cases may be correctly 
described as a branch of preventive medicine. A 
skilful accoucheur prevents danger oftener than he 
has to treat it. 
In every case of labour the following things must 
be attended to : 
(1) Prevention of septic infection. 
(2) Early diagnosis of what is abnormal. 
(3) Attention to the comfort of the patient. 
(4) Prevention of accidents. 
(5) Care for the child. 
(6) Prevention of haemorrhage. 
Of these, the second is the only one that requires 
a well-educated doctor The others are simple and 
easy, and a properly trained monthly nurse can do 
them quite well. The treatment of difficult labour is 
not within the province of the student or midwife. 
When sent for, go at once. Never judge by the 
report of the messenger whether the case can wait or 
not. Every complication of labour is much easier to 
treat at the beginning than later on; and many that 
are easily put right early in the case, become difficult 
and dangerous if aid is not afforded till the condition 
has lasted long. Prevention is better than cure. 
A medical student should not attend a case of 
labour in clothes that he has worn whilst dissecting, 
making post mortem examinations, or attending cases 
of infectious disease. A midwife or monthly nurse 
should wear a light-coloured cotton dress, made so 
I. Preliminary. 66 
Midwifery. 
[Chap. IV. 
that the sleeves can be turned up above the elbow. 
Such a dress when it is dirty will show the dirt, and 
can be washed. If an apron be worn, it also should 
be of light colour, and of material that can be washed. 
Fig. 46.-Douche Tin. 
The finger-nails should be kept short, that they may 
more easily be cleaned. Fancy rings should be taken 
off while the owner is in attendance on a case of 
labour, for it is almost impossible to be sure of keeping 
clean every crevice in such rings. 
Things required.-Take with you a hand-bag 
containing the following things: A Higginson's Chap. IV. I 
A ntisep tic Prep a r a tions. 
67 
syringe with a vaginal tube (the vaginal tube sold 
with the syringe had better be replaced by a glass one). 
If the patient can afford it, she should be told to 
provide herself beforehand with a douche tin (Fig. 46), 
by which the vagina can be douched better than with 
a syringe. A male gum elastic or celluloid No. 12 
catheter ; a pair of blunt-pointed scissors and some 
thread and a nail-brush (in case these articles should 
not be at hand in the house you are going to); anti- 
septics-either (1) a box of antiseptic powders, each 
composed as under : 
R Hyd. Perchlor gr. 20. 
Acid. Tartaric gr, 100. 
Cochineal gr- i- 
(The box should be labelled poison, and kept tied up, 
to prevent mistakes or accidents) ; or (2), what is more 
convenient, a tube of corrosive sublimate pastiles* of 
such strength that one in a pint of water makes a 
1 in 500 solution. One of these pastiles, or one of 
the powders, dissolved in a quart of water, will make 
a 1 in 1,000 solution. Take also an ounce bottle of a 
solution of sublimate in glycerine, 1 in 2,000 ; an 
ounce bottle of the liquid extract of ergot; and a 
bottle, or box of pills, each containing one grain of 
opium. 
Antiseptic preparations.-After entering the 
room, prepare with one of the powders, or pastiles, 
in a basin, or better, a jug, if there be one big enough 
at the top to admit the hand, a quart of 1 in 1,000 
sublimate solution. Then wash your hands in another 
basin with soap and water, using the nail-brush to 
them, and brushing the nails until there is not a 
speck of dirt on them. Having rinsed off the soap, 
* Sold by many chemists; among them, Allen and Hanburys, 
Vere Street, London, W., and Martindale, 10, New Cavendish 
Street, W. 68 
Midwifery. 
[Chap. IV. 
immerse your hands in the jug or basin of sublimate 
solution, and hold them there while you count sixty. 
Preparation of the bed.-It is the duty of 
the monthly nurse to see that the bed is properly 
prepared ; but whoever undertakes to attend labour 
ought to be able to give directions as to this, if 
required. A midwife will have to see to it herself. 
The best way to prepare the bed is to lay on it a 
mackintosh, over this a blanket, and over this a 
sheet; then another mackintosh; and on .this a sheet. 
If the bed has been prepared in this way, after 
delivery the upper mackintosh can be withdrawn, 
and the patient left in a clean dry bed. If you have 
the opportunity of advising as to the choice of bed, 
tell the patient to lie on a mattress, not on a feather 
or flock bed. In the houses of the poor who do not 
possess the things necessary to prepare the bed in 
this way, the best arrangement possible in the 
circumstances must be made to prevent the bed from 
being wetted. 
Dress of patient.-The best dress for the 
patient is a night-dress, under that a petticoat, and 
over these a dressing-gown. Then when the dis- 
charges become abundant the night-dress is rolled up 
under the arm-pits, to prevent its being wetted. It is 
customary for poor women whose stock of clothing is 
small to be delivered in their ordinary clothes, clean 
dry garments being reserved for putting on after 
delivery, and the old soiled clothes being washed 
during the lying-in. If the patient follow this custom, 
she should be told to take off her stays and drawers. 
Diagnosis of pregnancy.-These preparations 
having been made, you have to ascertain whether the 
patient is pregnant, and if so, whether she is in 
labour. To settle the first point, look at and 
feel the abdomen. If the patient be pregnant, the 
abdomen will be enlarged, and bulging forward. Chap. IV.] 
Diagnosis of Pregnancy. 
69 
(Iii enlargement due to fat or to dropsy, it bulges 
at the sides as much as in front.) On feeling it, 
practised hands will be able to make out the head 
and limbs of the child. The art of identifying 
parts of the child, and so finding out its position by 
feeling it through the abdominal walls, is a difficult 
one, and cannot be learnt without much practice. 
But it is so useful that you should lose no oppor- 
tunity of gaining proficiency in it. If you can make 
out the position of the child, and will put your stetho- 
scope or ear to the abdomen over the child's back, you 
will hear its heart beating. Each beat is a double 
sound, and there are from 120 to 150 beats per 
minute, which is much quicker than the mother's 
pulse. If you can hear this, you will have no doubt 
that the patient is pregnant and the child alive. 
Next examine by the vagina. (Before doing so 
wash your hands, and dip them, in the manner above 
described, in the sublimate solution.) Lubricate the 
fingers you use with the glycerine of sublimate. You 
will feel the child's hard round head filling the pelvic 
brim and bulging down into the pelvis. If this be 
not so, the child is either in a wrong position or the 
pelvis is deformed, and assistance is likely to be re- 
quired, and therefore aid should be sent for. Also 
if you are in doubt as to whether the patient be 
pregnant or not, further advice should be sought. 
The next question is whether the patient is 
in labour.-She is not likely to have sent unless 
she was feeling some pain, and the question is 
whether the pain she has is the pain of labour-that 
is, of uterine contractions-or whether due to some 
other cause. Pains which are not due to labour are 
called false pains, and their most common cause is 
the presence of wind ox* irritating matters in the 
bowels. You may form some opinion as to the 
nature of the pains by questioning the patient. 70 
Midwifery. 
[Chap. IV. 
(1) The pains of labour come on at tolerably 
regular intervals, while pains clue to disorder of the 
bowels come on without any regularity. 
(2) Each labour pain is like those that have gone 
before, and is gradual in onset and gradual in 
passing off, and is felt round the lower part of the 
stomach and back. The pains of bowel disturbance 
vary very much in severity and duration, one attack 
of pain from this cause not being always like the other 
pains which the patient has felt. They are not 
always felt in the same part of the belly; and they 
are not usually felt in the back. 
From these features of the pain you may make 
a rough guess as to its nature; but you cannot 
make sure without examining the patient. The pains 
of labour are due to contractions of the womb. There- 
fore, if the pains which the patient has are of this 
nature, your hands on the abdomen will feel that 
during the pain the womb gets harder, rounder, and 
somewhat smaller, and projects forward more. Each 
contraction of the womb that takes place during the 
first stage of labour forces the bag of membranes into 
the os uteri, and this puts the os uteri on the stretch. 
Therefore, by the vagina you will feel that during 
each pain the bag of membranes bulges at the os 
uteri, and the rim of the os gets tight and tense. 
Pains which are not those of labour are not accom- 
panied with these signs : with them there is no hard- 
ening of the uterus, bulging of the membranes, or 
stretching of the os. 
Having ascertained that the patient is in labour, 
the next thing is to make sure that everything is 
normal : the child's head of natural size, and the child 
in a favourable position; the mother's pelvis of 
normal size, and the soft parts healthy. Anything 
abnormal in these respects should be found out as 
early as possible. Chap. IV.] 
Management of Labour. 
71 
If you are in doubt as to any of these points, seek 
further advice. 
Management of the first stage of labour. 
-The great points in tjie management of the first 
stage of labour are to keep the membranes unruptured, 
and to maintain the patient's strength. Restrain the 
patient from bearing down. Tell her that the labour 
is oidy beginning, and that to try and help it by 
straining is at this stage useless. Let as much 
nourishment be given as she will take, and as to 
kind, any for which she has appetite, but no 
stimulants. Patients usually have not much inclina- 
tion for large meals while labour is in progress, and 
prefer the light diet commonly known as " slops "; 
but if a patient wishes for something more substan- 
tial, there is no reason why it should be forbidden; 
she should, however, be warned that it may make her 
sick. There is no need at this stage for confining the 
patient to any one position ; she may walk, sit, lie, or 
stand, just as she feels inclined. If she have any desire 
to go to sleep, she should be advised to try and do so. 
Having once ascertained that everything is right, 
examine no oftener than is absolutely necessary 
during the first stage. If by the time the os uteri has 
become dilated to four-fifths of its full size, the mem- 
branes are still unruptured, rupture them by scratch- 
ing through them with the finger-nail. 
In the second stage of labour.-During 
this stage the chief business of the attendant is to see 
that the labour goes on with speed proportionate to 
the number and strength of the pains. With strong 
and frequent pains the head ought to advance quickly, 
and the second stage be over in a couple of hours. If 
it does not, there is probably mechanical obstruction, 
and assistance should be sought. If the pains are 
weak and infrequent, delay is to be expected. If the 
patient be very tired, the pains may cease-that is, 72 
Midwifery. 
[Chap. IV. 
secondary uterine inertia may come on. The treat- 
ment of this condition is, to let the patient sleep. When 
she wakes she will be refreshed, and pains will return. 
The head should advance with each pain, and recede 
in the intervals of pain. If it does not-if it sticks 
fast, neither advancing nor receding--it is said to be 
impacted, and when this is the case assistance is 
urgently necessary. In a natural state of things, 
with a pelvis not undersized, and a head not larger 
than usual, no obstacle to delivery is offered by 
the pelvic bones; and the second stage of labour is 
simply the time occupied by the stretching of the soft 
parts which form the posterior part of the pelvic floor. 
Prevention of injury to perineum.-The 
part most stretched is the perineum. This structure 
is in first labours generally torn a little; and it is 
part of the attendant's duty to do all that can be done 
to prevent the perineum from being torn extensively. 
The way to do this is to press on the head so as 
to prevent it from coming out too fast and so 
stretching the perineum too quickly. A great 
tear of the perineum is likely to be produced 
if a large head comes out quickly. It used to be 
recommended to press on the perineum to " support " 
it. This is quite useless. Suppose anyone with a 
sleeve so tight that the arm cannot be bent without 
tearing the sleeve over the elbow. Would the tearing 
of the sleeve be prevented by pressing on it over the 
elbow? It has also been advised to press the sides of 
the perineum towards the centre. Try to do this, and 
you will find that the skin of the perineum is so 
slippery that it is quite impossible. The perineum is 
torn when there is a big head which comes out too 
quickly, or when the shoulders come out too quickly. 
You cannot alter the size of the head or of the 
shoulders, but you can take care by pressing back the 
advancing part, if necessary, that it does not come Chap. IV ] 
Separation of Child. 
73 
out so quickly as not to give the perineum time to 
stretch. Do not try to pull the shoulders out in the 
absence of a pain. 
The separation of tlie child is your next 
duty. There should be ready two ligatures, each 
composed of about half-a-dozen pieces of thread about 
a foot long, knotted together at each end. When the 
child is born, you will feel the cord pulsating through- 
out its whole length. If you wait a few minutes, the 
pulsation in the cord will gradually lessen in vigour, 
and the cord will get collapsed and flabby ; this change 
beginning at the part farthest away from the child. 
This flabbiness of the cord is due to some of the blood 
that was in it and in the placenta being sucked into 
the child by the movements of breathing, which 
expand the lungs, so that blood is required to fill 
them. The cord should not be tied until this change 
in it has taken place ; because if it is tied too soon 
the blood which ought to have been drawn into the 
child is lost to it, remaining in the placenta and cord, 
and the child is so much the weaker for its loss. 
When the cord is thus empty of blood, it should be 
tied with one of the ligatures placed about two inches 
from the umbilicus. If the ligature is too thin, it 
will cut through the cord ; if too thick, it cannot be 
pulled tight enough. The other ligature should be 
put about two inches farther from the umbilicus. If 
there be not another child, no harm will result from 
not applying this second ligature; but without it, 
more blood will spurt over the child when the cord is 
cut, so that it is cleanlier to tie it. When tied, the 
cord is cut between the two ligatures. Hold the cord 
while cutting it between the fingers of the left hand, 
with the knuckles turned to the child's abdomen, so 
that the cutting is done in the hollow of the hand, 
and thus nothing else but the cord can be cut. Take 
care that the cord is not dragged upon. The cut end 74 
Midwifery. 
[Chap. IV. 
of the cord should then be wiped, to see that no oozing 
takes place. If there is oozing the ligature is not 
firm, and another one must be put on. 
While waiting for the pulsation in the cord to 
cease, carefully wipe the child's eyes, mouth, throat, 
and nose with a clean napkin. 
Management of the third stage of labour. 
-This is one of the most important parts of your 
duty. The great danger of the third stage of labour 
is hjemorrhage. When this occurs, it so quickly puts 
the patient's life in danger that if the attendant can- 
not stop it the patient will die before a doctor can be 
got. Therefore, no one is fit to undertake the 
management of labour who does not know how to 
prevent and stop hsemorrhage in the third stage of 
labour. 
The duty you have to perform may be divided 
into three parts. 
First-to observe the expulsion of the placenta 
from the uterus into the vagina, and see that it 
takes place properly, and is not accompanied with too 
much bleeding. 
Second-to deliver the placenta and membranes. 
Third-to see that the uterus is properly retracted 
and contracted after the placenta and membranes 
have been delivered. 
First.-Immediately after the child is born, and the 
navel-string tied and cut, let the child, wrapped in 
the flannel receiver, belaid in a safe place near the fire, 
and put your hand on the mother's abdomen. You will 
(unless it be a case of twins) feel the uterus nearly as 
large as an adult head. It may be somewhat soft and 
doughy, or it may be firm and hard, according to 
whether a contraction is present or not; but it should 
be quite well defined. If soft when you first put 
your hand on it, you will soon feel it contract, and 
get harder and smaller. Keep your hand on it so as chap, iv.j 
Management of Third Stage. 
75 
to be sure that proper contraction is present. If the 
uterus gets large, flabby, loose, and shapeless, there 
is haemorrhage. But if the womb maintains its proper 
size and shape, contractions will follow one another, 
and will expel the placenta into the vagina; as 
the placenta passes out you will feel the uterus 
gradually getting smaller and smaller, until it is no 
bigger than a fcetal head. Do not try to interfere 
with or hasten this process. All you have to do is to 
feel that it is going on properly. It takes from 
fifteen to thirty minutes for the uterus, with three 
or four pains, to expel the placenta into the vagina. 
If at the end of half-an-hour the uterus feels still so 
large that you think the placenta is still inside it, 
examine by the vagina, and follow up the cord, and 
see if the placenta is still within the womb. If it is, 
and there is not much haemorrhage, wait half-an-hour 
more. If there be haemorrhage, or if after an hour 
the placenta is still in the uterus, send for aid. But 
if the case goes on properly, at the end of fifteen or 
thirty minutes the uterus will be firmly contracted, 
and not bigger than a foetal head. When the uterus 
feels as small as this, you will know the placenta has 
been expelled into the vagina. 
Second.-Now put your hand on the uterus, and 
press firmly downwards and backwards (Fig. 47). By 
this means you will press the placenta out of the 
vagina; you will see it emerge with the foetal surface 
first, the membranes following it. When it is outside 
the vulva, take it, and very gently turn it round and 
round, so as to twist the membranes as it were into a 
rope. This will help to prevent a piece of membrane 
from being broken off and retained. When the mem- 
branes are free, the placenta and membranes are re- 
ceived in a bowl or other utensil; it is customary 
afterwards to burn them. 
Third.-Lastly, having delivered the placenta and 76 
Midwifery. 
[Chap. IV. 
membranes, put your hand again on the abdomen. 
The uterus should be retracted, that is, no bigger than 
a foetal head, firm, and perfectly distinct and definite 
in shape; every now and then it hardens when a con- 
traction comes on. Keep your hand on the abdomen 
for about ten minutes, to see that this state of things 
Fig. 47.-Showing Mode of Expulsion of Placenta. 
persists; for if the uterus is properly retracted, there 
will be no haemorrhage. Also count the pulse. It 
ought to be slow, not over seventy beats per minute. 
If it be over 100, there is danger of haemorrhage, 
and need-for very careful watching of the patient. 
But if the pulse be slow, and the uterus retracted, 
the labour may be considered over. 
Objections to too early squeezing out of 
placenta.-It is bad practice to try and squeeze out 
the placenta too soon ; first, because, if you try to press 
out the placenta before it is fully expelled into the Chap. iv.| 
Attention after Delivery. 
77 
vagina, you will have to press and knead the abdomen 
a great deal more, which will cause the patient 
unnecessary pain ; and secondly, because in this manner 
the placenta may be squeezed out before the mem- 
branes are properly separated from the uterus, and a 
piece of membrane may be broken off and retained in 
the womb, and cause haemorrhage. 
Examination of placenta.-To be addition- 
ally sure that the placenta and membranes have 
completely come away, examine the placenta by 
putting it in a basin of water, with the uterine 
surface uppermost. This will float out the placental 
tufts, and you will at once see the gap if the placenta 
has been broken. Examine also the membranes; 
strip the chorion off the amnion, and thus be certain 
that the two membranes are present. 
Antiseptic douche. - When everything is 
finished, the placenta and membranes removed, the 
pulse quiet, the womb well retracted, give a vaginal 
douche of a quart of a 1 in 2,000 solution of corrosive 
sublimate, at the temperature of between 100° and 105°. 
The most important antiseptic precautions are those 
which you should take about your own hands, and 
the things you use : next to these comes the douche 
immediately after labour. After giving the douche, 
turn the patient on her back, and by pressing on the 
abdomen, press out any fluid that may be retained in 
the vagina. This is very important, because if several 
tablespoonfuls of the solution are left in the vagina, 
they may be absorbed, and may poison the patient. 
Attention to patient's comfort.-When you 
have given the douche, and again satisfied yourself 
that proper retraction of the uterus is present, the 
next thing is to make the patient dry and comfortable. 
Take the bottom of the soap dish, a bowl, or asaucer, and 
scoop up the fluid and clots from the hollow in which 
the patient lies, and empty it into the utensil. The 78 
Midwifery. 
[Chap. IV. 
garments which have been soiled during delivery- 
should be removed. Then, with a clean napkin dipped 
in warm water, the buttocks and thighs of the patient 
should be made quite clean. A. clean warm napkin or 
pad of absorbent wool should be put to the vulva, and 
the patient moved over towards the opposite side of the 
bed, where the sheet is dry. Now the soiled sheet, 
with the mackintosh 
under it, should be with- 
drawn. If the patient 
has been confined in her 
every-day clothes, a clean 
dry night-dress should 
presently be put on by the 
nurse. 
The hinder.-It is 
customary at or before 
this time to apply the 
binder. This is a broad 
firm bandage put round 
the patient's abdomen. It 
is valuable for the feel- 
ing of warmth and sup- 
port which it gives the 
patient, and most women 
like to have it for this 
reason. But it is not beneficial in any other way, 
and, therefore, if the patient does not like it, there 
is no need for pressing her to submit to it. Some 
women like to have their waist measurement kept 
small, and there are some few who follow employ- 
ments in which it is really important to them to keep 
their waists as slender as possible. With an 
ordinary binder one cannot produce any effect of this 
kind. To do this, the patient must have a specially 
constructed binder, such as are sold by surgical 
instrument makers, provided with straps and buckles 
Fig. 48.-Surgical Instrument 
Maker's Binder. Chap. IV.] 
The Binder. 
79 
by which it can be pulled as tight as the patient can 
bear (Fig. 48). Such compression is injurious, and 
the medical attendant ought to advise against it. The 
enlargement of the waist which takes place in most 
women who have had many children is due to fat, 
not to any change which a binder can prevent. The 
ordinary binder is best made of strong huckaback 
towelling, a yard wide, and a yard and a quarter 
long, doubled lengthways. In putting it on, its lower 
edge should reach four inches below the top of the 
thigh bone (the great trochanter). The free end of 
the binder should lie uppermost on the right side. 
Starting from the left Hank, the binder should pass 
over the abdomen, round the back, and again over the 
abdomen, ending on the right flank, where, after it 
has been tightened, and all creases smoothed out, it 
should be securely fastened by four strong pins. The 
patient's skin should be guarded by the left hand 
beneath, and the pins inserted in the following order, 
beginning from below:-One at the lower edge of the 
binder, three inches below the top of the thigh bone, 
and a second a similar distance below the top of the 
hip-bone, both fastening the binder tightly, serving to 
keep it in position, and preventing it from riding up. 
The third should hold the binder still more firmly on 
a level with the top of the womb; and the series is 
completed by a fourth applied near the upper edge of 
the binder, not too tightly. Straight pins, two inches 
long, or safety pins may be employed. 80 
CHAPTER V. 
DIAGNOSIS. 
You should take every opportunity of practising 
yourself in making out the position of the child by 
feeling it through the abdomen. This is at first 
difficult, but with practice becomes, in most cases, 
easy ; and it is very useful. 
What to ascertain.-By external examination 
you can make out the position of the child ; you 
can feel its head, back, breech, and limbs. You can 
tell whether it is large or small ; and from this you 
can judge whether the patient has gone to full term 
or not. You can also tell whether the head has 
descended into the pelvis, or whether it is still so high 
up that its largest measurement is above the brim. 
Tins is a most important point in forecasting the 
difficulty of labour. By noticing it you can suspect 
the existence of pelvic deformity or of excessive size of 
the child's headlong before any sign of obstructed labour 
has developed. There is scarcely anything in mid- 
wifery that will better repay you for the trouble 
taken in acquiring it than skill in the external method 
of examination. 
Method of examination.-The patient should 
lie upon her back, with a pillow under her head. Her 
stays should have been taken off, and the waistbands 
of her garments loosened and lowered, so that her 
abdomen may be quite uncovered. Her legs should 
be a little drawn up, and the knees slightly separated 
(Fig. 49). 
Then put your hands upon the abdomen, one on 
each side, to find out whether the uterus is contracted 
or not. If it be contracted it will feel rounded and Chap. V.] 
ABDOMINAL ExAMINA TION. 
81 
hard, and you must wait two or three minutes, until 
the contraction has passed off. When the uterus has 
relaxed, then go on with the examination. Put one 
Fig. 49.-Method of Abdominal Palpation. 
Land on each side, quite low down. To make sure 
that your hands are in the right position, begin by 
feeling the crests of the iliac ' bones on each side, and 
the symphysis pubis in front. When you feel these 
points you will know where the brim of the pelvis 
lies. Then press the tips of the fingers on each side 82 
Midwifery. 
[Chap. V. 
well down into the pelvic brim, and towards one 
another. In nineteen cases out of twenty you will 
feel between them a large, hard, rounded body, which 
fills the pelvic brim. This is the fcetal head. Its 
size, its hardness, and its roundness are its dis- 
tinguishing marks. The breech is nearly as large, but 
it is not so hard, and not so round. If the head is 
low down in the pelvis, it is pretty certain not only 
that the case is one of head, but that it is one of 
vertex presentation; for when the head presents in 
any other position, it does not usually descend low 
into the pelvis early in labour. You may also infer 
that the pelvis is large enough. 
Continuing the examination, feel the head all 
round with your fingers; and if you are dexterous 
you will find that while on one side there is no 
distinct projection marking off the head from the 
parts above, on the other side the hard mass of the 
head projects, and prevents you from pressing your 
fingers down into the brim. This projecting part is 
probably the forehead, and the smoother side along 
which you can most easily press the fingers into the 
brim is the occiput. 
Now proceed to confirm or correct this opinion by 
examining other parts of the abdominal swelling. At 
the top of the uterus, if the head be in the pelvic 
brim, will be felt the breech. It is nearly as large as 
the head, but less regularly rounded, and not so hard. 
Near it will be some small, hard, movable knobs . 
these are the feet. If the legs should be extended, 
these will not be felt near the breech ; and if the back 
be turned forward, so that the feet are behind, this 
may prevent you from feeling them. Having thus 
identified the two extremities of the foetus, the next 
thing is to find out which way its back is turned. On 
the side to which the back lies there will be felt a 
continuous smooth resisting surface, extending from Chap. V.] 
A BDOMINA L Ex A MINA TION. 
83 
the breech to the occiput of the child. This is not so 
easily felt as the head or the breech, because it is 
more yielding, and may be separated by liquor amnii 
from the wall of the uterus. If it cannot be made 
out by steady pressure, then by sudden but gentle 
pressure with the tips of the fingers try to displace 
the liquor amnii, and so come upon the parts of the 
child beneath. Having ascertained to which side the 
back is turned, then try and identify the abdomen on 
the opposite side. Here the fingers come upon no 
firm resisting surface, but feel instead small hard 
knobs, which can be moved ; these are the limbs of the 
foetus. If the child's back be turned forwards you 
may not be able to feel the limbs. In the first 
position, which is that in which three children out 
of four lie, the back is turned to the front and the 
left side; and the limbs, or some of them, may be felt 
behind and to the right. If you put your stetho- 
scope to the abdomen, you will hear the foetal 
heart more loudly on the side to which the back is 
turned. 
These things cannot be felt with equal ease in all 
patients. In a fat or a nervous woman, who strains 
very much, it may be difficult to feel the parts of the 
child, and so it will if there be a great deal of liquor 
amnii. But the more you practise this, the easier it 
will become, and you will, after a time, get so 
accustomed to the feel of the parts when the child is 
lying properly, that you will quickly recognise when 
the child is in a wrong position. It is of great value 
to be able to detect early that the presentation 
is not normal, even if you should not be able at once 
to find out what the position of the child really is. 
In a transverse presentation, when you try 
to press your fingers down into the pelvic brim you 
will find one end of the foetal ovoid, viz. the head, 
lying in one iliac fossa, while the opposite end will 84 
JZ/zw/zTr/c f. 
[Chap. V. 
be liigli up on the other side of the abdomen. 
You will identify the head by its size, its hard- 
ness, and its roundness. Do not think that the 
presentation cannot be transverse because the uterus 
looks as if it were the natural shape ; for, 
although before labour the child may have been 
lying quite across the abdomen, yet, when uterine 
contractions become strong, the contracting uterus 
so presses the child towards the middle line that 
the uterus becomes almost natural in shape. But, 
on careful palpation, after the contraction has passed 
off, it will be found that the position of the child 
is not what it should be. 
In breech presentations the head is at the 
fundus uteri. In these cases, for reasons elsewhere 
explained, if the patient be examined early, the pre- 
senting part will often be found not to have sunk into 
the pelvic brim, but to be lying above it, and often 
rather to one side. The parts are identified by the 
same characters as they present when the child is in 
a normal position : viz. the head by its large size, 
roundness, and hardness; the back by the large 
smooth convex surface which it presents; the 
abdominal surface by the small knobs formed by the 
limbs. If you have by practice become dexterous in 
recognising by the hands these three points-the 
head, the back, and the abdomen of the child-you 
will easily make out, not only whether the head or 
the breech is presenting, but also in which position 
the child is lying : whether the occiput is behind or in 
front, to the right or to the left. 
It is possible by feeling the abdomen to distinguish 
a face presentation. If the face be presenting, 
the head will be felt lying above or in the brim of the 
pelvis. On carefully feeling the head all round, it 
will be found that, as in vertex presentations, one 
side of the head projects more, and is marked off Chap. V.] 
Paginal Examination. 
85 
from the body by a deeper and sharper hollow than 
the other. If the face be presenting, this groove or 
hollow is deeper, and more distinct than usual, and is 
situated on the side to which the back of the foetus is 
turned, instead of the abdominal surface, as in vertex 
presentations. 
Having formed the best opinion you can by 
external examination, proceed to make your opinion 
still more accurate by internal examination, and by 
combined internal and external examination. 
Internal examination is made by the vagina. 
It may be made either with the patient on her back 
or lying on one side. The clearest idea of the position 
of the head is gained by examining with the patient 
on her back, and the combined examination can be 
made better in this position than in any other. The 
only objection to it is that in Great Britain it is 
unusual, and therefore the patient may not like it. 
The usual position is for the patient to be on her left 
side. In some few cases, which will be afterwards 
mentioned, it is better for the patient to lie on her 
right side. 
The examination is made by putting two fingers 
into the vagina. One finger alone will not always 
reach high enough. Accustom yourself to examine 
with either hand. With the patient on her left side, 
and lying across the bed, the left hand is the better, 
because then the front of the finger-tips come against 
the presenting part. If the patient be on her back, or 
lying with her head towards the head of the bed, 
instead of across it, the use of the right hand is more 
convenient. Before examining, the fingers should be 
lubricated by dipping them in the 1 in 1,000 solution 
of corrosive sublimate in glycerine. 
The first thing to be found out by internal examina- 
tion is the state of the vagina. It ought to be 
soft, not tender, not hot, bathed with plenty of 86 
Midwifery. 
[Chap. V. 
mucous secretion, and capacious. If it be tender, 
not soft and slippery, and not well moistened by 
secretions, it is a bad sign ; and if it be contracted, 
or there be any swelling projecting into it, and 
narrowing it or blocking it up, assistance should be 
sought. 
The next thing is the state of the os uteri. If 
the labour have come on prematurely the cervical 
canal may not yet have been completely opened up. 
Then your finger will enter the canal of the cervix, 
with the external os at the lowest part, the internal 
os above. Later on you will feel the external os only 
as a round hole, with a thin soft rim through which 
the bag of membranes protrudes in the shape of a 
watch-glass (Fig. 50). The margin of the os should be 
stretched and tense during each pain, but soft and loose 
between the pains. If it be hard and thick, it is a bad 
sign. After it has become dilated to the size of a 
shilling or more, its margin should be smooth and 
uniform in thickness and hardness all the way round. 
If there is a lump at one part, or a part of greater 
hardness than the rest, oi' if it feels ragged and 
uneven, assistance should be sent for. 
The size of the os uteri shows the degree to which 
the first stage of labour has advanced. If the cervical 
canal has not been opened up, you may leave the 
patient for three or four hours at a time. In a first 
labour you may do so if the os uteri is not larger than a 
crown piece. When it has reached this size, or, in a 
woman who has had children before, when the os 
uteri has become dilated to the size of a shilling, you 
should not go far away. Judge of the rapidity with 
which labour is likely to be over by the frequency of the 
pains and their strength, and the depth to which the 
head has engaged in the pelvic brim. Estimate their 
strength by the degree to which the os uteri is made 
tense and the bag of membranes made to protrude, and Chap. V.] 
VA GINA L EXA MINA TION. 
87 
by the length of time that the tension and protrusion 
last. But there are so many circumstances that may 
influence the duration of labour that it is imprudent 
to commit yourself to any statement as to when the 
child is likely to be born. Form your own opinion ; 
Fig'. 50.-The Membranes bulging at the Os Uteri. 
but to the patient and her friends merely say that 
everything is going on well, but that you cannot tell 
when the labour will be over. 
Having ascertained that the vagina and cervix uteri 
are healthy, next verify the impression you gained 
from the abdominal examination, as to the position 
of the child. 
If tiie head he presenting- you will not only 
more clearly appreciate its hardness and roundness, 88 
Midwifery. 
[Chap. V. 
but with the finger introduced in the interval between 
two pains into the os uteri you will feel what 
distinguishes the head from every other part of the 
body : viz. the sutures and fontanelles. Do not try 
and feel sutures or fontanelles during a pain, lest you 
should rupture the membranes by pressing on them 
while they are tense. During labour the bones are so 
Fig. 51.-First Vertex Position. (After Farabeuf.) 
pressed together that the posterior fontanelle is not to 
be felt as an open space, but as a spot at which three 
sutures meet; and the anterior is much smaller than it 
is after the child is born. Running from the spot at 
which three sutures meet to that at which four sutures 
meet is the sagittal suture. By feeling these lines 
you can make sure of the position of the head. The 
sagittal suture shows in which direction the length of 
the head lies: the meeting place of three sutures 
marks the back of the head, the anterior fontanelle 
the front. Make yourself quite sure by combining the 
two methods of examination. With the hand outside Chap. V.J 
Diagnosis of Positions. 
89 
feel the smooth resisting surface of the back on the side 
to which the fingers in the vagina tell you the occiput 
lies, and the little movable knobs formed by the 
limbs on the side to which the forehead looks. The 
projection felt at the lower part of the abdomen, 
which you take to be the face and chin of the child, 
you will know to be such by pressing on it while the 
Fig. 52.-Second Vertex Position. (After Farabeuf) 
finger in the vagina is in contact with the occiput, 
and noticing that each pressure imparted to it at once 
produces movement of the occiput. Then make your- 
self quite certain of the position of the child. ■ In the 
first position (Fig. 51)-the commonest-you will find 
the meeting place of three sutures forwards and to 
the left, that of four behind and to the right, and the 
sagittal suture joining them running obliquely from 
the front and the left to the back and the right. In 
the second position the posterior fontanelle is forwards 
and to the right, the anterior behind and to the left 
(Fig. 52). In the third position the posterior fontanelle 90 
Midwifery. 
[Chap. V. 
Fig. 53.-Third Vertex Position. (After Farabeuf.) 
is behind and to the right, the anterior forwards and 
to the left (Fig. 53). In the fourth position the pos- 
terior fontanelle is behind and to the left, the anterior 
forwards and to the right (Fig. 54). 
Fig. 54.-Fourth Vertex Position. (After Farabeuf.) Chap. V.] 
Diagnosis of Face. 
91 
It is very important to make out the position of 
the child as early as possible : because, before the 
membranes are ruptured, and the head engaged in the 
pelvis, it is quite easy to change an unfavourable 
position into a favourable one. If the back of the 
child be behind, it is quite easy with the hands on the 
Fig. 55.-First Face Position. (After Farabeuf.) 
abdomen to push it round, and make the occiput come 
to the front. 
If the face be presenting', the examining 
finger, instead of meeting the round smooth vault of 
the skull, intersected by its sutures, will feel the 
projections and hollows formed by the features : the 
nose, eyes, and mouth. Of these, the one most easily 
identified is the mouth. Put your finger in the 
mouth, and feel the gums and tongue ; nothing like 
these is felt in any other part of the body. If you 
think the face may be presenting, you should be very 
careful how you examine ; for by roughly pushing or 92 
Midwifery. 
[Chap. V. 
scratching with the finger injury may be done to the 
child's eyes. On examining with the two hands 
together, the abdominal hand will feel the round 
projection of the occiput on the side opposite to that 
to which the chin points, and above this will be a 
recess, owing to the spine being carried forwards in 
Fig. 56.-Second Face Position, (After Farabeuf.) 
consequence of the extreme extension of the head. 
On the opposite side the limbs will be felt more easily 
than usual, for the same reason; and the child's heart 
will be heard best on the side to which its chest is 
turned, instead of over its back as usual. Having 
ascertained that the presentation is of the face, note 
its position. In the first position the chin is behind 
and to the right, the forehead forwards and to the 
left (Fig. 55). In the second position the chin is be- 
hind and to the left, the forehead forwards and to the 
right (Fig. 56). These two positions are the un- 
favourable ones, for in them, if the child be of full 
size, it cannot be born unless its position changes. Chap. V.] 
Diagnosis of Face. 
93 
In the third position the chin is forward and to the 
left, the forehead behind and to the right (Fig. 57). 
In the fourth position the chin is forwards and to 
the right, the forehead behind and to the left (Fig. 
58). These positions are favourable : in them the 
danger either to mother or child is not much more 
than in an ordinary vertex presentation. When 
Fig. 57.-Third Face Position. (After Farabeuf.) 
cases of face presentations in the first or second 
position terminate favourably they do so by changing 
into third or fourth positions. Therefore, if, before 
the membranes have ruptured, you are able to make 
sure that the face is presenting with the chin behind 
and the occiput in front, it is in some cases a good 
practice to turn the child round by pressure on the 
occiput through the abdominal walls, so as to get the 
occiput behind. But do not attempt this without the 
sanction of your superior officer. 
The breech does not form quite so large a 
tumour as the head, and it is not so hard. When 94 
Midwifery. 
[Chap. V. 
you examine by the vagina you can feel no sutures 
or fontanelles, but you can feel the deep cleft 
of the nates dividing the presenting part into two 
portions. At one end of this cleft you can feel the 
genital organs of the child, and at the other end the 
point of the sacrum. In front of this is the anus, 
which the finger may possibly enter, and so become 
Fig. 58.-Fourth Face Position. (4/fer Farabeuf.) 
stained with meconium. The anus can scarcely be 
mistaken for the mouth, because there is nothing 
about it that feels in the least like the gums. The 
parts on each side of the cleft are exactly like one 
another, which distinguishes it from the recess between 
the ribs and arm leading up to the armpit, in which 
the arm is felt on one side, and the ribs on the other. 
The position of the child will be made out by 
noticing, with the finger in the vagina, which way the 
sacrum looks ; and finding this, confirm the impression 
gained by external examination as to the direction of 
the child's back. In the first position the back is Chap. V.] 
Di a gnosis of Limbs. 
95 
forward and to the left; in the second, forward and 
to the right; in the third, behind and to the right; 
and in the fourth, behind and to the left. 
If one of the limbs is felt presenting, care is 
needed to distinguish an elbow from a knee. The 
elbow presents a point with a hollow on each side of 
it. The knee, when bent, presents a depression in 
the middle, with a bony prominence on each side. 
The foot has to be distinguished from the hand. To 
do this, remember that the great toe is on a line with 
the other and parallel to them, and that the 
heel projects beyond the line of the leg. In the 
hand the thumb opposes the fingers, or if extended 
is not parallel to them; and there is no part of the 
hand which projects like the heel. 96 
CHAPTER VI. 
MANAGEMENT OF BREECH AND FOOTLING CASES. 
Labour with the breech or lower limbs presenting is 
not more dangerous to the mother than when the 
head presents, but is more dangerous to the child. 
The danger to (lie cStild is from the cord being 
compressed between the head and the pelvis. Hence, 
to save the child, the head must be delivered quickly. 
This cannot be done unless the passages are well dilated. 
Therefore the essential point in the management of 
breech or footling cases is not to hurry the delivery 
of the child until the body is born; for we shall thus 
get the soft parts more thoroughly dilated. The cord 
can scarcely be injuriously pressed on so long as the 
membranes are unruptured. For this reason, and 
also because the bag of membranes dilates the 
passages better than anything else, try in a pelvic 
presentation to keep the membranes unruptured as 
long as possible. Breech presentations are more 
favourable than footling, because the pelvic end of the 
child takes up more room when the legs are doubled 
up by the breech, and therefore when the legs are in 
this position the soft parts are better dilated. 
When the breech and legs are born you will be 
able to feel the umbilical cord. Trace it up into the 
womb, and if it pass up opposite the sacral pro- 
montory (where it will be exposed to strong pressure 
by the head), push it towards one side, opposite a 
sacro iliac synchondrosis, where it will be less pressed 
on. If you have not hurried the birth of the breech 
and legs, the arms will probably be crossed in front 
of the chest. Put a finger in the elbow, and thus 
bring each arm down. chap, vi.] 
Delivery of After-coming Head. 
97 
Now deliver the head as quickly as possible. 
If everything be normal, and you have not pulled 
upon the body, the head will have entered the 
pelvis in a flexed position, and with the face back- 
wards. If during the birth of the trunk the abdomen 
Fig. 59.-Showing one Mode of Delivering the after-coming Head. 
(From Galabin.) 
was anterior, the head will have rotated as it de- 
scended so as to bring the face backwards. If then 
you can feel the chin low down, carry the body of the 
child with the right hand high up towards the 
mother's abdomen, and put the left hand on the 
uterus. By rubbing and pressing over the uterus, 98 
Midwifery. 
[Chap. vi. 
stimulate it to contraction, and help it to press out 
the child's head. Then during a uterine contraction 
draw the child's body forwards. This will bend the 
head. The chin will emerge over the perineum, and 
the mouth, nose, and eyes will successively appear. 
Get anyone in the room who can assist you to press 
on the uterus, and put a finger of your left hand on 
each shoulder of the child (Fig. 59). Judge of the 
necessity for speed in doing this by the state of the cord. 
If the cord be pulsating at the normal rate the child 
is living, and the need for immediate delivery not very 
urgent ; but if the cord be pulsating slowly and irregu- 
larly, then, unless the child is quickly delivered, it 
will die. 
Bringing down the arms.-Sometimes the 
arms are extended up by the sides of the head. If 
this be so, you will have to bring them down ; and this 
is sometimes a most difficult task. Pass up the hand 
corresponding to the arm that you are going to bring 
down along the side of the child rather on the dorsal 
than on the abdominal aspect, until you can feel the 
child's elbow with your finger-tips. Then place your 
fore and middle fingers one on each side of the child's 
humerus, so that they may protect it like a splint; 
and with the tip of one finger in the bend of the 
elbow joint, move the elbow down across the child's 
face (Fig. 60). 
You must not try and get the arm down by 
pressing on a part of it higher than the elbow; if you 
do this, you will very likely break the arm. It is 
better to try first to get the posterior arm, because 
there is more room for your hand in the hollow of the 
sacrum. But if you cannot manage to get down the 
posterior arm, try the anterior. It is not very im- 
portant which you take first. 
Arrest of head above brim.-In some cases, 
when the pelvis is contracted or the head very large, chap, vi.] 
Arrest of Head above Brim. 
99 
the head does not enter the pelvis, but remains 
arrested at the brim. When the head stops in this 
situation it is no use carrying the child's body 
forwards. You must then put two fingers of one 
hand on the child's shoulders, and a finger of the other 
Fig. 60.-Showing how to bring clown the Arms when they are up hy 
the sides of the Head. {After Farabeuf.) 
hand in the child's mouth. With this hold pull down- 
wards and backwards during a uterine contraction, 
till the head has passed the brim; at the same time 
getting an assistant to press on the uterus, in a direc- 
tion downwards and backwards, through the abdominal 
wall. If you cannot succeed in this, send for aid. 100 
CHAPTER VII. 
DELAY IN LABOUR. 
Labour may be prolonged from 
(1) Premature rupture of the membranes. 
(2) Deficient power in the uterus; or from 
(3) Obstruction, which may arise from wrong 
position of the child, excessive size of the child or 
some part of it, contraction of the pelvis, disease of 
the soft parts. It is most important to distinguish 
between a uterus powerless in itself, and one which 
appears powerless because it cannot overcome an 
obstruction. The first two causes are those which 
most commonly occasion delay in the first stage. 
The effect of premature rupture of the membranes 
has already been described. (See chapter ii.) 
The cause of delay in the first stage of labour may 
be in the cervix itself. This is rare. 
Rigidity of the cervix may delay the first 
stage of labour. The most common cause of rigidity 
of the cervix is premature rupture of the membranes ; 
but it may come from other causes. It has been 
explained that in the last few days of pregnancy 
the internal os becomes gradually opened up, and 
the cavity of the cervix made one with the general 
uterine cavity, without the patient feeling pain. 
This is the preparatory stage of labour. Now, if from 
any cause pregnancy is terminated prematurely, 
labour may come on before this preparatory stage has 
been completed, or even begun. If this be so, of 
course the first stage of labour will be long, on 
account of the zcnprejiared condition of the cervix. 
A slow first stage of labour from this cause is natural 
in premature labour. Chap. VII.] 
Rigidity of Cervix. 
101 
The cervix may be diseased. It may be affected 
with cancer, or it may have been at some former 
time ulcerated or otherwise damaged, and the damage 
may have left behind it a great deal of scar-tissue, 
which is hard, fibrous, and stretches badly, or there 
may be a tumour in it. Any one acquainted with 
the natural feel of the parts ought without much 
difficulty to recognise that something is wrong. The 
cervix does not feel everywhere soft, smooth, and even, 
as it ought to do. If you think that the cervix is 
unhealthy, send for assistance. Cases of this sort are 
very uncommon, and so this is a difficulty we seldom 
have to do with. 
Any obstruction may cause delay in the first 
stage of labour. If the pelvis is so contracted, or the 
head so large, that the head cannot come down into 
the pelvis, it cannot press into the os uteri as it ought 
to do, nor can the part which presents if the child be 
lying transversely. It does not fill up the circle of 
the os, and thus dam off the portion of the waters in 
front of it from the rest, as it should do. Hence the 
part of the bag of waters in advance is exposed to the 
full pressure of the uterus and weight of the waters, 
and in consequence the membranes bulge down much 
more than is usual in normal cases, forming early in 
labour a long process like the finger of a glove ; and 
they are very liable to break early. If they break 
early, the dilatation has to be finished by the contrac- 
tions of the longitudinal fibres of the uterus pulling 
up the cervix without the help of the usual stretching 
open of the cervix by the head. In such a case you 
will feel the cervix hanging down like a loose, thick, 
soft fringe below the presenting part: this being high 
up, not pressing into the cervix at all during the 
pains. 
If you have made a thorough examination of the 
abdomen at the beginning of labour, you will have 102 
MIDWIFERY. 
[Chap. VII. 
detected the wrong position of the child, or you will 
have found that the largest measurement of the head 
was high above the pelvic brim, and could not be 
pressed into it; and from these signs you should 
diagnose probable obstruction at the brim without 
waiting to see the ellect of the pains, and therefore 
send early for help. You may be able to reach the 
sacral promontory easily with the finger. From this 
sign you may infer that the pelvis is contracted, and 
if you think it is, send for aid without delay. 
Uterine inertia. - When the pains are not 
strong enough in a labour in which everything else is 
normal, the condition is called uterine inertia. 
In uterine inertia the pains come on at long 
intervals; when they do come they are short, they 
soon pass off, and they are weak. If you note with 
your finger the effect of the pains, you will find 
they do not make the rim of the os feel so tight 
and tense as strong pains ought to do, and the bag of 
membranes is not so powerfully forced into the os. 
If you put your hand on the abdomen, you will find 
that the uterus does not get as hard as it does with 
strong pains, and such hardness as there is lasts a very 
short time. 
Uterine inertia in the first stage of labour is not 
a condition which exhausts the mother. It is not 
accompanied with any serious symptoms. The patient 
is quite placid and comfortable between the pains ; 
she takes food well; her pulse is not over 100, 
often much under; her breathing is slow and easy. 
There are two kinds of uterine inertia-primary 
and secondary. 
Primary uterine inertia is that condition in 
which the pains are weak and few from the beginning 
of labour. 
Secondary uterine inertia occurs when the 
pains at the beginning of labour are strong, regular, Chap. VII.] 
Uterine Inertia. 
103 
and frequent, and then after the patient has been 
some hours in labour they get less and less frequent, 
and at the same time less powerful. This comes on 
when the patient has got tired. It is apt to come on 
when the patient, it may be from false pains or some 
other cause, has been sleeping badly, and so got very 
tired before labour began. 
Uterine inertia is never a source of danger so long 
as the membranes are unruptured. It is very seldom 
a source of danger even after the membranes are 
ruptured, or in the second stage of labour. But in 
the third stage of labour it is very dangerous. 
Treatment of uterine inertia.-In primary 
uterine inertia during the first stage of labour the 
only treatment is patience. The os dilates slowly • 
the patient may be fidgety and her friends anxious; 
but the dilatation will in time be completed, and so 
long as there is nothing but uterine inertia present 
there is no cause for alarm, and no need for inter- 
ference. The patient must be persuaded to take as 
much food and drink as she can without discomfort, 
but no stimulant; and she should be encouraged to 
lie down and sleep if she feels at all drowsy. It 
should be impressed upon her that everything is well, 
except that the labour is slow. 
In secondary uterine inertia the remedy is to get 
the patient to sleep. If the patient be let alone, she 
will probably go to sleep, and wake up refreshed, and 
the pains will return. This is Nature's cure. The 
best way of treating secondary uterine inertia is to 
imitate Nature. Give the patient a pill of one grain 
of opium, and if in half-an-hour she is not asleep, give 
her another. She will now probably sleep, and when 
she wakes up the pains will return with renewed 
vigour. 
The foregoing description applies to uterine 
inertia in cases otherwise perfectly norma]. But do 104 
Midwifery. 
[Chap. VII. 
not think that because a patient has uterine inertia 
therefore there cannot be anything else wrong. 
Many complications of labour which are dangerous in 
other ways are liable to cause uterine inertia. Do 
not conclude that uterine inertia is the sole cause 
of delay until you have made a most careful examina- 
tion. If you are in doubt, send for assistance. 
Relative weakness of pains.-The uterus 
may be relatively weak. That is, there may be 
regular and frequent pains, quite strong enough to 
quickly drive a child of average size through a normal 
pelvis, but in consequence of large size of the child or 
smallness of the pelvis, the resistance to the progress 
of the child may be greater than the uterus can over- 
come within the usual limit of time. If such a case 
be left unassisted, one of two events must happen. 
Either the child wtZZ at length be born, but only after 
a very long labour, greatly exhausting the mother and 
possibly seriously injuring both mother and child : or 
the child will not be born, and the state of things 
described in the next paragraph will gradually develop. 
Obstructed labour.-If, either from pelvic 
contraction, or from large size, or wrong position of 
the child, it cannot be born, and no help is given, the 
pains go on occurring with shorter and shorter 
intervals, until at length there is no interval at all, 
the pains merge into one another, and the uterus 
remains continuously contracted. This condition is 
called tonic contraction of the uterus. When this 
condition has come on, the patient is in great danger; 
every hour adds to the danger, and if help be not 
given she will die. The patient begins to look 
anxious. She is restless, is thirsty, and her tongue 
and lips look parched and brown. The pulse becomes 
quicker and smaller, and the longer the condition 
continues unrelieved the smaller the pulse gets. The 
breathing becomes hurried in proportion to the pulse. Chap. VJI.] 
.Rupture of Uterus. 
105 
This state of things may continue, getting worse and 
worse, until the patient dies undelivered, worn out by 
exhaustion. Tonic contraction of the uterus is rare 
in the first stage of labour. 
Rupture of the uterus.-But the case may 
end in a different way. The upper part of the 
uterus, which has to contract to expel the child, 
goes on getting smaller, and harder, and thicker. 
The lower part, which has to stretch to let the child 
pass, is pulled by the upper part higher and higher 
up, is more and more stretched, and gets thinner and 
thinner. The division between the two parts can be 
felt by external examination as a furrow running from 
side to side across the front of the uterus, and this 
furrow rises higher and higher as the upper part is 
more and more contracted and the lower part more 
and more stretched. At length the lower part is 
stretched till it can stretch no more, and it gives 
way; rupture of the uterus occurs. The attendant 
ought to foresee this, and not let things get to such 
a pass that the uterus ruptures. 
Rupture of the uterus may occur before the 
uterine contractions have become tonic; for in some 
very rare cases it is due to disease of the womb, which 
gives way without any obstruction. These cases are 
excessively rare, and cannot be detected beforehand. 
But remember that there are such cases, and do not 
be uncharitable in your remarks if you hear of a case 
of ruptured uterus in some one else's practice. 
The symptoms of rupture of the uterus 
are sudden cessation of labour pains, with the equally 
sudden onset of symptoms of extreme prostration, 
pallor, whiteness of the lips, smallness and rapidity of 
the pulse, and haemorrhage. On examination, the 
presenting part will be found to be no longer pressed 
down as it was before : it has wholly or partly receded 
into the womb. Sometimes a sudden pain, different 106 
Midwifery. 
[Chap. VII. 
from that of labour, is felt at the time of rupture ; and 
sometimes there is vomiting. The bleeding comes 
from the torn wall of the uterus. Part of it escapes 
outside, and can be seen; part flows into the peritoneal 
cavity. If after rupture has taken place you 
examine the belly, you will feel the child in one place, 
and be able to identify its parts much more easily 
than in any case of pregnancy (because there is not 
the thickness of the walls both of the uterus and 
abdomen between your hands and the child, but only 
that of the wall of the belly), and in another place you 
will feel the contracted uterus. 
Incomplete rupture.-In some cases the 
rupture is incomplete. The muscular wall of the 
uterus is torn through, but the peritoneum instead of 
being torn through is lifted up and stripped off the 
womb and the adjoining parts, so that the child does 
not get into the peritoneal cavity. In these cases the 
symptoms which the patient feels are the same, but 
when you examine, you will find that the child has 
not completely receded ; and when you examine the 
belly, you will not be able to feel the outline of the 
child so well as in a case of complete rupture, and it 
will not be so movable as after complete rupture. 
Rupture of the uterus is a very dangerous occur- 
rence. Of the mothers, five out of six die, and of the 
children, about eleven out of twelve. 
If you think that rupture of the uterus has taken 
place, you should send for aid at once. But it is 
much more important to know when rupture is likely 
to take place, and send for assistance in time to 
prevent it. It is not creditable if uterine rupture 
takes place in a case which you are attending. 
Tonic contraction of the uterus is dis- 
tinguished from uterine inertia by noting the 
following points : On examination of the abdomen, in 
uterine inertia the uterus is not at all tender : it is lax; Chap, vii.] 
Premature Uterine Retraction. 
107 
the outline of the foetus can be felt, and the foetus can 
be easily moved about. In tonic contraction of the 
uterus, the uterus is tender to the touch : it is hard 
and firm, and tightly moulded to the shape of the 
foetus, which cannot be moved about. By vaginal 
examination in uterine inertia, the presenting part 
of the child can be pushed up, and moved about 
above the brim; while in tonic contraction of the 
uterus it is fixed in the pelvis, or above the brim. In 
uterine inertia the patient (unless there be some other 
complication present) shows no sign of great 
suffering or weakness ; her temperature is normal, and 
her pulse not over 100. In tonic contraction of the 
uterus the expression of the patient's face shows 
anxiety and exhaustion; her temperature may be 
raised, and her pulse is quick, small, and weak. 
Relative weakness of the pains is dis- 
tinguished from uterine inertia by the fact 
that the pains are regular, frequent, and apparently 
powerful. It is distinguished from tonic contrac- 
tion of the uterus by the fact that between the pains 
there are intermissions, during which the uterus 
becomes quite soft. But it is often very difficult to 
judge how far delay in labour is due to weakness of 
the pains, and how far to mechanical obstruction. 
Therefore in any case of lingering labour in which 
you have the slightest doubt as to the cause, you should 
send for assistance. 
There is a rare form of lingering labour which is 
due to premature retraction of the uterus. 
This occurs chiefly in first labours, and in young 
women of nervous temperament. The pains occur 
as often as usual, and each lasts as long as usual; and 
they cause more suffering than usual (because the 
patients are so sensitive), but they are inefficient. 
The upper part of the womb contracts, becomes 
smaller, harder, and its wall thicker; and the lower 108 
Midwifery. 
[Chap. VII. 
segment stretches, becomes elongated and thinned, 
just as in a case of obstructed labour. But there is 
no obstruction. During the pains the child is only- 
forced very feebly against the soft parts, and during 
the intervals between the pains it is quite movable. 
Tf the child is pulled upon with forceps, the head 
presenting, or by the foot if the breech present, it 
is delivered with ease. After the child is born the 
placenta is expelled quickly and naturally, and there 
is no haemorrhage. On abdominal examination in 
such cases the retraction ring can be felt, marking 
the limit between the part which retracts and the 
part which stretches ; and as the labour goes on, this 
ring rises higher and higher, till it gets near the 
umbilicus. 
This form of delayed labour is distinguished from 
uterine inertia by the regular and frequent occurrence 
of severe pains; and from obstructed labour by the 
child remaining quite movable, and not being the 
least impacted. 
It is rare, and for that reason may be difficult of 
diagnosis. Therefore, if you suspect it, send at once 
for assistance. 109 
CHAPTER VIII. 
TRANSVERSE PRESENTATIONS. 
Cases in which the child presents otherwise than with 
the head or breech, are grouped together under the 
Fig. 61.-Transverse Presentation : Dorso-posterior. 
name of transverse presentations or cross births. If the 
child remains in this position the shoulder is forced down. 
Transverse positions.-Transverse presenta- 
tions are divided into dorso-anterior and dorso- 
posterior, according to whether the back of the child 
looks forwards or backwards (Fig. 61). It is most 
common for its back to be turned forwards (Fig. 62). 110 
Midwifery. 
[Chap. VIII. 
These positions are again divided according to whether 
the head is towards the right or the left. The differ- 
ences in position are quite unimportant from the 
point of view of treatment. 
The term " transverse presentation " may make 
the beginner think that the largest measurement of 
Fig. 62.-Transverse Presentation : Borso-anterior. 
the child lies across the womb, the breech to one side, 
the head to the other. This is sometimes the case, 
but only very exceptionally. As a rule, the child's 
spine is so bent sideways, that although the shoulder 
is in the pelvic brim, and the head in the iliac 
fossa, the lower part of the body is nearly in the 
same position as if the head were presenting, so that 
on looking at the belly, the shape of the womb does 
not seem different from that which it has when the 
presentation is a normal one. For this reason, some 
prefer to speak of these cases as oblique presentations. Chap. VIII.] 
SPONTA NEO US E POL UTION. 
111 
When the fcetus lies transversely, it cannot, as a 
rule, be born without assistance. If the pelvis be not 
larger than usual, the child not smaller than the 
average, and the power of the uterus not greater than 
ordinary, the child will not be born. 
diodes of natural delivery.-But nature is 
not quite powerless in such cases. There are four 
ways in which they may terminate favourably 
without help. By the first, the wrong position is 
spontaneously corrected. Early in labour, as the 
uterus contracts round the child, it may press the 
head into the pelvic inlet, and raise the shoulder out 
of it. This is called spontaneous rectification. 
By the second process, which, when it happens, 
usually occurs late in labour, the uterine contractions 
turn the child and bring the breech into the pelvic 
inlet, instead of the shoulder. This is called spon- 
taneous version. 
Each of these events is rare. We cannot tell when 
the malpresentation is going to be corrected in this 
way. Therefore we cannot at all expect that a case 
will be set right in one of these ways, but must act as 
if there were no such thing as spontaneous rectification 
or version. 
The third way is called spontaneous evolution, or, 
at greater length, the spontaneous evolution of Douglas, 
after Dr. John C. Douglas, of Dublin, who was the 
first person who described it. I shall describe how it 
takes place nearly in Dr. Douglas's own words. The 
shoulder of the child is forced very low into the 
pelvis. The shoulder and thorax are at each suc- 
cessive pain forced still lower, until the ribs press 
on the perineum, and cause it to assume the same 
form as it would by the pressure of the forehead 
in a natural labour (Fig. 63). At this period not 
only the entire arm, but the shoulder, can be per- 
ceived externally, with the collar-bone lying under 112 
Midwifery. 
[Chap. VIII. 
the arch of the pubes. By further uterine con- 
tractions the ribs are forced more forward, appearing 
at the orifice of the vulva, as the vertex would in a 
natural labour, the clavicle having been by degrees 
forced round on the anterior part of the pubes. The 
entire foetus, immediately prior to its expulsion, 
Fig. 63. - Spontaneous Evolution : its Commencement. 
somewhat resembles the larger segment of a circle; 
the head rests on the pubes internally, the collar-bone 
presses against the pubes externally. The arm and 
shoulder are entirely protruded, with one side of 
the thorax not only appearing at the vulval orifice, 
but partly beyond it; the lower part of the same side 
of the trunk presses on the perineum, with the breech 
either in the hollow of the sacrum or at the brim of 
the pelvis, ready to descend into it. By a few further 
uterine efforts, the remainder of the trunk, with the 
lower extremities, is expelled. Delivery is finished Chap. VIII.] 
Sponta neo us Exp ulsion. 
113 
as in a labour in which the breech had presented 
(Figs. 64 and 65). 
This mode of delivery requires very powerful uterine 
action to accomplish it. If only the uterus is strong 
enough, a full-time child may be delivered through a 
pelvis of average size in this way, and may survive. 
Delivery in this way, if it is going to take place at all, 
Fig. 64.-Spontaneous Evolution in Progress. 
will do so quickly. In the cases seen by Dr. Douglas, 
the labour was in each case over in less than six hours. 
But it is very seldom that the uterus is strong enough 
to drive the child out in this way, and therefore we 
must not expect or wait for this to happen. 
The fourth way is called spontaneous expulsion. In 
it the child is driven through the pelvis doubled up, so 
that its chest and belly come out first, and then its head 
and legs (Fig. 66). This only happens with dead chil- 
dren, whose bodies are by decomposition rendered softer 
than natural, so that they can double up more easily. 114 
Ml DIV I FED Y. 
VIII. 
Dead children are often premature. If the child be 
premature, small, and dead, delivery in this fashion 
can happen easily. 
Management of transverse presenta- 
tions.-When you have ascertained that the presenta- 
tion is transverse, send for assistance. The child will 
Fig. 65.-Spontaneous Evolution : its Termination. 
have to be turned. Turning is sometimes a difficult 
operation, and an unskilful attempt at turning in a diffi- 
cult case may do much harm. But there are certain 
circumstances in which you may interfere. If you can 
recognise early in the labour, before the membranes 
are ruptured, and before the shoulder is pressed down 
into the pelvis, that the head is lying in one iliac 
fossa, try, with the hands applied to the abdomen, chap, viii.i 
Transverse Presentations. 
115 
to push the head into the brim of the pelvis. The 
patient being on her back, put one hand on the 
outer side of the head, and the other on the opposite 
Fig. 66.-Spontaneous Expulsion. 
side of the child's breech. Then press the head and 
the breech gently, but firmly, towards the middle line. 
If you cannot easily do this, send for help. 116 
CHAPTER IX. 
DESCENT, ETC., OF THE COED-DESCENT OF THE HAND. 
Descent of the cord means that the cord comes 
down by the side of the presenting part. Cases are 
divided into three classes : presentation of the cord 
(sometimes called chorda premia), when it presents at 
the os nteri before the beginning of labour • prolapse 
of the cord, which signifies that the cord falls down- 
wards when the bag of membranes ruptures; and 
expression of the cord, which means that the cord 
is squeezed out by the side of the presenting part later 
in the process of labour. In the first two classes the 
cord can often be returned, but in cases of expression 
of the cord, if it be put back it will be squeezed out 
again directly. 
When and why important.-Descent of the 
cord is a matter of no consequence to the life of the 
mother, but it is a very dangerous thing for the life 
of the child, because it leads to the cord being com- 
pressed between the child's head and the pelvis (Fig. 6 7). 
When the child is born with the pelvic end first, the 
cord is always compressed for a little while between 
the head and the pelvis ; but then the soft parts have 
been dilated by the body of the child, so that the 
head is quickly born, and in an ordinary case the cord is 
not compressed for more than a very few minutes. But 
if the head presents, and the cord comes down by its 
side, the cord is compressed during the whole time 
that the soft parts are being dilated by the head, 
which may take several hours, and in such a case the 
child is pretty sure to be dead. If the breech presents 
there is plenty of room for the cord to lie in while the 
soft parts are being dilated, so that it is not pressed Chap. IX.] 
Descent of Cord. 
117 
on till the head comes through. Therefore prolapse of 
the cord is a practically unimportant condition in 
cases in which the head does not present. 
Il ow produced.-Both prolapse and expression 
of the cord are prevented in normal labours by the 
Fig. 67.-Prolapse of Cord with Head Presentation. 
accuracy with which the head fills up the os uteri as 
it descends into the pelvis, so that the cord cannot 
get past it. Conditions that prevent the head 
coining down and filling the os uteri favour prolapse 
of the cord. Contracted pelvis is one of these. Re- 
member this, and if you find the cord down, examine 
carefully the size of the pelvis. Excessive size of the 
child's head, as from water on the brain, is another 
cause which acts in the same way.. In transverse 118 
Midwifery. 
[Chap. IX. 
and breech presentations the presenting part does not 
so nicely fill the os as the head does, and therefore 
prolapse of the cord is more common with these than 
with head presentations (Fig. 68). When the cord is a 
great deal longer than usual, it is liable to fall down 
Fig. 68.-Prolapse of Cord with Hand and Foot presenting. 
when the membranes rupture. If there is a great quan- 
tity of amniotic fluid, the rush of fluid when the bag 
bursts is apt to carry down the cord. If the placenta 
is implanted low down in the uterus, or if the cord, 
instead of being implanted near the middle of the 
placenta, joins it at its lower edge, then it more easily 
falls down through the os than if it were attached 
higher up. It is commoner in women who have had 
many children than in those pregnant for the first 
time. 
Management.-Descent of the cord, so long as 
the membranes are unruptured, does not put the child Chap. IX.] 
Postural Treatment. 
119 
in danger, because the bag of waters protects the cord 
from injurious pressure. Therefore it is very impor- 
tant in these cases to keep the membranes unruptured 
as long as possible. 
The treatment of presentation of the cord before 
rupture of the membranes is very simple. It is to 
put the patient on her knees and elbows (Fig. 69). In 
Fig. G9.-Postural treatment of Prolapse of Cord. 
this position the uterus is nearly vertical, the os uteri 
being the highest part, the fundus the lowest. There- 
fore the cord, which can move easily in the bag of 
waters, sinks down to the fundus of the uterus. The 
patient should be kept in this position for fifteen or 
twenty minutes, to give the cord time to sink to the 
fundus. Then she should lie on the side opposite to 
that on which the cord came down, in the hope that 
as uterine contractions drive the child's head down 
upon the cervix, the head will so fill it as to leave no 
room for the cord to come down again. She should 
be kept recumbent, and told to avoid straining, so as 120 
Midwifery. 
[Chap. IX. 
to postpone rupture of tlie membranes as long as 
possible. Should the cord come down again, the 
patient must be again put on her knees and elbows. 
This is a method of treatment that cannot possibly do 
any harm. 
After the membranes have ruptured this simple 
mode of treatment is not enough, although 
it may still be helpful. It may be sufficient if em- 
ployed soon after the rupture of the membranes, 
before all the amniotic fluid has escaped. But if it 
be found that on putting the patient on her knees 
and elbows the cord does not go back, then it will be 
necessary, for the sake of the child's life, either to 
replace the cord or to quickly deliver the child. You 
will therefore do well to send for assistance. You may, 
if the patient will let you, and aid is not at hand, try 
to replace the cord with your hand ; but as this cannot 
be done without putting the whole hand in the vagina, 
the patient will not readily let you attempt it. To 
replace the cord, put the patient on her knees and 
elbows, put the thumb and four Angers of the right 
hand together so as to form a cone, pass the whole 
hand into the vagina, then take the cord between the 
tips of the fore and middle fingers, or, if a large loop 
be down, in the palm of the hand, and between the 
pains carry it up past the largest measurement of the 
head. It is not the least use merely to push the cord 
up a little way, or to push up a part of it; the whole 
of it must be carried beyond the largest measurement 
of the head. If, when this has been effectively done, 
the cord again comes down, it is no use trying again; 
the only chance for the child is in speedy delivery. 
Leave it for some one of more knowledge and ex- 
perience to decide how to do this. 
Various instruments have been devised for re- 
placing the cord. One can be made out of a catheter. 
Pass the ends of a bit of string in at the eye and out Chap. IX.] 
Shortness of Cord. 
121 
at the encl of a catheter, so as to leave a loop pro- 
jecting at the eye. If you are not dexterous enough 
to do this, cut a hole in the catheter opposite the eye, 
and pass a loop of tape through the two openings; 
or get a piece of whalebone, and make a hole in it 
either with a pocket-knife or with a gimlet or bradawl, 
and thread the two ends of a piece of tape through 
the hole, thus leaving a loop. In either of these ways 
you will have a solid rod, with a loop at the end. 
The prolapsed piece of cord may be snared in the 
loop, and then carried up by the rod to the top of the 
womb. The noose should then be loosened, so as to 
let go the cord, and the rod withdrawn. But this is 
not so good a way as replacement by the hand. 
You must not forget that contracted pelvis is one 
of the principal causes of prolapse of the funis. In a 
case in which the cord is down, examine the size of 
the pelvis, and if it be contracted, send for aid, whether 
the cord will go back or not. 
Shortness of the cord*-The cord varies very 
much in length, and it may be so short as to delay 
delivery, and to risk inversion of the uterus oc- 
curring after delivery. Inversion of the uterus will 
be described in a subsequent chapter. It is more 
common for the cord to be made practically short by 
being twisted round the child's body or neck. Coiling 
of the cord round the body is not of much importance, 
as the child can either slip through the coils, or, as 
the body is being delivered, can turn so as to undo the 
twisting. Coiling of the cord round the neck is more 
important. If the cord be so short that it is tight, it 
may hinder the delivery of the shoulders, and even 
strangle the child. It is rare for it to be so tight as 
this. It is quite common to get one or two turns of 
the cord round the child's neck. Therefore you should 
always, when the head has been born, feel if there be 
a loop of cord round the neck. If there be, and the 122 
Midwifery. 
[Chap. IX. 
loop is not tight, pull it until it is so far enlarged that 
the shoulders can slip through it, or even that the cord 
can be passed over the head. If it be so tight that you 
cannot make it wide enough to let the child's body 
pass through it, there is nothing for it but to carefully 
cut the cord, and grasp and tie the end as quickly as 
possible after the body has emerged. 
Prolapse of tlie hand.-The hand may come 
down in a transverse presentation or in a breech pre- 
sentation ; but in neither of these cases does descent 
of the hand make any difference in their management. 
When the hand comes down by the side of the 
head, it may prevent the head from entering the brim 
properly. The causes which lead to prolapse of the 
band are the same as those which lead to prolapse of 
the cord, and to abnormal presentations of all kinds, 
among them being contraction of the pelvis. 
If, then, you find that the head is high up, not 
having entered the brim, and the hand is prolapsed 
by its side, remember that this may possibly be caused 
by contraction of the pelvis, and try and ascertain 
the size of the pelvis. If you find the pelvis contracted, 
send for aid. If the head is entering the pelvis, and 
the arm is only slightly down, so that only the fingers 
can be felt by the side of the head, it is likely that as 
labour goes on the head will advance before the arm, 
and the labour will be ended naturally. If the child 
be not of undue size, and the pelvis not contracted, it 
is quite possible for the head and arm to come through 
the pelvis together. But if the head does not advance, 
put the patient on the side opposite to that on which 
the arm has come down, and send for assistance. 123 
CHAPTER X. 
TWINS. 
Labour with twins.-In pregnancy with twins 
the uterus is larger than when it contains only one 
child (Fig. 70). Its wall is stretched and thinned, and 
Fig. 70.-Twin Pregnancy. (From Galabin.) 
therefore weakened. Hence the uterine contractions 
are often weak, and labour is slow. It is common 
also for one or even both of the twins to occupy an 124 
Midwifery. 
[Chap. X. 
abnormal position, and this may delay delivery. One 
twin may obstruct the birth of the other. The weak- 
ness of the uterus may persist after delivery, and cause 
post-partum haemorrhage. Therefore in any case of 
twins you must be specially on your guard against 
post-partumhoemorrhage. If there be delay or difficulty 
in the birth of either child, you should send for aid. 
Twins may each have a separate placenta and 
membranes, or they may have the same chorion and 
their placentae may be united. When the two twins 
are entirely separate, they may differ slightly in age : 
one twin may be even as much as three months older 
than its fellow, although this is not common. 
The following are the rules according to which 
labour should be managed when one child has been 
born, and there remains another in the womb. 
1. If, after the first child is born, the membranes 
of the second child still remain entire, wait for half-an- 
hour. If within that time the idacenta of the first child 
is expelled, do not in any way accelerate the birth of the 
second. Wait another hour, and then, if no uterine 
action takes place, and there is no haemorrhage, leave 
the patient, and tell her to send when the pains 
return. The second child may be retained for days, 
or even weeks. Such cases are rare. 
2. If, half-an-hour after the birth of the first 
child, its placenta has not been expelled into the 
vagina, and the membranes of the second child are 
still unbroken, ascertain how the second child is pre- 
senting, and, if the head or breech be over the os uteri, 
rupture the membranes. If any other part present, 
send for assistance. 
3. If the membranes of the second child have 
already broken, its delivery must be managed just as 
the delivery of any other child, only with more careful 
and prolonged attention to the prevention of post- 
partum haemorrhage. 125 
CHAPTER XI. 
CONTRACTED PELVIS. 
There are many kinds of pelvic deformity which 
contract the space through which the child has to 
pass, and so make labour difficult. The most common 
kind of contracted pelvis is what is called the flat 
pelvis. In this form the pelvic inlet is flattened from 
before backwards by an unusual projection of the 
sacral promontory. The worst kinds of this deformity 
are produced by rickets: a disease which occurs in 
infancy, and leads to softening of the bones so that 
they bend. In this disease other bones are affected 
beside those of the pelvis, and often therefore 
the legs are crooked and the patient is pigeon- 
breasted. But in many cases of flat pelvis there is 
no deformity of the limbs, and there are other causes 
of deformity of the chest besides rickets, so that you 
must not always draw conclusions as to the shape of 
the pelvis from that of the chest and limbs. 
The conjugate diameter of a well-shaped pelvis 
measures from four inches to four and a half. If it 
only measure three inches and three-quarters, a child 
of not more than average size can pass without 
much difficulty. If the conjugate be less than this 
there will be difficulty; and if it be under three inches 
and a quarter a full time child is not likely to pass 
without help. In the slighter cases of flat pelvis the 
pelvis is only narrowed in its measurement from 
before backwards, being of normal size in other direc- 
tions. In the worst cases the other diameters are 
shortened as well. 
A well-informed accoucheur will suspect the ex- 
istence of flatness of the pelvis from its effect on labour, 126 
Midwifery. 
[Chap. XI. 
and ascertain it with certainty by measurement of the 
pelvis. 
Mechanism of labour with flat elvis. 
-Great contraction of the pelvis prevents the head 
from entering the pelvis at all. The slighter forms 
only allow it to enter in a peculiar way. (1) The pro- 
jection of the sacral promontory prevents there being 
room for the head in the oblique diameter of the 
Fig. 71.-The Obliquity of Naegele.J (From Galabin.) 
a, Anterior fontanelle ; b, sagittal suture ; c, posterior fontanelle ; d, sacral 
promontory; e, symphysis pubis. 
pelvis. Therefore the head lies transversely instead 
of in the oblique diameter of the pelvis, as in a natural 
case. (2) The largest transverse measurement of the 
head is the biparietal, which is behind the joint which 
the head forms with the spine. Hence, if the pelvis 
is not quite large enough to let the head enter easily, 
the hinder part meets with the most difficulty, and 
the front part of the head is forced lower down than 
usual. Therefore, the anterior fontanelle can be easily 
felt, and is on the same level as the posterior: not 
higher up than the posterior, as in normal labour. 
(3) The measurement between the two parietal emi- 
nences is greater than the sub-parietal sriper-parietal 
measurement, that which is taken from a point below Chap. XL] 
Labour with Flat Pelvis. 
127 
one parietal eminence to a point above the other. The 
projection of the sacral promontory hinders the parie- 
tal bone that meets it from coming down. Hence the 
head gets so tilted that the sub-parietal super-parietal 
measurement engages in the brim. When this tilting 
has taken place, the sagittal suture is felt running 
from side to side across the pelvis, very close to 
the sacral promontory. This tilting is called the 
obliquity ofNacgcle (Fig. 71). 
When these peculiarities exist together, the 
obliquity of Naegele, a transverse position of the head, 
and a low position of the anterior fontanelle, it may 
be inferred that the pelvis is flattened, and you should 
try to measure it. 
Other peculiarities in labour produced by flat pel- 
vis are face presentations, prolapse of the funis, descent 
of the hand by the side of the head. When you meet 
with one of these conditions you should measure 
the pelvis. After a labour complicated with any cir- 
cumstance that leads to suspicion that the pelvis is 
flattened, even though delivery have taken place 
without help, you should measure the pelvis, that 
advice may be given in any future pregnancy. 
There is another kind of contracted pelvis in which 
the pelvis is not much altered in shape, but is smaller 
than it should be in all its dimensions. This is called the 
generally contracted pelvis. It is more diffi- 
cult to detect this kind of pelvic deformity than that 
due to simple flattening. You will only be able to find 
it out by the delay in delivery which it causes. If 
the child be small, it will pass easily through a gene- 
rally contracted pelvis. If the child be of average 
size, and the pelvis generally contracted, the difficulty 
in delivery will be just the same in kind as if the 
child were of excessive size and the pelvis perfectly 
normal. 
In the flat pelvis all the difficulty is at the brim. 128 
Midwifery. 
[Chap. XI. 
When once the head has got through the brim, delivery 
quickly takes place. In the generally contracted 
pelvis, on the other hand, there is difficulty all through. 
There is another form of contracted pelvis which 
is not very uncommon. It is called the kyphotic 
pelvis, and is that met with in hump-backed women. 
A hump in the back is usually due to disease of the 
bones of the spine. This disease in a woman who is 
bearing children is generally past and gone, leaving 
only the deformity behind it; for a woman in whom 
the disease is progressing is not likely to become preg- 
nant. The effect of this disease upon the pelvis 
depends upon its seat. The higher up it is, the less 
it affects the pelvis. If it be low down, the pelvis 
may be deformed. The deformity consists in enlarge- 
ment of the brim from before backwards, with 
narrowing of the outlet, the ischial tuberosities being 
closer together than they should be. Hence there is 
no particular difficulty in the early part of labour, but 
great difficulty when the head gets low down in the 
pelvis. In these cases the head is very apt to present 
with the occiput behind, because the projection of the 
spine, to which the front of the child's body usually 
adapts itself, is absent. You can soon identify this 
deformity, because the tuberosities of the ischium can 
easily be felt. They ought to be at their hinder 
part four inches apart. If they are only three inches 
or less apart there will be difficulty. 
Pelvimetry. - There are two ways in which 
you can measure the size of the conjugate diameter of 
the brim. The first is the indirect way. This can 
be done during labour until the head has passed 
the brim. It consists in measuring the diagonal 
conjugate. Put the fore and middle fingers of the 
left hand into the vagina (the forefinger alone cannot 
usually reach far enough), and press them up until 
you can feel the sacral promontory. Take care that Chap. XL] 
Diagonal Conjugate. 
129 
your finger is on the promontory, and not merely on 
the front of the sacrum below the promontory ; and 
that it is on the middle of the promontory. Then, 
keeping the middle finger on the promontory, press 
Fig. 72.-Mode of Measuring the Diagonal Conjugate. 
the side of the forefinger against the lower edge of 
the symphysis. Then place the forefinger nail of the 
right hand where the examining hand is touching the 
lower border of the symphysis (Fig. 72). Then remove 
the two hands together without separating them, so that 
the finger-nail may accurately mark where the hand was 130 
Midwifery. 
[Chap. XI. 
in contact with the symphysis. Now get some one 
to measure with a graduated tape or foot-rule the 
distance between the tip of the middle finger and 
the place where the side of the hand touched the 
lower edge of the symphysis. This distance is the 
diagonal conjugate, and it usually measures about 
Fig. 73.-Pelvimetry : Measurement four inches. 
half-an-inch more than the true conjugate. By 
deducting, therefore, half-an-inch, you will come very 
near to a correct measurement of the true conjugate. 
If, when you have pushed the fingers up as far as you 
possibly can, you still cannot feel the promontory of 
the sacrum, the probability is that the conjugate 
diameter is not contracted, and it certainly is not much 
contracted. This mode of estimating the conjugate 
diameter of the brim does not in all cases give a per- 
fectly accurate result. But it gives a result very chap, xi.] 
Measurement of Conjugate. 
131 
near the truth, and it is nearest to the truth in the 
slighter degrees of deformity. 
After delivery the conjugate can be measured 
directly, and exactly, by Johnson's method.* This 
method can be used before delivery in cases of great 
deformity, but not in slight cases. 
To measure in this way you should be acquainted 
with the measurements of your own hand. The fol- 
lowing measurements, which Mr. Johnson gives, are 
those of a man's hand of average size. Measure your 
own hand, and see if and how much the measurements 
differ from those given. 
1. The fingers being bent into the palm, and the 
thumb extended and applied close to the middle joint 
of the forefinger, the distance between the end of the 
Fig. 74.-Pelvimetry: Measurement three inches and a half. 
* So called after Mr. Robert Wallace Johnson, who first de- 
scribed it in "A System of Midwifery." London, 1769. 132 
Midwifery. 
[Chap. XI. 
thumb and the outside of the middle joint of the little 
finger is four inches (Fig. 73). 
2. In the above position, the distance from the 
thumb at the root of the nail, in a straight line to 
Fig. 75.-Pelvimetry: Measurement three inches and a quarter. 
the outside of the middle joint of the little finger, is 
three inches and a half (Fig. 74). 
3. The fingers being in the same position, and 
the thumb laid obliquely along the joints next the 
nails of the first two fingers, and bent down upon 
them, the distance between the outside of the middle 
joint of the forefinger and the outside of that of the 
little finger is three inches and a quarter (Fig. 75). 
4. The hand being opened, and the fingers held 
straight, the whole breadth from the middle joint of Chap. XI.] 
Johnson's Method of Pelvimetry. 
133 
the forefinger to the last joint of the little finger is 
three inches (Fig. 76). 
5. The fingers being so far bent as to bring their 
tips to a straight line, their whole breadth across the 
joint next to the nails is two inches and a half (Fig. 77). 
If the measurement be below two inches and a half, 
Fig. 7G.-Pelvimetry : Measurement three inches. 
it is immaterial, so far as the student or midwife is 
concerned, how much less it is. 
You should usually make this measurement either 
during or immediately after the third stage of labour. 
Make it during the first stage of labour if the head 
has not entered the brim. Put your fingers together 
into a cone, and put the whole hand into the vagina 
and up to the pelvic brim. Then put your hand, in 134 
Midwifery. 
[Chap. XL 
the different positions described, in the conjugate 
diameter, and see which measurement fills that 
diameter. Be quite certain that the part of the hand 
by which you are taking the measurement is in 
the narrowest part of the brim. 
Other measurements at the brim beside the con- 
jugate may be taken in this way if the pelvis be 
[Fig. 77.-Pelvimetry : Measurement two inches and a half. 
contracted enough; but cases in which the other 
measurements are so small that they can be thus 
measured are very rare. 
In the kyphotic pelvis the transverse measurement 
at the outlet-viz. that between the hinder parts of the 
tubera ischii-is important. This may be taken by 
Johnson's method, but it is not quite easy to do so, on 
account of the thickness and resistance of the soft parts 
over and between the bones. The best way of taking Chap. XI.] 
Measurement of Outlet. 
135 
this measurement is to make the patient kneel up on 
her knees and elbows, and then feel for* the bones, 
and with an aniline pencil mark on the skin of the 
buttocks the outline of the bones beneath. When 
you have made marks accurately corresponding to the 
bones, you can measure the distance between the 
important points. 
External measurements of the pelvis and other 
internal measurements than those given above may be 
taken ; but they are less important. There are also 
other forms of contracted pelvis, but they are so rare 
as to be comparatively unimportant. 136 
CHAPTER XII. 
HEMORRHAGE. 
Haemorrhage is the greatest immediate danger 
that attends pregnancy and labour. No one ought 
to undertake to attend women in labour who does not 
thoroughly understand how to stop haemorrhage from 
the womb. 
Haemorrhage may occur -before delivery or after 
delivery. 
Hemorrhage before Delivery. 
This may come from one of three causes. 1. Disease 
of the passages. 2. Injury of the passages. 3. De- 
tachment of the placenta. 
1. From disease.-There are diseases of the 
vagina and neck of the womb which may cause 
haemorrhage during pregnancy. Haemorrhage from 
this cause is seldom great, because disease of the 
womb of such a kind as to cause very profuse 
haemorrhage usually prevents pregnancy from taking 
place. With the haemorrhage and in the intervals 
between -it, there are symptoms which generally make 
the patient go to a doctor. Hence you are not likely 
to be troubled much about haemorrhage of this kind. 
But you should remember that haemorrhage may be 
the result of disease. 
2. From injury.-During pregnancy the blood- 
vessels of the genital organs are enormously increased 
in size. Hence if a pregnant women near term re- 
ceives a wound in the genital organs (as sometimes 
happens, for instance, from falling so that the genitals 
meet something sharp, or from sitting on a broken 
utensil), the bleeding is terrific, and often kills the Chap. XII.] 
Accidental Haemorrhage. 
137 
patient before a doctor can be fetched. The way to 
stop the bleeding is to lay the patient flat down and 
press hard on the bleeding point, pressing it against 
the nearest bone, and to send for assistance. 
3. From separation of placenta. - The 
placenta should beimplanted on the upper or middle part 
of the uterus. If so, the child ought to be born before 
the placenta is detached, and separation of the placenta 
before the birth of the child is an unfortunate accident, 
not a necessary event. Hence haemorrhage before 
delivery, when the placenta is normally situated, is 
called accidental haemorrhage. 
The placenta may be implanted over the lower 
segment of the uterus : that is, over the part which 
has to expand and open up to let the child pass. This 
is called placenta praevia (from the Latin words, 
before, via, the way): that is, placenta in the way of 
the child. When this is the case, the child cannot 
possibly be born without some of the placenta being 
detached and some haemorrhage taking place. This 
form of haemorrhage is therefore called unavoidable 
haemorrhage. 
Accidental Haemorrhage. 
Causes.-We know very little about the causes 
of accidental haemorrhage. Sometimes it is clue to 
violence, such as a fall or a blow ; sometimes it seems 
caused by some excitement, such as fright or anger; 
these causes probably act either by causing some 
irregular contraction of the uterus, or by exciting the 
circulation, leading in one of these ways to rupture of 
blood-vessels passing from the uterus to the placenta. 
Haemorrhage of this kind is more common in women 
who have had many children than in those pregnant 
for the first time. It is believed that it is often due 
to disease of the womb itself, of the placenta, or of 
the blood-vessels, or to constitutional disease of the 138 
Midwifery. 
[Chap. XII. 
mother. But we do not know enough about its 
causes to be able to do anything to prevent it, beyond 
keeping the mother as healthy and as quiet as possible; 
and this is what ought to be done in the case of every 
pregnant woman. 
Diagnosis.-Accidental haemorrhage can only be 
distinguished from unavoidable haemorrhage by vaginal 
examination after the os uteri is large enough to 
admit the finger. Then in accidental haemorrhage the 
smooth membranes will be felt over the os ; in unavoid- 
able haemorrhage the rough spongy placenta will be felt. 
It used to be taught that in accidental haemorrhage 
the blood flowed in the intervals of pain and stopped 
during the pains; while in unavoidable haemorrhage 
the pains brought on bleeding, which stopped during 
the intervals. This is quite true as to the time at 
which the blood escapes from the vessels, but it is not 
correct as to the time at which it flows out from the 
vagina; for in accidental haemorrhage blood may flow 
from the vessels in the intervals between pains, and 
be retained in the womb or in the vagina until a 
pain comes, which forces it out; and in unavoidable 
haemorrhage the blood may escape from the vessels 
during the pains and yet not all escape from the 
vagina, but go on flowing from the vagina after 
the pain has passed oft*. Hence this distinction is not 
of the least use in practice. Before the os is large 
enough to admit the finger, we cannot tell whether 
haemorrhage is due to placenta praevia or to accidental 
separation of the placenta. 
The danger of accidental haemorrhage entirely 
depends upon its amount. If only a small quantity 
of blood is lost, it is a trifling complication. But in 
some cases the bleeding is profuse, and these cases 
are very dangerous. Judge of the danger, not only 
by the amount of blood which, from inspection of the 
napkins, clothes, utensils, etc., you can see has been chap, xii.] 
Accidental Haemorrhage. 
139 
lost, but by the condition of the patient. Remember 
that a loss from which one patient can recover may 
be enough to kill another; and that you cannot be 
sure that the evidence of blood lost which you see 
accurately represents all that has been lost. If the 
patient be pale, her lips white, her pulse quick and 
small, she is in danger, whether the stains on her 
clothing be large or small. 
Treatment. - Haemorrhage before labour is 
stopped in exactly the same way as haemorrhage after 
labour: first by pressure on the vessels, then by 
clotting of the blood in them. When the uterus 
contracts, its muscular fibres compress the vessels, as 
they do after labour. If the bleeding point should be 
opposite a hard part of the child, such as its head, 
and the womb is able to contract firmly about the 
child, this hard part will by its pressure on the 
bleeding point stop the bleeding. And if the bleeding 
can be stopped long enough for the blood in the 
vessels to clot, it will not return when the pressure is 
removed. 
The treatment of accidental haemorrhage, therefore, 
is to provoke uterine contraction, and the readiest 
way of doing this is to rupture the membranes. This 
brings with it certain disadvantages, which have been 
pointed out (page 25). Among these is that if the child 
be in a wrong position, turning is rendered more diffi- 
cult. Therefore unless the haemorrhage be so. great 
as to put the patient in imminent danger, it is better 
to seek further advice before doing this. If the 
haemorrhage be not very great, rupture of the mem- 
branes will usually provoke uterine action and stop 
the haemorrhage. Its effect will be aided by putting 
a firm binder round the abdomen, so as to press on 
the uterus. But if the haemorrhage be very great, 
the patient may be so exhausted that rupture of the 
membranes fails to provoke contraction of the uterus. 140 
Midwifery. 
[Chap. XII. 
Such cases are among the most dangerous and diffi- 
cult cases that occur in midwifery. Therefore you 
should in any case of haemorrhage lose no time in 
procuring assistance. 
Concealed accidental Inemorrliag'e. - In 
some cases of separation of a normally situated 
placenta, the blood does not escape outside, but is 
pent up in the womb. The patient loses the blood 
just as much when it flows into the womb as when it 
escapes outside. The bleeding produces even a greater 
effect in prostrating the patient, for the blood distends 
and stretches the womb, causing the patient very 
severe pain. 
This kind of bleeding is recognised by the following 
symptoms 
1. There are the signs of loss of blood. The patient 
is blanched, her lips are pale, her pulse is small and 
quick, just as if she had lost much blood externally. 
2. She has severe continuous pain, which she often 
says is of a tearing, stretching kind. 
3. The uterus is large, rounded, very hard, and 
very tense, its tension not passing off as that of uterine 
contraction does. 
If you are called to a patient presenting these 
symptoms, you should send for assistance without 
delay. The treatment is to rupture the membranes, 
and so relieve the distension of the womb and enable 
it to contract; and then to put on a binder. If the 
patient be very bad, and you are so situated that 
aid cannot be obtained quickly, you should do this 
at once. But if the patient be not so prostrate as to 
make delay dangerous, it is better (for the same 
reasons as in cases of haemorrhage which is not con- 
cealed) to let your superior officer decide what is 
best to be done. Chap, XII.) 
Placenta Praeeia. 
141 
Placenta Pr/evia. 
Placenta praevia is present when any part of 
the placenta is implanted over the part of the uterus 
that has to dilate to let the child pass. This part is 
called the lower segment of the uterus, and, roughly 
speaking, extends about two inches from the os 
uteri. The placenta may cover the os uteri all round, 
and this is called complete placenta praevia (Fig. 78). 
It may only cover one side of the os ; this is called 
pxirtial placenta praevia. It may not cover the os at 
all, but a part of it may extend over the lower seg- 
ment of the uterus, not reaching so far as the os ; 
this is called marginal placenta praevia. Central 
placenta praevia is the most dangerous; marginal 
placenta praevia the least. 
Symptoms. - In placenta praevia hcemorrhage 
before delivery is inevitable. The haemorrhage begins 
when the os uteri internum begins to dilate. It may 
begin before this, because the placenta praevia may be 
detached by any of the causes that lead to detachment 
of a normally situated placenta; so that haemorrhage 
in placenta praevia may begin at any period of 
pregnancy. There is reason to think that early mis- 
carriage is sometimes due to placenta praevia. When 
haemorrhage begins early in pregnancy, it is not 
usually so great as when it occurs for the first time 
near the end of pregnancy. 
The haemorrhage from placenta praevia is pro- 
duced, as a rule, by the commencing dilatation of the 
internal os, by which the cavity of the cervix becomes 
part of the general uterine cavity. With this dilata- 
tion there is an onward movement of the lower end of 
the bag of membranes, which comes to lie over and 
press into the os externum. But if the lower end of 
the bag of membranes be formed by the placenta, 
which is attached round the os uteri internum, this 142 
Midwifery. 
[Chap. XII. 
onward movement cannot take place without some 
detachment of the placenta. The detachment is not 
entirely due to the dilatation, because the placenta 
can stretch to some extent with the uterus ; it usually 
Fig. 78.-Placenta prrevia. (From Galabin.) 
becomes detached first at one side, which permits the 
onward movement of the bag of membranes. Then 
as labour goes on another piece becomes detached, 
and the bag of membranes moves on a little more, 
and so on. Hence it is exceptional to meet with 
great haemorrhage in placenta praevia without some 
dilatation of the os uteri. chap, xii.] 
Treatment of Placenta Pr/eria. 
143 
Treatment.-If there is reason to believe that 
placenta praevia is the condition present, you should 
lose no time in seeking aid. The condition is so 
dangerous, and the result so much dependent upon 
proper and timely treatment, that you should not 
take upon yourself the responsibility of postponing 
resort to the best available help. 
Delivery of placenta first. - Sir J. Y. 
Simpson recommended that the whole placenta should 
be detached, and delivered before the child. This 
cannot be done without forcing the hand into the 
uterus. All accoucheurs are now agreed that it is 
bad treatment. Sir James Simpson was induced to 
recommend it because in some cases the placenta is 
naturally expelled before the child, and such cases 
generally do well. Therefore he thought it would be 
a good plan to imitate nature in a course which was 
generally followed by happy results. But the reason 
why cases in which the placenta is born before the 
child generally do well is, that for this to happen 
there must be strong pains, and cases in which 
there are strong pains are the cases which do well; 
for the strong pains quickly force the child down on 
the bleeding part, and quickly close the bleeding 
vessels. But you must not trust to this. In any 
case of placenta praevia send for assistance as early 
as possible. 
Plugging the vagina is sometimes recommended. 
For a hundred years or more, while some accoucheurs 
have advocated plugging the vagina, others have dis- 
approved of it. As a means of checking haemorrhage 
it is quite useless. If the bleeding goes on, the blood 
first collects above the plug, filling out the vagina and 
stretching it. The plug soon becomes saturated with 
blood, lies loose in the stretched vagina, and the blood 
flows past it. All that the plug does is to hinder for 
a little while the appearance of the blood outside. It 144 
Midwifer y. 
[Chap. XII. 
does not at all prevent the mother from, losing it. 
It might perhaps be possible to stuff the vagina so 
tightly as actually to press effectively upon the 
bleeding points; but such plugging as this is very 
difficult to do, and cannot be done without hurting 
the patient very much, and leaving her in great pain 
when it is done ; and even if you were able unassisted 
so to pack the vagina, you will seldom find a patient 
who will submit to its being done. Such plugging as 
you can do without help is without more than a very 
slight temporary effect upon haemorrhage from the 
uterus. The presence of the plug in the vagina some- 
times acts as a stimulant to the uterus and provokes 
pains. But it cannot be relied upon to do this. 
Rupture of the membra nes is in some cases 
good treatment. It acts in placenta praevia as it does in 
accidental haemorrhage. If there are strong pains, the 
part of the child which is in advance is pressed down 
on the bleeding part, and stops the haemorrhage. But 
if there are not strong pains the haemorrhage is not 
stopped, and further treatment is rendered more diffi- 
cult. Do not, therefore, take upon yourself to rupture 
the membranes without further advice. 
Scutl for assistance at once.-If the haemorr- 
hage be very profuse you may plug the vagina with 
pocket handkerchiefs or diapers, first dipped in the 
1 in 2,000 solution and then wrung out, as a temporary 
measure, and put a binder round the abdomen to 
press the uterus down on to the plug; but never 
trust to this, or let apparent success from this treat- 
ment induce you to postpone sending for assistance. 
Post-partum Haemorrhage. 
This means haemorrhage after the birth ot 
the child. It comprises both haemorrhage occurring 
between the birth of the child and the delivery of 
the placenta and that occurring after the delivery Chap. XII.] 
PosT-PAR TUM H/EMORRHA GE. 
145 
of the placenta. Haemorrhage occurring more than 
twenty-four hours after the birth of the child is called 
secondary post-partum haemorrhage. 
It has been already mentioned that the third 
stage of laboui' is always accompanied with some 
slight haemorrhage. The course of the case may be 
considered normal if the quantity of blood lost does 
not exceed a pound. 
The great cause of excessive haemorrhage after 
delivery is uterine inertia: that is, deficient con- 
traction and retraction of the uterus. There are 
other causes which are rarer. These are : retention of a 
piece of placenta or membrane; laceration of the 
cervix so extensive as to open a large blood-vessel; 
inversion of the uterus; and "hourglass contraction " of 
the uterus. When the placenta is separated from the 
uterus, the large veins which returned the blood by 
which the placenta had obtained nourishment for the 
foetus are laid open. If the uterus contracts and retracts 
as it ought to do, the veins are compressed by the mus- 
cular fibres of the uterus so that they cannot bleed. 
If contraction and retraction are imperfect, the pla- 
centa will be slowly separated, and the haemorrhage 
attending and following its separation will be greater. 
Adhesion of placenta.-Beginners often think 
that adhesion of the placenta is much commoner than 
it really is, both because they are apt to fail to distin- 
guish between retention of placenta in the vagina, due 
to want of skill in the attendant in pressing it out, and 
retention in the uterus ; and because, until they find 
out how rare adhesion is, they often take mere slow 
separation of the placenta for retention by adhesions. 
With increasing skill in pressing out the placenta, in 
recognising the diminution in size of the uterus which 
accompanies the expulsion of the placenta into the 
vagina, and increasing knowledge of the great 
difference between different cases of normal labour, 146 
Midwifery. 
[Chap. XII. 
you will come to learn that adhesion of the placenta is 
a rare thing. 
Adhesion of the placenta is caused by disease 
of the decidua, but we do not yet know enough 
about the diseases of the decidua which lead to 
adhesion of the placenta to be able to foretell or pre 
vent such adhesion. 
If the placenta should be everywhere adherent, of 
course no bleeding can take place, for then no vessel 
could be opened. But such cases are infinitely rare ; 
usually the adhesion is only partial. In that case the 
part which is not united to the uterus with abnormal 
firmness becomes separated, while the part which is 
adherent remains attached and prevents the uterus 
from properly contracting and retracting, and so the 
vessels which have been opened by the detachment of 
the healthy part of the placenta bleed. If it be only 
a very small piece of the placenta that is adherent, the 
mass of the placenta may be torn off from it and ex- 
pelled. In that case the little adherent bit of 
placenta in the womb will prevent persistent uterine 
retraction, and post-partum haemorrhage will result. 
In this connection it must be mentioned that in rare 
instances there is a little bit of placenta attached 
separately from the main part. Such little detached 
islands of placenta are called placentce succenturiatce. 
One of these may be retained after the bulk of the 
placenta has been expelled, and may cause hsemor- 
rhage. The retention of an adherent bit of placenta 
from which the main part has been broken off can be 
found out by examining the placenta, in which the 
gap left by the torn-off piece will be perceived ; but 
examination of the placenta will not reveal the re- 
tention of a placenta succenturiata, for then there 
will be no gap in the main mass. But in the latter 
case a piece of chorion will be retained along with the 
island of placenta, and therefore if you examine the Chap. XII.] 
AtoiVk of Uterus. 
147 
membranes as well as the placenta yon will be able to 
find out that there is a piece of membrane retained. 
Keteittioii of membrane even without a piece 
of placenta may cause post-partum haemorrhage. Such 
retention is favoured, as has been shown, by too early 
rupture of the membranes, too late rupture of the 
membranes (page 24), too hasty squeezing out of the 
placenta (page 76). 
Uterine inertia, or atony of the uterus.- 
This is the great cause of post-partum haemorrhage. In 
the worst cases the uterus instead of feeling like a hard 
ball feels like a loose, flabby bag. It may be so loose 
and shapeless that the hand on the abdomen cannot 
make it out at all. When the uterus is so relaxed as 
this, its muscular fibres do not compress the veins, 
and so bleeding goes on. The blood escapes into the 
cavity of the womb and distends it, thus making it 
more difficult for the enfeebled womb to contract. 
In such extreme cases as this, the woman, if not 
properly treated, may bleed to death in a few minutes. 
In any case in which the womb does not remain hard 
and firm after delivery there is need for constant 
watchfulness. 
Uterine inertia in the third stage of labour is some- 
times a continuation of uterine inertia in the first and 
second stages of labour: the uterus being weak 
throughout the whole process. But it is seldom that, 
if the uterus has been contracting regularly up to the 
birth of the child, even though the pains have not 
been forcible, haemorrhage occurs. It is not so much 
weak pains as irregular pains in the second stage of 
labour that should make us expect haemorrhage in the 
third stage.- Emptying the uterus while contraction 
is not present is a very sure way of provoking dan- 
gerous post-partum haemorrhage. If, while the uterus 
is in a state of inertia, pains being absent, the child 
is dragged away, this is one of the surest ways of 148 
Midwifery. 
[Chap. XII. 
producing post-partuni haemorrhage. This is why, in 
breech presentations, you should be careful to pull only 
with the pains ; and why, in inertia delaying the birth 
of the head, in cranial presentations, you should not be 
in a hurry to ask someone to come and apply forceps, 
but rather let the patient have a sleep, and then, when 
the pains have returned, if they are not powerful 
enough, they may be helped by aid from without. 
In delivery, uterine contractions may be helped, not 
replaced, by pulling. There are certain conditions in 
which the uterus is apt to be weak from over-disten- 
sion, and in them, because of this weakness, there is 
apt to be inertia in the third stage. Such are preg- 
nancy with twins, or with dropsy of the amnion. 
After very prolonged labour, such as occurs with very 
big children, the uterus is likely to be exhausted, and 
to contract badly after delivery. Uterine inertia is 
also likely to happen if the mother has been enfeebled 
by haemorrhage before the birth of the child. There 
are other rarer causes, such as the presence of tumours 
in the womb or of disease of the womb. There are 
also some women, known as " bleeders," who are more 
prone to lose blood than most people ; they bleed much 
from slight cuts, after having a tooth extracted, etc. ; 
and such women after delivery are very prone to 
haemorrhage, and need the greatest care. The fault 
in them is that the blood does not clot, adhere to, 
and plug the vessels so readily as it ought to do. 
Although the above - mentioned causes favour 
haemorrhage, you must not think that because none of 
them appears to be present the patient will not have 
haemorrhage. The occurrence of haemorrhage cannot 
be foretold, nor can we be in any case sure that after 
delivery uterine contraction and retraction will be 
perfect. 
Haemorrhage from uterine inertia comes on within 
the first hour after delivery. It is profuse. If CI14P- XII.] 
POST-PARTUM HAEMORRHAGE. 
149 
you do not do your duty, but leave the uterus un- 
watched, hemorrhage to a dangerous extent may take 
place before external bleeding is noticed, or symptoms 
arise which draw attention to the patient's condition. 
Haemorrhage from inertia may take place either 
before or after the placenta is expelled. The treat- 
ment is the same in either case. If it takes place 
before the expulsion of the placenta, the treatment 
which stops the haemorrhage will hasten the expulsion 
of the placenta. 
Symptoms.-The bleeding may be external or 
internal. In the worst cases, in which the relaxation 
of the uterus is greatest, the blood does not escape 
outside in any quantity, but flows into the flabby uterus, 
filling it with blood, and filling also the vagina. This 
does not cause pain, and the only indication that this 
internal haemorrhage is going on is the effect pro- 
duced by loss of blood. The patient becomes pale : 
it may be literally said, " deathly pale." The pulse 
becomes quick, small, and feeble. The hands and feet 
and nose become cold. The patient breathes with 
irregular, sighing, hurried breaths. She looks anxious, 
groans, and sighs, and she becomes restless, throwing 
her limbs about. This restlessness is a very bad sign, 
and generally foretells death. There may be vomit- 
ing, and the patient may complain of noises in the 
ears or of a mist before her eyes, although generally 
she is too ill to mention such small troubles. These 
symptoms' are present in greater or less degree accord- 
ing to the amount of blood lost : and the appearance 
of any of them should make you carefully examine 
the abdomen. If there be internal hemorrhage, as 
soon as vigorous pressure is made on the abdomen, 
blood, mingled with large black soft clots, will pour 
from the vagina in quantity. 
If you have conducted the third stage of labour in 
the manner that has been advised in chapter iv., you 150 
Midwifery. 
[Chap. XII. 
will have recognised the relaxation of the uterus long 
before matters get to this pass, and will have applied 
proper treatment. 
Treatment.-In the treatment of post-partnm 
haimorrhage the first thing to be done is to put 
your hand on the abdomen, and if you cannot feel 
the uterus, to rub and knead the lower abdomen until 
uterine contraction is provoked, and you feel the 
uterus hardening under the hand. Then keep your 
hand on the uterus, to be sure that it remains con- 
tracted ; and if it relaxes, the rubbing and kneading 
must be resumed. 
This is the quickest way of provoking uterine con- 
traction, and therefore the one which should always 
be preferred. Other ways are sometimes mentioned, 
such as putting cold cloths to the abdomen or vulva, 
that the shock caused by the cold may make the 
uterus contract. But the patient may lose a quantity 
of blood while the cold cloths are being got ready. 
There is no way of provoking uterine action so quick 
as kneading and rubbing the abdomen. 
When you have got the uterus contracted, give the 
patient a teaspoonful of the liquid extract of ergot in 
some water. Be as quick as possible in getting this, 
so that the uterus may be left unwatched for as short 
a time as possible. If there be anyone else in the 
room, instruct her to rub and knead the belly while 
you are getting the medicine ready. 
If you find that the uterus will not remain con- 
tracted, that the rubbing and kneading produce 
momentary contraction only, then you must, while 
keeping your right hand on the uterus, pass your 
left hand (first rinsed in sublimate solution) into the 
vagina, and then into the uterus. Do this because 
the haemorrhage may be caused by a bit of retained 
placenta or membrane, or a clot may be hindering 
perfect uterine contraction. Having passed your Chap. XII.] 
PoST-PARTUM HAEMORRHAGE. 
151 
hand into the uterus, feel for any bit of placenta, or 
membrane, or clot, and clear out with your fingers 
everything that you find, so as to make sure that 
there is nothing retained in the womb. Having done 
this, withdraw your hand from the uterus into the 
vagina. Then with the right hand press on the 
back of the uterus through the abdominal wall, while 
Fig. 79.-How to compress the Uterus to stop Post-partu.ni 
Haemorrhage. 
with the hand in the vagina you press on the front of the 
uterus (Fig. 7 9). You can thus seize the uterus between 
the two hands, and compress it as firmly and as long as 
your strength will permit. While you are in this 
manner grasping the uterus and pressing its two walls 
together, it is scarcely possible for serious haemorrhage 
from the inside of the uterus to take place. If the 
haemorrhage has been great, you should, while you 
were doing what has been described, have sent for 
aid. If you have not yet done so, and find that if 
you leave off holding the uterus it at once relaxes, 152 
Midwifery. 
[Chap. XII. 
you should send for assistance. While waiting for 
the arrival of help, hold the uterus between the hand 
in the vagina and the hand outside until assistance 
comes. 
Hourglass contraction of the uterus means 
that the cervix is contracted, hindering the expulsion 
of the placenta. When this condition is present, 
steady draining of blood goes on from vessels (laid 
open by the separation of the placenta), which the 
uterus cannot close because the retained placenta 
hinders it from contracting. You will easily detect 
this by tracing up the cord, and feeling the tight ring 
of the contracted cervix encircling it. 
The treatment is to dilate the cervix with the 
hand, made into a cone by putting together the thumb 
and tips of the fingers. While this is being done, 
grasp the body of the uterus with the other hand on 
the abdomen, and press it downwards and backwards : 
the object of such counter-pressure being (1) to push 
the cervix down within easier reach of the internal 
hand, and (2) to prevent tearing the uterus away 
from the vagina. But as this treatment is sometimes 
difficult, and these cases are dangerous, you should 
send for assistance without delay, and only attempt 
it yourself if the haemorrhage is so great that delay 
will make death imminent. 
Haemorrhage may occur from laceration of the 
cervix or some other part of the genital canal. 
Lacerations short of rupture of the uterus or vagina 
seldom cause dangerous haemorrhage. You will 
recognise this kind of haemorrhage by noticing that it 
continues although the uterus is well contracted and re- 
tracted. If you find copious haemorrhage going on which 
appears to you to be from this cause, send for assist- 
ance, and meanwhile examine the cervix and vagina 
with your fingers (and eyes, as far as possible), to see 
if any tear be present; and if you find one, press with Chap. XII.) 
Inversion of the Uterus. 
153 
your fingers the margins of the tear against the 
nearest bony surface, and maintain the pressure until 
help comes. 
Inversion of the uterus may be the cause of 
haemorrhage after delivery. Fortunately it is very 
rare. It means that the uterus is turned inside out, 
so that what is naturally its inner surface becomes 
the outer, and occupies the vagina, with the cervix 
encircling its upper part. This occurs if, at a time 
when the uterus is quite relaxed, the body of 
the uterus is either (1) pulled down by the cord- 
either in the birth of the child from the cord being too 
short, or made too short by being coiled round the 
child-or afterwards, from the attendant trying to 
deliver the placenta by pulling at the cord; or (2) 
pushed down, as by some effort on the part of the 
patient. If the body of the uterus is thus pushed or 
pulled down through the cervix, and then, when it is 
down, the cervix contracts, the body will be held 
down. In this way inversion of the uterus is pro- 
duced and maintained. 
The symptoms of inversion of the uterus are 
haemorrhage, with great prostration. When you put 
your hand on the abdomen and feel for the body of 
the uterus, you cannot perceive it, however much you 
knead and rub the abdomen. Then you examine by 
the vagina, and find it filled with a fleshy tumour 
nearly as big as a child's head, and this tumour is 
encircled high up by the ring of the cervix. The 
placenta may be attached to this tumour, and if so, 
you can have no doubt what it is. 
The treatment of inversion of the uterus is to 
push it back. This is easily done immediately after the 
inversion has occurred ; but later on, when the cervix, 
has become more persistently contracted, it is difficult. 
Therefore, if you discover that the uterus is inverted, 
carefully try and replace it. Press the inverted body 154 
Midwifery. 
[Chap. XII. 
of the uterus with the thumb and tips of the fingers 
steadily, and with moderate force, upwards, making 
counter-pressure with the other hand over the lower 
abdomen, so as to steady the cervix. If this does not 
replace the inverted body of the uterus, send for 
assistance. If you do succeed in replacing it, use 
most carefully the measures recommended in the 
treatment of post-partum haemorrhage to produce and 
maintain uterine contraction. 155 
CHAPTER XIII. 
OTHER COMPLICATIONS OF LABOUR. 
A pregnant woman is not by her pregnancy pro- 
tected from disease. A patient in labour may present 
symptoms not due to labour, but to illness accompany- 
ing it. If the pulse is over 100, take the temperature. 
If it be over 101, some acute disease is probably 
present. If the respirations are over 25 per minute, 
and the patient has a cough, there is probably some 
chest affection. If symptoms of this kind, or any 
other which cause alarm, and which you do not under- 
stand, be present, you should seek further advice. 
The most important of the diseases which may 
accompany pregnancy, because the one to which preg- 
nant women are especially liable, is disease of tlse 
kidneys. The symptoms of this disease are often 
slight and insidious in onset. The most common are 
swelling, which pits on pressure, not only of the legs 
(which is quite common in pregnancy), but of the 
arms and face ; vomiting; pain at the pit of the 
stomach ; severe headache, and impairment of sight. 
If symptoms of this kind, even though slight, be 
present, the patient's urine should be examined. 
In some cases of kidney disease-about one in 
three or four- eclampsia occurs. The patient has 
ejrileptiform convulsions: that is, fits like those of 
epilepsy-indeed, only distinguishable from epilepsy 
by the fact that the patient has never had fits before, 
and that when the urine is examined kidney disease is 
found to be present. You ascertain that the fits are epi- 
leptiform convulsions, and neither hysterical seizures, 
nor random movements of the limbs due simply to the 
patient being nervous and excited, by the fact that 156 
Midwifery. 
[Chap. XIII. 
consciousness is lost during the fit. Test this by 
opening the eyelids, and touching the white of the eye 
with a clean finger. If the patient be unconscious, 
this will not provoke closure of the lids; if she be 
conscious, it will. 
In a case of this kind, send for assistance, and in 
Fig. 80.-Hydrocephalus. 
the meantime do all you can to prevent the patient 
from hurting herself during the fits. Put a spoon or 
a bit of firewood between her teeth, to prevent her 
from biting her tongue. Loosen all garments that 
can impede the movements of breathing. Save for 
examination as much of the urine as you can get; if 
possible, draw it off with the catheter, but do not per- 
sist in efforts to do this if they provoke struggling 
and excitement in the patient. Chap. XIII.] 
Deformity of Child. 
157 
Deformity of the child.-The child may be 
malformed or diseased, so that its bulk is abnormally 
great, and hence there is difficulty in delivery, the 
cause of which, from its unusual character, may be 
very difficult to ascertain. The only disease of this 
kind that is at all easy to recognise is hydrocephalus, or 
water on the brain (Fig. 80). In this disease the head is 
much larger than it should be, and the bones are so 
separated by the pressure of the fluid within that the 
sutures and fontanelles are felt, on vaginal examina- 
tion, as wide spaces between the bones. Although it 
is very difficult to ascertain before birth the nature 
of other malformations, yet if you make a point of 
always finding out early in labour, by abdominal ex- 
amination, the position and size of the child, you will, 
when you make this examination, soon perceive that 
something is unusual, although you may not be clear 
what, and you will therefore have sought assistance 
early. 158 
CHAPTER XIV. 
HOW TO REVIVE STILL-BORN CHILDREN. 
Still-birth.-After difficult labour, children are 
often born in a state of suspended animation : the 
child does not move or breathe, but its heart beats. 
If the child's heart has stopped beating, it is dead, 
and cannot be revived. It is easy enough at first to 
tell whether the heart is beating by feeling the 
cord, which pulsates at each beat of the heart. After 
the cord has been tied the beating of the heart can 
be felt by putting the hand over the left side of the 
chest, or heard by putting the ear to the left side of 
the chest. Before the heart ceases to beat it becomes 
irregular; hence, do not conclude that the child is 
dead merely because for a minute or two you are 
unable to feel or hear pulsations. If the skin is peel- 
ing off, there can be no doubt that the child is dead. 
Children who are born still, but not dead, are seen 
in two states--the blue and the white. In the former 
the skin of the child is of a mottled bluish colour, but 
its limbs are firm, not flabby and relaxed, and it can 
move its limbs. In the white state the skin is very 
pale and the limbs are flabby, and nothing that is 
done to them provokes movement. Children in the blue 
state are easily revived; children in the white state 
with great difficulty. Children, if not properly treated, 
may pass from blue asphyxia into white asphyxia. 
Treatment.-To revive a still-born child, the first 
thing to be done is to wipe away from its mouth and 
nose all fluids that may prevent air from getting in. 
Put a handkerchief over its mouth and blow down 
it. This will blow the mucus out of its nostrils. Then 
lay it face downwards, taking care that its mouth is Chap, xiv.] 
Treatment of Still-birth. 
159 
free, press on the back of its chest so as to help fluid 
out of its mouth and windpipe, and rub down the 
spine. If this produces no effect, slap the buttocks 
and the inside of the thighs, and sprinkle the chest, 
face, and back with cold water. With children in blue 
asphyxia treatment of this kind will usually provoke 
movements of breathing. But slapping, etc., are no 
use in cases of white asphyxia, and do not always 
succeed in blue asphyxia. In that case you should 
perform artificial respiration in the following way :- 
Put the child on its back. Take hold of the arms 
just above the elbows, and carry them upwards and 
outwards, bringing them up to the sides of its head. 
Then carry them downwards and forwards to the 
sides of the chest, and press them gently, but firmly, 
against the sides of the chest. These movements 
should be so done that they take about two or 
three seconds ; they should be repeated from twenty 
to thirty times a minute. The upward and outward 
movement of the arms expands the chest and draws 
air into it • the downward movement, and especially 
the pressure against the sides of the chest, contracts 
the chest and presses the air out. If the child is to 
be saved, the first sign of success will be that it will 
make a single spasmodic inspiration. After an 
interval there will come another, and these inspirations 
will recur at gradually shorter and shorter intervals 
until respiration becomes regular. As respiration 
becomes regular the heart's beat will become regular 
too, and quicker, and the colour of the skin will 
change from the blue or white colour that it had 
before to a healthy pink. After signs of life have 
appeared, the efforts at breathing may be stimulated 
by dipping the child in cold water, or alternately into 
hot and cold water. But if you do this, do not then 
discontinue artificial respiration, but persevere until 
the child breathes regularly. 160 
CHAPTER XV. 
THE LYING-IN PERIOD. 
The month following labour, during which the changes 
which had taken place in consequence of pregnancy 
are undone, and the parts restored nearly to the same 
state as before pregnancy, is called the lying-in 
period. The womb and vagina do not return 
exactly to the same state as before pregnancy; there 
is always some permanent difference produced by 
child-bearing. Besides the undoing of the pregnancy 
changes in the pelvic organs, there is the full estab- 
lishment of a new function : that of lactation, or 
suckling. 
Immediately at the close of labour it is very 
common for the patient to shiver. It at this time is 
not a sign of disease. It is followed by warmth and 
perspiration, and is not accompanied with fever. The 
patient naturally feels tired after the fatigue of 
labour, and after she has been made clean and 
comfortable will probably go to sleep. The pulse 
after delivery should sink to about 72 beats per 
minute, or even fewer. After the first twenty-four 
hours the pulse should sink still further : to 60 beats 
per minute, or under. It remains slow until the 
patient begins to get up. If the labour has been very 
long and exhausting, the pulse may be quicker than 
this, its quickness during the first few days being, 
as a rule, proportionate to the length of labour. If 
at first quick, it ought gradually to get slower. A 
quick pulse in the first three days is not by itself a 
proof that the patient is doing badly, but it should 
make you exceedingly careful. 
The temperature of the lying-in woman ought Chap. XV.] 
After-pains. 
161 
to be between 98° and 99°, and ought never to exceed 
100°. This is the most trustworthy index of the 
patient's condition that we have. Take the tempera- 
ture every time you visit the patient. The temperature 
may be taken either under the tongue or in the arm- 
pit. Before taking it, the index of the thermometer 
should be shaken down below 95°. In taking the 
temperature in the mouth, see that the bulb of the 
thermometer is placed well under the tongue and is 
kept there, and that the patient's lips are kept closed. 
If it be taken in the armpit, see that the arm is 
kept close to the side. Either make the patient lie 
on that side, or hold the arm close to the side with 
the other hand while the thermometer is in the arm- 
pit, and see that the bed-clothes are closely tucked in 
round the patient's neck. The thermometer should 
be left in five or ten minutes. Five minutes is enough 
for practical purposes. 
If the temperature is over 100° there is something 
wrong, although it may be only something trifling. 
If it be over 101° further advice should be asked for. 
During the lying-in period the uterus goes on con- 
tracting, just as it did during labour. For the first 
few days these contractions are painful, and they are 
called after-pains. They are more severe and per- 
sist longer in women who have had many children. 
If you put your hand on the abdomen during one of 
these pains, you will feel the uterus harden during 
the pain. The use of these pains is to expel clots 
and discharge from the womb. They can be provoked 
by rubbing the belly, or by putting the child to the 
breast, or by the movements of the patient. Some- 
times they are so severe as to make the patient sick, 
or keep her awake at night. In that case some medi- 
cine may be required to relieve them. A mixture 
suitable for the purpose is provided for use in most 
maternity charities. 162 
Midwifery. 
[Chap. xv. 
The discharge which escapes from the vagina 
during the ten or twelve days following delivery is called 
the lochia. At first this discharge is pure blood, 
and for three or four days it is mixed with blood, so 
that it is red or pink in colour. It gradually gets 
lighter in colour and less in quantity. It should not 
contain blood after the first week. After the first day 
its quantity should not be more than that at a tolerably 
copious monthly How, and this should steadily diminish. 
If the loss is much more than this, there is need of 
treatment. If it contains blood after the first fort- 
night, further advice should be sought. It should 
never smell offensively, and if, in spite of syring- 
ing, it is offensive, ask for further advice. When 
patients are properly taken care of, and vaginal 
douches are used, the discharge usually ceases alto- 
gether within a fortnight after delivery, but when the 
douche is not used it often lasts longer. It is usually 
received in a napkin, like the ordinary monthly flow. 
It is better to use pads of absorbent cotton, or Gam gee 
tissue, or wood-wool for the purpose, which can be 
burnt as soon as soiled. But if the patient be very 
poor, you need not put her to additional expense on 
this account, for if they are clean, ordinary napkins 
will do. Wool or clean napkins should be used foi' 
cleansing the parts, and not sponges ; for in ordinary 
practice it is almost impossible to be sure of the 
cleanliness of sponges. 
Retention of urine sometimes occurs in the 
first few days of the lying-in period. There are two 
causes which usually combine to produce this : the 
urethra has been bruised during the passage of the 
child, and is in consequence swollen ; the abdominal 
walls have been so stretched in the pregnancy that 
they are weakened, and the patient cannot strain to 
expel the urine. Therefore, a patient often cannot 
pass water while recumbent, but if she kneels up in Chap. XV.] 
Passage of Catheter. 
163 
bed she can do so. It is a good thing for her 
occasionally to kneel up in bed, because it helps the 
escape of discharge from the vagina. Hence, if there 
be retention of urine this is the first thing you should 
advise. If even when kneeling the patient cannot 
pass water, let some very hot water be put in the 
utensil, so that the steam from it may warm and 
moisten the parts. This will often so relax the 
swollen parts that the patient will succeed in passing 
water. If this fails, and the patient is in pain, you 
must pass the catheter. But do not use the catheter 
merely because the patient lias not passed water. If 
the quantity of urine retained is not enough to cause 
her distress, there is no urgent need for its being 
withdrawn. 
To pass the catheter.-Place the patient on 
her back, with her knees drawn up. Cleanse the 
parts by gently wiping them with wool dipped 
in 1 in 2,000 sublimate solution. Take the catheter 
in the right hand, and hold it about two inches 
from the tip. (It is a good thing to put about 
three feet of indiarubber tubing over the open end of 
the catheter; the urine is then conveyed out of the 
bed into a utensil on the floor.) Stand on the patient's 
right side, and pass the right hand holding the 
catheter under the patient's right thigh. Pass the 
left forefinger over the abdomen between the labia 
into the vagina. Then draw it upwards exactly in 
the middle line until the pulp of the forefinger feels 
the orifice of the urethra. The meatus urinarius feels 
very like one of the small linen-covered buttons 
with which underclothing is often fastened : a little 
ring, with a slight depression in its centre. When 
you feel this, draw the finger upwards till it is just 
above the meatus, and then with the right hand pass 
the point of the catheter below the tip of the left 
forefinger into the urethra. If you cannot succeed in 164 
Midwifery. 
[Chap. XV. 
thus quickly finding the meatus by the touch, it is 
better to look than to annoy the patient by prolonged 
attempts at passing the catheter by the touch alone. 
Diet.-During the first two days of childbed a 
patient seldom has much appetite, and she should be 
limited to light food, such as is easily digested : gruel, 
beef-tea, bread and milk, etc. But as soon as appetite 
returns she may be allowed to eat and drink what 
she likes. It used to be the custom to half-starve 
lying-in women, under the idea that by restricting food 
inflammation and fever were prevented; but we know 
now that diet has nothing to do with the development 
of these diseases in childbed. It is usual on the third 
morning after delivery to give an aperient. It is not 
of great importance what the aperient is ; and if the 
patient prefers any particular laxative, you may let 
her wish influence you. 
The secretion of milk.-The breasts begin to 
produce milk quite early in pregnancy, and by the 
time of labour milk can easily be squeezed out of the 
nipples. After delivery, the secretion of milk rapidly 
increases, and by the third day the breasts are 
generally quite full, and if they are not emptied will 
become hard and painful. This secretion of milk 
comes on just the same when the child has been still- 
born, so that it is not altogether dependent upon 
suckling; but if the child does not suck, the secretion 
of milk soon ceases. It is in many ways better for 
the mother to suckle the child if she can. The first 
milk that is produced is rather yellowish in colour, 
and is called " colostrum." 
Suckling.-The child should be put to the breast 
for a few minutes only, three times in the twenty-four 
hours, until there is plenty of milk. A healthy child 
does not suffer from the deficient supply of milk 
during the first day oi' two. After that, it should be 
put to the breast regularly every two hours, for about Chap. XV.] 
Soreness of Nipples. 
165 
ten minutes each time, to one breast only at a time : 
the breasts being used alternately. But if the child 
be asleep, it should not be awakened to take the 
breast. The mother should be careful not to fall 
asleep while the child is at the breast. 
The nipples.-If the nipple should not stand out 
sufficiently for the child to take it, it should be pulled 
out with the fingers before putting the child to it. If 
this is not successful, a nipple shield should be used. If 
the child cannot draw the milk through the shield, the 
nurse should put her lips to the shield and fill it with 
milk, so as to give the child an easy start. There are 
nipple shields made, fitted with two tubes, by one of 
which the mother can herself suck the milk into the 
shield, while the child sucks it out with the other ; 
but these are rather more expensive than simple 
shields. If there be no shield at hand, the nipple 
may be drawn out by filling a soda-water bottle with 
hot water, emptying it, and applying the mouth of 
the bottle over the nipple. A napkin or pocket- 
handkerchief wrung out in cold water should then 
be wrapped round the bottle. The hot bottle makes 
the air inside it expand; when it is cooled, the air 
inside shrinks in volume, and the nipple is sucked in. 
After the child is taken from the breast the 
nipple should be washed, and carefully dried with a 
soft napkin. A woman pregnant for the first time 
should be instructed to wash the nipples night and 
morning during the last month of her pregnancy with 
equal parts of brandy or whisky and water, or eau- 
de-cologne, in order to harden them. This often 
prevents sore nipples. 
Soreness of the nipples is very common. If 
not properly looked after, about half of all nursing 
mothers suffer in this way. It is more common in 
nursing the first child than subsequent ones. It is 
more common in delicate than in robust women. It 166 
Midwifery. 
[Chap. XV. 
is especially apt to occur when the child is strong, and 
grips the nipple hard; when the nipple is badly 
shaped, so that the child has difficulty in getting it ; 
and when the nipple is not properly washed and dried 
after suckling. 
Soreness of the nipples generally begins soon : in 
most cases within the first three days. There are two 
chief kinds of sore places : One is at the top of the 
nipple, and begins as a little vesicle or bladder, or 
several of them, about the size of a pin's head. These 
soon break, and dry up into black or brown crusts. If 
these are picked off (which there is no need to do), sore, 
easily bleeding places will be found beneath them. If 
they are properly treated they will generally heal by 
the end of the first week. The other sort is a crack 
or ulcer, which runs round the base or side of the 
nipple-usually at the place where the nipple joins 
the breast. This is produced by the biting and 
pulling of the child; and the crack is usually where 
the child's upper gum seizes the nipple. If such a 
crack is present, care should be taken that the child is 
not put to take the breast in such a position that the 
nipple is pulled upon so as to stretch open the crack. 
This form lasts longer than the one first described. 
Nipples so affected may remain sore a fortnight or 
more. 
The treatment of sore nipples consists in carefully 
washing and drying them after suckling, and then 
applying glycerine of borax. If suckling causes much 
pain, the child should only be allowed to take the 
breast through a nipple shield. 
Painful fulness of breasts.-Sometimes- 
especially if the nipples are sore, or the child 
feeble-more milk is produced than the child 
draws out; the breasts become very full, swollen, 
knotted, hard, and tender; and this condition may 
make the patient feverish, and if not relieved, may go Chap. XV.] 
Fulness of Breasts. 
167 
on to abscess. If the breasts are so full as to be 
uncomfortable, they should be emptied by a breast 
pump or a soda-water bottle. If the child was still- 
born, or has died, or the mother is not going to suckle 
her child, this may be repeated as often as necessary, 
and will soon cease to be required; for if the breasts 
are deprived of the stimulus of a sucking baby, they 
soon leave off producing milk. It would often be 
very desirable, in the case of babies too feeble to suck, 
or nipples too badly-shaped for the baby to grasp 
them, to draw the milk from the breast with a pump, 
and give it to the child with a spoon; but as a rule 
this cannot be done, for the breast soon ceases to 
produce milk when the child is not applied to it. 
You need not, therefore, prescribe any medicines to 
drive away the milk. See that the breasts are made 
comfortable, and the milk will go away if the mother 
does not suckle. 168 
CHAPTER XVI. 
ON GERMS, DISEASE, AND ANTISEPTICS. 
NIicrobes, and what they do.-The air is 
full of living matter. When a beam of light is let 
into a dark room, in the track of the beam a tine dust 
is seen floating in the air. In every place that men 
inhabit this dust is formed of (among other things) in- 
numerable living particles, seeds of small plants, and 
also living things too low in organisation to be called 
either plants or animals. These living things can 
only be seen by a very powerful microscope, and some 
of them cannot be seen even by the most powerful 
microscopes until by the use of chemicals they have 
been stained a dark colour so as to make them con- 
spicuous. They are spoken of as micro-organisms, 
microbes, or germs. Mr. Darwin left a plot of 
ground, two feet by three (which he called his " weed 
garden "), quite uncultivated, to see what would 
happen-he neither sowed, nor manured, nor weeded 
it. In three months 357 different weeds had sprung 
up in it. This shows what a number of seeds there 
are floating about in the air ; but this observation 
only shows how many seeds there are which grow into 
plants big enough to be seen. The seeds of plants of 
microscopic size are innumerable. Now, just as the 
higher animals feed upon animal and vegetable matter, 
and after digesting it excrete it in the changed and 
noxious forms of urine and faeces, so these germs feed 
upon organic fluids and solids, and as they consume 
them, alter them. Some feed upon milk, and turn it 
sour ; others upon bread, and make it mouldy; others 
upon flesh, and make it putrid. It is through microbes 
that urine left in a vessel a few days comes to stink. Chap. XVI.] 
Action of Microbes. 
169 
If milk, or meat, or urine be kept free from germs, it 
will remain unchanged for any length of time. The 
germs can be killed by heat or by certain chemicals. 
Thus, preserved meat is freed from germs by boiling, 
which kills the germs. In museums, parts of animal 
bodies are kept unchanged by being immersed in 
spirit, which kills the germs, and so prevents putre- 
faction. 
Action of microbes in tlic body.-There 
are microbes which feed upon the tissues and fluids of 
the human body. Some are able to live and multiply 
in the living body.* By doing so they produce disease. 
There are many different kinds of them, and they 
produce many different diseases. The diseases which 
are most important in the case of lying-in women- 
because those which, in consequence of delivery, she is 
especially liable to get-are those caused by germs 
which enter the body through wounds, and multiply in 
the blood. The chief forms are called septicaemia, 
pyaemia, diffuse inflammation of the cellular tissue, 
and of the peritoneum. These diseases are very dan- 
gerous, and generally fatal. 
Microbes in the secretions.-There are 
other germs which can live in the tissues of the body 
when those tissues are dead, or in the fluids of the 
body after they have been separated, but which are 
destroyed by the living tissues. Germs of this kind 
can live in the lochial discharge, and then alter it and 
make it stink ; and if the patient be not kept clean, 
and this stinking discharge be allowed to accumulate, 
it may be absorbed, and make the patient ill. But in 
this disease (which is called sapramia), as the germs 
do not enter the blood, the patient quickly gets well 
when the discharge which the germs have rendered 
poisonous is washed away. 
With regard to this disease some practical 
points must be remembered. First, the patient may 170 
Midwifery. 
[Chap. XVI. 
be clean externally, and yet there may be, high up, in 
the uterus or top of the vagina, some poisonous dis- 
charge which is not flowing away as it ought to do, but 
is poisoning the patient. So you must not think that 
because no bad smell is perceived about the patient, or 
the discharges that can be examined, therefore the 
secretions are perfectly healthy. Secondly, the dis- 
charge may smell badly, and yet, if it flow freely 
away, it may not be absorbed-or rather, not enough 
of it may be absorbed to make the patient very ill-and 
so the offensive discharge may <Jo no mischief. Do 
not, therefore, take upon yourself to judge from the 
character of the discharge whether the patient is 
doing well or badly. This is one of those details, 
the importance of which only a well-trained medical 
man can estimate. But if the discharge be offensive, 
it shows that the patient has not been well taken 
care of. 
How microbes come to attack patients. 
-These germs all come from without. They are 
brought to the patient; the patients do not breed 
them. The most poisonous germs-those that enter 
the body by wounds, and grow and breed in the dis- 
charges and in the blood-are hardly ever found in places 
where houses are kept clean and people not crowded 
together. But in hospitals, where wounds abound, 
they find their pasture so abundant that they can 
only be kept down by incessant care. Before Sir 
J. Lister introduced antiseptics these diseases were 
never absent from hospitals : they could not be 
kept down. Every lying-in hospital in London has 
had from time to time to be shut up because these 
diseases prevailed in it. They prevailed because the 
germs had got into the hospital, and being continually 
present in it, floating about in the air, adhering to in- 
struments, to the hands of the attendants, etc., were 
transferred from patient to patient. They were only Chap. XVI.] 
Antiseptic Treatment. 
171 
got rid of by shutting up the hospital, thus depriving 
the germs of their food, and preventing their multipli- 
cation : and then by plenty of washing they were got 
rid of for a time. 
Antiseptic treatment.-Sir Joseph Lister dis- 
covered that these diseases were due to germs, and 
could be prevented by killing the germs. The drugs 
that kill the germs are called antiseptics. The pre- 
cautions that are used to prevent germs from getting 
to the patient, and to kill them if they do get to her, 
are called antiseptic treatment. Anything that is 
perfectly clean and has no germs of disease or putre- 
faction attached to it is said to be aseptic. Anti- 
septics are used to make things aseptic. 
Why necessary.-Some people think that anti- 
septics are not necessary, and point out what good 
results have often been got without them. In private 
houses, especially those in the country, the patient and 
her surroundings are generally free from germs of 
disease, although those of putrefaction are everywhere 
present in our climate. In practice among such 
patients, if antiseptics are not used, septic diseases do 
not occur so long as the lochia flow away properly, 
and the soiled napkins are removed from the patient 
before they have time to stink. But we never can be 
absolutely certain that everything is aseptic ; and in 
hospitals we may be sure that if antiseptics are 
not used things will not remain aseptic long. In 
hospitals, therefore, no detail of antiseptic treatment 
should be omitted, and a lying-in woman wherever 
she may be is safer if antiseptics are used. The only 
reason for not using them is that if carelessly used 
harm may be done. But antiseptic treatment does 
not do harm if carried out carefully. 
The antiseptic precautions used in midwifery 
practice are of two kinds : (1) those which aim at 
rendering aseptic everything which comes into contact 172 
Midwifery. 
[Chap. XVI. 
with the patient, and (2) those which aim at killing 
any germs that may already have reached her. Of 
these, the first are the more important, for, as women 
do not themselves breed disease germs, if we could be 
sure of making everything round her aseptic there 
would be no need of the second class of precautions. 
The first class comprises perfect cleanliness of the 
attendant's dress and of the patient's linen, the cleans- 
ing of the attendant's hands and nails with soap and 
water and a nail-brush, and the soaking of them in an 
antiseptic solution, and the similar cleansing of instru- 
ments. The second class consists in the use of 
vaginal douches of antiseptic fluids. 
The antiseptics in common use are corrosive 
sublimate, carbolic acid, and permanganate of potash, a 
solution of which is sold by all chemists under the 
name of Condy's fluid. 
Corrosive sublimate is the most powerful. 
So far as we know, there is no living thing that 
corrosive sublimate will not kill. The disadvantage 
of its use in midwifery practice is that if used with- 
out proper precautions it may be absorbed, and 
poison the patient. But it cannot poison instruments, 
and no harm can result from dipping the hands in it. 
Therefore, if you want to make your patients safe, 
take corrosive sublimate with you, and let the nozzle 
of the syringe and the catheter which you may use 
for the patient lie in the sublimate solution before 
use. The sublimate solution decomposes soap, and 
therefore you cannot use the sublimate solution for 
washing your hands, you must dip the hands in it 
after washing. Immediately after labour is ended, 
the vagina should be syringed with a sublimate solution 
of 1 in 2,000. It is not necessary to syringe the 
uterus, except in cases in which it has been necessary 
to pass the hand into the womb; and as in such cases 
you should have sent for your superior officer, he will chap, xvi.] Douches in Lying-in Period. 
173 
direct whether this should be done or not, and how 
it should be done. Tt has been already said that 
women do not breed germs of disease, and therefore, 
that there are none in the womb; and if any have 
been accidentally carried up to the neck of the womb, 
they will have been washed down into the vagina by 
the haemorrhage accompanying the third stage of labour. 
Germs may get into the vagina from the air, and 
therefore it is safer to wash out the vagina, and it is 
harmless if properly done. The essential precaution 
in doing it is to see that all the injected fluid escapes. 
After the injection is finished, press on the lower part 
of the abdomen, pressing the uterus downwards and 
backwards, in the same way as when you pressed out 
the placenta. This will press out all the fluid, so that 
not enough of it will be absorbed to do harm. A 
solution stronger than 1 in 2,000 is slightly irritating 
to the mucous membrane, and it has been found by 
experience that 1 in 2,000 is strong enough. 
In well-managed lying-in hospitals a vaginal douche 
of 1 in 2,000 sublimate solution is given night and 
morning for the first three days, because it is during these 
days that the risk of infection is greatest. After the first 
three days, a douche of 1 in 4,000 is given until the 
lochia have stopped. In most patients no harm what- 
ever follows these douches. Some people are more 
susceptible of poisoning by corrosive sublimate than 
others, but we do not yet know how to identify 
beforehand such patients. In hospitals, the very first 
symptoms of poisoning are at once detected, the sub- 
limate is left off, and the symptoms quickly subside. 
In attendance on patients at their own homes, 
remember that if when a sublimate douche is given 
all the fluid is not well pressed out afterwards, 
there is great risk of poisoning. Also if the use 
of sublimate is continued after symptoms of poisoning 
have appeared, the symptoms may become serious. 174 
Midwifery. 
[Chap. XVI. 
For these reasons do not let any one but yourself 
administer sublimate douches to a patient under your 
care. And as the risk of septic poisoning is much 
less in private houses than in hospitals, and circum- 
stances may prevent you from visiting the patient 
twice a day, it is better, in private houses, to use 
during the lying-in period an antiseptic which is not 
dangerous. A weak antiseptic douche regularly given 
twice daily is better than a strong one given less often. 
These douches during the lying-in period are the 
least important of the antiseptic precautions. If the 
labour has been natural, every precaution has been 
observed during its course, and an efficient antiseptic 
douche given at its close, vaginal douches during 
the lying-in period are probably superfluous so far as 
the prevention of septic infection is concerned, 
although they make the patient cleaner and more 
comfortable. Moreover, it is possible, if the nurse is 
careless about the cleanliness of her syringe, and the 
proper preparation of the douche fluid, for these 
douches to do harm. Therefore, if there be any 
doubt as to the competence and carefulness of the 
person who will give the douches, it is better not to 
prescribe them at all. 
In special cases it may be well to use sublimate 
during the lying-in period, even in private-such 
cases, for instance, as those in which the child is 
decomposing, and the discharges in labour are 
offensive; cases of very long labour: of placenta 
prsevia ; or cases in which the patient before labour 
has had a profuse yellow discharge. As to this, 
get further advice before employing sublimate. 
The first symptoms of sublimate poisoning' 
are a coppery taste in the mouth, soreness of the 
gums, with the formation of a red line where they 
join the teeth, and diarrhoea. If these symptoms 
appear in a patient who is having sublimate douches, Chap. XVI.] 
Sublimate Poisoning. 
175 
they should be left off at once. If the symptoms are 
severe, further advice should be sent for, and you 
should be careful to let whoever has to prescribe 
know that the patient has had sublimate used to her, 
lest he should prescribe opium, which is dangerous in 
cases in which diarrhoea is due to sublimate poisoning. 
Carbolic acid solution of a less strength than 
1 in 40 cannot be relied upon as a disinfectant. A 
stronger solution than this is irritating. Carbolic acid 
must be carried in a bottle, and the strength of the 
solution measured; and this is less convenient than 
carrying powders or pastiles, which go in the pocket 
or bag. Therefore, carbolic acid is not so convenient 
for use at"the time of labour as sublimate, besides being 
not so trustworthy. It is an excellent antiseptic to 
use after labour, but is not so convenient as Condy's 
fluid. 
A solution of permanganate of potash is sold every- 
where, under the name of Condy's fluid. It is 
decomposed by the secretions of the vagina, and 
turned from the rich purple, which is its proper colour, 
to a brown. So long as this change in colour takes 
place, the fluid is incapable of doing any work as a 
disinfectant. The nurse should make a solution of 
the strength of two table-spoonfuls of Condy's fluid to 
a quart of water, and go on syringing the patient 
with it, using more than one quart of the solution if 
necessary, until thefluid returns exactly the same colour 
as it went in. When it does this, it has a powerful 
antiseptic effect; but until it does this it is useless.* 
Iodine is sometimes used as an antiseptic in mid- 
wifery practice, jij of tincture of iodine being mixed 
with a quart of water. This is more expensive than 
either sublimate or Condy's fluid. It has this further 
disadvantage, that when a watery solution of iodine 
is exposed to the air, the iodine rapidly evaporates. 
* See Baxter : "Reports of Med. Off. of Privy Council, 1875." 176 
CHAPTER XVII. 
THE INFANT. 
The nurse's duty.-After labour, the nurse 
should not set about washing the baby until she has 
done everything necessary for the mother-has cleared 
away the soiled draw-sheet, applied a clean pad or 
napkin, and put on the binder if so directed. She 
should, before she begins, see that everything that is 
wanted for washing and dressing the child is at hand. 
In the interval, the child should be left in a safe 
position near the fire. 
The nurse should wash the baby in water at the 
temperature of 98°. The eyes, mouth, nose, and ears 
should be first cleansed with especial care and gentle- 
ness. The child's body is covered with an adherent 
cheesy coating, which is called the vernix caseosa. To 
remove this, the skin must be gently rubbed with oil 
or vaseline. Then this must be washed off with soap 
and water. Ordinary yellow soap is as good as most 
fancy kinds. The child should be well lathered all 
over with a piece of soft flannel, and then dipped in 
the bath, and the soap well rinsed off. When the 
child is in the bath, by placing the left hand under its 
back, and at the same time supporting the neck with 
the fore-arm, a sufficiently firm hold on the child is 
obtained, and the head is prevented from falling back 
into the water, while the right hand is left entirely at 
liberty. After the soap has been rinsed off, the child 
should be quickly dried and powdered-especial care 
being taken to thoroughly dry and well powder all 
creases and folds of the skin-in front of the fire, and 
not unnecessarily exposed to the cold air. Before 
dressing the child, care must be taken to see that the Chap. XVII.] 
The Umbilical Cord. 
177 
cord has been properly tied, and that there is no oozing 
from the stump. 
In dressing- the umbilical cord, the essential 
thing is to keep it dry and clean. If it be not kept 
dry, it will stink. If the dressing put to it is not 
clean, disease may be produced. If it be kept dry 
and clean, it shrivels up without smell, and drops off 
in about five days. 
The best method of dressing it is to powder it well 
and wrap it up in clean dry wool. Among the poor the 
customary dressing is a bit of rag which has been 
scorched at the fire; a hole is cut in the middle of 
tliis, the cord put through the hole, and the 
rag folded over it. This is a very good dressing, 
because the scorching of the rag ensures its being dry, 
and destroys any germs that may be attached to it. 
Sometimes, until the cord has separated, the child is 
washed every day without being immersed in the 
bath. In that case the dressings of the navel-string 
are left undisturbed, and it is necessary to guard 
against wetting them. Sometimes the child is bathed 
every day, and the dressing of the cord renewed each 
time. As to this, the nurse must be guided by 
circumstances. 
Ilaniiorrliage from the cord.-Occasionally, 
soon after birth, some oozing of blood may be found 
taking place from the navel-string. This is due 
either to the ligature being not tight enough, or 
having slipped in consequence of not being properly 
tied, or being too thin, so that it has cut through the 
vessels instead of compressing them. If there be. 
oozing, the cord must be tied again between the first 
knot and the child's abdomen, taking care to avoid 
the fault that made the first tying inefficient. 
Diseases of the umbilicus.-If germs of 
disease have got access to the umbilicus-which may 
happen if proper attention is not paid to cleanliness- 178 
Midwifery. 
[Chap. xvn. 
it may become inflamed. There may be inflammation, 
slight or severe, of the skin round it, or the umbilical 
vein may become inflamed. The latter, when it 
occurs, often leads to fatal blood-poisoning. Your 
duty is to prevent these diseases. If they occur, you 
should seek further advice. 
Sometimes after the fall of the cord the umbilicus 
is slow in healing. The best treatment is to keep it 
clean, and apply a little zinc ointment on a bit of 
clean rag, the ointment being pushed down to the 
bottom of the umbilical depression. If the umbilicus 
has not healed at the end of three weeks, advice should 
be sought. 
There may be hernia: that is, a protrusion of bowel 
from deficient closure of the umbilicus. This may be 
present at birth, the protrusion being into the cord, 
and having for its outer covering the amnion, which 
should cover the cord only. This condition is rare. 
It is a very serious one, for it is usually fatal if not 
treated. If you think it present, further advice 
should be sought at once. After the umbilicus has 
healed a slight protrusion is very common, and usually 
diminishes and disappears as the child gets older. If 
the protrusion be larger than a nut, advice should be 
sought. The treatment is to hold together the skin 
at the sides of the opening, and then put on a broad 
piece of strapping to keep them together. 
It takes about three weeks for the child to 
get fully accustomed to the conditions of indepen- 
dent life. Certain structures which fulfilled impor- 
tant functions while it was in the womb gradually 
waste, and practically cease to be; and other parts, 
especially the lungs and stomach, take on a new 
activity. These changes take about three weeks for 
their full accomplishment. 
Tlie cry.-After the child has begun to breathe, 
almost the first thing it does is to cry : because it feels Chap. XVII.] 
Caput Succedaneum. 
179 
cold, and is exposed to unaccustomed pressure. The 
use of the cry is to make known the child's wants, and 
to call attention to anything that hurts it. The cry 
is composed of two noises: a weak wail as it is 
drawing in its breath, and a loud squall produced by 
air passing out of its windpipe. Strong children cry 
more loudly than feeble ones, and in them the 
inspiratory sound is very slight; but in very small or 
weakly children it is sharper and longer. Hence the 
character of the cry is an indication of the well-being of 
the child. If a child cries long, its brain and lungs 
become greatly congested, and this is injurious. The 
nurse, therefore, ought not to let a child go on crying, 
but should try to find out why it is crying. 
Effects of labour on the child's head.-At 
birth the child's head is often slightly deformed, from 
compression during labour, partly from alterations in 
the shape of the bones by squeezing, partly from swell- 
ing of the soft parts covering the bones. The precise 
changes in shape that take place depend upon the 
position in which the head has been delivered. The 
changes in the shape of the bones get much less in 
the first few days, but often persist in a slight degree 
throughout life. 
Caput succedaneum.-When labour is long, 
the head is so pressed on by the wall of the genital 
passage that the vessels of the scalp are compressed, 
and the circulation through the part beyond the 
girdle of pressure is impeded. Hence there is effusion 
of serum, and often of blood, into the loose tissue 
under the skin of the part which, being in advance 
of the girdle of pressure, is not so much pressed on. 
This kind of swelling is called the caput succedaneum. 
It forms a soft doughy swelling, which, as a rule, is 
greatest over the part which presented at the os uteri. 
(This part, in the first position, is the upper and 
posterior angle of the right parietal bone.) From the 180 
Midwifery. 
[Chap. XVII. 
point where there is most swelling it diminishes 
gradually all round, without any sharp edge or line of 
demarcation. It all disappears in a day or two. 
After delivery with the face presenting, swelling of 
the face of a similar nature may make the child's 
appearance repulsive; but you may comfort the 
mother by telling her that it will soon go away. 
After delivery with the breech presenting, the scrotum 
may be greatly swollen. This also will quickly 
diminish. 
CephalliaMnatoma.-In some few cases there 
is haemorrhage, not into the loose tissue underneath 
the skin, but between the pericranium (the membrane 
covering the bone, and from which the bone is formed) 
and the bone. This is called cephalhematoma. This 
swelling differs from a caput succedaneum, in that it 
is limited to the space over one bone, never trans- 
gressing a suture. It is usually over a parietal, less 
often on the occipital bone. There may be more than 
one such swelling, but this is very rare. Further, 
during the first two or three days the cephalhaematoma, 
instead of disappearing like the caput succedaneum, 
gets a little larger. It is firmer and feels elastic, not 
doughy. It is bluish in colour. After a few days 
the pericranium (the bone-making membrane) begins 
to form bone. It does this at the edge of the 
swelling, because here it is best supplied with blood. 
Therefore, in about a fortnight you feel a soft, elastic 
swelling, evidently containing fluid, with a hard raised 
edge all round, as if the fluid were in a cup sunk in 
the skull. The fluid is gradually absorbed, and the 
swelling disappears in a few weeks. Neither caput 
succedaneum nor cephalhematoma requires treatment. 
Cyanosis.-Some children are born with heart 
disease. You will suspect this if, after breathing is 
well established, the child's skin and lips do not 
acquire the natural rosy tint that they should, but its Chap. XVII.] 
Meconium. 
181 
skin and lips are bluish, like those of a child in 
suspended animation. This blue condition is called 
cyanosis. If there are symptoms of this kind further 
advice should be sought. 
Loss of weight. - The average weight of a 
newly-born child is from 7 lbs. to 8 lbs. During the 
first three days of life children lose weight, on the 
average, to the extent of not quite half-a-pound. 
Then they begin to increase, and by the end of the 
first week the loss is made up again. This is 
because during the first three days the child generally 
does not get very much food. 
Sleep.-In the first few weeks of life the child 
should sleep almost continually ; and if healthy, it does. 
The usual cause of its waking is that it either feels 
hungry or cold. It wakes more often during the 
night, because the night is colder. If it be hungry, it 
will go to sleep again after being fed, but if cold, it 
will go on crying, although it has been fed. Often 
the mother finds out the reason of this, and to pacify 
the child takes it into her own bed, where the heat of 
her body keeps it warm. This is a dangerous 
practice; for the mother may go to sleep, and some 
unconscious movement on her part may lead to the 
suffocation of the child-"overlaying," as it is called. 
A good nurse ought not to let the mother keep the 
child in bed with her, but should sit by her till she 
has satisfied the baby's hunger, and then put the child 
into its cradle, first putting warm dry things on it, 
and taking care that it is well wrapped up, and, if 
the weather be cold, that a hot bottle well wrapped 
in flannel is put in the cradle with it. 
That which the child passes with the first actions 
of the bowels is called meconium. This is the 
Greek word for poppy-juice, which this stuff some- 
what resembles. It is thick, and greenish-black in 
colour Sometimes some is passed during labour or 182 
Midwifery. 
[Chap. XVII. 
directly after delivery. But the more usual time for 
the first action of the bowels is six or eight hours after 
birth, and it may be delayed for twenty-four hours or 
more. But if twenty-four hours after birth no motion 
has been passed, you should examine the child to see 
that no malformation is present; and if you are in 
doubt as to whether there be one or not, or if it has 
not passed water for twenty-four hours after birth, 
you should seek further advice. The motions remain 
of the same character for from two to five days. Then 
they gradually alter, and become of about the colour 
and consistence of beaten-up eggs. A healthy child 
usually passes motions two to four times daily. In 
conditions of ill-health the motions may become 
green ; they may be very watery ; they may smell 
very badly, contain solid lumps of undigested matter, 
or be mixed with blood. If any of these conditions 
be present, you should inquire as to the food the child 
is taking. If it is being improperly fed, you should 
give directions how to feed it properly; and if, 
although properly fed, it continues ill, seek further 
advice. The mere fact that the stools are green is not 
important if the child is not ill, if it eats and sleeps 
as usual, and if it is not fretful. 
Artificial feeding'.-If the mother cannot suckle 
the child, great care is necessary in feeding it. The 
best food to begin with is cow's milk diluted with 
three times as much water, and sweetened. Milk is 
composed of water, cream, sugar, and casein. Casein 
is an albuminous substance : that is, one, in chemical 
composition and nutritive power, something like white 
of egg. Just as white of egg is made hard by boiling, 
so casein is coagulated by the juices of the stomach. 
Hence the casein is the part most difficult of digestion. 
When a child cannot digest its food properly, and 
vomits it up, the coagulated casein is seen in the 
vomit as white curds. Cow's milk differs from human Chap. XVII.] 
Feeding of Infant. 
183 
milk in containing less sugar and more casein. In 
consequence of this greater quantity of casein, a young 
infant cannot digest cow's milk. To make it a fit 
food for an infant, cow's milk must be diluted 
with two or three times as much water, and sugar 
added to it. A table-spoonful of lime-water may be 
added to each meal with advantage; and instead of 
plain water, barley-water may be used. The casein of 
cow's milk coagulates in the stomach in larger lumps 
than the casein of human milk, and is therefore more 
difficult of digestion. Barley-water prevents the 
formation of lumps quite so large as would be formed 
without it. The very last drops of milk drawn from 
the cow contain more cream than that first drawn, 
and are called by dairymen " strippings," or in Scot- 
land " afterings." This is better suited for children 
than the bulk of the cow's milk. Cream is quite 
easily digested by infants, and may be added to the food 
in a proportion as large as 1 to 4 without harm. If 
the milk prepared as above directed seems not to 
agree, it may be boiled before use. 
Feeding'.-About three or four ounces of food is a 
sufficient meal for an infant. If more be given, it will 
probably make the child sick. It should be given at 
about the temperature of the body-98'5°. The food 
should be freshly prepared each time, not allowed to 
stand about and get sour. The child should be fed 
every two hours during the day, and every four hours 
during the night. 
Feeding-bottles.-One reason why bottle-fed 
babies do not thrive so well as those that are 
suckled, especially among the poor, is the difficulty of 
keeping the bottles clean. The best kind of bottle is 
the old-fashioned boat-shaped bottle, which has no 
tube, but simply a teat fastened on the spout. But 
this kind of bottle requires that the nurse must hold 
the child and the bottle all the time that it is taking 184 
Midwifery. 
[Chap. XVII. 
food. Therefore nurses and mothers generally prefer 
a bottle with a flexible indiarubber tube, so that they 
can lay the child down and leave it to suck out of the 
bottle while they are busy with other things. The 
objection to these is the difficulty of cleaning them : 
there are so many joints and crevices in which drops 
of food may remain lodged. If this sort of bottle be 
preferred, the best are those in which the tube and 
the cork are all made of one piece of indiarubber. 
There should be two bottles, to be used alternately, so 
that thorough cleansing of the bottle and tube may 
never be prevented by hurry. If the bottle and tube 
are not thoroughly clean, the drops of milk clinging 
about them will turn sour (from the access of micro- 
organisms). The most common result of dirty bottles 
is the production of thrush, a disease characterised 
by the presence of white spots on the inside of the 
child's mouth. These white spots are due to a micro- 
scopic plant, called the o'idium albicans. To prevent 
this, not only should the bottles be kept clean, but the 
child's mouth should be wiped out after taking food. 
If there be any suspicion of thrush, or doubt as to the 
nurse's care in washing the bottle, she should be told 
to boil bottle, tube, and teat. This will destroy any 
germs that may be clinging about them. Some 
glycerine of borax should also be applied to the inside 
of the child's mouth with the finger. 
Ophthalmia is one of the most serious diseases 
that affect young infants, for it leads, if neglected, to 
total blindness. It is manifested first by redness of 
the eyes, then swelling of the lids, and yellow dis- 
charge from the eyes. Some women suffer from 
vaginal discharge of a kind capable-if some of the 
matter should enter the child's eyes-of causing this 
severe inflammation of the eyes. The discharge both 
in the woman and in the child is produced by 
microbes. These microbes get into the eyes, either Chap. XVII.] 
Ophthalmia. 
185 
during birth, or by contact with dirty fingers or 
towels after birth. Fortunately, there are not many 
women who at the time of delivery suffer from vaginal 
discharge of this virulent kind. 
Prevention.-Ophthalmia is to be prevented by 
washing away and killing the microbes. If the mother 
has been suffering from a profuse yellow vaginal dis- 
charge before labour, the vagina should be washed out 
towards the end of the first stage of labour (that is, when 
the os uteri has reached nearly full dilatation) with a 1 
in 2,000 solution of corrosive sublimate. After the 
child is born, having cleansed its eyes as usual, as 
soon as your duty to the mother will permit, wash your 
hands clean, and dip them in the sublimate solution. 
Then dip a corner of a clean napkin in the 1 in 2,000 
sublimate solution : hold the child's eyelids open with 
one hand, and with the other squeeze out a few drops 
of the sublimate solution into the eye, so that the 
globe of the eye and inside of the lids may be well 
washed by it. Do this to each eye. 
In any case in which signs of ophthalmia, however 
slight, appear, seek further advice. 
Jaundice.-It is not uncommon in children a 
few days old for the skin to become of a yellowish 
colour. This is often called jaundice; but it is not 
true jaundice, for the motions are natural in colour. 
It passes off in a few days, and requires no special 
treatment. True jaundice, with whiteness of the 
stools, is very rare in infants. If it occur, advice 
should be sought at once. 
Swelling of breasts.-The breasts of young 
infants sometimes become swollen, hard, and tender, 
and even secrete milk. Sometimes this condi- 
tion is the result of their being squeezed and 
rubbed by ignorant persons; or by such, treat- 
ment of this kind may be proposed for it. No such 
squeezing or rubbing should be done; the breasts 186 
Midwifery. 
[Chap. XVII. 
should be protected from pressure or friction, by a 
wool pad ; and if with this the condition does not 
improve, further advice should be sought. 
Convulsions form one of the most frequent of 
serious diseases in young children. It is not common 
for a child to have convulsions in the first two weeks 
of its life, and unlikely that you will be there at the 
precise moment when the fit comes on. But should 
this happen, let the child be put at once into a warm 
bath ; and remember that the most common cause of 
convulsions at this early age is indigestion. Let 
further advice be sought, and in the meantime inquire 
into the character of the child's food, and stop the 
giving of anything unsuitable. INDEX. 
Abdominal palpation, 80 
Accidental haemorrhage, 137 
, Concealed, 140 
Adhesion of placenta, 145 
After-coming head, Delivery of, 
97, 99, 183 
After-pains, 161 
Amnion, Dropsy of, 1, 148 
Antiseptic douche after labour, 77 
preparations, 67 
Antiseptics, 171 
Arms, How to bring down, 98 
Artificial feeding, 182 
respiration, 159 
Aseptic, 171 
Atony of uterus, 147 
Attendant, Duties of, 65 
B 
Barley water, 183 
Bed, Preparation of, 68 
Binder, The, 78 
" Bleeders," 148 
Bottles, Feeding, 183 
Breasts, Fulness of, 166 
, How to empty, 165 
, Swelling of, in infant, 185 
Breech, Diagnosis of, 93 
labour, Management of, 96 
positions, 56 
Bregmato-cotyloid position, 42 
Brim of pelvis, 12 
Brow presentations, 57 
C 
Caput succedaneum, 179 
Carbolic acid, 175 
Casein, 182 
Catheter, How to pass, 163 
Cavity of pelvis, 13 
Cellular tissue, Inflammation of, 
109 
Cephalhsematoma, 180 
Cervix, Laceration of, 152 
, Rigidity of, 101 
Child, Deformity of, 157 
, Position of, 31 
, Separation of, 73 
Chorion, 1 
Clitoris, 5 
Coccyx, 9 
Concealed accidental haemorrhage, 
140 
Condy's fluid, 175 
Conjugate, diagonal, How to 
measure, 128 
diameter, 13 
Contracted pelvis, 125 
Contraction of uterus, 21 
of pelvis, 102 
, Tonic, of uterus, 104, 106 
Convulsions in infant, 186 
Cord, Descent of, 116 
, Dressing of, 177 
, Expression of, 116 
, Ligature of, 73 
, Presentation of, 116 
, Prolapse of, 116 
, Shortness of, 121 
, Umbilical, 5 
Coronal suture, 16 
Corrosive sublimate, 172 
Cream, 183 
Cross births, 109 
Cry, The, 178 
Cyanosis, 180 
D 
Darwin, Mr., his " weed garden," 
168 
Decidua, 1 
Deformity of child, 157 
of head, 179 
Delay in labour, 100 
Descent of cord, 116 
Diagnosis of breech, 93 
of elbow, 95 
of face, 91 188 
Midwifery. 
Diagnosis of foot, 95 
of hand, 95 
of knee, 95" 
of position of child, 80 
of positions, 88 
-- of pregnancy, 68 
Diagonal conjugate, How to 
measure, 128 
Diameters of pelvis, 13 
Diet in childbed, 164 
Difficult face positions, 56 
Disease of passages, 136 
Douche, Antiseptic, after labour, 
77 
tin, 66 
Douches in lying-in period, 173 
Douglas, Spontaneous evolution 
of, 111 
Dress of nurse, 65 
of patient, 68 
Dropsy of amnion, 148 
E 
Eclampsia, 155 
Elbow, Diagnosis of, 95 
Evolution, Spontaneous, 111 
Examinations, Abdominal, 80 
, Vaginal, 85 
Expression of cord, 116 
Expulsion, Spontaneous, 113 
Extension, 35 
External examination, 80 
F 
Face, Diagnosis of, 91 
positions, 49 
presentations, 45 
, Causes of, 48 
False pains, 69 
Feeding bottles, 183 
Fossa navicularis, 5 
First breech position, 59 
face position, 55 
position, 33 
stage of labour, Management 
of, 71 
Flat pelvis, 125 
Flexion, 34 
Foetal head, 15 
Fontanelles, 17 
Foot, Diagnosis of, 95 
Foramen magnum, 17 
ovale, 11 
Fourchette, 5 
Fourth face position, 52 
breech position, 64 
position, 44 
Frontal bone, 16 
suture, 16 
Fronto-cotyloid position, 42 
Fulness of breasts, 166 
G 
Generally contracted pelvis, 127 
Germs, 168 
Green stools, 182 
H 
Haemorrhage, 136 
, Accidental, 137 
, Concealed accidental, 140 
from cord, 177 
, Post-partnm, 144 
, Prevention of, 74 
, Secondary post-partum, 145 
, Unavoidable, 137 
Hand, Diagnosis of, 95 
, Prolapse of, 122 
Head, after-coming, Delivery of, 
97, 99 
, Deformity of, 179 
, Impaction of, 72 
Hernia, Umbilical, 178 
Hospitals, Lying-in, 170, 171, 173 
Hourglass contraction of uterus, 
152 
Hydrocephalus, 157 
Hymen, 5 
I 
Ilium, 9 
Ilio-pectineal eminence, 12 
line, 12 
Impaction of head, 28, 72 
Indirect pelvimetry, 128 
Inertia, Uterine, 72, 102, 107, 147, 
145 
Infant feeding, 182 
, The, 176 
Inlet of pelvis, 12 
Innominate bones, 9 
, Movement of, 11 
Inversion of uterus, 153 
Iodine, 175 
Ischium, 9 Index. 
189 
J 
Jaundice of infant, 185 
Johnson's method of pelvimetry, 
131 
K 
Kidney disease in pregnancy, 
155 
Knee, Diagnosis of, 95 
Kyphotic pelvis, 128 
L 
Labia majora, 5 
minora, 5 
Labour, 21 
, Attendance on, 65 
, Delay in, 100 
, Obstructed,|101, 104 
with twins, 123 
Laceration of cervix, 152 
Lactation, 160 
Lambdoidal suture, 17 
Ligature of cord, 73 
Lister, Sir J., and antiseptics, 
170 
Lochia, 162 
, Stinking, 169 
Loss of weight, infant, 181 
Lying-in hospitals, 170, 171, 173 
period, 160 
M 
Management of breech labour, 
96 
of labour, 71 
Measurement of pelvis, 128 
Measurements of foetal head, 18 
Mechanism of labour, 9 
with flat pelvis, 126 
Meconium, 181 
Medulla oblongata, 15 
Membrane, Retention of, 147 
Membranes, 1 
• , Bag of, 23 
, Bursting of, 24 
--, Rupture of, 139 
, When to rupture, 71 
Microbes, 168 
Milk, Secretion of, 164 
Monthly nurse, Dress of, 65 
Motions, Morbid conditions of, 
182 
Muscular fibres of uterus, 22 
N 
Naegelfi, Obliquity of, 126 
Nipples, The, 165 
Nurse, Duty of, 176 
Nymphse, 5 
0 
Obliquity, 33 
• of Naegele, 126 
Obstructed labour, 101, 104 
Obturator foramen, 11 
Occipital bone, 16, 17 
condyles, 17 
protuberance, 18 
Occipito-posterior positions, 39 
Oidium albicans, 184 
Ossa innominata, 9 
Ophthalmia, 184 
Orbital plates, 17 
Os uteri, in labour, 86 
Outlet, Measurement of, 134 
of pelvis, 12 
" Overlaying-,'' 181 
P 
Pains, False, 69 
of labour, 24 
, Relative weakness of, 104, 
107 
Palpation, Abdominal, 80 
Parietal bones, 16 
Pelvic brim, 12 
canal, 11 
cavity, 13 
contraction, 102 
floor, 5 
inlet, 12 
measurements, 12 
outlet, 12 
presentations, 57 
Pelvimetry, 126-129 
Pelvis, 8 
, Contracted, 125 
, Generally contracted, 127 
, Kyphotic, 128 
, Movement of, on sacrum, 11 
Perineal body, 7 
Perineum, 6 
, Protection of, 72 
Peritonitis, 169 
Permanganate of potash, 175 
Placenta, 4 
, Adhesion of, 145 
, Delivery of, 75 190 
Midwifery. 
Placenta, -Expulsion of, 29 
praevia, 137,141 
, Separation of, 137 
succenturiata, 146 
, Too early squeezing out of, 
76 
Plugging in placenta praevia, 144 
Poisoning, Sublimate, 174 
Positions, Diagnosis of, 88 
of breech, 59 
Post-partum haemorrhage, 144 
Postural treatment of prolapse of 
cord, 119 
Potash, Permanganate of, 175 
Pregnancy, Diagnosis of, 68 
Premature rupture of membranes, 
25 
uterine retraction, 107 
Presentation of cord, 116 
, Transverse, 109 
Prevention of haemorrhage, 74 
Prolapse of cord, 116 
of hand, 122 
Promontory of sacrum, 12 
Pubes, 11 
Pulling at cord, Effect of, 30 
Pulse after labour, 160 
Pyaemia, 169 
R 
Rectification, Spontaneous, 111 
Rectum, 5 
Relative weakness of pains, 104, 
107 
Respiration, Artificial, 159 
Restitution, 37 
Retention of membrane, 147 
of urine, 162 
Retraction of uterus, 21 
, Premature, 107 
Rickets, 125 
Rigidity of cervix, 101 
Rotation, 35 
, External, 37 
Rupture of membranes, 139, 144 
of uterus, 105 
of uterus, Incomplete, 106 
S 
Sacral promontory, 12 
Sacro-iliac synchondrosis, 11 
Sacrum, 9 
Sagittal suture, 16 
Sapreemia, 169 
Second breech position, 63 
Second face position, 54 
position, 38 
stage of labour, 26 
, Management of, 
71 
Secondary post-partum haemor- 
rhage, 145 
" Secret " stage of labour, 23 
Separation of child, 73 
Septicaemia, 169 
Shield, Nipple, 165 
Shivering, after labour, 160 
Shortness of cord, 121 
Simpson, Sir J., on placenta 
prcevia, 143 
Soreness of nipples, 165 
Sphenoid bone, 17 
Spontaneous evolution, 111 
expulsion, 113 
rectification, 111 
version, 111 
Stages of labour, 21 
Still-birth, 158 
Stinking discharge, 169 
" Strippings," 183 
Sublimate, Corrosive, 172 
poisoning, 174 
Succenturiate placenta, 146 
Suckling, 164 
Sutures, 16 
Symphysis pubis, 11 
T 
Temperature in lying-in period, 
160 
Temporal bones, 17 
Third breech position, 63 
face position, 51 
position, 39 
stage, Management of, 74 
of labour, 29 
Thrush, 184 
Tonic contraction of uterus, 104, 
106 
Transverse presentations, 109 
Twins, 123 
U 
Umbilical cord, 5 
, Dressing of, 177 
--, Ligature of, 73 
Umbilicus, Diseases of, 177 
Unavoidable haemorrhage, 137 
Urethra, 5 
Urine, .Retention of, 162 Index. 
191 
Uterine inertia, 72, 102, 107, 145, 
147 
Uterus, Atony of, 147 
, Body of, 3 
, Contraction of, 21 
, Hourglass contraction of, 
152 
, Incomplete rupture of, 106 
, Inversion of, 153 
, Lower segment of, 141 
, Neck of, 3 
, Position of, 1 
, Premature retraction of, 
107 
, Retraction of, 21 
--, Rupture of, 105 
, Tonic contraction of, 104,106 
V 
Vagina, 6 
, Condition of, 85 
Vaginal examination, 85 
Vernix caseosa, 176 
Version, Spontaneous, 111 
Vestibule, 5 
Vulva, 5 
W 
Weakness of pains, Relative, 104, 
107 
Weight, Loss of, in infant, 181 
Wounds in pregnancy, 136 
Printed by Casseli. & Company, Limited, La Belle Sauvage, London, E.C. 
20.891