Obstetrics Midwifery

Much the most common cause of failure of the woman to deliver herself is due to relative or absolute weakness of the uterine con tractions (pains). Relative, if in a first confinement the soft passages, and especially the outlet, are rigid, or in any confinement in which owing to the size of the child or its position or the narrowness of the passages, some extra effort on the part of the womb is required and is not forthcoming. Absolute weakness is present in those cases in which no additional effort is called for and yet there is insufficient power to expel the child without great prolongation of labour.

Feeble action of the womb may be due to loss of the stimulus of the dilating bag by early breaking of the waters; if the present ing part comes down to take the place of the bag, all will go well, but if it does not there is nothing to prevent all the waters drib bling away and a dry labour of this kind is always difficult, and the child may be stillborn. A loaded bowel or a full bladder also inter feres with uterine action and these viscera must be kept empty. Fatigue is a very important factor in this regard for the womb of the tired out woman will not function efficiently. Anxiety, lack of confidence in her own powers and long continued pain act in the same way and hasten the production of fatigue. The relief of pain, the obtaining of rest and general management of the patient is, therefore, a most important part of the medical attendant's duties. The problem is not an easy one because sedatives, anaes thetics and means of relieving pain also tend to lessen, at any rate, for a time, the muscular activity of the uterus.

Lying-in Period.

During the lying-in period, rest and quiet are essential, particularly for highly-strung women, but rest to mind more than to body. The patient should sit up in bed and move about so as to promote free escape of the discharges. She is not an ill woman and is kept in bed to allow time for healing and the return of the enlarged and relaxed structures to their pre pregnancy state. It is useless to say how long the woman should remain in bed or in her room ; every case must be decided as an individual problem ;—a longer stay being required by those who have had complications, who are worn out and require rest, sleep badly or are of a nervous and over-anxious temperament ; a shorter by those in whose cases everything has been straightfor ward, who sleep well and are of an easy-going nature and do not worry. Much can be done in the way of massage and bed

exercises and after rising by Swedish exercises to restore the abdominal and pelvic muscles,—a most important measure in pre serving the figure and lessening the chances of dropping of the abdominal viscera and womb. The chief danger during the lying in period is that of puerperal fever (q.v.) and its sequelae.

Preventive Obstetrics.

In the last 20 years a striking change has occurred in the science of obstetrics and its practice, chiefly as the result of its invigoration by the spirit of preventive medi cine.

The term "preventive medicine" (q.v.) does not connote any special creed or peculiar doctrine in medicine. Its first object is to seek out the causes of disordered function and remove them bef ore they can become operative and, in the second place, when these causes are unknown, to detect the early signs of deviation from normality and restore the normal before trouble arises. The maintenance of natural function in all bodily systems is its aim. If obstetrics is regarded from this point of view the difference between the new and the old practice will become obvious. Its immediate purpose will be to secure normal reproduction by de tecting and removing all known causes of disorder of function and by observing the healthy pregnant woman from conception on wards to discover any sign of departure from the normal. Though a physiological state, pregnancy imposes a strain on the efficient working of every system of the body, and the thorough examina tion of the state of health of mind and body of the woman early in her pregnancy and further observation to see how she is stand ing the test seem but reasonable precautions. Apart from those who have some organic weakness and may break down under the strain, there are disorders of function that may develop in those previously of sound physique. A special strain falls on the ex cretory organs, and the kidneys and the liver may be affected and lead to acute or chronic disease. Hence the need for the routine and repeated examination of the urine. The good health of the mother throughout childbearing increases her resistance to infec tion (e.g., puerperal fever) and her efficiency in the rearing of her family.