The care of the pregnancy itself is likewise a matter of greater concern than in the older obstetrics, not only because of the loss of prospective life, but because miscarriage is a prolific cause of operative interference, during or after its occurrence, and of in fective and other diseased conditions of the reproductive tract and thus of subsequent disability. Premature labour results in the birth of weakly infants difficult to rear and is a prominent factor in the persistent high mortality among new-born infants. Another important object of the supervision of the pregnant woman, that of foreseeing and avoiding difficulties and compli cations during labour, provides the simplest illustration of the changed outlook in obstetrics.
The usual custom of a generation ago was for the woman to retain her doctor for attendance on her confinement and for the doctor to do little more than note the expected date on which his services might be required. Unless consulted by the patient be cause of some disturbance of health, he might not see her again until summoned at the onset of labour. He then made a thorough investigation to see if all was straightforward or if there was any malpresentation or other difficulty, and was prepared to do his best to remedy any untoward condition that might be present or arise later, often being exceedingly ingenious and resourceful in so doing. His obstetric training as a student had been directed largely toward teaching him the management of normal labour, the emergency treatment of abnormal presentations and obstruc tions to the passage of the foetus through the birth canal and other complications during labour, and his reputation as an accoucheur was largely determined by his capacity to cope with emergencies.
To avoid difficulties in labour, examination is begun about six weeks before the expected date of confinement in order to determine that the child is presenting normally and that there is sufficient accommodation in the bony pelvic canal to allow of its easy passage. This examination is repeated two or three times
to make sure that no change has occurred in the presentation and position and that the child does not become unduly large to pass readily. For the most part these matters can be determined with a fair degree of accuracy by the ordinary methods of ob stetric examination, but in difficult and special cases examination under anaesthesia and by X-rays may be required. Should it be discovered that even at six weeks before full time there will be difficulty in the child being born by the natural passages, because of rickety or other deformity of the pelvic bones, the question arises whether it is better to resign all hope of the delivery of a living child by the natural passages and perform Caesarean section or to induce labour and learn if the natural powers can effect the delivery of a small and premature infant.
If there does not appear to be any obstruction at the time of the first examination but at a later one there is evidence of a tight fit, labour should be brought on then to avoid the risk of the child becoming too large to be born without difficulty. By eliminating difficulties due to disproportion in size between the child and the mother's pelvic canal and such malpresentations as those previously mentioned most of the serious difficulties in labour can be obviated in some way or other. The change in presentation and position of the child can be effected by manipula tion through the abdomen, if done before the child is too large to be moved readily, and in favourable cases and under anaesthesia sometimes even up to and after the onset of labour, but if left until the waters have broken or labour is advanced, requires in ternal operative procedures with their additional risks of injury and infection.
In these instances the cause of difficulty can be anticipated and removed before labour begins, but there are also many conditions of which the cause is unknown so that the obstetrician must fall back on the second line of defence, that of discovering the earliest signs of disturbance, taking them as a warning of danger ahead and making the best possible dispositions. Premature detachment of the after-birth commonly shows itself by haemorrhage and all pregnant women whilst under supervision are warned to report at once any bleeding, so that immediate measures may be taken to lessen the chances of serious consequences. Albuminuria, dis covered by frequent examination of the urine, convulsions (eclampsia), excessive vomiting and visual disturbances are warnings of dropsy.