When expulsive pains commence, the physician must approach the bed of his patient, on the right side if possible, so as to supervise the descent of the head from time to time, and support the perineum at the time of its disengagement.
While the dilatation is still incomplete, the woman may lie down, sit up, or walk about. But as soon as the dilatation is complete, whether the bag of waters be intact or broken (we shall see later that it is some times advisable to rupture it), the woman, especially if a multipara, must be absolutely recumbent, unless a retardation of the labor be noticed, in which case it will be advisable to let the patient walk about until the pains become regular and pronounced.
Back pains and cramps are to be combated by frictions and massage, often, it is true, without much success.
Ordinarily, the membranes rupture spontaneously, but in some cases they preserve their integrity too long, and their resistance alone suffices to retard the labor, by interfering with the regularity of the contractions. When the bag of waters is very tense in the vagina, it can be easily rup tured by pushing the finger against it during a contraction; but if the membranes are flaccid or if the bag of waters is small and flat, we may sometimes meet with some difficulty. In the former case, it is generally sufficient to carry the finger farther back and upward, where a greater accumulation of liquid is generally encountered, with greater tension, and where pressure with the finger nail against the prominent point will effect the rupture. ' When the bag of waters is flat, pressure with the finger will fail; then the membranes must be scraped, as it were with the nail, so as to break them by erosion. If these measures fail, a lead pencil, a
tooth-pick, a quill cut to a point, guided by two fingers introduced up to the membranes, will perforate them and cause the liquor amnii to escape. Depaul, in such cases, trims the nail of his index finger to a slight point and breaks the membranes by a to and fro movement.
We have seen above that in primipara3 the anterior lip of the cervix often becomes caught between the head and the symphysis, causes vio lent pains and interferes with the engagement of the head. We must beware, in this case, of pressing on the cervix and endeavoring to increase the, dilatation. This will only produce one result—it will aggravate the pains, and chafe and bruise the cervix. It is best, during a contraction, to pass the finger between this anterior lip and the presenting part, to support the lip in this manner, and crowd it back a little so as to permit the foetal part to descend and the lip to rise. [We believe it preferable, as well as less risky to the integrity of the cervix, to push the lip above the head during the interval, and hold it there during the pain.—Ed]. The head often descends rapidly in consequence of this little manipulation.
When the head has arrived at the perineum,. we must beware of intro ducing the fingers into the inferior portion of the vagina, and of pressing upon the pelvic floor, upon the coccyx. Not only is it useless, but it is badly borne by the patients. It is best to lubricate the parts with a little sweet oil or cold cream, and to watch the distending perineum which the head, about to emerge, is approaching.