RUPTURE OF THE OF AVOIDING IT.
It is important that the perineum should suffer no laceration. Former ly, it was advised to support the perineum directly by putting the hand upon it, the thumb on one side of the vulva, the other fingers on the other side, the posterior commissure of the vulva being thus in contact with the edge of the hand, the thumb separated from the fingers. (Figs.
239 and 240). Aside from the inconvenience of being thus deprived of the view of the perineum, this procedure often fails, and the laceration occurs under the hand pressing on the perineum, without its being able to prevent it. Depaul gives another procedure which appears to us far pre ferable, and which consists in leaving the perineum uncovered, and in opposing the too rapid progress of the head. When the head has arrived at the vulva, he places two fingers of the left hand on that portion of the head which corresponds to the anterior commissure of the vulva, and two fingers of the right hand on that portion which touches the inferior com missure, and thus counterbalances the effect of the uterine contraction.
The vulva can thus dilate gradually, the head is gently directed higher against the pubes, which aids the movement of deflexion, and in this way the strain on the posterior commissure is diminished.
Sometimes, however, the distension of the perineum is such that ture threatens in spite of these precautions. In that event, episiotomy may be performed; small incisions are made into the vulva, so as to re lieve the tension and thus prevent a laceration which we cannot always control. Authorities are not in accord as to the point where these inci sions ought to be made. The great majority of obstetricians make them into the latero-inferior portions of the vulva, that is to say. obliquely, in the direction of the tuberosities of the ischium (a single incision gener ally suffices).
Tarnier and Budin have demonstrated, on the one hand, that these lateral incisions do not always prevent a median laceration, and on the other hand, that these perineal lacerations invariably started at the vagi nal orifice, at the mucosa, the skin parting subsequently. Tarnier there fore advises to divide the vaginal orifice, first exactly in the median line. by an incision with scissors which encompasses both the vaginal :4nd the vulvar orifice; then, when the incision has reached an extent of one fourth to one-half inch at the most, to incline the scissors either to the right or left, so as to make the incision, which commenced perpendicu larly, terminate laterally; this possesses the advantages of the lateral in cision, and prevents the longitudinal rupture from passing certain limits should it tend to occur..
Again, different perinea vary in their power of resistane, toward rupture. Those which are thin and supple most frequently r ain in tact; those .which are large and thick, almost cedematous, are the ones which generally rupture.
After the head has emerged, the disengagement of the shoulders must be supervised, for it is not rare to see a perineum, which the head has left intact, give way during the delivery of the posterior shoulder. It is best to aid the passage of the trunk by elevating it toward the symphysis pubis, so as to make the posterior shoulder glide over the perineum, and then to guide it outside the vulvar orifice.
The accoucheur must never forget to watch the condition of the foetus attentively by the aid of the stethoscope, and when its condition or that of the mother requires intervention, to proceed with it at once by putting the woman in the obstetrical position, across the bed near its edge, the but tocks close to the edge, the feet resting on two chairs.
It is hardly necessary to mention that the accoucheur must have at hand a certain number of napkins, which are taken away as they be come soiled.
Ergot.—Ergot must never be employed during labor; it does not find application until later, and we consider the law formulated by Pajot as absolute: "When there is anything in the uterus, be it an infant about to be de livered or clots, never use ergot until the uterus is completely emptied." Such are the general rules which must guide the accoucheur with refer ence to the care to be given to the mother.
Care of the Infant.
Watch the fcetal heart-beats carefully. So long as they are distinct and undisturbed, abstain from any intervention; but proceed at once to ter minate the labor by manual or instrumental means, as soon as danger threatens; provided, however, that the dilatation of the cervix permits the extraction without endangering the mother.
We will see, in connection with the several presentations, when this in tervention is called for.
We have laid it down a,s a principle, that we must assure ourselves toward the end of pregnancy that the presentation is regular, normal (breech or vertex), with a view to correct it before labor by external manipulations; but if not called in a case of faulty presentation until the beginning of labor, version must nevertheless be attempted by external, or if need be by combined manipulations (bi-polar version of Braxton Hicks), so as to change the presentation. It is true that we often fail, but we shall be on our guard, and be prepared to interfere at the time we have chosen.