SPECIAL PROVISIONS REQUIRED BY EACH PRESENTATION. Vertex Presentation.
Since the vertex presentation is the most favorable, it will require the least special care. Ordinarily, the accoucheur's part is passive; he confines himself to encouraging the patient, to advising resignation mid patience, and explaining that he not only cannot, but must not interfere—that it is Nature who will accomplish her task, and that intervention must be re served for cases of absolute necessity. Still there are certain indications to be met, especially in primipane, and some cases in which the accouch eur can be really useful. Without wishing to anticipate here what will be considered in the chapter on the employment of anesthetics in normal labor, we may say that there are certain primiparie who are so nervous, on whom the pains make such an impression, that their excitement rises to utter indocility, and if not allayed, the labor is retarded or arrested and the patient put into an unsatisfactory condition. It therefore be comes absolutely necessary to calm this excitement, and of the drugs which have answered best in our hands in these cases chloral stands fore most. It is especially in the stage of dilatation, when the cervix is hard, tense, and somewhat rigid, that this excitement occurs, and we resort to chloral, either in solution in syrup, or, preferably, by enema. Sixty grains of chloral in three fluid ounces of quince mucilage, introduced by means of a syringe and not by the irrigator, repeated if necessary after five or six hours, will frequently calm this extreme agitation, and secure to the patients relative rest,' of which they are in great need. Not that we reject in these cases the applications of belladonna ointment or extract to the cervix, which Dubois advises, but the action of chloral seems to us far superior.
In a certain number of primipare the first stage drags for an indefinite time, owing to the slowness with which the cervix dilates. The slowness is not due, as in the before-mentioned cases, to rigidity of the cervix,which is soft, but the pains are slow, feeble, and irregular. The cervix attains a dilatation of about half a dollar and remains at this point without progress ing. The membranes bulge slightly, and there is nothing to explain the slowness of labor but the feebleness of the uterine contractions. It is in these cases that certain accoucheurs employ ergot, which we absolutely prohibit. There is in our opinion a far more certain measure, and that is rupture of the membranes. However, this must not be done at haphaz
ard; certain conditions only authorize this intervention. It is necessary, first, that the presentation be good (vertex); second, that the foetal heart beats be regular, normal—in one word, that the child do not suffer; third, that the conformation of the pelvis be good; fourth, that the labor be in progress relatively long, that the cervix be normal, and that its di latation be at least equal to the diameter of a silver half dollar. In such cases, we have often observed Chat the rupture of the membranes was followed by an acceleration and a relatively rapid termination of the labor. In certain cases, rupture of the membranes alone does not suffice, and the foetal head must be slightly elevated so as to evacuate some of the liquor amnii. The latter manipulation should always be practised in the interval of contractions. [Instead of premature rupture of the membranes, we should be tempted to try a mild faradic current, one electrode over the abdomen, the other over the back, or held in the patient's hand. If the current be mild, and not passed directly through the fo3tal poles, it can do no harm, and will intensify and regulate the pains.—Ed.] If the presentation is oblique or irregular, beware of rupturing the membranes before the presentation and engagement have become regu lated.
It is not rare, in posterior positions, for rotation to be delayed, or even fail to occur, and some obstetricians advise to bring the occiput forward. Velpean advises, when the head has descended into the excavation, and almost immediately after the rupture of the membranes, to make it devi ate to the right or left, in the intervals of the contractions, by sliding two or three fingers either in front of the sacrum to push the occiput forward, or behind the pubes on the sides of the forehead so as to carry it back ward. Tarnier advises to take hold of the head with two fingers placed behind the ear, and thus to act upon the head so as to bring the occiput forward. We believe, with Cazeaux, that these manipulations are abso lutely useless. Either the rotation tends to take place, and then it will occur spontaneously; or it fails to occur; or else, it is effected in the pos terior direction, the occiput returning into the concavity of the sacrum. In that event, although we may work upon the head, rotation will not occur, and the forceps alone, and not even invariably, can effect this ro tation; hence we much prefer to abstain.