LABOUR.
The practitioner should never forget that nine out of every ten women in labour would deliver themselves safely if left alone, and that an atten dant who is unable or unwilling to approach the birth canal with surgically clean hands merely adds a considerable element of danger to these cases, while in the small minority where interference is required safety from the risks of labour will he dearly bought if the hand which brings it introduces into the vagina the germs of puerperal fever.
In the first stage of labour the practitioner should accustom himself to mak? out the position of the foetus and the amount of progress by abdom inal palpation. A vaginal examination is only required to discover the degree of dilatation of the os and possible prolapse of the cord. Before making it the hands should be scrubbed with soap, warm water and nail brush for 5 minutes, special attention being paid to the nails, which should be kept carefully trimmed. Methylated spirit (7o per cent.) is then swabbed on with cotton-wool, and the hands are finally immersed in in 2,000 Perchloride or Biniodide of Mercury for 2 to 5 minutes. The vulva is then washed with warm water and sterilised liquid soap and sponged with plenty of i in 2,000 perchloride or drachm to the pint Lysol solution. The hair on the labia, unless very scanty, should be clipped short. The examination is made with the hand dripping with antiseptic, and no other lubricant is necessary. Rubber gloves are now very com monly worn for vaginal examinations. It is quite true that one cannot guarantee an aseptic skin, and that one can guarantee an aseptic glove. Considerable experience of students and nurses has taught me, however, that a rubber glove gives a dangerous sense of security to those who are not perfectly familiar with antiseptic methods. It is at once recognised that the bare sterilised hand is contaminated and must be reimmersed in antiseptic if it has accidentally touched the bedclothes, the patient's thighs or one's own person. The same fact is not so easily grasped when one is relying on a rubber glove; one even sees well-meaning individuals after a cursory sterilisation of the hands carefully transferring all the surviving microbes on the skin of the left hand to the surface of the right hand glove in the lengthy process of fitting each finger into place, and then proceeding to inoculate the vagina with them. There is only one way of safety for the obstetrician, and that is to develop an aseptic conscience. If he has that, he will be perhaps a little safer, and certainly easier in mind with gloves on ; if he has it not, gloves may make him more confident, but they cannot render him less dangerous to his patient. The gloves should be fresh boiled in a batiste bag, and shaken out of it into i in 2,000 Perchloride or Biniodide. They should be put on wet with the aid of a
gauze swab dripping with the lotion, and never with the bare hand. The hands should be as carefully sterilised as if gloves were not to be worn, and the gloved fingers should be kept in sight from the time they leave the lotion basin till they enter the vagina so as to avoid the possibility of contamination. Gloves must be worn if the patient is suffering from syphilis, or if the doctor's hands are rough, chapped, abraded, or have been recently exposed to septic substances—e.g., pus or faeces.
After making out the size of the os and observing the frequency and force of the pains the doctor can make up his mind whether or not to leave his patient for the time. If the first stage is slow and the patient is becoming tired and fretful he is likely to be pressed to give some relief. Chloroform should not be given unless there is a prospect of delivery within two hours at most. Ergot is totally inadmissible. Quinine is unreliable as an oxytocic. It is at this stage that the doctor will have to consider the advisability of the use of morphine and hyoscine injections, known so widely to the lay public as " twilight sleep." As used at first the method consisted in the giving of Morphine or gr.) combined with I lyoscine gr.) repeated in an hour or two if necessary, and in this method the results were rather haphazard, some patients being greatly relieved and cased and others being apparently unaffected. The more modern method is to give the initial injection and to follow it up by one to three doses of Hyoscine or of a grain) as required, usually at intervals of one or two hours. The room is kept perfectly quiet, lights arc lowered and every disturbance of the patient avoided. Most authorities are agreed that while this method is being carried out the medical man should remain in constant attendance. The results claimed for this method are more uniformly successful. The pains are not interfered with, and may even increase in force and frequency. A certain percentage of the children do not cry out vigorously at birth and breathe at first very quietly, but after considerable experience of the method, I must say I have never seen a case of asphyxia or stillbirth which could be fairly ascribed to the influence of the drug, and I believe those who have tried it most extensively are of the same opinion. Chloroform may be safely given in the second stage, and these patients take it well. In my opinion, the method is of great value in the case of nervous, highly strung and excitable women, but should not be used indiscriminately. It may be remarked that some patients while under the influence of the drug become restless and intoxi cated, and will endeavour to get out of bed unless restrained.