Light nourishment should be given in a tedious case, but no alcohol. It is a mistake to keep a patient walking about too much. If she is tired she should lie down in bed and rest as much as possible. During this stage the bowels should be well cleared out by an enema, and everything prepared for the delivery.
In the second stage, the commencement of which may usually be diag nosed by the altered character of the pains without vaginal examination, chloroform may be given on a Skinner's mask with each pain, but avoid ing full anzesthesia with loss of reflexes, which delays the tends to produce atony of the uterus, with consequent post-partum haemorrhage. The anaesthetic may be given more freely when the head is on the perineum, and should he eased off when delivery has occurred. If the membranes are still intact they should be ruptured with the finger during a pain, or a sterilised metal stilet or hairpin may be used. As the head comes down on the perineum the attention of the accoucheur is directed to the preven tion of a rupture. Many methods have been at different times recom mended to attain this desirable end, and the impartial critic who has faithfully tried them will he inclined to say that all are equally disappoint ing. That most in fashion at present, and as good as any, is to pass the left hand between the patient's thighs as she lies on her side and keep the tips of the fingers pressed on the child's vertex, so as to keep it in contact with the pubes and to retard its progress to some extent. The fingers of the right hand may be used at the same time to resist the progress of the head if the pains are very violent, but no direct pressure should be put on the perineum. The mother, if conscious, should be told not to hold her breath or bear down during the final pains. When the head has been delivered the accoucheur should always ascertain whether the cord is round the child's neck, and if it is should slip it over the shoulders if a long enough loop is available, or cut and clamp it with forceps if it is very tight and unyielding. Care must be taken in the delivery of the shoulders lest a partially lacerated perineum be still further injured. The cord should not be tied until it has ceased to pulsate.
Forceps in Non-Obstructed Labour.—It should be the general rule that
forceps are not to be used before the os is fully dilated. Until that stage is reached the prolongation of labour is practically unattended with risk to either mother or child. It is now recognised that a prolonged second stage is dangerous to both, and the classic indications for forceps are a rising pulse and temperature, heat and dryness of the vagina, and exhaus tion of the mother, or a marked alteration in the fatal heart or the passage of meconium. The wise obstetrician will intervene long before such symptoms appear, and, speaking generally, the question of forceps arises whenever the second stage has lasted for 2 hours and shows no signs of speedy termination. If the head is not steadily advancing ; if the pains are small, weak and ineffectual; if the mother is a primipara of over 3o; or if the first stage has been lengthy and trying, the timely application of forceps will save the patient from a prolonged second stage and its effects— a fatigued and more or less atonic uterus, and an exhausted nervous system which may take months to regain its normal elasticity. Added to this is the fact that delivery by forceps, skilfully conducted, is probably safest for the perineum. In applying forceps the practitioner should remember to boil the instruments, to sterilise his own hands and the patient's vulva, to pass the catheter, and to deliver very slowly and with frequent pauses so as to avoid laceration of the perineum. I fe may safely disregard the presence or absence of pains. I formerly douched all cases in which I had put on forceps, but for several years past I have omitted to do so, and I have never had any reason to regret it.
In everyday practice the use of forceps has been to a great extent superseded by the use of pituitrin. Every practitioner is familiar with the case which drags slowly on with weak and ineffectual pains, and it is in such a case that pituitrin is of the greatest service. It should not be given until full dilatation of the os has been reached, but if i c.c. of the drug is then given hypodermically into the gluteal muscles, the labour terminates as a rule with magical quickness, the whole second stage being often passed through in tenor fifteen minutes.