[Obstetrics or midwifery 531]

Examination of the Patient.—­The physician needs to satisfy himself as to the position of the child, etc.  This can be done by an examination of the abdomen and also of the vagina.  He must determine whether the child is alive, its position, the condition of the cervix and mouth of the womb.  In making such examination a routine plan should be adopted.  The coat must be removed, the shirt sleeves turned up and the hands and arms washed with soap and water.  The abdomen should be thoroughly palpated (felt) and listened to with the ear or stethoscope to determine the character of the child’s heart beat, whether it be very slow, one hundred and twenty or less, or a very rapid one, one hundred and fifty or more.  It may indicate danger to the child and necessitate a hurried delivery.  After these things have been done, the hands and arms must again be thoroughly washed and sterilized, the fingers anointed with carbolated vaselin and the examination of the vagina made.

This cleanliness is necessary, and if this plan were carried out by everyone connected with the patient during the whole confinement, there would be fewer cases of “child-bed” fever, with its resultant diseases.  The patient should lie on her back with the knees drawn up.  There is no need for any exposure now, for the covering can be held up by an attendant so that it will not touch the physician’s hands.  The soft parts are now separated by the fingers of one hand while the examining fingers are introduced into the vagina.  These fingers should never touch any external part and especially the parts near the anus.  If the cervix is found to be long and the canal still undilated, or only slightly so, and especially if it is the first child (primipara), the physician’s presence is not needed and he may safely leave for an hour or two.  But if the mouth (os) of the womb is dilated to the size of a silver dollar he should on no account leave the house.

Frequent examination of the vagina should not be made.  In ordinary cases during the first stage, the woman should be up and encouraged to walk about the room, to sit or assume any comfortable position.  During a pain she may stand beside the bed resting her hands upon something or kneel in front of the bed or chair.  The standing position assists in the birth.  The bladder should be emptied frequently, as a distended bladder retards labor and may even stop the womb contractions.  The pains become more frequent and severe as the end of this stage approaches and each contraction is now accompanied by straining or a bearing down effort on the part of the woman, and as a rule the membranes rupture spontaneously about this time.  An examination of the vagina should now be made with the woman in bed, and if the membranes have not broken and the womb is completely dilated as shown during the pain, they may be ruptured by pressing against them with a finger-nail during a pain.  Sometimes we use