Dr. Manton, of Detroit, says:—­“The dangers of anesthetics are the same when employed for obstetric purposes as in surgery, and then use should be governed by the same rules in each instance.”  As soon as the head begins to dilate the vulvar opening, the patient should be turned on her left side with her knees drawn up and her body lying diagonally across the bed, with the buttocks close to and parallel with the edge.  This position allows the physician to give better assistance and is no harder for the patient.

[Obstetrics or midwifery 533]

The physician with his hands thoroughly sterilized and with a clean sterilized gown, seats himself on the edge of the bed and watches the progress of the labor, ready to assist the woman at any moment.  And at this time he can do much by words of encouragement and proper directions to the laboring woman how to use her pains so as to get the most from them; and also by manipulation of the soft parts and the head.  The head advances more and more with each succeeding pain, and the perineum is put on the stretch, each contraction is followed by a resting pause during which the head slips back a little and relieves the perineum.  Tear of the perineum is liable to take place when the head is about to escape through the vulvar opening, especially if the contractions are strong, the woman bears down forcibly and the interval between the pains is short, so that the head is forced out before the parts have time to completely dilate and soften.  Here is where the physician’s work comes in, by holding the head back and fully flexed (bent), chin upon the breast, and keeping the back of the head (occiput) well up towards the bone in front (pubic arch) until thc perineum is completely dilated.

The effect of the pains can be lessened, if necessary, also, by telling the woman to open her mouth and not to bear down during the pain for a few times.  In this way the perineum will dilate properly and be torn little, if at all, and perhaps much future trouble for the woman saved.  I always tell my patient why I ask her to do certain things in labor and I have never found any woman who, when able, was not willing to do as I asked.  A torn perineum is not desirable, because even when sewn up immediately after labor, it may not unite thoroughly, and thus cause displacements of the womb in the future.  A little time and care at the time of labor will save the perineum and every woman is willing to do her share when the conditions are plainly explained to her.  It takes only a few minutes longer, and only a few more pains to bear.  When the head begins to stretch the opening, the left hand of the physician should be carried over the woman’s abdomen and between the thighs, her right leg being supported by a pillow placed between her knees, and this left hand presses the back of the head (occiput) forward and against the “pubic arch.”  The right hand may also press the head upward by being