placed against the posterior portion of the dilated perineum.  The edge of the perineum should now be closely watched.  A small towel wrung out of a bowl of hot water placed handy on a chair, should be held constantly against the perineum to hasten the softening and dilatation of these tissues.  Plenty of hot water and small towels should be at hand.  The head advances with each pain and again recedes until the parts are properly dilated, and the perineum slips backward over the child’s face.

[534 Mothers’ remedies ]

If torn, it should be sewed before the physician leaves, as it can be done easily and without pain to the mother.  As the head of the child emerges, the anesthetic should be pushed, or the woman told to open her mouth and cry out.  This lessens the pain and the child’s head emerges slower, and the perineum is saved.  The child’s head should be received in the hand.  After the head is born, there is a lull for a few moments.  Then the shoulders rotate into the proper position and are easily born.  There may then be a flow of watery fluid for a few seconds.  Before this time the physician has examined to see whether the cord is around the child’s neck, released it if it has been, and also cleaned out the child’s mouth.  The child usually cries a little about this time and it is soon seen whether it needs quick attention.  The perineum should be guarded also while the shoulders are being born as it can be torn by them.  The shoulders are generally born without any help.  The child’s head is held in the physician’s hand.  As soon as the body is born, the child should be laid upon the bed behind the mother’s thighs, and the cord pulled down to prevent it pulling upon the after-birth.  After the beating in the cord has ceased, generally from five to ten minutes have elapsed, the cord is then tied, tight enough so it will not bleed afterward, about one or one and one half inches (some say more) from the body and tied a second time an inch or so from the first ligature, and the cord cut between the two ligatures.  Care should be taken so as not to cut a finger or toe of the baby.  If the cord is very thick it is best to pinch it at the point of tying and the contents stripped away before the first ligature is applied.  After the cord is cut it should be wiped off to determine that bleeding from the vessels has been permanently cut off, and if not it should be tied again.  The child is now taken up by placing the back of its neck in the hollow between the thumb and forefinger, and the other hand over the backbone.  It should then be placed in a warm receiving blanket, and put in a safe place.

Management of the Third Stage,—­The contractions of the womb are renewed and with the second or third the after-birth may be expressed.  The top (fundus) of the womb is grasped by the hand through the relaxed abdominal walls, and squeezed, and at the same time make a downward pressure.  The after-birth is loosened from the womb and slides through the vagina and outlet, and it may be caught in a tray which has been placed between the patient’s legs, or by the hand and given a few twists in order to roll the membranes together; while this is being done, gentle rubbing should be applied to the womb, when the membranes will slip out without tearing; no drawing on the cord should be done in delivering the after-birth.