The signs of beginning labor are pains in the lower part of the abdomen and back, occurring at regular intervals, about once every half hour, and a discharge of mucus tinged with blood from the vagina.

True pains can be distinguished from false by placing the hand over the lower part of the abdomen; in true pains the contractions of the uterus are to be readily felt through the abdominal wall. As the labor advances the pains grow more severe and the intervals shorter. The first stage of labor consists in the dilation of the uterus, and ends when the membranes have ruptured and the uterus is completely dilated.

The second stage or stage of expulsion ends when the child is born.

First Signs

The third stage ends when the placenta is expressed and the uterus contracted to the size of a closed hand.

At the beginning of the first stage, the patient should have a bath, and her hair braided in two braids. Her bowels are emptied by the giving of a soap suds enema. After this the external parts are washed with bichloride solution, 1-5000, and a pad wet with bichloride solution, 1-10000, or boric acid applied. She is as a rule allowed to walk around the room during the first stage, which may last from ten to twelve hours, and even longer.

She is best clad at this time in a night gown, warm wrapper, and long stockings made of flannel or an old blanket, coming well up over the thigh.

Milk and broths should be given every two hours; alcohol and other stimulants must be withheld.

The patient must be instructed not to bear down during the pains of this stage, and to sit or lie down when a pain occurs.

During the second stage the patient must be kept strictly in bed. The wrapper is removed and a short dressing sack put on in its place, the night gown is tied up under the arms, and with it a sheet, the end of which comes down over the legs covering the blanket stockings, which are left on; it can be folded up in the center when necessary.

The patient usually lies on her back. A strong band of muslin around the foot of the bed, with the ends so that she can hold them to pull on, will help the patient during pains.

The Second Stage

The attendant's hands must be well scrubbed and disinfected with bichloride, 1-1000, that she may be ready to help the doctor.

If the doctor does not arrive in time, the attendant, taking all antiseptic precautions, must place her hand against the head as soon as it appears and hold it back during the pains, thus preventing too rapid descent. When the head is delivered insert the finger into the passage to see if the cord be around the neck, if so, pull it carefully over the head. The right hand supports the child as it comes, and the other is placed on the abdomen and pressed firmly but gently downward till the child is expelled. One hand must be held over the uterus from this time until at least half an hour after the placenta is expelled.

Place the child on its right side between the mother's thighs, wipe out its eyes and mouth with swabs wet in boric acid; place gauze over the mouth and blow into it; if it does not cry, slap it on the back and chest; if the color does not improve the cord will have to be tied and cut immediately (it is generally better to wait five minutes before doing this) and the child plunged into a hot bath. It is rarely necessary to do this, however. The cord should be tied tightly with the sterile tape about an inch and a half from the navel, and again an inch further on; it is then cut (with sterile scissors) between the two knots. The baby is rubbed with vaseline or olive oil, rolled in the flannel square, and a warmed blanket, then put in its crib with at least one hot water bottle until the mother is attended to. The placenta is generally expressed about fifteen or twenty minutes after the birth of the child; but even if it take longer, the cord should not be pulled upon- it is better to gently manipulate the abdomen above the uterus, and continue doing this very gently with one hand as the placenta comes out, while with the other hand twist slowly to aid its coming. Even after

the placenta is expressed, the hand must remain pressed downward over the uterus until it feels hard and firm. An assistant can in the meantime be washing the patient with bichloride, 1-2000, and removing the soiled linen. When the uterus is firm and hard a binder should be applied, a dressing of sterile gauze and a pad being first placed over the vulva; this is afterward pinned on to the binder to keep it in place. The binder is best made of unbleached muslin. One for a medium size woman should be a yard and a quarter long and half a yard wide. It should, when pinned in place, extend from the border of the ribs to below the prominence of the hips, and should be made to fit the contour of the body by taking in darts over the hips on the upper and lower edges.

A binder is also used to make compression upon the breasts. There are a variety of these, but the Y breast binder originally used in the Boston Lying-in Hospital is perhaps the easiest one to manage, and has the advantage of leaving the nipples exposed. A bandage shaped like a T is made by folding muslin lengthwise and pinning it at right angles to another strip folded in the same way. The T is then made into a Y by making a diagonal fold in the middle of the cross piece and fastening the middle of the plait with safety pins.

To apply, dust the surface of breasts with powder, draw base of Y beneath the patient's back until apex of the fork is external to the outer edge of breast. Lift breasts upward and toward each other. Draw lower arm of fork snugly across chest beneath breasts, the inferior border of this arm extending at least one inch below margin of breasts; the end of arm is pinned to end of strap, which has been passed beneath back; the lower border is pinned in the center to abdominal binder. The upper arm of fork is then drawn across chest above the breasts and pinned like the lower to the main strap.

Watch for the signs of hemorrhage already described. Should hemorrhage occur send for the doctor immediately; induce contractions of the uterus by grasping the fundus and employing a firm but gentle kneading (no doctor would leave the case in your charge without showing you exactly how to do this). Elevate the foot of the bed, and give a hot douche of sterile water, 120° F. Sometimes astringents such as vinegar are added to the douche, but unless the case is very urgent it is best not to use it without the doctor's order.

The patient must be kept quiet and on her back for the first six or seven hours, afterward she can turn on her side but should not sit up for at least five days. She is generally allowed to sit up on fourteenth day, if all discharge has ceased. In no case should the usual routine of life be resumed under four weeks.

The diet is usually liquid for the first twenty-four hours, after which all symptoms being normal, the patient is allowed almost any easily digested food.

Hemorrhage

The dressing and pad should be changed every two hours until the discharge diminishes, later every three to five, as the case demands. After the third day it is usually necessary to change it only after it has been removed for the requirements of the patient. These dressings must all be sterile and the hands disinfected before applying them. If douches are ordered, boil the douche nozzle for five minutes before and after use.

The breasts must be washed with boric acid solution before and after nursing.

Ends Of The Y Breast Binder

Y Breast Binder (a) And Abdominal Binder (b) In Place