STRATEGY AND TACTICS IN OBSTETRICS
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820 be a positive Wassermann reaction, evidence of anaemia, and rarely of polycythsemia. Albuminuria may be found as an accompaniment of nephritis, or of the physical state with a low blood pressure and vasomotor instability. The nose and sinuses must receive attention, and the cervical fascia and muscles should be palpated. In treatment any obvious or discovered cause must .naturally be dealt with. Vigorous antisyphilitic treatment is required if there is any reasonable suspicion of this infection. Attention to teeth, removal of adenoids, cleansing of sinuses, correction of a refractive error, the treatment of anaemia by iron, the use of vasodilators or venesection, may be required, or the administration of calcium salts. On the digestive side appropriate treatment by aperients, &c., or the restriction of alcohol is often desirable, and in more elusive cases a search may be made for some allergic peculiarity. I once traced an otherwise inexplicable headache to ingestion of egg- albumin, and there may be many similar possibilities. But often symptomatic treatment must be employed. Cold applications or evaporating lotions will be acceptable in almost any case. The numerous members of the salicylate group in their various combinations are too well known to need enumeration, and the idiosyncracies of some people in relation to these are equally familiar. Gelsemine has a reputation for neuralgic states. Cannabis indica is very useful for the headache associated with nervous strain in men, but caution in administration in the case of women is emphasised. Potassium iodide in small doses is well worth trying, even if there is no suggestion of syphilis. For the intractable headache of tumour, when surgical relief is impossible, hypnotics are necessary. Finally, as a resort in a particularly obstinate case, the old-fashioned treatment by a seton may well be tried. ° STRATEGY AND TACTICS IN OBSTETRICS. (MR. BRIGHT BANISTER.) I am taking strategy to mean the general art of .conducting a campaign, and tactics the detailed manoeuvres of units incidental to the development of a campaign. The conduct of a natural pregnancy, labour, and puerperium comes under the heading of -strategy, while the detailed treatment of abnormalities as they arise will call for tactics. It has been suggested that if antenatal care were perfect no obstetric fatalities would arise, but though I am unwilling to minimise the importance of ante- natal care it must not be forgotton that it has certain limitations. Obstructed labour, for example, should be rare to-day, but this danger cannot be wholly avoided by antenatal supervision. Gross abnor- malities of the pelvis or malpresentations of the baby ,should certainly be recognised during pregnancy, but the contractile power of the uterus itself cannot possibly be estimated before labour begins. Very rarely irregular action of the uterus may produce a contraction-ring which obstructs delivery. Gross cases of primary uterine inertia are found in a recog- nisable type of woman-the nervous type, who approaches her labour in a state of fear. It is important to begin the management of labour before labour begins, by putting the patient into the proper condition to face it. By antenatal care it may be possible to arrange our tactics so as to minimise the risk of hæmorrhage. It is possible, for example, to recognise placenta prævia fairly early, before there is danger of haemor- rhage. There is want of engagement of the presenting part, or an abnormal position of the foetus. One side of the head is more easily palpable than the other, both on abdominal and vaginal examination, and one uterine artery is felt to be pulsating more powerfully than the other. Bleeding in placenta prævia is painless unless associated with the onset of labour. Labour, where there is mild disproportion, is easier to conduct if the case has been thoroughly investigated beforehand. Where the mother has an asymmetrical pelvis, for example a pelvis smaller on the left side, a right occipito-anterior presentation will be accepted as a good sign, because the widest part of the child’s head will engage in the widest part of the maternal pelvis. A left occipito-anterior presentation, on the other hand, will be unfavourable ; you will know that the ground is untenable, and that you are bound to lose. When there is any doubt one should never hesitate to examine the patient under an anaesthetic at the onset of labour. The way in which the head is entering the brim should be observed, and its favourable or unfavourable aspects con- sidered. As labour progresses the state of the lower uterine segment must be watched. As- long as the cervix is stretched, the occipital pole coming down, and the caput only increasing gradually, progress is being made. If the cervix is beginning to get cede- matous the outlook is not so favourable. It is impossible to decide what is happening in a tight fit for some time after the membranes have ruptured; even if labour is advancing well, we must be prepared to change our tactics suddenly if the condition of mother or child demands it. A uterus must never be bullied or prodded after the baby is born ; the placenta will not come out of the vagina till it is out of the uterus, and if time is given the danger of post-partum haemorrhage is infinitely reduced. We do too little to ensure that the patient will be well when she gets up. Lax abdominal walls are common after childbirth, and should be prevented by suitable exercises. It is useless to tell the patient what to do ; exercises should be done under the supervision of the nurse, and should be begun in bed. Massage is valuable and diminishes the chances of thrombosis and embolism. Hitherto it has been believed that serious or fatal morbidity during the puerperium is most commonly due to infection of the placental site or of an injured perineum, but a recent investigation at Liverpool seems to show that a condition approaching gangrene in the lower uterine segment is the most common lesion. This implies that there must be a larger number of cases with serious lesions of the cervix than we have been accustomed to think, and perhaps this is an indication for not leaving patients too long in labour. Fever and rise of pulse- rate in the patient may be signs not only of exhaustion but of the onset of infection and should be taken as an indication for expediting delivery. Many of the cases showed cervical tears but I cannot believe that these were all due to the too early application of forceps ; some I believe to be due to strong uterine contractions acting on a relatively resistant cervix. Where haemorrhage continues after delivery, although the uterus is hard, the cervix should be examined and any tears sutured. A postnatal examination should be made six to eight weeks after delivery, and if the pelvis is normal the woman can be dismissed. She should be warned to return, however, if she experiences pain, discharge, or any interference with the menstrual cycle when this reappears.
Transcript of STRATEGY AND TACTICS IN OBSTETRICS
820
be a positive Wassermann reaction, evidence ofanaemia, and rarely of polycythsemia. Albuminuriamay be found as an accompaniment of nephritis,or of the physical state with a low blood pressureand vasomotor instability. The nose and sinusesmust receive attention, and the cervical fascia andmuscles should be palpated.
In treatment any obvious or discovered cause must.naturally be dealt with. Vigorous antisyphilitictreatment is required if there is any reasonablesuspicion of this infection. Attention to teeth,removal of adenoids, cleansing of sinuses, correctionof a refractive error, the treatment of anaemia byiron, the use of vasodilators or venesection, may berequired, or the administration of calcium salts.On the digestive side appropriate treatment byaperients, &c., or the restriction of alcohol is oftendesirable, and in more elusive cases a search maybe made for some allergic peculiarity. I once tracedan otherwise inexplicable headache to ingestion of egg-albumin, and there may be many similar possibilities.But often symptomatic treatment must be employed.
Cold applications or evaporating lotions will beacceptable in almost any case. The numerous membersof the salicylate group in their various combinationsare too well known to need enumeration, and theidiosyncracies of some people in relation to these areequally familiar. Gelsemine has a reputation for
neuralgic states. Cannabis indica is very useful forthe headache associated with nervous strain in men,but caution in administration in the case of womenis emphasised. Potassium iodide in small doses iswell worth trying, even if there is no suggestion ofsyphilis. For the intractable headache of tumour,when surgical relief is impossible, hypnotics are
necessary. Finally, as a resort in a particularlyobstinate case, the old-fashioned treatment by a
seton may well be tried. °
STRATEGY AND TACTICS IN OBSTETRICS.
(MR. BRIGHT BANISTER.)I am taking strategy to mean the general art of
.conducting a campaign, and tactics the detailedmanoeuvres of units incidental to the development ofa campaign. The conduct of a natural pregnancy,labour, and puerperium comes under the heading of-strategy, while the detailed treatment of abnormalitiesas they arise will call for tactics.
It has been suggested that if antenatal care were
perfect no obstetric fatalities would arise, but thoughI am unwilling to minimise the importance of ante-natal care it must not be forgotton that it has certainlimitations. Obstructed labour, for example, shouldbe rare to-day, but this danger cannot be whollyavoided by antenatal supervision. Gross abnor-malities of the pelvis or malpresentations of the baby,should certainly be recognised during pregnancy,but the contractile power of the uterus itself cannotpossibly be estimated before labour begins. Veryrarely irregular action of the uterus may produce acontraction-ring which obstructs delivery. Grosscases of primary uterine inertia are found in a recog-nisable type of woman-the nervous type, who
approaches her labour in a state of fear. It is
important to begin the management of labour beforelabour begins, by putting the patient into the propercondition to face it.
By antenatal care it may be possible to arrangeour tactics so as to minimise the risk of hæmorrhage.It is possible, for example, to recognise placentaprævia fairly early, before there is danger of haemor-rhage. There is want of engagement of the presenting
part, or an abnormal position of the foetus. Oneside of the head is more easily palpable than theother, both on abdominal and vaginal examination,and one uterine artery is felt to be pulsating morepowerfully than the other. Bleeding in placentaprævia is painless unless associated with the onsetof labour.
Labour, where there is mild disproportion, is easierto conduct if the case has been thoroughly investigatedbeforehand. Where the mother has an asymmetricalpelvis, for example a pelvis smaller on the left side,a right occipito-anterior presentation will be acceptedas a good sign, because the widest part of the child’shead will engage in the widest part of the maternalpelvis. A left occipito-anterior presentation, on
the other hand, will be unfavourable ; you willknow that the ground is untenable, and that you arebound to lose. When there is any doubt one shouldnever hesitate to examine the patient under an
anaesthetic at the onset of labour. The way in whichthe head is entering the brim should be observed,and its favourable or unfavourable aspects con-
sidered. As labour progresses the state of the loweruterine segment must be watched. As- long as thecervix is stretched, the occipital pole coming down,and the caput only increasing gradually, progress is
being made. If the cervix is beginning to get cede-matous the outlook is not so favourable. It is
impossible to decide what is happening in a tight fitfor some time after the membranes have ruptured;even if labour is advancing well, we must be preparedto change our tactics suddenly if the condition ofmother or child demands it.A uterus must never be bullied or prodded after
the baby is born ; the placenta will not come outof the vagina till it is out of the uterus, and if timeis given the danger of post-partum haemorrhage isinfinitely reduced. We do too little to ensure thatthe patient will be well when she gets up. Laxabdominal walls are common after childbirth, andshould be prevented by suitable exercises. It isuseless to tell the patient what to do ; exercises
should be done under the supervision of the nurse,and should be begun in bed. Massage is valuable anddiminishes the chances of thrombosis and embolism.
Hitherto it has been believed that serious or fatalmorbidity during the puerperium is most commonlydue to infection of the placental site or of an
injured perineum, but a recent investigation at
Liverpool seems to show that a condition approachinggangrene in the lower uterine segment is the mostcommon lesion. This implies that there must be alarger number of cases with serious lesions of thecervix than we have been accustomed to think,and perhaps this is an indication for not leavingpatients too long in labour. Fever and rise of pulse-rate in the patient may be signs not only of exhaustionbut of the onset of infection and should be taken asan indication for expediting delivery. Many of thecases showed cervical tears but I cannot believe thatthese were all due to the too early application offorceps ; some I believe to be due to strong uterinecontractions acting on a relatively resistant cervix.Where haemorrhage continues after delivery, althoughthe uterus is hard, the cervix should be examinedand any tears sutured.A postnatal examination should be made six to eight
weeks after delivery, and if the pelvis is normal thewoman can be dismissed. She should be warned toreturn, however, if she experiences pain, discharge,or any interference with the menstrual cycle whenthis reappears.
