When all other external methods have failed, by placing one hand in front of the fundus and the other behind it, the uterus may be compressed from above downward between the two hands and the placenta gradually expressed into the vagina.

Delayed Delivery of the Placenta.-(While this really belongs to abnormal labor, it is given here because it is usually due to lack of skill in the use of the Crede method, and not to any abnormal condition). If, after an hour, the placenta is not delivered, an examination should be made. If most of the placenta is in the vagina, slight traction may be made upon the cord or placenta, but if the placenta is within the uterus, one or two fingers should be introduced to enlarge the cervix and to straighten the uterine canal during contractions. The squeezing of the fundus should be continued for three or four pains, then, if the placenta does not come, it is probably adherent and reujires the introduction of the hand into the uterus. (See Abnormal Labor).

Delivery of the Membrane.-As the placenta is expelled from the vulva, it is caught in the hand, the membrane brought together, twisted over the finger, and, by gentle traction and more twisting, delivered. If considerable traction is necessary, it is best to wait until the cervix has time to relax, as a clot of blood may be in the membrane within the cervix, preventing delivery.

The Examination of the Placenta and the Membranes.-The fundus is left in charge of the nurse or patient while the afterbirth is being examined. A careful examination should be made of the maternal surface of the placenta. Raw spots show that the placenta has been torn during delivery or handling, or that some of the maternal portion of the placenta has been retained. Marked unevenness indicates that more than the average amount of the maternal portion has been retained. This is due to improper Credeing, or to the irregular distribution of the weakest cells. Fissures may be present from separation of cotyledons during expulsion, and not necessarily from loss of tissue. When any of the placenta is retained, it should be immediately removed by the finger. The membranes should be carefully examined. If the opening is no more than the size of the child's head, and there are two distinct layers (one of which, the combined decidua vera, reflexa and chorian, cannot be peeled from the surface of the placenta, but is continuous with the edge of the placenta), the mem

branes have very probably all come away. If there is any doubt as to the retention of a piece, the uterine cavity should be immediately examined. By using extreme care in regard to the afterbirth, many cases of sepsis are prevented.

The Treatment of the Placenta.-The placenta should be placed in a paper and burned or buried, but, for sanitary reasons, never put into a vault.

The Hand On the Fundus.-The hand of the accoucheur, nurse or patient, should be kept on the fundus from the time the head is born until the bandage is applied, or for one hour. This prevents post-partum hemorrhage, aids involution and greatly lessens the severity of after pains.

The Post-Partum Chill.-This is easily controlled by getting the patient dry, well covered, and giving her a cup of hot milk. It is always a good plan to give every patient a cup of hot milk just as soon as she is covered. This prevents chilling and gives strength. If the chill occurs, warm cloths next to the limbs, hot whiskey, hot bottles, and more covering should be used.

Antisepsis. The patient should be upon a Kelly pad or bedpan and near the edge of the bed, or, better, in the obstetric position. Then the vulva and vaginal orifice and adjacent soiled areas should be carefully cleansed with gauze or cotton sponges and soap, and then with bichlorid solution (1 to 2,000); next the perineum should be carefully examined for tears, by sponging and spreading the parts. Tears are often seemingly insignificant, until carefully examined under good light, with the patient cross-wise on the bed. If there is no tear, the vulvar pad should be applied.

The Repair of Lacerations of the Perineum.-All tears, however small, should be sutured at once. The patient should be under chloroform to the stage of unconsciousness. The pan containing the sterilized instruments-two needles, needle holder, scissors, and ten silk and worm-gut sutures-should be brought in and placed conveniently on a chair. The patient should be cross-wise on the bed, in the forceps position (lithotomy position), or if a slight tear, the feet on chairs. The Kelly pad should be under the hips. The tear should be well opened to show its extent. The needle should be introduced perpendicularly to the surface and about a quarter of an inch from the edge of the tear, directed back from the tear to take up more tissue and to include the

levator ani, then kept beneath the tissue by the guide of the left index finger until the middle of the tear is reached, when it should be brought to the surface, immediately reintroduced and carried beneath the tissues half an inch beyond the opposite edge of the tear, back to a quarter of an inch and then brought to the surface. Each suture should be tied at once. The vaginal sutures should be tied extra tight. The other sutures are introduced in the same way and near enough together to make the walls come in perfect apposition. The vaginal rent is closed without taking up the tissues belonging to the external tear. To prevent the ends from pricking the patient they are left long and tied together. The site of the wound is wiped dry and the vulvar pad applied. (The sutures should be removed on the tenth day. See Chapter XV, The Management of the Puerperal Period. (It is to be remembered that tears, apparently transverse, are usually longitudinal).

Changing Sheets and Pads.-If, for any reason, the bed sheets have become soiled and the patient's back and thighs are bloody, she is first turned on to her near side, her back exposed, washed and wiped. The soiled lower sheet and pads, which have not been removed, are rolled up to her back from the far side of the bed, a clean sheet, hip-pad and abdominal bandage are placed on the back part of the bed and their near half rolled so that it is next to the soiled one and just behind the patient's back. Then the patient is turned on to her back upon the clean bandage, pad and sheet, and the soiled upper sheet removed from the farther thigh, which is now washed, wiped and covered with the clean upper sheet, the soiled upper sheet removed from the bed and the nearer thigh washed and covered. After this the patient is turned on to her far side on the clean pad and sheet, her back rewashed, if necessary, and the soiled under sheet and pads removed from the bed and the clean roll brought forward into place and the patient turned on to her back.

Changing Gowns and Shirts.-If the patient's gown is soiled, it should be removed while she is on her back or side before placing her on the clean sheet. The best way to change the gown, if the bedding is changed, is to take the soiled gown from the upper arm and slip it over the head while the patient is on her near side, then slip the clean gown on her bare arm, and, when everything is ready, to turn the patient upon her opposite side,

slip the soiled gown from the upper arm and the clean gown over the head and on this arm. (Extending the arm over the head often facilitates its introduction into the sleeve). When the bedding is not changed, it is best to roll the gown up to the armpits and, while the patient's back is held up from below the axillae, the gown drawn over the head and off the arms, which are extended over the head, and a clean gown slipped over the head and

arms.

The Abdominal Binder.-(See Labor Directions under Hygiene of Pregnancy). (Two flour sacks make a very fair bandage. A bandage 18x40 inches is long enough to reach around the body at the trochanters, and wide enough to reach from the breasts to below the trochanters). Before applying the bandage, the gown should be rolled up to the breast, the vulva covered by the dressings or a sterilized towel, the sheet pushed down to the trochanters and the lower limbs extended. The binder should now be brought into place, if not done before, and pinned on the left side of the abdomen from below upwards with large safety pins. The left hand should hold the bandage taut while the right hand introduces and fartens the pins. The pins should be introduced parallel with the length of the patient and close together. The bandage should be made extra tight as far up as the crests of the ilia. Above this point the bandage should be snug, but not so tight as to predispose retroversion of the uterus. If it hurts the patient after it is pinned it is too tight and should be loosened at the tight points. Many do not use the bandage because of the belief that it tends to cause displacement of the uterus, but if properly applied it tends to prevent displacement and gives the patient much relief by stopping the "falling apart" sensation and allowing the patient to turn on her side without the uterus sagging. It also tends to keep the womb retracted and, therefore, lessens the danger of hemorrhage. Patients desire it, as they believe it preserves their shape.

The General Condition of the Mother. The patient should be asked how she is feeling, and her pulse, the height, width and consistency of the fundus and the amount of flow determined. It is well to remember that the fundus should be below the navel and firmly retracted, but as an exception, it normally may be above the navel a finger's breadth or two, as the height of the fundus.

does not necessarily indicate the size of the uterus. The cervix may, if the fundus is above the navel, be opposite the brim, or if half way between the pubes and navel, be nearly on the perineum.

The Care of the Child's Eyes.-One or two drops of a two per cent. solution of protargol should be dropped into each eye as soon as the obstetrician has cared for the mother. This is used to prevent ophthalmia neonatorium.

The Umbilical Cord.-After the nurse has washed the baby, the cord should be dressed. If it is very thick, i. e., contains a large amount of Wharton's jelly, it should be cut just above the knot, stripped from the navel to expel the jelly and retied. Boric acid should be dusted about the cord. The cord shold be pushed through a small hole made in a three-inch square of gauze, sterilized cheese cloth or scorched soft linen, turned upwards, i. e., away from the genitals, to prevent soiling the gauze folded over it, a square of absorbent cotton applied-to prevent rubbing when the baby is lifted and the belly-band put on and pinned sufficiently tight only to hold these dressings in place.

The Care of the Instruments and Other Articles.—All should be removed from the room as soon as possible; the obstetrician's hands should be washed with soap and water to remove blood or other stains; the instruments should be washed with soap or sapolio, wiped dry and put in their proper places. The Kelly pad should always be washed at once, as otherwise it will show the stain of blood and will indicate untidy habits on the part of its

owner.

Directions as to the Subsequent Care of the Mother and Child. These are directions regarding the care of the mother's vulva, breasts, nipples, hands, position, sleep, bladder, bowels, after pains, flow, tears, diet etc., and the child's nursing and navel. (These will be given under "The Management of the Puerperium).

The obstetrician should state the time he will make his first post-partum visit, and direct that if any abnormal condition ap pears he should be sent for at once, though it is near the appointed time of this visit, as he might be delayed because of other important cases or by loss of sleep.

Labor Records. These are of much importance, but they should be brief. They may be kept on printed blanks, but one or