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2. PART II.

The Position of Women among Civilized Races of the Present Day in the Agony of the Expulsive Pains.

Abler obstetricians than myself have undoubtedly understood the movements of women, and the positions which they assumed in the agony of the expulsive pains. As regards myself, I must candidly confess this was not the case; and it was not until I had undertaken this work, and had begun to study the positions assumed by savage and civilized people during labor, that I began to understand that there was a method in the instinctive movements of women in the last stage of labor. I had seen them toss about, and sought to quiet them; I bade them have patience, and lie still upon their backs; but, since entering upon this study, I have learned to look upon their movements in a very different light. I have watched them with interest and profit, and believe that I have learned to understand them. It has often appeared to me, as I sat watching a tedious labor case, how unnatural was the ordinary obstetric position for one parturient woman; the child is forced, I may say, upwards through the pelvic canal in the face of gravity, which acts in the intervals between the pains, and permits the presenting part of the child to sink back again, down the inclined canal. If we look upon the structure of the pelvis,

more especially the direction of the pelvic canal and its axis, if we take into consideration the assistance which may be rendered by gravity, and, above all, by the abdominal muscles, the present obstetric position seems indeed a peculiar one.

The contractions of the previously inactive and rested abdominal muscles are a powerful adjunct to the tired uterine fibre, in the last prolonged and decisive expulsory effort, and in the dorsal decubitus they are somewhat hampered; they act to the best advantage in the inclined positions, semi-recumbent, kneeling, or squatting. We know that the squatting position is the one naturally assumed if an effort is required to expel the contents of the pelvic viscera; we, moreover, all know how difficult, even impossible, it is for many to perform those functions recumbent in bed, and mainly because they have not sufficient control of the abdominal muscles in that position. Much more is this the case in the expulsion of the child; but the recumbent position is sanctioned by custom; it is pointed out as apparently convenient; it is imperatively demanded by prudery, and by a false modesty which hides from view the patient's body beneath the bed-clothes; and above all it is dictated by modern laws of obstetrics, the justice of which I have never dared question; we have all been taught their correctness, and we all thoughtlessly follow their dictates. There is no reason for assuming this position, though we are taught it; it is not reason, or obstetric science, but obstetric fashion which guides us,—guides us through our patients; and blindly do we, like all fashion's votaries, follow in the wake.

We have seen in the first part of this paper that the recumbent position is one but rarely taken by women among savage tribes, or among people who still follow their instinct and not the dictates of the latest obstetric fashion. Now what does civilized woman in the hands of the modern obstetrician do when in the intense agony of the last expulsive pains? She loses control of herself, forgets the admonition of her physician, and gives way to her own instinct.

You have all seen what I have learned to understand but recently. The parturient woman, at the time of the expulsive pains, raises herself in bed into a semi-recumbent position upon her hands or elbows. This struck me most forcibly when I observed this motion in a young primipara who had gone through the earlier stages of labor bravely, and although partially under the influence of chloroform, when, with the last severe pains the head of the child would advance and then again recede, she finally, in

FIG. 46.—Semi-recumbent, in the agony of the expulsive effort

[Description: Woman on bed holds herself up with one arm while using the other to hold onto a rope tied to a bedpost at the foot of the bed. Black and white illustration.]

her agony raised herself up into a semi-recumbent position, resting on her arms, and with the next pain the child was born.

Other women assume this semi-recumbent position by clinging to the neck of the husband, or an assistant who may be seated by the bedside. It is not love for the person which dictates this motion; it is an instinctive desire to raise herself into a semi-recumbent position, to facilitate the expulsion of the burden she bears. Others, again, have a sheet or rope fastened to the bedpost, upon which they pull with their arms; the object of this is only to assist in the effort of raising herself partially in bed, into a semi-recumbent position, as the kneeling savage raises herself by

a rope which is fastened above her head, or as others recumbent in bed or upon the floor, half raise themselves by a rope or pole above the head. It was instinct, certainly not obstetric teaching, which told the patients referred to by Dr. Campbell to assume the squatting position by which they were so easily delivered of their children, whilst tedious labor stared them in the face if they obeyed the modern obstetric fashion. In one case it was a negro, in the other it was a white woman of high social standing, who had suffered in several tedious labors while obliged to follow the dictates of her physician to remain in her bed; in her agony, following her instinct, regardless of advice or appearances, she assumed the squatting position, and was easily delivered. In another case Dr. Campbell refers to a girl whom he had lately confined kneeling upon the floor, her arms resting upon a low rocking-chair. Being asked how she came to assume this position, she said that in a former labor, four years ago, the midwife had kept her strictly in bed, never allowing her to get up; this, however, she was able to do occasionally, when the pains always seemed to improve. She said that the midwife threatened to tie her in bed if she did not remain quiet. She was, upon that occasion, in labor from four o'clock in the afternoon until ten o'clock of the second day; being in great distress, she disobeyed the midwife, and left her bed; her pains immediately increased, and she knelt down on the floor with her face resting in the lap of her mistress, and was in the same position as with the chair in the following labor; she says that she had not been in that position more than five minutes before the child was born. Her expression was, "The floor is the best place to have a baby, and I don't think I ever could have one in bed.'' The woman seemed quite intelligent, and afterwards candidly stated that her first thought, on the doctor's entering the room, was a dread that she would be put to bed and stopped from completing her labor.

I need hardly continue this evidence, as every one of the members is aware how frequently, in the last moments, a

change of position is made by the agonized woman. Rarely the inclined position, kneeling, or squatting, is assumed, mostly the semi-recumbent position, and that is the one which seems dictated by the instinct of the patient, and the one which I would accordingly advocate.

RÉSUMÉ AND CONCLUSIONS.

I WILL briefly recall the more striking and important features elicited in the inquiries I have made in regard to the posture of women in labor.

I. The women of the various tribes and races are delivered according to customs, and in positions, which are peculiar to their people, whenever they are free to follow their own instincts.

(a.) These positions are now adopted as customary and traditional, but in the first place they were assumed because they had proved the safest and best; delivery, in simple cases, being thus accomplished in the shortest possible time with the least possible suffering.

(b.) So great do the advantages of posture in childbirth seem to be, that people cling to this custom more firmly than to any other of their traditions, as we have seen by the chair of the Cypriote midwife, who to-day reënacts the labor scene of 2,300 years ago; and of the native Peruvian woman, who is still confined as were her ancestors at the time of the Incas.

II. The positions assumed in civilised communities, by the advice of learned authorities, have varied greatly with the change in obstetric science, and with the demands of comfort and of modesty; thus, in the days of Greece and Rome, in the early centuries of the Christian era, a semi-recumbent position was advocated, either upon a low stool or in bed; later came the obstetric chair, and toward the end of the last century the dorsal decubitus, which has retained its supremacy, yielding, however, to the position on the side in the British Isles, and to the dictates of Nature in the agonies of the expulsive pains, when women will occasionally

disobey the conscientious obstetrician, that they may obtain speedy relief.

III. The same woman often assumes various position in the course of a natural labor; usually, she is more at her ease in the early stages, and not until the pains become more regular, rapid, and severe, does she take the position in which she is confined.

Thus, the Coyotero-Apache squaw occupies any position she pleases, generally standing or walking about until bearing-down pains supervene (which, in fact, is almost universal among the North American Indians), then she assumes the squatting posture. The squaws of the Laguno Pueblo stand with their hands on their knees, much as they urinate, in the earlier stages; later, they stand up erect, supported by assistants or clinging to a rope. The Modocs maintain a curved position, lying on the side, until the labor is nearly completed, when they assume a position on their knees and hands, which is continued until the child is born.

Among the Nez-Percés and Gros-Ventres the parturient is in a stooping posture during the first two stages of labor, the buttocks resting on the heels, whilst during the expulsion of the child she lies down, on either side, or on the back.

IV. In the last stages of ordinary labor, those positions which I have classified as inclined are most frequently resorted to; most common of all is the kneeling position which we mainly find among the Tartars, Mongolians, and North American Indians: the squatting posture is also at home among our Indians, and among the Malays, the Australian and African negroes; equally frequent are the semi-recumbent positions, which, although resorted to by savage nations, are more closely connected with the progress of civilization. The ruder methods. such as the semi-recumbent position in the lap of an assistant, or on the ground, answer the same purpose as the more comfortable and refined posture in the obstetric chair or in bed.

Least frequent are the recumbent or horizontal, and the standing or erect postures.

V. In all positions, whether the patient is swinging by the limb of a tree, whether she is kneeling by a stake, or semi-recumbent in bed, there is a decided change in the axis of the body during the pain, and in the interval of rest; and usually the patient has a support of some kind within reach, a rope, a stake, or an assistant, by means of which she can change the axis of the body, and intensify the contractions of voluntary and involuntary muscles during the pains.

The pelvis itself is usually steadied, whilst the upper portion of the trunk sways to and fro.

Some of our Indians walk about in the interval, and kneel down, clinging to the stake during the pain; for this purpose the Comanches, for instance, have a number of stakes planted in the ground at the place of confinement, in order that the patient may walk about,

and still find a support to kneel by at any moment, when the pain overtakes her.

The weakly woman, among the Kootenai Indians, who is confined in a recumbent position, raises herself by a rope which is suspended above her during the severer pains, and during the expulsion of the child.

The Indians on the Mexican frontier, who are confined in a kneeling position, usually stand or recline on the bed during the interval between the pains; but when a pain is coming on, they immediately grasp the convenient rope and hang on with all their might; and this position permits

of the easiest and freest motion of the body for the purpose of best adapting the inclination of the pelvic axis to demands of the advancing head.

The native Mexican is often confined kneeling on the floor; in the interval between the pains she lets herself down, her buttocks resting upon her heels, whilst during the pain she raises the body, throwing it backward or forward, according to circumstances, and clings to a rope, an assistant, or the neck of the midwife.

Surgeon George W. Adair, U. S. A., justly characterizes the difference in the methods pursued by various people. He says: "The English midwife exhorts the patient to lean forward; in America, the feet are fixed, and the patient is given a rope by which she raises herself during the pain; the Mexican midwife fixes the knees and holds the upper portion of the trunk as in a vice, and pulls the pelvis forward, hinged, as it were, upon the acetabulum, and thus overcomes the dip of the plane of the superior strait, and straightens the passage with greater efficiency and certainty.''

Dr. Campbell closely observed the negro woman whom he saw confined in a kneeling posture, her arms resting upon a low chair, and saw that during the pain her body would move backwards so that her buttocks would rest between her heels, while in the intervals she would glide forward again, so that the thighs became perpendicular and the body horizontal.

VI. In tedious cases, when delivery is retarded and labor will not advance, a change is usually made in the posture of the patient, and massage is freely resorted to; thus, the Cheyennes, Arapahoes, Nez-Percés, and Gros Ventres, who assume the dorsal decubitus in ordinary labor cases, raising themselves into a semi-recumbent position during the expulsion of the child, resort to the knee-elbow position in difficult cases.

The Siamese, who usually assume the recumbent position, and our Coyotero-Apaches, who squat in ordinary cases, both suspend the parturient by bands about the

chest, if labor is delayed, and let several assistants cling to the sufferer, suspending themselves from her with their arms above the uterine tumor; the Siamese draw their patient up in an erect posture, whilst the Apache squaw is swung in a more kneeling position.

Upon the Pacific slope, where the dorsal decubitus is the rule in ordinary cases, the patient is partially suspended in a kneeling or squatting position in difficult cases; the Syrians, who usually permit their patients the comforts of the obstetric rocking-chair, toss them in a blanket to shake the child out, or turn it, if the labor becomes tedious.

Instinct and experience teach the savage that by a change of position, labor may be hastened or retarded, and involuntarily they change the axis of the body in a way most favorable to a natural and safe delivery, hastening labor as much as is compatible with the safety of mother and child; all the inclined positions, especially the kneeling and squatting, clinging to a rope, are such that the direction of the pelvic axis can be readily changed. It remains for the scientific observer to demonstrate with precision the positions which are the most favorable under given conditions.

Herr von Ludwig, the speculative and theoretical writer, who has been condemned and ignored by practical obstetricians, describes the knee-elbow position as the one which retards the expulsion, making it slower and safer in difficult cases, saving the perineum, and the kneeling position, with the body inclined forward, as the one which retards expulsion but moderately, with proper care of the perineum.

Although it is not within the scope of this study to discuss the question as to the best position for women in labor, we may well look to the ethnological facts cited for a solution of this puzzling and highly important problem, and I will outline the more important conclusions which have developed.

I. In the ordinary labor case, which is a purely mechanical process, the patient should be given greater liberty and should be permitted to follow the dictates of her instinct

in regard to her movements more freely than is now customary.

II. In the earlier stages of labor the parturient must be guided in her actions, and in the position assumed, by her own comfort and by the dictates of her instinct; not only is this the invariable rule among savage races, but it was also warmly advocated by the shrewd and observing obstetricians of the past, and by those eminently practical and successful midwives of old.

III. The care with which the parturient women of uncivilized people avoid the dorsal decubitus, the modern obstetric position, at the termination of labor, is sufficient evidence that it is a most undesirable position for ordinary cases of confinement; and I am convinced that the thinking obstetrician will soon confirm the statement not unfrequently made by the ignorant but observing savage, by Negro and Indian, that the recumbent position retards labor and is inimical to easy, safe and rapid delivery.

Several of the most esteemed of my colleagues have already given me a very decided expression of their opinion, taking the same grounds practically and theoretically. Dr. Campbell, of Georgia, says that a careful study of the actions of parturient woman in her natural state will force us to permit our patients, sometimes, at least, to obey their own impulses, and to assume a squatting, kneeling, or sitting posture, in their attempts to deliver themselves; and this, he adds, "would, in my opinion, often do away with the necessity of resorting to the forceps, which, though a great blessing, too often become the reverse in the hands of eager obstetricians, who are inclined to use them on the least occasion, or without any real occasion at all.'' He has given me the history of a number of cases, most of which I have already cited, in which labor was retarded, progress had entirely ceased, and the propriety of the forceps was under consideration, when a speedy and unaided delivery followed a change of position from the routine dorsal decubitus to the squatting, sitting, or kneeling posture, as the instinct of the patient prompted; but be it remembered, the same patient,

when free to follow her instinct, always adopted the same position.

The cases related by Dr. Campbell are as striking as the one told me by Dr. V. Mansfelde, of Kansas: the patient being in great distress, labor having continued for several days, entire cessation of pains in the usual obstetric position, their sudden recurrence upon assumption of an inclined position, their disappearance, with the certainty of a chemical experiment, upon a return to the dorsal decubitus, and final speedy delivery in the position of the patient's choice.

Dr. Wilcox, of Massachusetts, and others have related similar cases, most of which I have already given, but I cannot close without again referring to the views of my friend, Dr. Campbell: "I will say that I regard what may be called the Obstetric position, as generally practiced in this country, recumbent on the back, as not only the most unnatural, but the most disadvantageous and therefore the most unphilosophical; it is the position which, above all others, deprives the woman in labor of the advantages which gravity would give us in promoting expulsion; there the position almost nullifies the power of the abdominal muscles, leaving the almost unassisted uterine muscle to effect expulsion. The English method, on the side with the body bent forward and the thighs drawn up, is much more advantageous in so far as the abdominal muscles can act better.''

IV. In ordinary labor cases the expulsion of the child should be expected in an inclined position: Kneeling, squatting or semi-recumbent, in bed, on the chair or lap, as is done by the great majority of uncivilized people, and for the following reasons:—

a. These positions permit the free use of the abdominal muscles.

b. The force of gravity does not counteract the expulsive effort as in the recumbent position, nor does it unite with it too freely, and hasten labor unduly, as in the erect posture.

c. With the assistance of a rope, stake, or other support the parturient can vary the inclination of the body and correct the labor, hasten or retard the descent of the child, and relieve the

pain, changing the axis of the body and throwing the fetal head toward the sacrum or symphysis.

d. Injury to the soft parts is less liable to occur in these positions, if we may accept the rapid getting up, and freedom of our Indian squaw from all uterine diseases, as proof of this statement.

V. Of these positions the semi-recumbent is the most serviceable, and should be adopted as the obstetric position in all ordinary labor cases; it is preferable to the kneeling or squatting.

a. As more convenient and comfortable, not exposing the person, and not being objectionable to the modesty of the patient.

b. As affording more rest and not being tiresome, which is a serious objection to the kneeling and squatting position as applicable to the tender female of our civilization.

c. The semi-recumbent position in bed, the body at an angle of forty-five degrees, the hips resting on a hard mattress, thighs well flexed, is the easiest, most comfortable, and appears to afford the greatest relief, and the greatest freedom from pain, coupled with the greatest effect of the uterine contractions, relaxation of all the parts, and free play of the abdominal muscles.

d. The pelvis is more readily fixed in this position.

e. The perineum has a certain support which does away with the questionable proceeding of supporting the perineum during expulsion of the head and shoulders, by which more harm than good is usually done.