MODERN MIDWIFERY PRACTICE IN

INDIA.

By g. t. birdwood, M.D.,

Major, i.s.s.,

Civil Surgeon, Mussoorie.

This paper is written with the hope that it

will bring before practitioners in India one or

two recent advances in midwifery practice. By practitioners 1 do not mean only I. M. S.

officers who have probably have had time to

attend a course at the Rotunda or elsewhere, but the large number of qualified and diplo- maed Indian practitioners who attend confine-

ments in native cities. It is also written with

the hope that these advances may be impressed upon Indian students who are being educated at Indian schools. 1 also wish to advocate one

or two measures, which may ensure medical

subordinates attached to hospitals and dispen- saries doing more thorough midwifery. Some

years ago when I was a student, it was the

custom during a confinement for a practi- tioner to make as many vaginal examinations as he thought fit to see'how progress was going on. There was no disinfecting of the orifice

of the vagina?the labia minora?no rubber

gloves were used, douching before and after

confinement was the practice. Few perineums were stitched. Craniotomy f?r contracted

pelvis was the rule. By 1906 some advances had been made. The principle of practice as

enunciated by Dr. Horrocks was to interfere

as little as possible. The fewer vaginal examin- ations the better. The practitioner was not

to follow down the uterus after labour. Not

to use a binder ; not to give chloroform; not to douche. In fact, to leave everything to Nature. Now in 1011 further steps have been made and

the more important principles seem to be

these?

(1) In normal labour no vaginal examina- tion at all is advocated. The Master ot the

Rotunda says : " We strongly recommend the

management and normal labour without a vag- inal examination."

(2) If a vaginal examination is necessary, boiled rubber gloves or a fingerstall must be

worn, also the labia minora must be disinfected

l>y swabbing before examination by soap and

water and then an antiseptic. (3) Throughout the confinement rubber

gloves must be worn and a second pair ready for intra-uterine use if subsequent necessity arises. At the Rotunda, by strict surgical cleanliness morbidity has been reduced from

8*7 per cent, to 3*7 per cent, in last ? years.

(Morbidity is defined by a rise of temperature above 100? for any two days between the second and eighth day.)

(4) The diagnosis of foetal position and

presentation must be done chiefly by abdom- inal palpation.

(5) The abandonment of douching after

normal cases.

(6) The accurate measurement ot the pelvis in the seventh or eighth month, so that in con-

tracted pelvis treatment is decided on some

weeks before labour commences. Dr. A. \\.

Russell of the Samaritan Hospital says : "Ihe

proper moment to discuss contracted pelvis is

long before labour sets in ; until this is done we

March, 1911.] THE TEACHING OF MIDWIFERY IN INDIA. 97

shall have the almost unjustifiable operation of craniotomy." The Master of the Rotunda says: " With the various excellent modern operations it is no longer justifiable to perforate a living child. We c*o further than this, and make the

definite statement that a child should not be

allowed to die through delay in delivery from

contracted pelvis." (7) The accurate internal measurement of

contracted pelvis by Skutsch's pelvimeter. (8) The introduction of Walcher's position by

which the true conjugate is lengthened by ^ inch. (9) The introduction of pubiotomy, by which

2 inch is also added to the true conjugate and the transverse diameter also widened.

(10) The stitching of the perineum in nearly all cases.

(11) The examination of the urine once or

twice during the pregnancy, or more often if

symptoms of toxsemia are present. In fact, the key-note of modern midwifery is

the prevention of complications which may arise from sepsis, abnormal positions, contracted pelvis, and toxaemia. Dr. A. W. Russell trulj' says :

"

Prophylaxis is the central position of the art of obstetrics, and the ideal to which the true obstetrician must costantly strive." How far can this ideal be realized in India and how far can Indian students be taught to practise up to this standard ?

(1) To begin with. Can the Indian student be

taught to use rubber gloves ? And is the use of rubber gloves a practical possibility for Indian private practitioners ? Objectors will at once say that finger-stall and rubber gloves will not stand the Indian climate, and even if they did, the cost -would be prohibitive for hospitals and private cases. These objections can both be overcome. For six months of the }^ear rubber gloves will keep quite well, for the hotter months the

necessary supply (calculated on the annual num- ber of confinements) could be got in April to last over to October, when a fresh supply could be got for the colder months. Gloves keep well in the powder the}' are sent in, or in methylated spirits or suspended in the kerosene oil vapour. As regards cost, finger-stalls can be purchased at Rs. 12 a dozen, and gloves at Rs. 2-6 a pair. A pair of gloves, if properly treated, can be used for 4 or 5 cases. For Rs. 100 about 250 midwifery cases could be attended with gloves. Up- country hospitals do not probably have more than this number of confinements in the year. I" hospital practice and also in teaching students and nurses, I am strongly of the

opinion that no vaginal examination should be permitted without a finger-stall. The fingers of partially damaged gloves can readily be used for fii iger-stails subsequently. They can be boiled and kept in a bowl of methylated spirits for the use of students. If the Rotunda can afford

finger-stalls and gloves for 1,800 cases annually, surel}' Indian Maternity hospitals, with the health of India at their back, can afford these

ai tides for the 200 to 300 cases which occur in a hospital. For private cases the practi- tioner should supply his own gloves. If a female sub-assistant-surgeon attends a rich native lady, she should insist that the patient pays for the gloves or the fee be large enough to enable her to purchase them. I am strongly of (he opinion that every student should be taught that he or she must use finger-stalls or gloves in midwifery practice after" leaving the hospital, and that every Dufferin and Maternity hospital should keep a supply of gloves for hospital use and for the use of the staff* when they attend cases in the city and that the officers in charge of these institutions should see that the gloves are fit for use and that they are used. Is it fair on a Maternity case that a female sub-assistant-surgeon who has been opening a septic abscess or dressing syphilitic sores at out-patients should go ofi' to the city and attend a confinement& with recently septic hands with perhaps only a brief preliminary dipping of the hands in lotion ?

(2) Again, 1 do not think students in India are definitely taught the disinfecting of the labia minora. The Master of the Rotunda devotes a whole pnge on the preparation of the vaginal examination. It will be a step in advance if Indian students are taught that this is one of the essential points in the conduct of a case. Whitridge Williams has shown after an examination of 300 women that the vagina in healthy women is steiile. The Indian student must be taught that he must not carry serins from the labia minora into the vagina.

(3) Again, midwifery books lay down that a definits obstetrical kit should be taken in a bag to a case. Tweedy and Wrench devote a whole chapter to this subject. How many Maternity hospitals in India who send women out to treat patients in the city keep a properly equipped bag ? How many practitioners who attend city cases keep a proper outfit them- selves ? Such a bag is bought and equipped at a small expense. I do not know any Maternity or Dufferin hospital or any female sub-assistant-surgeon who keep such a bag. The essential contents are?(a) for ordinary cases, finger-stalls or rubber gloves, nail brush, biniodide tabloids or lysol, a piece of soap, a

packet of Salallembroth wool, ergot, waterproof sheet, douche can, canula, scissors, catheter and needles and forceps; a small Etna spirit lamp, or sterilizer ; (fc) for those who wisli to meet further emergencies the bao- can contain uterine plugging forceps, iodoform gauze, flushing curette transfusion apparatus, axis traction forceps and Carlton's mucous catheter and pelvimeter. How many Indian students who are now in practice have been taught that the equipment mentioned in (?) is absolutely necessary for the proper management of cases in practice. Every Maternity hospital in India should undoubtedly keep such a well equipped

98 THE INDIAN MEDICAL GAZETTE. [March, 1911.

bag and every student should be taught that

he cannot conduct cases without these neces-

saries.

(4) Again, is it possible to teach Indian

students to diagnose fcetal positions by abdom- inal palpation ? Is this done now ? Diagno- sis by abdominal palpation is not always easy especialty in a fat subject, but much may be

done by making it one of the principal points of a student's training. It is not difficult to

find out whether the breech or the head is at the

fundus and whether the foetal back is looking forwards or backwards. The Pawlik grip will

tell whether the head is fixed in the brim or

not. In my opinion this method of diagnosis should be one of the principal things taught to a student in his course of training.

(5) Is it possible to teach Indian students to

measure^ the pelvis accurately ? Is this done

now ? I he pelvimeter at present is generally produced to measure an obvious contracted

pelvis which could be diagnosed by sight or the

hand. Skutsch's pelvimeter is invaluable for I

accurate internal measurements, but I should not recommend it for the general instructions of students. Its flexibilit}' makes it more difficult to use accurately and for internal measurements, when it is really needed, chloroform is necessary. It is not the very obviously contracted pelvis which need measurement by the practitioner so

much as those with a brim from 3 to inch

which escape detection till labour is well ad-

vanced. It may be said that most Indian wo-

men vvho have contracted pelvis do not come to

the dispensaiy or seek skilled assistance till

labour is far advanced. This is often the case,

but it is not always so. Cresarean section has

been many times done at Agra by others and

myself on women who have reported themselves some weeks before confinement. The student

should be taught the advantages of premature labour, Walcher's position and pubistomiy for the treatment of contracted pelvis. Then, with an

accurate training in pelvimetr}7, they would be

able to send to skilled assistance such cases as

needed it. I constantly see certificates to the effect that

the holder has studied midwifery for two years and attended 50 cases. It would be better if

the certificates definitely stated that the holder

had diagnosed the foetal position by palpation in 50 cases, had accurately measured 50 pelves, and had examined 50 cases with rubber gloves.

(G) I further think it would advance the

cause of good midwifery practice among Indian students and nurses in India, if a short leaflet

was written for each on the management of

normal labour, so that essential points should not be forgotten in practice in future years. The following points should be briefly dealt

with? How to prepare the bed. How to prepare lotion and basins. How to prepare rubber gloves for use.

How to disinfect the labia minora. What to have ready at the second stage. How to conduct the second stage. How to conduct the third stage. What to do in cases of haemorrhage. How to revive the infant. The leaflet for nurses would differ consider-

ably and would vary with the practice and wishes of the physician conducting the case.

I have drawn up a leaflet for the direction of

nurses working under nie, stating exactly what

preparation and procedure I wish carried out.

It is based on one given me by the Civil Surgeon of Naini Tal, and 1 hope to find it of the greatest use.

Conclusion.

The summary of what I advocate in this

paper is?

(1). That Indian students should be taught the necessity for the use of rubber finger-stalls and rubber gloves in confinements.

(2). That every Maternity and Dufferin hos-

pital should keep a stock of lubber gloves for hospital use, and the use of those who attend

cases in the city. (3). That no practitioner should attend a

case without using boiled gloves or finger-stalls. (4). That no vaginal examination is neces-

sary in normal cases.

(5). The students should be taught that the disinfection of the labia minora is an essential

point in practice. If a vaginal examination is

to be made, a boiled finger-stall must be used

and the labia minora disinfected. (6). That every Maternity and Dufferin

hospital should keep a properly equipped ob-

stetrical bag for the nse of the staff attending cases in the city. This should contain at least

antiseptics, pelvimete'r, gloves, waterproof sheet, and douche can and antiseptic wool.

(7). Every student must be taught that if

he or she goes into midwifery practice, he or

she must keep a proper obstetrical kit.

(8). Every student should be taught the

necessity of diagnosis, the foetal position by abdominal palpation in all cases.

(9). Every student should be taught to make accurate pelvic measurements in all cases, and

in after practice, if necessary, call in skilled

assistance earl}*. (10). That a leaflet for the management of

normal cases would be a help to Indian prac- titioners in remembering essential points.

(11). That a leaflet of ' instructions to nurses' would be a help to nurse and doctor in attend-

ing a case. These points which 1 advocate are not counsels

of perfection or bej'ond the range of practical application, but are possibilities which can be

and should be realized ; improvement can only be effected by insistency and thorough teaching of the rising generation at Maternity and

Dufferin hospitals. I believe most ot these

March, 1911.J TIGER AND PANTHER WOUNDS. 99

points are not taught or practised at present. The population of India is over 300 millions and the number of births annually enormous.

The number of European practitioners in India (not in military employment) is probably not

much over 1,000. Therefore the midwifery practice of India now and in the future must

"ecessarily be almost entirely in the hands of Indian practitioners. This emphasizes the im- portance of the fact that the teaching of our schools must be thorough and that it should strive towards the ideal.