terilized gown, seats himself on the edge of the bed and watches the
progress of the labor, ready to assist the woman at any moment. And at
this time he can do much by words of encouragement and proper directions
to the laboring woman how to use her pains so as to get the most from
them; and also by manipulation of the soft parts and the head. The head
advances more and more with each succeeding pain, and the perineum is put
on the stretch, each contraction is followed by a resting pause during
which the head slips back a little and relieves the perineum. Tear of the
perineum is liable to take place when the head is about to escape through
the vulvar opening, especially if the contractions are strong, the woman
bears down forcibly and the interval between the pains is short, so that
the head is forced out before the parts have time to completely dilate and
soften. Here is where the physician's work comes in, by holding the head
back and fully flexed (bent), chin upon the breast, and keeping the back
of the head (occiput) well up towards the bone in front (pubic arch) until
thc perineum is completely dilated.

The effect of the pains can be lessened, if necessary, also, by telling
the woman to open her mouth and not to bear down during the pain for a few
times. In this way the perineum will dilate properly and be torn little,
if at all, and perhaps much future trouble for the woman saved. I always
tell my patient why I ask her to do certain things in labor and I have
never found any woman who, when able, was not willing to do as I asked. A
torn perineum is not desirable, because even when sewn up immediately
after labor, it may not unite thoroughly, and thus cause displacements of
the womb in the future. A little time and care at the time of labor will
save the perineum and every woman is willing to do her share when the
conditions are plainly explained to her. It takes only a few minutes
longer, and only a few more pains to bear. When the head begins to stretch
the opening, the left hand of the physician should be carried over the
woman's abdomen and between the thighs, her right leg being supported by a
pillow placed between her knees, and this left hand presses the back of
the head (occiput) forward and against the "pubic arch." The right hand
may also press the head upward by being placed against the posterior
portion of the dilated perineum. The edge of the perineum should now be
closely watched. A small towel wrung o