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No teaching of medical science has been given greater prominence of late than the principle of prevention. In obstetrics it finds a particularly wide field of application, and its practice is responsible for removing many of the former terrors of childbirth. We have just learned that preventive measures effectually reduce the frequency of puerperal infection, and in an earlier chapter we saw the value of routine examination of the urine as a means of anticipating other complications.

Moreover, the benefit of promptly reporting to the physician anything that does not seem to be as it should has been urged constantly, for in this way is afforded the earliest opportunity to treat complications. Similarly a visit from the doctor about four weeks before the expected date of confinement is indispensable to skillful management of the delivery; neglect of this precaution is sometimes responsible for bad results.

At this visit the physician not only becomes familiar with the general health of his patient, but he also notes certain facts which will have a direct bearing upon the course of labor. By means of a few simple measurements he may accurately determine the character of the pelvis, the bony structure through which the fetus passes. When they are compared with what we know as the normal measurements, a very good idea is gained as to whether the birth-canal will present any obstacle to the passage of the child; and, if it will, there is opportunity to deliberate what treatment may be necessary.

Since another factor in the problem, namely, the size of the child, cannot be accurately predicted, occasionally the physician may hesitate to express as definite an opinion as the patient may wish. Nevertheless, though it may be impossible to learn every detail, the available information well repays the time and trouble expended. In nine out of ten cases nothing whatever is found out of the way; the result is an assurance which always justifies the examination.

During this examination the position of the child is also ascertained. By means of a series of painless manipulations through the abdominal wall of the mother, the head, the body, and the extremities of the child may be mapped out, and the conclusions verified by locating the fetal heart-sounds. In this regard, also, the physician usually finds normal conditions. The most favorable presentation, that in which the head is the part to be born first, occurs in ninety-seven of every hundred cases. When less favorable conditions are recognized, they may frequently be corrected at once; but should that prove impossible, with foreknowledge of the presentation, the physician will be more competent to conduct the delivery.

With a clear understanding of the character and value of the information gathered at the preliminary examination, patients are not likely to refuse it. If they do, the risks should be fully explained to them. Some physicians decline to assume the responsibility of a patient who will not permit these observations. Such a decision is rarely necessary, for in my experience the patient's consent has never been difficult to obtain. Many women now regard the visit as part of the routine attention, and inquire when it will be made.

The appropriate time for this examination, as I have indicated, is approximately one month prior to the calculated date of confinement. Before this period, we have no assurance that the presentation which is found will continue until the time of birth. The fetus frequently alters its position as long as it is not large enough to fill out the cavity of the womb, consequently it is only during the last month of pregnancy that the final presentation can be determined. But to defer the examination after the period I have specified is unsafe since we lack an exact method of fixing the day of confinement, and too long a delay might render a preliminary examination impossible.

Aside from its relation to the observations just outlined, the preliminary visit provides an opportunity for the physician to criticize the preparations which have been made, and for the patient to inquire about the personal preparation advisable at the beginning of labor. She will also learn the signs which indicate that labor has begun and will be told what to do when they appear. Although physicians may not agree in all these directions, there can be no difference of opinion relative to the essential points. At least, the rules given here will serve to bring the patient and the doctor to a definite understanding as to the course he desires her to follow.

Tags: Pregnancy & Childbirth