Abortion.—Miscarriage.—Premature labour.—Causes.—Symptoms.—Prophylactic measures.—Effects of repeated abortion.—Treatment.
Abortion.—Miscarriage.—Premature labour.—Causes.—Symptoms.—Prophylactic measures.—Effects of repeated abortion.—Treatment.
The uterus does not always carry the ovum to the full term of pregnancy, but expels it prematurely. This expulsion of its contents may occur at different periods, and is characterized accordingly: thus, among most of the Continental authors, it has been divided under three heads; those cases which occur during the first sixteen weeks coming under the head ofabortion; those which occur between this period and the twenty-eighth week are calledmiscarriages; and when they take place at the latter period, until the full term of utero-gestation, they receive the name ofpremature labours.
It is perhaps useful to distinguish those cases of premature expulsion which occur before from those which occur after the fourth month, inasmuch as they seldom prove dangerous before that time, from the diminutive size of the ovum and from the slight degree of development which the uterine vessels have undergone; whereas, after this period the hæmorrhage is more severe, and the general disturbance to the system greater. In other respects it will be more simple to divide premature expulsion of the ovum under two heads only; those cases which happen before the twenty-eighth week, or seventh month, being termedabortions, and after this period (as before)premature labours. This division is highly important in a practical point of view, since it marks the period before which the child has little chance of being born alive; whereas, after this date it may with care be reared.[61]A fœtus may be expelled, at a very early stage of pregnancy, not only alive but capable of moving its limbs briskly for a short time afterwards, but it is unable to prolong its existence separate from the mother beyond a few hours. Cases do occur now and thenwhere a child is born in the sixth month, and where it manages to struggle through, but these are rare, and must rather be looked upon as exceptions to the general rule.
Abortions usually occur from the eighth to the twelfth week, a period which is decidedly the least dangerous for such accidents. “The liability to abortion is greater in the early than in the later periods of pregnancy; for as the union between the chorion and decidua is not well confirmed, as the attachment of the latter to the internal face of the uterus is proportionably slight, and as the extent of surface which the ovum now presents is very small to that which it offers in the more advanced state of pregnancy, and as it can of course be affected by smaller causes, it will be seen that a separation will be more easily induced, and prove much more injurious to the well-being of the embryo, than a larger one at another stage.” (Dewees,Compendious System of Midwifery, § 929.) Abortions coming on at a later period, viz. from the sixteenth to the twenty-eighth week, which corresponds to the second division, ormiscarriages, of the continental authors, are not only more dangerous than abortions at an early stage, for the reasons above-mentioned, but also than premature labours, as in this last division the uterus has attained such a size as to make the process rather resemble that of natural labour at the full term.
Causes.Premature expulsion may be induced by a great variety of causes, which may be brought under the two following heads: those which act indirectly, by destroying the life of the embryo, and those which act directly on the uterus itself. These various causes may be general or local; the process of nutrition for the growth and development of the embryo may be defective and scanty, from general debility or disease: hence, whatever depresses the tone of the patient’s health renders her liable to abortion by causing the death of the embryo. Thus, dyspepsia and derangement of the chylopoietic viscera; debilitating evacuations; depressing passions of the mind; bad or insufficient nourishment; intense pain, as in toothach; severe suffering from existing disease, especially where the health is much broken down by some chronic affection; syphilis, and febrile attacks, all act as indirect causes of abortion.[62]Salivation from mercury not unfrequently has a similar effect; in some instances, however, febrile affections appear to act much more directly, stimulating the uterus to powerful contractions and rapid expulsion of its contents. The symptoms which indicate the death of the child have already been detailed in the chapter upon that subject.
The period which may elapse between the death and the expulsion of the embryo varies exceedingly: in the early months the one usually follows the other pretty quickly, owing probablyto the slight attachment of the ovum to the uterus; during the middle third of pregnancy the interval may be of considerable duration, and cases every now and then occur where the fœtus is retained, not only several weeks, but even some months after its death; whereas, during the latter third of pregnancy, expulsion follows the death of the child after a short interval, seldom exceeding two or three days; for now the weight of the dead fœtus speedily irritates the uterus to contraction, and, as has been observed by Smellie, the membranes, running gradually into putrefaction, and being now unable to bear the weight of the liquor amnii, burst, and expulsion soon follows.
Among the causes which act locally in inducing premature expulsion by first destroying the child, may be enumerated external violence applied to the abdomen, such as blows, falls, and other violent concussions; these act indirectly by producing separation of the ovum from the uterus, and thus destroying the life of the child. Under the same head may be classed all violent exertions, as lifting heavy weights, straining to reach something high above the head, &c. The mere act of walking, when carried to such an extent as to induce exhaustion, will suffice, in weakly delicate females, to bring on expulsion; sudden and violent action of the abdominal muscles, when excited by a half-involuntary effort to save herself from falling, or receiving any other injury, may produce a similar effect: if the fœtus be so young that its movements cannot be felt by the mother, she feels from this moment more or less pain in the pelvis, with a sensation of weight and bearing down; and this, in all probability, will be followed by a discharge of blood from the vagina: where pregnancy has sufficiently advanced for the motions of the fœtus to be perceptible, the mother will frequently feel them in an unusually violent degree for a short time immediately after the injury, and then they cease entirely.
Premature expulsion may also be induced immediately without the previous death of the child, by causes which directly excite the uterus to action: thus, various violent mental emotions, as rage, joy, horror, may act in this manner, although they may also act more indirectly; sudden exposure to cold, as sudden immersion in cold water, will occasionally produce it instantly. Irritation in the intestinal canal will directly excite uterine contraction; hence an attack of dysentery is frequently a cause of abortion, and we not unfrequently meet with patients who are liable to this affection in every pregnancy: a similar effect may be produced by the improper use of drastic purgatives, which irritate the lower bowels, viz. aloes, scammony, savin, &c.; or the uterus may, in some cases, be excited to contract from the peculiar action of secale cornutum. On the other hand, a loaded state of the bowels equally predisposes to abortion, by impeding the free return of blood from the pelvis. A state ofgeneral plethora acts in the same manner; and this is more particularly the case if it takes place at what would, in the unimpregnated state, have been a menstrual period; for, occurring in conjunction with the increased vascular action which prevails at these periods in the uterine system, it produces, as it were, an apoplectic state of the uterine sinuses, which form the maternal portion of the placenta; blood is extravasated between the ovum and uterus; their connexion is more or less destroyed, and the death of the fœtus becomes unavoidable: hence, in these cases the expulsion may result either from this latter circumstance, or from the uterus being irritated to contract by the effused blood between itself and the membranes.
In patients who have suffered from attacks of dysmenorrhœa in the unimpregnated state, the irritable uterus, when pregnant, is very apt to contract upon its contents and expel them. This usually happens at what would have been a menstrual period, and not unfrequently takes place so soon after impregnation as merely to be looked upon as an unusually severe attack, the little ovum having been imperceptibly expelled among the discharges. Under this head must be brought those cases of spasmodic affection of the uterus, which Dr. Burns has described, and where, from the diminutive size of the ovum, the case has rather resembled one of menorrhagia. Cases of abortion are also mentioned by authors where the uterus is stated to be incapable of undergoing the necessary dilatation and increase of size which pregnancy requires; but we are strongly disposed to refer them to the above head of great uterine irritability, as we neither know of any diagnostic marks which will enable us to detect this condition during life, nor are we aware of any physical condition of the uterus short of actual disease, to be detected after death, which can produce this inability.
The uterus may be also excited to expel the fœtus, without its previous death by local causes, as acute leucorrhœa, or other inflammatory affections of the vagina, by inflammation and other affections of the bladder, as calculus, &c. Too frequent sexual intercourse during the early months of pregnancy is peculiarly liable to excite abortion: this is especially observed among primiparæ of the better ranks, where, from luxurious living, &c., there is but little physical strength in proportion to the great irritability of the system: hence we find that a fifth, or even a fourth, of these females abort in their first pregnancies. In conclusion we may briefly state that the same circumstances which in the unimpregnated condition produce menstrual derangement and other disorders of the uterine system, now act as so many causes of abortion.
The sudden cessation of the breeding symptoms, with sense of weight and coldness in the lower part of the belly, flaccid breasts, pain in the back and loins, and discharge of blood from theuterus, are pretty sure signs of abortion: they are those which are “produced by separation of the ovum and contraction of the uterus,” (Burns;) the one is attended by hæmorrhage, the other by pain. Although these are two chief symptoms which characterize a case of threatened abortion, and although they must necessarily be present more or less in every instance where premature expulsion actually happens, still neither of them, either separately or conjointly, can be considered as a certain proof that the uterus will carry its contents no longer. Cases not unfrequently happen where patients have repeated attacks of hæmorrhage during the early months of pregnancy, and sometimes to a considerable amount, without any apparent disturbance to the process of gestation, and are delivered of a living healthy child at the full term: on the other hand, we have known instances where the pain of the back was severe, and where, on assuming the erect posture even for a minute, the sense of weight and bearing down in the lower part of the abdomen was so great as to make the patient fear that the ovum was on the point of coming away; still even these threatening symptoms have gradually subsided, and the pregnancy has continued its natural period. Puzos considered that neither pain nor hæmorrhage were necessarily followed by expulsion. (Mém. de l’Acad. de Chir.vol. i. p. 203.) When, however, both occur together, and to a considerable extent, the case must be looked upon as one of at least doubtful if not unfavourable termination. Where pain comes on at regular intervals, with hardness of the uterus, and dilatation of its mouth, this is a serious symptom, for it shows that the uterus will no longer retain its contents, but is evidently preparing to expel them.
The part of the ovum at which the separation of it from the uterus has taken place, not only determines which of the above symptoms will appear first, but also the probability of expulsion. “When a considerable separation takes place, as must be the case when it commences at the upper parts of the uterus, pain will more likely occur than when it happens near the neck; hence we sometimes have pain before the blood issues externally. The uterus in this instance suffers irritation from partial distension from the blood insinuating itself behind the ovum; contraction ensues; the blood is thus forced downwards, and is made to separate the attachment between the ovum and the uterus in its course, until it finally gains an outlet at the os tincæ. In consequence of the uterus being excited to contraction, the friendly coagula which may have formed from time to time are driven away, and the bleeding each time is renewed and accompanied most probably with increased separation of the ovum, until at last from its extent the ovum becomes almost an extraneous body, and is finally cast off. Hence a separation at or near the os uteri will not be so dangerous, and in all probabilitythere will be hæmorrhage without pain, which is the contrary when it takes place near the fundus.” (Dewees,Compend. System of Midwifery, § 981, 982.) The pain during the abortion is sometimes exceedingly severe, and not unlike that of dysmenorrhœa: this is probably owing to the violent contractions of the uterus, which are required to dilate the os and cervix before the ovum can pass: they are frequently attended with nausea, vomiting, and fainting, and sometimes with more or less general fever and local inflammatory action; the pain is generally attended with much irritability of the bladder, and frequent desire to pass water; the pulse is mostly quick and small, and where there is arterial excitement, it is sharp and resists the finger.
Treatment.The treatment of premature expulsion consists in, 1, that which is intended to guard the patient against its occurrence, orprophylactic; and 2, in that which is requiredduring an attack.
A knowledge of the various causes of premature expulsion will materially assist us in the prophylactic treatment; under all circumstances, even where there is not the remotest fear of such an accident coming on, it is nevertheless highly important to pay strict attention to the state of the stomach and bowels, for these are almost always more or less influenced by the presence of pregnancy; the vomiting and sickness must be relieved in the manner already pointed out under the chapter on theTreatment of Pregnancy; the bowels, if constipated, must be moved by the mildest laxatives, such as castor oil, Confect. sennæ, or a Seidlitz powder; and thus all sources of irritation in the primæ viæ prevented as far as possible. The patient must carefully avoid every thing which may excite the circulation, such as violent affections of the mind, rich indigestible and stimulating food, violent exertion, &c. The diet should be light, nourishing, and moderate; heavy meals must be forbidden, and especially suppers; she should keep early hours, take gentle and regular exercise, and in fact, endeavour by every means in her power to raise her health to a full degree of tone and regularity. In those patients who have already miscarried in their previous pregnancies, these precautions must be enforced with double vigilence; for the system becomes exceedingly irritable, and the uterus soon acquires, as it were, a habit of retaining its contents only to a certain period, and then prematurely expelling them. When this is the case, it becomes exceedingly difficult, and is often actually impossible, to make it carry the ovum to the full term of utero-gestation, and, despite of the greatest care, the symptoms of premature expulsion will come on at about the same time at which they occurred in former pregnancies, and sometimes to the very same week.
In the treatment of such cases, where there is so much liability to abortion, we must first examine the precise condition of the circulation,and ascertain whether it be above or below the natural standard of strength; for as abortion may arise from very opposite conditions of the circulation, our treatment must consequently vary. If there be signs of arterial excitement, a small bleeding may be necessary; it unloads the congested vessels, diminishes the force of the circulation, and therefore also the chance of an extravasation of blood between the uterus and ovum; the bowels must be kept open by cooling saline laxatives, and the circulation may be still farther controlled, by the use of nitre two or three times a day. The diet must be spare; she must take regular exercise in the open air, wear light clothing, dress loosely, and sleep upon a hard mattress.
In these cases we are often warned that congestion of the uterine vessels is present, by pain and throbbing, and sense of fulness in the groins; leeches applied to these parts give much relief, and frequently render venesection unnecessary. Tight lacing ought to be strictly prohibited in all cases of pregnancy, particularly where there is a disposition to plethora: among other bad effects, it prevents the proper development of the breasts, the nipples are pressed so flat as to be nearly useless, the child being unable to get sufficient hold of them: this may in some degree be avoided, by putting thick ivory rings upon the breasts, and thus shielding the nipples from injurious pressure. It will, however, be much better to have the dress made loosely, to allow for the development of the breasts, which takes place during pregnancy; for there can be little doubt, that irritation of these glands is very liable to be followed by a corresponding state in the uterus.
The common but erroneous notion that it is necessary to take an extra quantity of nourishment for the support of the child as well as of the mother must be strenuously opposed. Nature contradicts it in the most striking manner; for, by the nausea and sickness which most women experience during the first half of their pregnancy, she raises an effectual obstacle to any error of this kind. “It certainly cannot be intended for any other purpose, since it is not only almost universal, but highly important when it occurs, as it would seem to add much to the security of the fœtus; for it is a remark as familiar as it is well grounded, thatvery sick women rarely miscarry; while on the contrary, women of very full habits are disposed to abortion, if exempt from this severe, but as it would seem, important process.” (Dewees,on Children, § 45.)
Where the case has become one of habitual abortion, the patient’s only chance will be by living separate from her husband for twelve or more months: the uterus, not being exposed to any sexual excitement during this period, becomes less irritable, and it gradually loses the disposition which it has acquired of expelling its contents prematurely. In such a case, when pregnancyhas again commenced, it requires to be watched most narrowly; every possible source of irritation must be removed by the strictest attention to diet and regimen, and the patient must make up her mind to be entirely subservient to the rules laid down by her medical attendant. Although the chances are against her escaping without premature expulsion, still we are not to despair, experience showing that cases every now and then occur where the patient has gone the full term of pregnancy in safety, in spite of repeated previous abortions. Dr. Young of Edinburgh, in his lectures on midwifery, describes a case where the patient actually miscarried thirteen times, and yet bore a living child the fourteenth time.
On the other hand, where the condition of the patient evinces a state of strength considerably below the natural standard, we find a very different set of symptoms to those which have been just described, requiring opposite treatment: the face is pale and even sallow; the pulse is soft, small, and irritable; the tongue pale and flabby; the digestion impaired; the bowels torpid; and the extremities cold: fatigue, or rather a sense of exhaustion, is induced by the slightest exertion, and this is attended with dull, heavy, dragging pain about the pelvis and loins, and a feeling as if the contents of the abdomen required more support, and were disposed to prolapse either by the rectum or vagina, on her maintaining an upright posture for any length of time.
Even at a very early period of pregnancy, there is the sensation of a weight in the lower part of the abdomen, falling over to that side which is lowest, as we described among the signs of the death of the fœtus at a later period, resulting in all probability from a loss of tone and firmness in the uterus. In this state, if nothing be done to restore the mother’s strength, the embryo will inevitably perish, and expulsion follow, sooner or later, as a necessary result.
In all cases where pregnancy occurs, in a weakly delicate woman, measures should be taken to increase the general tone of health, in order to fit her for going through this process safely, by removing her to the country, or to the sea-side, or to some watering place, where she will have the opportunity of drinking a mild chalybeate, and enjoying a purer air. Where it is even hazardous to move her, she should be put upon a course of mild chalybeates. The food should be light and nourishing, and a glass or two of wine or mild ale, may generally be taken with advantage. Where she can bear it, tepid salt-water bathing, or sponging, will have the best effects.
“For a number of years, (says Mr. White of Manchester,) I have been convinced of the good effects of cold bathing, not only in preventing miscarriages when every other method has been likely to fail, but other disorders which are incident to pregnant women, and generally attendant upon a weak lax fibre. Idon’t mean the cold bath in the greatest extreme, but such as that of Buxton or Matlock, or sea-bathing, or bathing in a tub in the patient’s house, with the water a little warmed. I have frequently advised my patients to bathe every other day, at a time when the stomach is not overloaded, and not to stay at all in the water; to begin this process as early as possible, even before they have conceived, as there will be then no danger from the surprise, and continue it during the whole term of pregnancy; and several have bathed till within a few days of their delivery.” (White,on Lying-in Women, p. 70.) Where exercise can be taken without fear, it should be done regularly but cautiously, so as not to induce fatigue or exhaustion, which is the very effect we must be so careful to avoid; in fact, every means and opportunity should be used of recruiting the powers and the vigour of the system. In proportion as the strength increases, so does the irritability diminish; the uterus becomes less sensitive to external impressions, and can, therefore, bear its gradual development without being excited to contraction; the fœtus receives its due supply of nourishment; the feeling of relaxation and deficient support of weight, and bearing down, go off as health returns; and by thus keeping up the powers of the system to the proper standard, it will be enabled to continue the process of pregnancy to the full term.
Although some women recover very quickly after an abortion, and appear for the time to suffer but little from its effects, they seldom escape with impunity, more especially if it has been repeated more than once: anæmia, with its varied train of anomalous symptoms and concomitant gastric and cerebral disturbance, profuse leucorrhœa, menorrhagia, and dismenorrhœa, are some of the more direct results of repeated abortion; we may also enumerate prolapsus uteri, inflammation of the cervix, with induration and scirrhus, as the more remote effects.
In the treatment of a case where expulsion is threatened, our object will be either to stop that process in time to save the life of the fœtus, or if this cannot be attained, to carry it through, in such a manner, as to expose the mother to as little danger and injury as possible.[63]In the first instance, we must be guided nearly by the same rules as in the prophylactic treatment: if there be considerable arterial excitement, and evidence of general plethora, a small bleeding will be useful in restoring a calm to the circulation; the most perfect quiet of body and mind must be insisted upon; the patient should lie upon a hard mattress, and be covered with as little clothing as is consistent with safety; she must refrain from all exertion, and strictly maintaining thehorizontal posture for a considerable time. The indications for our treatment will be, 1. to remove every thing which may, in any degree excite the circulation, and, 2. to prevent the contraction of the uterus. Stimulants of every description, and animal food must be forbidden; the bowels must be opened by gentle saline laxatives; and if the pulse still betrays any sharp or resisting feel to the finger, small doses of nitre may be taken as already recommended. When the circulation has become perfectly calm, and every trace of excitement allayed, opiates will prove of inestimable value: they stop any disposition to uterine contraction, and remove the pain in the back and loins which this will cause. The form which we prefer is the Liquor Opii Sedativus, as being more sure in producing a sedative effect than common laudanum, while at the same time, it produces less irritation and derangement in the stomach and bowels.
A moderate discharge of blood from the vagina, although showing that a separation has taken place between the ovum and the uterus, cannot be looked upon as an unfavourable sign, for it relieves the pelvic vessels, diminishes the pain in the back, and makes the patient feel more light and comfortable; but if it be at all brisk, and continues so after the employment of the above remedies, if also there be heat and throbbing in the region of the uterus, it will be necessary to apply cloths wrung out of cold water to the lower part of the abdomen and vulva, and to the groins and sacrum; and this treatment must be continued in full force until the symptoms of congestion have abated, and the discharge lessened or stopped.
If the hæmorrhage be really profuse, it shows that the separation of the ovum from the uterus must be of considerable extent; and as there will be no chance of preserving the life of the fœtus under such circumstances, the expulsion of the ovum is no longer to be avoided, but rather to be promoted; our attention therefore must now be directed to assist the uterus in the evacuation of its contents, with as little injury and danger to the mother as possible. It is, however, no easy matter to decide with certainty when we must give up all hope of preserving the ovum, for a large quantity of blood may be lost without expulsion being a necessary consequence. Uterine contractions may have even taken place, and yet by careful management the mischief may be sometimes averted, and the patient be enabled to go her full time. Even where they have been of sufficient force and duration to dilate the os uteri, we are not justified in discontinuing remedial measures unless the flooding has seriously affected the patient’s strength, and the ovum be actually projecting through the os uteri. “We might often prevent abortion (says Baudelocque) if we were perfectly acquainted with its cause, even when the labour is already begun. A very plethoric woman felt the pains of childbirth towards the seventh month of her pregnancy, and the labourwas very far advanced when I was called to her assistance, since the os uteri was then larger than half a crown; two little bleedings restored a calm, so much that the next day the orifice in question was closed again, and the woman went the usual time. Food of easy digestion prudently administered quieted a labour not less advanced in another woman, where it was suspected to be the consequence of a total privation of every species of nourishment for several successive days. Delivery did not take place till two months and a half afterwards, and at the full time. Emollient glysters and a very gentle cathartic procured the same advantage to a third woman, in whom labour pains came on between the sixth and seventh months of pregnancy, after a colic of several days’ continuance, accompanied with diarrhœa and tenesmus.” (Baudelocque,) § 2232. Nor is it always easy to decide whether it be the ovum or not which we feel protruding through the os uteri. “When the abortion is in the second or third month, the practitioner must bear in mind that it may have been retention of the menses, and, therefore, what he feels in the os uteri may either be an ovum or a coagulum of blood. To decide this point he must keep his finger in contact with the substance lying in the os uteri, and wait for the accession of a pain (for where clots come away, pains like those of labour are present,) and ascertain whether the presenting mass becomes tense, advances lower, and increases somewhat in size; this will be the case where it is the ovum pressing through the os uteri. On the other hand, if it be a coagulum, which it is well known assumes a fibrous structure, it will neither become tense nor descend lower, but be rather compressed. Generally speaking, the ovum feels like a soft bladder, and at its lower end is rather round than pointed, whereas, a plug of coagulum feels harder, more solid, and less compressible, and is more or less pointed at its lower end, becoming broader higher up, so that we generally find that the coagulum has taken a complete cast of the uterine cavity. If we try to move the uterus by pressing against this part, it will instantly yield to the pressure of the finger, if it be the ovum; whereas, the extremity of a coagulum under these circumstances is so firmly fixed, that when pressed against by the finger the uterus will move also. When abortion happens at a later period of pregnancy, we shall be able to feel the different parts of the child as the os uteri generally dilates, viz. the feet, or perhaps the sharp edges of bones, although we cannot distinguish the form of the head from the cranial bones being so compressed and strongly overlapping each other.” (Hohl,on Obstetric Exploration.)
Although expulsion must be looked upon as the only means of placing the patient in a state of safety, where the symptoms have advanced so far as to preclude all hopes of preserving the life ofthe fœtus, there are so many steps of this process to be gone through before it can be entirely completed, that more or less time must necessarily be required for that purpose. The ovum must be completely separated from its attachments to the uterus, and the contractions of that organ must have been of sufficient strength and duration to produce such a degree of dilatation of its mouth and neck as to allow the ovum to pass; but before this can be effected, such a quantity of blood may have been lost as greatly to endanger the life of the patient. Hence we must use such means as shall enable us to control the hæmorrhage, whilst we give the os uteri time to dilate sufficiently: this object will be gained most effectually by plugging the vagina. The best mode of performing this operation is that recommended by Dr. Dewees of Philadelphia: a piece of soft sponge, of sufficient size to fill the vagina without producing uneasiness, must be wrung out of pretty sharp vinegar, and introduced into the passage up to the os uteri; the blood, in filling the cells of the sponge, coagulates rapidly, and forms a firm clot, which completely seals up the vagina without producing any of those unpleasant effects which are produced by the insertion of a napkin rolled up for the purpose. A hard unyielding mass of this nature frequently produces so much tension, pain of back, and irresistible efforts to bear down, as to render it incapable of being borne for any length of time. The sponge plug may be borne for hours without inconvenience; we may either leave it to be expelled with the ovum, or after awhile remove it for the purpose of ascertaining what progress has been made. If the os uteri be still undilated, and the hæmorrhage going on, the plug must be returned. It is however by no means a remedy to be used in every case of hæmorrhage, for in most instances the treatment already mentioned will be sufficient to keep it within safe bounds. Where, however, the flooding has become very alarming, and the os uteri still remains firm and but little dilated, the plug will prove an invaluable remedy; and so long as the os uteri remains in this condition, and the uterus itself shows no disposition to contract, we may safely trust to perfect rest, cold applications, and the plug. Opium, which in the early stages of the attack is so useful in keeping off contractions of the uterus, will now for this very reason be contra-indicated; it will diminish the power of the uterus, and interfere with the process of expulsion.
The acetate of lead has been extolled as a powerful remedy for stopping hæmorrhage, more especially by Dr. Dewees, who states that “in many cases it seems to exert a control over the bleeding vessels as prompt as the ergot of rye does upon the uterine fibre.” (System of Midwifery, § 1045.) We have never tried this remedy in premature expulsion, having found the means of treatment above mentioned sufficient; the authority howeverof such an author demands respect, the more so as it is known to be a valuable remedy in certain forms of menorrhagia.
Where a considerable quantity of blood has been lost, and the patient is much reduced, we must endeavour not only to excite the contractile power of the uterus, but also to assist this organ in the expulsion of its contents: syncope in these cases is a dangerous symptom, because, as the patient is in the horizontal posture, it will seldom be induced except by a serious loss of blood; although we must not therefore allow her to flood until she faints, still, however, when the pulse has become considerably affected, the os uteri dilates more readily, and in this way facilitates the expulsion; we must no longer trust to the plug, for the whole system is beginning to sympathize and grow irritable, the pulse grows quicker and smaller, and the stomach rejects its contents. Although vomiting as well as syncope are symptoms which we cannot safely wait for, they are nevertheless means which nature adopts to relieve herself from the impending danger: by syncope she not only produces greater dilatability of the os uteri, but also, by causing a temporary cessation of the heart’s action, she favours the coagulation of blood, and thus checks the discharge; whereas, by the involuntary effort of muscles which she excites by the action of vomiting, the ovum is more speedily separated and expelled.
Where it becomes evident that expulsion cannot be prevented, it is our duty to promote this process before nature has had recourse to the means just mentioned. The ergot of rye is here a valuable remedy, for by inducing or increasing the contractions of the uterus we shorten the process and diminish the danger: the powder given in cold water is decidedly the best form in which it can be given; in infusion its powers seem to be injured by the heat of the water, and in tincture by the action of the spirit: the addition of about half its quantity of borax renders its action more powerful and certain. Borax has been long considered in Germany to possess a specific power in exciting uterine contraction, but it was first recommended for that purpose in this country by Dr. Copland. (Dict. Pract. Med.artAbortion.) A scruple or half a drachm of ergot powder with ten grains of borax may be given in cinnamon water, and this repeated every hour for several times.
In all cases threatening premature expulsion, wherever there has been much pain and discharge, the napkins which come from the patient should be carefully examined by her medical attendant, for otherwise the ovum may escape among the coagula and not be perceived. Where the separation is nearly complete, a portion of it protrudes at the os uteri; and this we can sometimes hook down with one or two fingers, and bring away: a still better mode is recommended by Levret, viz. of throwing up a pretty powerful stream of warm water by means of a syringe. Dr.Dewees has recommended a wire crotchet, which he has used with very good effect. (Op. cit.§ 1011.)[64]We ought not, however, to be in a hurry to bring away the ovum, for when the uterine contractions have been of sufficient strength to dilate the os uteri, it will generally come away of itself. One objection to the wire crotchet is, that it tears the membranes, and lets out the liquor amnii, and perhaps the embryo.[65]This is by all means to be avoided; the larger the body which is to be expelled, the more powerfully and effectually does the uterus contract upon it: hence, therefore, if the membranes of a three or four months’ ovum be imprudently pierced with a view of hastening the expulsion, the liquor amnii and embryo escape, but the secundines remain and require protracted efforts of the uterus to expel them, during which time the sufferings of the patient are prolonged, and the hæmorrhage kept up; whereas, if the ovum had remained whole, it would have been expelled more easily and quickly. On the other hand, where the fœtus has already attained a considerable size (fifth month,) the plan recommended by Puzos of rupturing the membranes is very desirable; by this means the sizeof the uterus is reduced by the escape of liquor amnii, and thus the hæmorrhage checked; and the fœtus remaining in the uterus is of sufficient weight and bulk to excite contractions to expel itself and the membranes.
The treatment after abortion varies considerably: in many cases it will be merely necessary for the patient to remain in bed for a few days afterwards; but where she has been much reduced, a mild course of tonics will be necessary, in order to prevent that disposition to leucorrhœa and menstrual derangement which is so common a result: this, where it is possible, should be combined with removal into the country, or to the sea-side, or, what is still better to a watering place, where there are mineral springs of chalybeate character. For the treatment of anæmia we must refer our readers to the chapter onHæmorrhage.
EUTOCIA, OR NATURAL PARTURITION.
STAGES OF LABOUR.
Preparatory stage.—Precursory symptoms.—First contractions.—Action of the pains.—Auscultation during the pains.—Effect of the pains upon the pulse.—Symptoms to be observed during and between the pains.—Character of a true pain.—Formation of the bag of liquor amnii.—Rigour at the end of the first stage.—Show.—Duration of the first stage.—Description of the second stage.—Straining pains.—Dilatation of the perineum.—Expulsion of the child.—Third stage.—Expulsion of the placenta.—Twins.
Preparatory stage.—Precursory symptoms.—First contractions.—Action of the pains.—Auscultation during the pains.—Effect of the pains upon the pulse.—Symptoms to be observed during and between the pains.—Character of a true pain.—Formation of the bag of liquor amnii.—Rigour at the end of the first stage.—Show.—Duration of the first stage.—Description of the second stage.—Straining pains.—Dilatation of the perineum.—Expulsion of the child.—Third stage.—Expulsion of the placenta.—Twins.
Parturition may be divided into two great orders,EutociaandDystocia, the one signifying natural labour which follows a favourable course both for the mother and her child; the other signifying faulty or irregular labour, the course of which is unfavourable.
We may define eutocia to be the safe expulsion of the mature fœtus and its secundines by the natural powers destined for that purpose. No function exhibits such infinite varieties, within the limits of health and safety to the mother and her offspring, as that of parturition; no two labours, even in the same individual are exactly alike; still, however, the great objects of the process will be the same, viz. 1st. the preparation of the passages and the fœtus for its expulsion; 2dly, the expulsion of the fœtus; and 3dly, the expulsion of the placenta and membranes.
That we may form a clearer and more comprehensive view of this process, labour has usually been divided into stages or periods, marked by the changes just now alluded to: hence it is generally said to consist of three stages; the first, or preparatorystage, commencing with the first perceptible contractions of the uterus, and terminating in the full dilatation of the os uteri; the second, or stage of expulsion, terminating with the birth of the child; and the third, consisting of the expulsion of the placenta.
Preparatory stage.—Precursory symptoms.For some time before the commencement of actual labour, a variety of changes are taking place which must be looked upon as the precursors of this process: during the last weeks of pregnancy, nature appears, as it were, to be preparing for the great change which is at hand, and to be making such arrangements as shall enable it to be completed with the least possible danger both for the mother and her child.
One of the earliest warnings which we have of approaching labour is an alteration in the form of the abdominal tumour; the cervix uteri has by this time (especially in primiparæ) entirely disappeared; the presenting part of the child has therefore descended to the lowest part of the uterus; the fundus has sunk lower and more forwards; and from the diaphragm being enabled to act with greater freedom, the respiration is performed with more ease and comfort to the patient; she therefore feels more capable of moving about, and is in better health and spirits than for some time previously. Upon examination per vaginam, the head will be found deep in the cavity of the pelvis, covered by the lower and anterior segment of the uterus; the os uteri is still closed, and situated in the upper part of the hollow of the sacrum, forming merely a small circular depression. In women who have already had children, a portion of the cervix uteri is still remaining; it is thick and bulky; and in some cases, where the uterus has been greatly distended in several successive pregnancies, it is nearly as long as in the unimpregnated state; the os tincæ or os uteri externum is open, its edge irregular from former labours; the upper extremity of the canal of the cervix is contracted, and forms the os uteri internum; it has been closed during the greater part of pregnancy, but usually is now sufficiently open to admit the finger; the os uteri is neither so high up nor so far backwards in the pelvis as in primiparæ, and is reached with greater ease; whereas, the head of the child, instead of being felt in the cavity of the pelvis, generally remains at the brim until labour is more advanced.
First contractions.The first contractions of the uterus (in a state of health) are so slight as scarcely to be noticed by the patient: they create a sensation of equable pressure and general tightness round the abdomen, and during the contraction the uterus feels somewhat firmer, but they are neither attended with pain, nor do they appear at first to have any effect upon the os uteri; these precursory contractions generally come on a day or two before actual labour commences, and sometimes are felt atintervals for one or two weeks. Where the uterus has been exposed to any source of irritation, and especially where there is a disposition to rheumatic affection of this organ, they may produce much suffering and give rise to one form of what are calledfalse pains, hereafter to be described. “The first contractions, says M. Leroux (Sur les Pertes de Sang, § 41.,) are feeble, and communicate no sensation to the patient; in order to discover them we must hold our hand upon the abdomen, and if we feel the globe of the uterus raise itself and become hard, this is a true contraction. These contractions gradually increase until they excite pain: but pain is not essential to a contraction; it depends on the distension and compression of the nerves produced by the resistance of the body upon which the uterus acts, and increases in severity in proportion to the degree of resistance and contraction.”
In proportion as the lower part of the uterus descends into the cavity of the pelvis, so does it exert a degree of pressure on the neighbouring parts; the capacity of the bladder and rectum is diminished; and being therefore unable to contain the usual quantity of urine and fæces, and being probably rendered more irritable by the pressure above-mentioned, the patient experiences frequent calls to pass water and evacuate the bowels, which is sometimes effected with considerable difficulty: in some instances she is obliged to lean forward, or support the abdomen, in order to take the weight of the child off the neck of the bladder before she can empty it: the same cause occasionally requires the use of the catheter, and sometimes renders the introduction of it a matter of considerable difficulty.
As these various changes make their appearance, the patient becomes restless and anxious; she cannot remain long in the same posture; the slight precursory contractions which have been just described, are becoming stronger, and begin to produce a sensation of pain; the os uteri (in primiparæ) opens somewhat, its edge at first is exceedingly thin, and feels almost membranous; by degrees however it swells, grows thick and cushiony, and is now more dilatable.
Action of the pains.The os uteri does not dilate merely by the mechanical stretching which the pressure of the membranes and presenting part exert upon it; it dilates in consequence of its circular fibres being no longer able to maintain that state of contraction which they had preserved during pregnancy; they are overpowered by the longitudinal fibres of the uterus, which, by their contractions, pull open the os uteri equally in every direction.
The vagina also swells and grows more cushiony, and this is followed by a copious secretion of colourless and nearly inodorous mucus. “The more albuminous it is the better, and it is always a good sign when lumps of albuminous matter come awayfrom time to time; the thicker, softer, and more cushiony the os uteri is, the more mucus does it secrete.” (Wigand,Geburt des Menschen, vol. ii. p. 292.) The thin hard os uteri does not dilate, its fibres are all in close contact, and like a well-twisted cord will not yield; whereas, when they are separated from each other by the swelling of the os uteri, they easily yield to the dilating force which is applied to them. Besides serving the purpose of lubricating the passage, the secretion of mucus is of great importance as a topical depletion, for, by thus unloading the congested vessels, they diminish the vascularity and heat of the part, and render it more capable of dilatation. “If, on the other hand, the entrance of the vagina is small, the neighbouring parts cool, dry, inelastic, and as if tightly stretched over the bones; if the finger, in spite of being well oiled and carefully introduced, produces pain upon the gentlest attempt to examine, we may expect a tedious and difficult labour.” (Op. cit.p. 190.)
The patient is now no longer able to conceal her pains when they come on. If she be in the act of conversing she stops short, and remains silent until the severity of the pain is over; if she be walking about her room she is obliged to stand still for the time, and rest against or hold by something until the pain has gone off. The true labour pains are situated in the back and loins; they come on at regular intervals, rise gradually up to a certain pitch of intensity, and abate as gradually; it is a dull, heavy, deep sort of pain, producing occasionally a low moan from the patient: not sharp or twinging, which would elicit a very different expression of suffering from her.
Auscultation during the pains.“If we direct our attention to the changes of tone which the uterine pulsations present during auscultation, we shall find them generally stronger, more distinct and varied in tone during labour; and this is especially the case just before a pain comes on. Even if the patient wished to conceal her pains, this phenomenon, and more especially the rapidity of the beats, would enable us to ascertain the truth. The moment a pain begins, and even before the patient herself is aware of it, we hear a sudden short rushing sound, which appears to proceed from the liquor amnii, and to be partly produced by the movement of the child, which seems to anticipate the coming on of the contraction: nearly at the same moment all the tones of the uterine pulsations become stronger; other tones, which have not been heard before, and which are of a piping resonant character, now become audible, and seem to vibrate through the stethoscope, like the sound of a string which has been struck and drawn tighter while in the act of vibrating. The whole tone of the uterine circulation rises in point of pitch. Shortly after this, viz. as the pain becomes stronger and more general, the uterine sound seems as it were to become more and more distant, until at length it becomes very dull, or altogether inaudible. But assoon as the pain has reached its height and gradually declines, the sound is again heard as full as at the beginning of the pain, and resumes its former tone, which in the intervals between the pains is as it was during pregnancy, except somewhat louder. This is the course of things if the pain be a true one, and attain its full intensity: where the pains are false or irregular it is very different; the uterine sound either remains unaltered, or increases only for an instant, or its seeming increase of distance, as above mentioned, is not observed.” (Die Geburtshülfliche Exploration, von Dr. A. T. Hohl, erster theil, s. 105.)
Effect of the pains upon the pulse.It is curious to observe the effect which a regular pain has upon the rapidity of the mother’s pulse; as the former comes on and goes off, so does the other increase or diminish. “The increasing rapidity of the pulse announces the commencement of the pain; it rises and attains itssummumwith it; and as the pain subsides so does the pulse gradually resume the rate which it had during the intervals; a similar ebb and flow may be heard in the uterine souffle. The more regular the pain is, and the more distinctly it rises to its full extent, the more marked, regular, and distinct, is this change in it. We may also invert the order of things, and say, the more distinctly the rapidity of the pulse comes on and announces the pain, the more regularly it rises and attains a certain height, which it maintains, and then gradually subsides; in like proportion will the pain be more perfect, attain its full extent more completely, and act more efficaciously upon the regular progress of the labour. Where however the rapidity of the beats subsides before it had scarcely begun to increase, the pain is too weak; or where the rapidity rises by sudden starts, the pain is a hurried one; and in either case its effect will be imperfect.” (Hohl,op. cit.vol. i. p. 108.) In order that we may ascertain these changes correctly, we ought to note the rapidity of the pulse during each successive quarter of a minute as directed by M. Hohl; thus, in a pain which lasts two minutes, the increase and diminution in the rapidity of the pulse may be as follows, 18. 18. 20. 22.; 24. 24. 22. 18. As labour advances it increases, so that shortly before the birth of the child we shall find that what was the rate of the pulse during the height of the pains at the beginning is now the rate of it during the intervals.
Symptoms to be observed during and between the pains.When a pain comes on, the uterus grows hard and tense; if the fundus be somewhat to one side, as is not unfrequently the case, it now gradually moves, so that the median line of the uterus corresponds with that of the patient’s body; the various prominences of the child are no longer to be felt, the whole is now firm and unyielding; the os uteri is put tightly upon the stretch, the membranes which were loose become tense and are firmly pressed against it, and the presenting part is rendered indistinct: as thepain gradually subsides, the uterus becomes softer, and yields to the pressure of the hand; the different parts of the child which project, as also its movements, can now be felt more distinctly; the patient is free from pain, and feels herself in an agreeable state of tranquillity, which is frequently attended by a short refreshing doze; the os uteri, which has become somewhat more dilated during the last pain, is now soft and loose, so that we can hook the finger into it and move it about; the tight bladder of membranes becomes relaxed and flaccid, and retracts more or less into the uterus, so that we shall now be able to introduce the finger into the os uteri and feel the presenting part through the membranes; while the presenting part of the child, which during the pain was fixed, can be moved somewhat by the finger.
Characters of a true pain.In examining the course of a true pain we shall find that the contractions of the uterus do not begin in the fundus, but in the os uteri, and pass from the one to the other. (Wigand,op. cit.vol. ii. p. 197.) Every pain which commences in the fundus is abnormal, and either arises from some derangement in the uterine action, or is sympathetic with some irritation not immediately connected with the uterus, as from colic, constipation, &c. We very seldom find that a contraction of the uterus, which has commenced in the fundus, passes into the cervix and os uteri, and becomes a genuine effective pain; usually speaking, the contraction is confined to the circumference of the fundus, without detruding the fœtus at all. When a genuine pain comes on, so far from the head being pressed against the os uteri, it at first rises upwards, and sometimes gets even out of reach of the finger, whilst the os uteri itself is filled with the bladder of membranes: if it had commenced in the fundus instead of the inferior segment of the uterus, so far from the head being drawn up at the first coming on of the pain, it would have been forcibly pushed down against the os uteri. In the course of a few seconds the contraction gradually spreads over the whole uterus, and is felt especially in the fundus; the head which had been raised somewhat from the os uteri is now again pushed downwards to it, and seems to act as a wedge for the purpose of dilating it; it is not until the whole uterus is beginning to contract that the patient has a sensation of pain. We may, therefore, consider that a genuine uterine contraction consists of certain phenomena which occur in the following order: first, the os uteri grows tight, and the presenting part rises somewhat from it; then the rest of the uterus, especially the fundus, becoming hard, the patient has a sensation of pain, and the presenting part of the child advances. The period of time necessary for all these changes varies not only in different individuals, but in the same individual in different labours, and in different stages of the same labour.
“The more completely the os uteri is opposite the fundus, andthe more the axis of the uterus corresponds with that of the pelvis, the sooner are the pains,cæteris paribus, capable of dilating the os uteri.” (Wigand, vol. ii. p. 273.) The cushiony state of the vagina and os uteri, and the free secretion of thick albuminous mucus from these parts, as already mentioned, will be of great importance in ensuring their easy dilatation. Where this secretion is either absent, or very scanty, the passages become dry, hot, and tender, from no relief being afforded to the congested vessels by its effusion; andvice versâ, where there is a febrile state of the circulation and considerable topical excitement, the secretion is sparing, or, perhaps, stops entirely. This state may arise from a variety of causes, such as from general plethora, too warm clothing, bad ventilation, derangement and irritation of the primæ viæ, and abuse of spirituous and other stimulating liquors: it may arise from constipation, or may be induced by rough and too frequent examination. The patient becomes flushed, excited, and feverish, with a hot skin, dry tongue, thirst, and headach; the uterine contractions become irregular, they produce much suffering, and but very little advance in the progress of the labour; the passages are in a state of inflammation, and more especially the os uteri, which is much swollen and excessively tender. The process of labour is completely interrupted, and can only be restored to a healthy condition by bleeding, warm bath, laxatives, and enemata.
Formation of the bag of the liquor amnii.When the os uteri has dilated more or less, a quantity of liquor amnii begins to collect between the head and the membranes, so that when a pain comes on they form a tense, elastic, and conical bag, which presses firmly against the os uteri, and protrudes through it into the vagina, and from its form and elastic nature greatly facilitates the speedy dilatation of it. If the edge of the os uteri be still thin, it will become so tense during the pain, and the bag of membranes will press so firmly against it, that we shall have some difficulty for the moment in distinguishing the one from the other. As the labour advances, the intervals between the pains become shorter, whereas the pains themselves are of longer duration and more effective. In this way pain succeeds pain until the os uteri, at length, attains its full degree of dilatation; if the membranes have not yet ruptured, we may now expect them to burst with every succeeding pain.
Rigour at the end of the first stage.At this moment the patient is occasionally seized with a sudden and violent fit of shivering, so much so as to make the teeth chatter, and even communicate a tremulous motion to the bed itself; this is not the result of cold, nor is it relieved by the application of external warmth; and, in many cases, the patient will express her surprise that she should shiver thus violently, and yet not feel cold. It appears to be a modification of convulsive action, excited by sympathy betweenthe os uteri on its becoming fully dilated, and certain muscles in other parts of the body.
Show.On examination at this stage of the process, streaks of blood will be found in the mucus which soils the finger, and sometimes it amounts to a slight discharge of blood: this appearance is called by midwives “a show,” as it usually indicates that the os uteri is nearly or fully dilated. It is produced by a separation of the membranes from the vicinity of the os uteri, and consequent rupture of any little vascular twigs which may have passed from the uterus to them.
The full dilatation of the os uteri terminates thefirst stageof labour. During this stage, the action of the pains does not appear to have been so much for the expulsion of the child, as for preparing it as well as the passages for this purpose, viz. by so arranging and regulating the different forces of the uterus, and at the same time by giving the child such a position (i. e.with its long axis parallel to that of the uterus,) and the os uteri such a degree of dilatation, as shall ensure its expulsion with the greatest possible ease and safety.
Duration of the first stage.The duration of the first stage of labour varies exceedingly, both in primiparæ and those who have had several children; nor is it at all easy to determine with precision the exact moment when labour commences. The sensation of pain to the patient is no guide whatever, for what is attended with much suffering in one patient is scarcely sufficient to excite the notice of another. The dilatation of the os uteri as marking its commencement, must also be taken with some caution: in primiparæ, where it generally remains closed until the contractions are becoming painful, it would obviously be wrong to date the commencement of labour from the moment that the os uteri opens, as regular uterine contractions have been evidently present for some hours previously, although not of sufficient force to produce actual pain. On the other hand, in women who have already had several children, the os uteri is found open some days and even weeks before labour comes on. As a general rule, we may state that regular and genuine contractions of the uterus, sufficiently powerful to produce pain, seldom require more than six hours to effect the full dilatation of the os uteri; in many cases a much shorter time will be sufficient; whereas, in others, the first stage of labour may last for more than quadruple this period before it is completed: in neither can it be considered as abnormal; and we usually find that where the pains of the first stage have been slow and lingering, they become remarkably quick and active during the second stage. This agrees with the experience of Dr. Churchill, in his report of the Western Lying-in Hospital at Dublin, viz. that, “no evil consequences resulted, and they (the labours where the first stagewas so protracted) were amongst those in whom the remaining stages of labour were shortest.”
The first stage terminates with the full dilatation of the os uteri; the rupture of the membranes is a change which is necessarily more or less uncertain, as to the precise period of labour at which it takes place. Thus, in primiparæ, it frequently occurs before the first stage is completed; whereas in other cases the membranes sometimes do not give way until the head approaches or has even passed through the os externum; generally speaking, however, they burst at this period of the labour, and usually effect a remarkable change in the whole process. The pains are now of longer duration and more powerful, the intervals between them are shorter, and yet, although the suffering is actually more severe, it is more tolerable to the patient than that of the first stage. During the first stage they are chiefly confined to one spot in the loins; and as they must necessarily continue for some hours without any distinct evidence of the labour being advanced by them, the patient feels discouraged and gets a little impatient at the endurance of so much apparently useless suffering: but as soon as the gush of liquor amnii takes place, she feels that a great alteration has been produced; the abdomen becomes smaller: the pains assume a very different character, and every thing combines to assure her that she has made progress, and encourages her to patience and resolution.
Description of second stage.The os uteri has now disappeared entirely, so that the vagina and uterus form one continuous canal, and is thus admirably adapted for the easy passage of the head: the anterior lip, however, dilates much more slowly than the other parts of it, and this is especially the case in primiparæ, for, being pressed between the head and pelvis it becomes œdematous, and swells to a considerable size: if the pains be strong, it is pushed down more or less before the head, and may be frequently felt beneath the symphysis pubis, and occasionally it is detruded so far as to be visible between the labia. According to Wigand, the swelling of the anterior lip sometimes attains such a size as makes it liable to be mistaken for the bladder of the membranes (op. cit.vol. ii. p. 308;) it seldom produces much obstacle to the advance of the head, and with a little patience gradually disappears of itself. All attempts to push it up above the head are objectionable, because, in the first place, the finger cannot reach sufficiently high to effect this object, and therefore the swelling descends again to its former situation; and, secondly, the efforts to push it up only tend to inflame it and increase the swelling. Those who imagine that they can push up the anterior lip of the os uteri above the head deceive themselves; and even if they do succeed, it merely shows that had they let it alone, it would have gone up very shortly of itself.
Straining pains.As the head enters the vagina, not only do the contractions of the uterus become much more powerful, but now another set of forces are called into action, and the half involuntary efforts of the abdominal and other muscles come to aid the uterus in expelling its contents. The sole object of this stage is the expulsion of the child, and even the vagina by its contractions contributes to effect it. The head is therefore subjected to considerable pressure; hence we may now feel the cranial bones overlapping each other at the sutures, and the fontanelles diminished in size; and, from the tightness with which the head is embraced by the vagina, the circulation in the scalp is more or less impeded, and a large œdematous swelling, calledcaput succedaneum, forms on that part of the head which presents.
Each pain is attended with a violent and irresistible impulse to bear down, and every muscle which can assist in effecting this object is now brought into play. The tone of the patient’s voice, the expression of her face, the hurried breathing and sudden inspiration, stopping short the moment a pain comes on, in order that she may add still greater power to the efforts which she is about to make, all betoken a very different process to that of the first stage, and one which requires a powerful struggle of muscular strength and energy for its completion. Hence it is that the sound of the patient’s voice during the pain is frequently of itself sufficient to inform us how far labour is advanced, for “we never see the really powerful straining pains come on (the head may be never so low in the pelvis,) so long as the os uteri is not fully dilated.” (Wigand,op. cit.vol. ii. p. 310.) This is a wise provision of Nature, for by this means it prevents the danger of laceration to which the os uteri would be otherwise exposed, and shows the importance of not permitting a patient to strain and bear down until the os uteri be fully dilated. In those cases where a patient has been induced to exert herself prematurely, the efforts being voluntary are never so powerful, and soon produce much fatigue.
Several reasons have been assigned why the straining pains should come on at this stage. It cannot be owing to the pressure of the head upon the parts of the pelvis, as has been supposed and especially the rectum, thus producing the sensation of a violent desire to evacuate the bowels, because, in almost every case of first labour, the head for several days before the actual commencement of labour is sufficiently deep in the pelvis to produce these effects. It evidently arises from a sympathetic connexion “between the os uteri and vagina on the one hand, and the abdominal and other muscles on the other. We see this connexion most distinctly in those difficult labours where the head is pushed down deeply in the pelvis even to the very outlet, and where the os uteri which is but little dilated is protruded before it. In such cases we never see the really powerful and continuedaction of the abdominal muscles excited, let the head press never so forcibly upon the rectum; but as soon as the os uteri (perhaps after much suffering) has retracted over the head, the whole auxiliary action of the abdominal muscles commences.” (Ibid.vol. ii. p. 467.)
There is the same relation between these muscles and the vagina, as there is between them and the rectum: the moment the vagina becomes distended, it begins to contract upon the distending body, and like the rectum excites them to strong and involuntary action. The tenesmus of dysentery is a sympathetic action of the same nature; the rectum is highly irritated by the acrid nature of its contents, and excites an irresistible disposition to bear down. The patient wishes for the next pain and yet she dreads it, from the suffering it creates, and the tremendous effort which it compels her to make; the pulse is quicker, and is not only so during the intervals, but undergoes a greater increase of rapidity during the pains themselves than in the first stage; the face becomes red, swollen, and bathed in perspiration; the breath is hurried; the lips are apart; the eyes are wild; every thing betokens a state of the highest excitement. When a pain comes on, she catches hold of whatever she can reach, plants her feet upon any thing which is firm, and, by thus fixing her extremities, she is enabled to bear down with greater power and effect. During the struggle the face often changes its expression surprisingly, so much so, that even her own attendants would scarcely recognise her.
Dilatation of the perineum.As pain succeeds pain, gradually increasing both in force as well as duration, the head descends along the vagina, and begins to press against the perineum; the rectum becomes flattened; the sphincter ani dilated, and therefore any fæcal matter which may have been lodging there is unavoidably expelled; the anterior wall of the rectum is pressed close against the anus, and where the pressure is very great, even protrudes somewhat through it; the hæmorrhoidal veins are frequently much distended, and form a roll of cushiony swelling around the anus. A small quantity of liquor amnii dribbles away from time to time, but is neither during a pain, nor during the absence of a pain, for in the former case the pressure of the head acts as a plug and prevents its escape, and in the latter there is no uterine contraction present to expel it: the liquor amnii dribbles away only at the moment when a pain is coming on or going off.
Expulsion of the child.As the head descends farther it begins to press more powerfully on the perineum, and during each pain pushes it out like a large ball; and then, as a contraction goes off, and the resiliency of the soft parts regain their superiority, it retires again. The breadth of the perineum (viz. from the anus to the vulva) increases, whilst it diminishes considerably in thickness, especially towards its anterior margin. Whilst passingthrough the inferior aperture or outlet of the pelvis, the head advances more or less forwards under the pubic arch, and begins to distend the os externum; during a pain it separates the labia, and protrudes between them, and again retires as the pain goes off; a larger and larger portion of the head gradually forces itself through the os externum as this dilates; the perineum becomes still thinner, so that at length it is scarcely thicker than parchment. When more of the head has passed through, it does not now recede when the pain goes off; the os externum and perineum are at their greatest distension, for the largest diameter of the head, which is presented to the os externum is now encircled by it; the next pain brings the head into the world.
This is the moment of greatest pain, and the patient is frequently quite wild and frantic with suffering; it approaches to a species of insanity, and shows itself in the most quiet and gentle dispositions. The laws in Germany have made great allowances for any act of violence committed during these moments of phrenzy, and wisely and mercifully consider that the patient at the time was labouring under a species of temporary insanity. Even the act of child-murder, when satisfactorily proved to have taken place at this moment, is treated with considerable leniency. This state of mind is sometimes manifested in a slighter degree by actions and words so contrary to the general habit and nature of the patient, as to prove that she could not have been under the proper control of her reason at the moment. It is a question how far this state of mind may arise from intense suffering, or how far the circulation of the brain may be affected by the pressure which is exerted upon the abdominal viscera.
A short cessation of pain succeeds the birth of the head. The violent distension of the os externum has ceased for a time, and the patient feels comparatively easy; but in the course of a few minutes the pains return as before, although not quite so severe: first, the shoulder, which is turned forwards, passes under the pubic arch, followed by the other which sweeps over the perineum. The rest of the child is expelled with comparative ease, and as soon as its pelvis has passed through the os externum, a gush of the remaining liquor amnii, which had been retained in the upper portions of the uterus, follows; the whole abdomen instantly sinks and becomes flaccid, while the uterus contracts into a firm globe upon the placenta, which is shortly to be expelled. A most delightful and perfect calm succeeds, and the sense of freedom from suffering, and joy for the termination of her trial, are expressed in the liveliest terms of gratitude.
Third stage.—Expulsion of the placenta.The period between the birth of the child and expulsion of the placenta varies considerably. Sometimes it follows the child very rapidly, so that, apparently, they are both expelled by the same effort of uterine action; at others, the interval is more considerable. There isgenerally an interval of ten or fifteen minutes, and then pains of a totally different character make their appearance: these are supposed to denote the separation of the placenta from the uterus, and, from their being usually attended with discharge of more or less blood, have been termeddolores cruentiby many of the foreign writers. The expulsion of the placenta is attended with little or no suffering; it descends into the vagina inverted,i. e.with its fœtal or amniotic surface turned outwards: whether or not this is produced by pulling at the cord is perhaps a question.