Onmaking an examination the mouth of the Womb will be found to be dilating, and a discharge of mucus, tinged with blood, issuing from it. The membranes may also be felt protruding into the Vagina, and distended, like a bladder. The female complains of being drawn powerfully together in the inside; she trembles, and gasps for breath; her pulse sinks, and she often becomes sick and deadly faint; she complains of great thirst, and breaks out into profuse perspiration; frequently she will weep, and apparently suffer from some terrible apprehension, while her strength will be completely exhausted. Occasionally however, she will be perfectly passive, and almost immoveable, appearing as if in a dream.
The pains however, gradually become more and more acute, and closer together; the patient is excited and irritable; her pulse becomes quicker again, the thirst increases, and vomiting frequently ensues. Before each pain she frequently experiences a severe chill, with chattering of the teeth, and not unfrequently becomes perfectly delirious.
With each pain the mouth of the Womb expands more and more, till at last it totally disappears, and the cavity of the Uterus and the Vagina form but one uniform passage, which is completely occupied with the distended membranes, or bag of waters, which may be felt like a soft round tumor. This is well represented in the following Plate:—
PLATE XXXVIII.—a.Fig. 1.Fig. 2.state of the partsFig. 1 shows the state of the parts at the beginning of labor. The mouth of the Womb is considerably dilated, and the Membranes, A, are protruding slightly.Fig. 2 shows the state of the parts at the end of the first period. The neck of the Womb is now so fully dilated that it forms a continuous passage with the Vagina, while the bag of waters, A, projects far down and occupies the whole width of the canal.
PLATE XXXVIII.—a.
PLATE XXXVIII.—a.
Fig. 1.Fig. 2.
Fig. 1.
Fig. 2.
state of the parts
Fig. 1 shows the state of the parts at the beginning of labor. The mouth of the Womb is considerably dilated, and the Membranes, A, are protruding slightly.Fig. 2 shows the state of the parts at the end of the first period. The neck of the Womb is now so fully dilated that it forms a continuous passage with the Vagina, while the bag of waters, A, projects far down and occupies the whole width of the canal.
Fig. 1 shows the state of the parts at the beginning of labor. The mouth of the Womb is considerably dilated, and the Membranes, A, are protruding slightly.
Fig. 2 shows the state of the parts at the end of the first period. The neck of the Womb is now so fully dilated that it forms a continuous passage with the Vagina, while the bag of waters, A, projects far down and occupies the whole width of the canal.
The first period may be much protracted, and is generally very exhausting, though not attended with any danger or special difficulty.
At this stage all the previous symptoms become much exaggerated. The contractions are more powerful, and the pains more acute, but with a perfect period of repose between them, during which the female will feel quite easy, and even sometimes fall asleep, but only to be aroused by the pains coming on again. The muscles of the Abdomen, and the diaphragm, are now called into play; the patient strains, or violently bears down, and pants with exertion, while the perspiration streams from every pore, the pulse quickens, and the expression of the countenance betrays the wildest anxiety and excitement.
The bag of waters now descends, and enlarges more and more, until at last, being unable any longer to bear the strain to which it is subject, it bursts, and the waters flow away in a profuse gush. Immediately this takes place the head descends, and closes up the passage; the pains cease for a time, and the patient again has a respite, while the uterus apparently gains fresh power. Very soon the contractions recommence, more energetically even than before, the head passes the mouth of the Womb and enters the Vagina, which keeps enlarging as it descends, till it reaches the lower part, or floor of the pelvis. The pains now become more violent than ever, the patient screams with agony, clutches hold of any object near her, throws herself back, draws in her breath, and bears down with all the force she can command.
The fearful cries which most females emit at this time appear to assist the delivery, by the convulsive efforts at breathing which they necessitate, and the expulsive straining also does the same. These naturalefforts are much assisted by providing a firm support for the patient's feet, against which she can push, which she will do with tremendous force.
The head now presses, at each pain, against the perineum, which begins to project outwards, as also does the Rectum. The Vulva begins to dilate, the lips separate wider and wider, and part of the child's head becomes visible. Gradually the lips become thinner and thinner, and at last disappear nearly altogether, so that the mouth of the Vulva is only composed of thin ring, which seems ready to give way every moment. The head however recedes, and the parts again assume something like their natural condition for a short time, when the same process again takes place, and the distension proceeds still further, while the head does not retire so far. This alternate action is repeated perhaps many times, so that the external mouth is opened gradually, and without the lips or perineum being torn, which they would be if the head were to pass suddenly, before they were softened and dilated.
After this has been continued for a sufficient period a strong expulsive pain is felt, the female screams, the head passes clean through the external opening, and the lips close round the neck. This however, is only for an instant, the rest of the body speedily following the head, in the manner hereafter to be explained. Most usually, in fact, the whole body follows the head without any stoppage at all, but sometimes there is a delay of a few seconds.
The Third period of deliverycomprises the delivery of the Placenta, which will occupy our attention in another place.
Differences in the process of Labor.—Although, in most cases, labor proceeds much in the way I havejust explained, and is attended with similar phenomena, yet still we occasionally see marked exceptions. This is particularly the case with regard topain. Most females suffer severely at this time, and some even the most torturing agony, while others again experience scarcely anything to complain of, and some even feel nothing at all. I am acquainted with a lady at the present time, the mother of several children, who assures me she never felt any pain at all in her labors, nor was she in any ways exhausted by them. I have known her rise from her bed in the night, from feeling indications of the approaching event, make all her arrangements, and send for the nurse, as if it was the most ordinary affair imaginable. On one of these occasions, before her husband returned with the assistants, she was delivered while alone, without any difficulty, and they found her sitting up in bed nursing the child. She had cut it loose, and tied up the cord herself, having heard how to do so at one of my Lectures, and actually brought away the Placenta with her own hand. In two days after she was about as usual. And yet this lady was by no means strong, nor remarkably healthy; and what is very singular, she suffered severe pains at most of her monthly periods; much more, as she assured me, than from all her labors put together. M. Chailly also mentions an instance of a young girl of sixteen, with her first pregnancy, whose Vagina was also partly closed by an internal membrane, whose delivery nevertheless was almost painless. She woke up, he tells us, about four o'clock in the morning, with some very slight pains, which scarcely disturbed her, but which continued till about six, when the child was born suddenly and safely, without any assistance, and with scarcely any increaseof pain to the mother. I have known many other such cases as these, and plenty of them can be found recorded; but what this fortunate exemption from suffering, in such cases, depends upon, is not known.
The nature, and the seat of the pains, is also very variable. Some only feel a dull sort of aching, with powerful contraction, or drawing together, while others call itgrinding,cutting, andburningpain. Some feel it in the back, and some at front, while others feel it most in the groins, and others again experience it in all these parts at once. The peculiar sharp pain which results from the extreme dilatation of the external mouth, when the head passes, is perhaps the most constantly felt, and the most alike in all.
The manner in which the mouth of the Womb opens, and the time required for its dilatation, differ much in different cases. In females who have previously borne children, as before explained, the mouth is always considerably opened at the full term, while in a first pregnancy it is nearly closed, even till some time after the labor actually commences. Sometimes the dilatation takes place rapidly, and at others very slowly; it is especially liable to be delayed if the Membranes break too soon, because then the pressure of the bag of waters is lost, and that is an important agent in expanding the Os Uteri. In some cases the neck of the Womb is very hard and rigid, so that a long time is required to make it give way. When any other part than the head presents also, the opening of the mouth will not take place so soon, because no other part so completely fills up the passage.
The breaking of the bag of waters will sometimes occur very early, almost as soon as it protrudes;while at other times it will be delayed till the whole Vagina is filled up by it, or even till it appears externally. The quantity of the water discharged at the time of the rupture is also variable; if the presenting part of the fœtus does not completely block up the passage, the whole may pass away when the rupture takes place; but if it does, as is usually the case when the head presents, only a part flows then, and the rest comes in gushes, as the head is raised, and when the child is born. The too early escape of the waters, as already explained, may retard the delivery, by delaying the expansion of the mouth of the Womb; and in this way unskilful accoucheurs have caused lingering labors, by breaking the membranes too soon.
It is important to recollect also, as I explained before, that a portion of fluid sometimes exists between the amnion and chorion, which may pass first, and induce the belief that the true waters have escaped, when they have not. This is called thefalse waters, orshows, and is not connected with the true waters at all.
Thegeneralphysiological phenomena of a natural delivery having thus been explained, we have now to state its duration, and then proceed to its conduct or management.
The duration of natural labor is not by any means constantly the same, nor can it be predicted with anything like certainty in any case; but still by keeping careful records, and by duly observing a vast number of cases, a tolerable approximation canbe made. There are various circumstances that tend to lengthen the duration of labor, some general, and others belonging to the individual. The mode of life and early habits of the female, the climate in which she lives, and the manner in which she has conducted herself during gestation, all have an important influence. As a general rule, the period becomes longer in proportion to the civilization of the community in which she lives. The first labor is generally more tedious than the succeeding ones, owing to the slower dilatation of the parts. It is also thought by some, that the labor is longer in proportion to the age of the female, particularly with the first child; but this opinion is not well founded.
The average duration of labor in our country, isfrom eight to twelve hours. In some parts it is longer than this, and in others again it is much shorter. I have good reason also to think, that it is longer in cities than in the country.
An experienced practitioner can sometimes predict with tolerable certainty, when called to a labor, how long it will be before it is over; but this is seldom the case, and most frequently his success is owing more to chance than to judgment. If the mouth of the womb be well dilated, the contractions powerful, and the patient vigorous, with the presentation natural, he is of course justified in predicting a speedy delivery; or the reverse, if these favorable conditions do not exist. Many unforeseen conditions may exist, however, and many accidents arise, that may falsify an apparently safe conclusion. No judicious practitioner, except in a few rare cases, will hazard his reputation by fixing anytime, and no well informed patient wouldaskhim to do so, because she would know that it was out of his power.