THIRD SPECIES OF DYSTOCIA.
_Difficult labour from faulty condition of the parts which belong to
the child.--The membranes.--Premature rupture of the membranes.--
Liquor amnii.--Umbilical cord.--Knots upon the cord.--Placenta._
In describing this species of dystocia, according to the arrangement of
Professor Naegelé, which we have adopted, it will be necessary to observe
that serious obstructions to the passage of the child is seldom produced
by it, although, at the same time, many slight derangements in the
progress of labour are liable to result, which demand the care of the
practitioner.
The membranes when too thick or tough (Merriman's _Synopsis_, p. 217,) may
retard the labour occasionally, especially during the second stage, when
instead of bursting and allowing the uterus to contract more powerfully
upon the child by the evacuation of the liquor amnii, they are pushed down
into the vagina, forming a large conical sac, which may even protrude
externally. We doubt much, however, if the non-rupture of the membranes at
the proper time during labour is of itself sufficient to retard its
progress, for it is frequently observed that the head will, nevertheless,
advance rapidly and even be born covered by the protruded membranes. Where
labour is rendered tedious by the unusual strength of the membranes, it is
generally connected with considerable distention of the uterus from liquor
amnii; in which case the bag of waters is so spherical that it will not
descend readily into the vagina, even although the os uteri is fully
dilated, and, therefore, prevents the advance of the head: to this we
shall recur immediately. So long as there is no undue accumulation of
liquor amnii, we may safely allow the membranes to descend to the os
externum before we rupture them. In former times a variety of instruments
were employed for this purpose, many of which were dangerous, and all
unnecessary, the finger being in most cases sufficient. The most effectual
way of doing this is to press the thumb and middle finger upon the
membranes during a pain and thus increase their tension, whilst the point
of the fore-finger is pushed against them: scratching them with the nail
during a pain will be sufficient when they are higher up the vagina.
_Premature rupture of the membranes._ More frequently the membranes
rupture too soon, that is, before the os uteri is fully dilated: this may
arise from their being too thin, a condition, however, which it is not
very easy to prove: in most instances, it is observed where the uterus is
but moderately distended, and where it has that oval or pyriform shape
which we have already pointed out as being best adapted for acting
efficiently upon the os uteri. This, perhaps, is one reason, why too early
rupture of the membranes so frequently occurs in primiparæ; and this may
be one cause, among many others, why first labours are generally so much
more tedious and severe. The membranes may also be prematurely ruptured by
violent exertions, coughing, sneezing, vomiting, &c. by straining
immoderately and too soon, by rough and awkward examination, &c. Where
this is the case, the patient should preserve the horizontal posture, and
keep as quiet as she can until the os uteri has dilated sufficiently and
allowed the head to advance.
_Liquor amnii._ Where the uterus is distended by an unusual quantity of
liquor amnii, its contractile power is necessarily much impaired; and
until the quantity of its contents be somewhat diminished, the progress of
the labour will be more or less retarded. The average quantity of liquor
amnii at the full period of pregnancy is about eight ounces; but it
frequently exceeds this very considerably, occasionally amounting to
several pints or even quarts. The causes of this extraordinary
accumulation are still but little known. "M. Mercier has, in some cases,
attributed it to an inflammatory condition of the amnion, the foetal
surface of this membrane being stated to have been partially coated with
false membrane, and the amnion itself crowded with blood-vessels of a rose
colour:" in another case "about a quarter of the foetal surface of the
amnion was inflamed, being of a deep red colour and double the natural
thickness."[117] The results of Dr. R. Lee's observations, after having
paid a good deal of attention to the subject, do not tend to confirm this
view: he has described six cases of unusual accumulation of the liquor
amnii, in one amounting actually to sixteen pints. In five of them "there
existed with dropsy of the amnion some malformed or diseased condition of
the foetus or its involucra, which rendered it incapable of supporting
life subsequent to birth." In two only of the preceding cases was "the
formation of an excessive quantity of liquor amnii accompanied with
inflammatory and dropsical symptoms in the mother; and in none did the
amnion, where an opportunity occurred for making an examination, exhibit
those morbid appearances produced by inflammation, which M. Mercier has
described, and which led him to infer that inflammation of the amnion is
the essential cause of the disease." (Lee, _op. cit._) Dr. Merriman has
given a similar opinion, and states, that "when the embryo or foetus is
diseased, the liquor amnii is sometimes immense in quantity. I once saw at
least two gallons evacuated from the uterus: the child was monstrously
formed and much diseased."[118]
In these cases the size and globular form of the uterus, the tenseness of
its parietes, the more or less distinct feel of fluctuation, the absence
of the child's movements and of any prominences arising from the
projecting portions of its body, the rapid increase which has been
observed in the size of the abdomen, the pain in different parts of the
uterus, especially in the groins and pelvis, the oedema or anasarca of the
lower extremities, serve to mark this condition. On examination per
vaginam we also feel the inferior segment of the uterus much expanded, the
cervix probably shorter than might be expected for the period of
pregnancy; the ballottement is unusually free and distinct. In some
instances the patient has suffered so much, either from the effects of the
retarded circulation in the lower extremities, or from the impeded
respiration as to require the membranes to be punctured in order to reduce
the size of the uterus. The child is usually born dead where the
accumulation has gone to so great an extent: in the three cases recorded
by La Motte, it was dead before birth in the first two, and died
immediately after birth in the third. Many of these cases, which have been
complicated with disease or malformation of the foetus, have appeared to
arise from a syphilitic taint; but in others, of more common occurrence,
where there was merely an unusually large quantity of liquor amnii without
any disease either of the mother or her child, the cause must still remain
a matter of uncertainty. This latter condition is mostly seen in women who
have been frequently pregnant; the os uteri in them is generally yielding,
and when once it has attained its full degree of dilatation, we may safely
rupture the membranes and thus expedite labour considerably.
There being an unusually small quantity of liquor amnii can scarcely
operate as an obstruction to labour, except where the membranes have been
prematurely ruptured.
The _umbilical cord_ may obstruct labour, by either being too short, or
rendered so from being twisted round some part of the child. Its length
varies very considerably. Although we have stated it to average about
eighteen or twenty inches,[119] we have met with extreme deviations both
within as well as beyond this medium length. The shortest cord which we
know of occurred some years ago at the General Lying-in Hospital, "where,
after two or three violent pains, the child was suddenly and forcibly
expelled the cord was found ruptured at about two inches from the navel of
the child, which cried stoutly. After removing the child the matron sought
for the other end of the funis, but could not find it; she examined per
vaginam but could not feel it; and on introducing her hand into the
uterus, found the placenta with the remains of the cord ruptured at its
very insertion; so that in this case the cord could not have been much
more than two inches long." (Printed Lectures in Renshaw's _Lond. Med. and
Surg. Journ._ May 1835, p. 426.)
We quite agree with Professor Naegelé, that unusual shortness of the cord
can rarely if ever retard labour; and that where the cord really produces
an impediment to its progress, it is from being twisted round the neck, or
some other part of the child. (_Lehrbuch_, 2d ed. p. 289.) This generally
arises from its unusual length, and from its having formed several coils
around the child: we have met with it forty-eight inches long, and twisted
four times round the child's neck; but Baudelocque mentions a case where
it actually measured fifty-seven inches, "forming seven turns round the
child's neck." (Heath's _Transl._ vol. i. § 516.) Mauriceau has given an
instance (_Obs._ 401.,) where the cord had "longueur d'une aune et un
tiers de notre mesure de Paris:" which, converted into English measure,
amounts to somewhat more than sixty-one inches.
Although nothing is of more common occurrence than the cord being twisted
once or twice round the child, it nevertheless, happens, but very rarely,
that its advance is thereby obstructed. In a case of this sort, the labour
usually commences quite favourably; the os uteri dilates, and the head
advances to a certain extent, beyond which it makes no other farther
progress; the uterine contractions are attended with much pain in the
fundus, during which the head advances somewhat, but retires again during
the intervals. Where the head is already near the os externum, this may be
easily attributed to the elasticity of the soft parts, until the delay
which takes place to the farther progress of the labour warns the
practitioner that something more than ordinary is the cause. But where
this takes place, and the head is still in the pelvic cavity; where at the
same time, although it refuses to advance, it is quite moveable, and
allows the finger to be passed freely round it; where any attempt to
extract it with the forceps has not only met with great opposition, but
has greatly aggravated the sense of painful dragging in the upper parts of
the uterus there will be pretty certain evidence of the cord being either
too short, or, what is most probable, of its being twisted round the
child. In each of the three cases recorded by La Motte, the head had
descended to the os externum; whereas, in two others described by Burton,
it was evidently much higher up: he ruptured the cord in both instances;
La Motte succeeded in cutting the cord with a pair of scissors in one
case, in another he appears to have separated the placenta, and in the
other to have delivered by little else than force. Where upon introducing
the hand we find it impossible to undo the coil of the funis, we should
endeavour to slip it first over one and then the other shoulder, as we
have recommended under the more ordinary circumstances: should this fail,
we must try to cut it through either by a finger nail slightly notched for
the purpose, or by the introduction of a Smellie perforator well guarded.
The cord being twisted round the child's neck may not only retard labour,
it may destroy the child itself by preventing the free return of blood
from the head: this may take place some little time before birth, or
during the actual process of labour. That suffocation cannot possibly be
the cause of death under these circumstances is sufficiently evident.
_Knots upon the cord_ have been mentioned by some authors as a cause of
danger to the child shortly before and especially during labour; for the
circulation in the umbilical vessels being more or less compressed, the
child would either be born dead or in a very weakly state. Experience has,
however, shown that these effects have been much over-rated, and that
these knots are seldom injurious to the child.[120] Baudelocque has not
only met with single, but even triple and very complicated knots tied
tightly upon the cord, and yet the child was not only born alive, but
remarkably robust and healthy. Circumstances, however, may occur by which
the knot is gradually drawn so tight as to destroy the child. Smellie has
given a case of this kind; but it is to the late Matthew Saxtorph, of
Copenhagen, that we are indebted for an admirable essay on this subject.
The result of his observations coincides with those of Baudelocque, viz.
that it rarely proves fatal to the child.[121] The manner in which these
knots are formed may be easily imagined; when by chance the cord lies in
the form of a ring, and the foetus happens to float through it, a noose is
made, which, when drawn tight by accident, forms a knot.
The most favourable time for the formation of such knots is in the earlier
months of pregnancy, when the quantity of liquor amnii, in proportion to
the bulk of the foetus, is so much greater than at an after period, and
when its movements are consequently less impeded. The circulation in the
knot will be obstructed in proportion as the knot is drawn closer: if it
be merely somewhat impeded, the vessels on each side of the knot will be
distended and varicose, and the cord itself, where it forms the knot, from
the constant gradual pressure of one fold against the other, will become
more or less flattened.[122] We believe that in every case the cord has
been of unusual length.
The _placenta_ cannot easily obstruct the birth of the child, although it
may render the labour exceedingly dangerous in a great variety of ways:
these circumstances will be considered under their respective heads.