SIXTH SPECIES OF DYSTOCIA.
_Faulty Labour from a faulty Condition of the expelling Powers._
I. _Where the uterine activity is at fault--functionally or
mechanically--from debility--derangement of the digestive organs--
mental affections--the age and temperament of the patient--plethora--
rheumatism of the uterus--inflammation of the uterus--stricture of the
uterus.--Treatment._ II. _Where the action of the abdominal and other
muscles is at fault.--Faulty state of the expelling powers after the
birth of the child.--Hæmorrhage.--Treatment._
Although this species includes that condition of the expelling powers,
where their action is excessive, we shall defer this portion of the
subject until we treat of _precipitate labour_, with which it is
essentially connected.
The agency by which the child is expelled during labour is of two kinds:
1st, involuntary action of the uterus, assisted, _secondly_, by the partly
voluntary and partly involuntary action of the abdominal muscles.
On the approach of labour, the uterus, which hitherto had been merely
performing the office of a receptacle and a means of conveying nourishment
to the foetus, now assumes a totally different character; from being in a
nearly passive state, it assumes an entirely opposite condition, viz. of
high irritability and powerful action. We might almost suppose that its
connexion with the nervous system was become more close and intimate; for
it is now sensible to the influence of impressions which had before
produced no effect upon it. Thus, we see, that affections of the mind,
even but of moderate intensity, and to which it was, before labour,
nearly, if not quite, insensible, are now capable either of rousing its
efforts to the utmost violence, or of arresting them in the midst of full
activity; and, on the other hand, we see that where its action has been
deranged or interrupted, it gives rise to serious affections of the
nervous system, or even convulsions.
With all this, it now displays peculiarities of function, which strikingly
distinguish it from all other organs of the body; in some cases it appears
to annihilate or to absorb, by its all-pervading influence, the functional
energies of other organs; and, in spite of its increased nervous power and
susceptibility to various impressions, it seems to possess the faculty of
continuing its efforts uninfluenced by general disease, unimpaired by
exhaustion, and, for a time, almost independent of the life itself of the
mother. In convulsions and paralysis, in general fever and inflammation of
vital organs, its powers appear to be undiminished: on the contrary, where
the patient, from whatever cause, is rendered incapable of assisting its
efforts by the abdominal muscles, the uterus will take upon itself the
whole task of expelling the child, which will be born apparently without a
single effort upon the part of the mother.
We also observe, that organs, the various conditions and derangements of
which have exerted little or no influence upon the uterus in its state of
quiescence during pregnancy, now affect it powerfully, and are capable of
modifying its action very considerably. The stomach, the intestinal canal,
and the skin, are remarkable instances of this, and seldom fail to disturb
or pervert the natural efforts of the uterus, whenever these organs
deviate from a healthy condition. It will be, therefore, of the highest
importance to watch their functions narrowly, in order that we may form a
correct estimate of their effects upon the uterus.
Derangements in the contractile power of the uterus may arise from a
variety of causes, which may be chiefly brought under two heads, viz.
_functional_ and _mechanical_.
The functional derangements may arise from insufficient activity, the
result of general or local debility; from a deranged condition of the
digestive organs; from passions or affections of the mind; from hereditary
temperament, constitution, or peculiarity; from the patient's age, being
either very young or considerably advanced in years, and pregnant for the
first time; from plethora, general or local; from rheumatic affection of
the uterus; and from uterine inflammation.
The contractions of the uterus may be _mechanically_ impeded, by tumours
imbedded in its substance; by organic diseases, as schirrus, cephaloma,
and hæmatoma; cicatrices from former ulcerations or rupture, or by any
other circumstances which interrupt the action of the longitudinal fibres
upon the os uteri.
_From debility._ Where uterine action is insufficient from debility, the
pains are feeble, and do not appear to act in the right direction; they
are frequently attended with much greater suffering than might be
expected from their inefficiency; the intervals between the pains are
unusually long, the pains themselves are very short, or, after a while,
cease altogether.
This condition, when depending on _general_ debility, may be the result of
previous disease, loss of blood, or other debilitating evacuations,
poverty, with its attendant miseries, depressing passions of the mind, and
health broken down by intemperance.
The contractile power of the uterus itself may be injured by previous
leucorrhoea or menorrhagia, by abortions, or by attacks of hæmorrhage
during the latter part of pregnancy; it may be weakened by over-distention
of the uterus, either from plurality of children or too much liquor amnii,
by the patient exerting herself improperly at the commencement of labour,
straining violently, and endeavouring to bear down before she is
involuntarily compelled to do so by the presence of the head in the
vagina. It may also be produced by the membranes giving way too soon, as
is so frequently observed in first labours.
_From derangement of the digestive organs._ We have already described the
change which takes place in the relation between the uterus and other
organs, as soon as it passes into a state of action. The intestinal canal
stands foremost in the influence which it exerts upon the uterus; whether
it be from constipation or diarrhoea, irritation from acrid contents, &c.,
it will greatly modify, and even derange, its contractile power; the pains
cease to be genuine uterine contractions, and assume a spasmodic
character, producing much painful griping and pinching about the front and
lower part of the abdomen, without any of that regularity of interval and
duration, and gradual accession and recession, which mark the presence of
real labour pains, and, we need scarcely add, with little or no effect
upon the progress of the labour itself. These griping colicky pains appear
to supersede the true process of parturition, and either to prevent the
uterus acting with due regularity and effect so long as they last, or so
to pervert its action as to produce a species of metastasis towards other
organs. The pains lose their peculiar character as the expelling powers of
the uterus; they cease entirely, and the patient is suddenly attacked with
dyspnoea, cramps in the extremities, violent shivering, great
restlessness, intense headach, delirium, convulsions, or even mania.
Wherever the action of the uterus is deranged by gastric or intestinal
irritation, the abdomen is generally more or less tender in front,
particularly over the symphysis pubis; the os uteri is thin, tense, and
rigid; the vagina is hotter than natural; the secretion of mucus is
sparing; and both os uteri and vagina are more than usually tender to the
touch.
_From mental affections._ The mind is capable of influencing the action of
the uterus during labour in a remarkable manner, not only where it is
suffering from depressing emotions, as grief, great anxiety, or painful
anticipations as to the result, but from causes of a much slighter
character, which are nevertheless well worthy the attention of the
practitioner: his sudden appearance in the room, without the patient
having been properly warned of his arrival: the dread of an examination;
or annoyances of a much slighter character, as regards his manner, or that
of the nurse, &c., will not unfrequently be quite sufficient to stop the
progress of the pains.
The _age and general temperament of the patient_ will also affect the
character of the pains. When pregnancy occurs for the first time, either
at a very early age, or considerably advanced in life, labour is apt to be
protracted, from defective uterine contraction; in the first case, she has
not yet attained that degree of adult strength which is requisite to
undergo a process requiring so much exertion; the pains are weak, of short
duration, and inefficient, but very exhausting to the patient. From the
irritability both of the nervous and vascular systems, so peculiar to
youth, arises a long train of troublesome symptoms, such as congestion of
blood to the head, spasms, syncope, convulsions, &c. In the other case,
the condition of the system is the reverse, the irritability is
diminished, the uterus is sluggish in its action, the pains are weak and
inefficient, follow each other very slowly, and the course of the labour
is much protracted; besides this, the short passages through which the
child advances are now less capable of dilatation, from having that
elasticity and suppleness peculiar to youth, and therefore oppose a much
greater resistance.
Where the patient is of a slothful phlegmatic habit, the uterus generally
indicates a corresponding state, by the slowness of its action and want of
excitability during labour. The same condition is manifested during the
catamenial periods in the unimpregnated state, by the absence of pain,
weight, throbbing, and other symptoms of local congestion, which are
usually observed at these times; so that, but for the discharge, the
patient has scarcely any guide to mark their recurrence. On the contrary,
where the appearance of the menses is preceded and accompanied by severe
pain in the back and loins, throbbing, heat, weight, &c., indicating
considerable excitement in the uterine system, we usually observe a
similar condition in the uterus during labour, the pains being quick,
energetic, and efficient. It is probably from some peculiarity of
temperament that we can explain the hereditary disposition which some
women show in the unusually lingering or rapid character of their labours.
_From plethora._ A congested or overloaded state of the uterine
circulation, whether from general plethora or from other causes, is not an
uncommon cause of feeble contractions. The spongy tissue of the uterine
parietes is so gorged with blood, as to prevent, in a great measure, the
free action of the pains, and may thus seriously impede the progress of
labour. We have already pointed out, when speaking of the signs of
pregnancy, the disposition which the system manifests for forming a larger
quantity of blood than before; the pulse is stronger and more full, the
animal heat is increased; this is especially observed in the uterus, and
continues so during the whole process. Whilst in the state of inaction
which belongs to pregnancy, but little inconvenience, comparatively, is
felt; but when labour commences, and it contracts, the blood is driven
from its engorged veins and sinuses into the general circulation; if,
however, it cannot do this, from the general state of plethora, its
contractions are rendered very imperfect and inefficient.
Besides the appearances of general plethora, we shall easily recognise
this condition by the following symptoms: "the patient has much heat of
surface and yet but little thirst; the face, eyes, and skin, are red and
considerably swollen; we can feel vessels pulsating in every direction;
she gets but little sleep, and finds the bed and the bedclothes
uncomfortable to her; the uterus is large, thick, tense, and very warm:
the os uteri swollen and cushiony, and the vagina also warm and spacious;
the foetus is very restless, and causes a good deal of pain by its
movements. The pains are short and ineffective, and accompanied with a
peculiar sensation of painful stretching or tension, without any symptoms
of rheumatism, cramp, or other morbid conditions of the uterus being
present." (Wigand, _Geburt des Menschen_, vol. i. p. 138.) This condition
is not unfrequently accompanied with tendency to hæmorrhoids, inactivity,
constipation, varicose veins of the lower extremities, &c.
_Rheumatism of the gravid uterus_ is an affection which, although it has
received but little or no notice in this country, has been long known and
described by the continental authors. It appears to be a similar condition
of the uterine fibres, when developed by pregnancy, to rheumatism in other
muscular tissues, arising from the same causes, connected with the same
conditions of the system, and producing similar effects; hence, therefore,
it must interfere considerably with the healthy action of the uterus, and
greatly diminish or entirely destroy, the efficiency of the pains.
The whole uterus is unusually tender to the touch; the contractions are
excessively painful from their very commencement, the slightest excitement
of the uterus producing a sensation of pain; they come on with a sudden
twinge or dragging pain about the pelvis and loins, and where the
contractions are still powerful, they sometimes rise to an intolerable
degree of intensity. This condition is frequently observed to a slight
extent at the commencement of labour; the mild precursory pains which, in
a healthy state, are merely attended with a sensation of equable pressure
and tightness round the abdomen, now produce much suffering and give rise
to one form of spurious pains, to which we have already, under that head,
alluded. Where the symptoms are of considerable severity and have been
aggravated by improper treatment, this state may easily pass into that of
actual inflammation.
On examining into the history of the case, we shall frequently find that
for several days, or even more than a week, the patient has remarked the
uterus to be unusually tender to the touch, scarcely bearing the pressure
of the clothes; and at night-time the uneasiness has increased to such a
degree that she could scarcely remain in bed. There is a frequent desire
to pass water, which is highly acid, and deposites much red sediment; and
in all probability she complains of rheumatic pains in other parts of her
body.
The causes of this condition are the same as those of rheumatism under
ordinary circumstances: exposure to cold, and alternations of temperature,
particularly when heated; derangement of the stomach, with much prevalence
of acid, &c.: insufficient clothing, and, upon the Continent, especially
in Holland, where it is said to be very frequent, by the use of
chauffe-pieds.
_Inflammation of the uterus_ is another condition which can not only
greatly impair, but entirely suspend, the activity of the uterus. It is
usually brought on by improper treatment during labour, where the real
cause of the lingering ineffective pains at the commencement has been
entirely overlooked, and a state of uterine irritation aggravated into one
of actual inflammation by the abuse of stimuli and other heating drinks,
given with the view to increase the pains; it may be produced by external
violence, improper attempts to dilate the os uteri, rough and too frequent
examination, endeavouring to turn the child or to apply the forceps before
the soft passages were in a fit condition for that purpose.
The whole abdomen becomes extremely tender, and even the slightest
contractions of the uterus produce intense suffering; the vagina is hot
and dry, and very tender to the touch--its mucous secretion suppressed;
the os uteri is swollen, tense, and painful, and the anterior lip is
sometimes so distended as to have been actually mistaken for the bladder
of membranes; the bowels are confined; the urine is suppressed; the
abdomen becomes distended from tympanitis; and general, and probably
fatal, inflammation of its contents follows.
_Treatment._ The causes of insufficient uterine action are so numerous
that the modifications to which they give rise are almost endless, and
demand no little variety of treatment. A great deal may be done to avoid
this state by attention to the patient's health shortly before labour; and
by so carefully regulating it as to ensure a healthy condition of the
whole system. Lingering labour from feeble uterine activity is seen most
frequently in young primiparæ of delicate form and nervous irritable
habit; the pains produce much fruitless suffering, and greatly exhaust the
patient. If the cause continues, the case becomes much protracted, and
serious consequences may ensue; such as hysterical symptoms, or even
convulsions, inflammation of some organ, general fever, or complete and
dangerous exhaustion, hæmorrhage, retained placenta, or hour-glass
contraction of the uterus. In a slight degree this condition is not of
unfrequent occurrence, whether from an enfeebled uterus or general
debility, and requires general, rather than special treatment for its
removal. Change of posture, walking about the room, gentle friction of the
abdomen, and occasionally taking some refreshing or mildly nutrient drink,
as tea, wine and water, or beef-tea, &c., prove serviceable in such cases;
friction of the abdomen, if well applied, frequently produces a great
alteration in the character of the pains, and greatly assist the progress
of labour: if it be still in the first stage (the os uteri not yet fully
dilated,) an enema will not only clear the rectum of any fæcal matter
which may be lodging there, but assist in rousing the uterus to greater
activity.
Where we can satisfy ourselves that none of the above-mentioned causes are
present to protract the labour, we may proceed to the use of those
remedies which are considered to have the power of exciting the uterine
contractions, such as secale cornutum, borax, cinnamon, and the several
diffusible stimulants. This state of uterine inactivity is, however, rare;
and we would earnestly warn young practitioners against too readily
concluding that it is present. They will find that the more carefully they
investigate such cases, the less frequently will they require these
remedies. In using the secale cornutum, we give the preference to the
powder: it should be carefully kept from moisture, air, or light: from
twenty to thirty grains, mixed in cold water, will be the proper dose, and
this may be repeated two or three times, at intervals of half an hour, or
rather more. Borax is also another remedy which appears to possess a
peculiar power in exciting the activity of the uterus: although it is
scarcely ever used for such a purpose in this country, its effects upon
the uterus have been long known in Germany; and in former times, both it
and the secale cornutum entered largely into the composition of the
different nostrums which were used for the purpose of assisting labour. We
have combined these two medicines with the best effects, and generally
give them in the following manner:--[Symbol: Recipe] Secalis Cornuti
[Symbol: scruple] i--ij; Sodæ Subborat. gr x; Aq. Cinnamomi [Symbol:
ounce] jss. M. Fiat haust. Cinnamon, which is a remedy of considerable
antiquity, has also a similar action upon the uterus, although to a less
degree.
Our own conviction with regard to the use of these remedies is, that they
are seldom required _during_ labour, except in nates, or footling
presentations, or in cases of turning, where the head is about to enter
the pelvis, and where, at this critical moment, the action of the uterus
is apt to fail, when it is important to the safety of the child that
there should be brisk pains to force the head through the pelvis and
internal parts with sufficient rapidity. The chief value of these remedies
is for the purpose of exciting uterine contraction _after_ labour, and
thus to promote the safe expulsion of the placenta, where there is a
disposition to inertia uteri, and ensure the patient against hæmorrhage.
Where the contractile power of the uterus is so enfeebled that it becomes
nearly powerless, we deem it much safer and better to apply extractive
force to the head by means of the forceps, and thus overcome the natural
resistance of the soft parts, to using medicines which excite uterine
action, and thus stimulate the exhausted organ to still farther efforts.
The mere cessation of uterine action, however, where the labour has been
tedious and fatiguing, is no proof that the uterus is exhausted, and
incapable of farther efforts: so far from its sinking into a state of
quiescence, being a symptom of exhaustion, experience shows that, in
labours of this character, it indicates a very opposite condition, being
nothing more than a state of temporary repose, during which nature affords
it an opportunity of recruiting its own powers, as also those of the whole
system. The interval of ease which is thus given to the patient is
accompanied by refreshing sleep; the skin grows moist; a gentle
diaphoresis creeps over her; the circulation becomes calm; and after a
time, the uterus awakes again to renewed and astonishing exertions; thus,
Wigand has remarked, "the pains during the same labour may cease once,
twice, or even oftener, and yet after a little rest will return with
renewed strength." (_Geburt des Menschen_, vol. ii. p. 242.) On the other
hand, where the pains, in spite of their becoming more and more
ineffective, continue to exhaust the patient with fruitless suffering, and
prevent her from enjoying that repose which is so desirable under such
circumstances; when the uterus, from increasing irritability, scarcely
ceases to contract even for a moment, but continues tense and more or less
tender during the intervals of the pains, we can have little or no
reasonable expectation that such a labour can be terminated by the natural
powers. If the head be not far advanced in the pelvis, or the passages
fully dilated, if the bowels have been relieved before labour, and there
is no febrile excitement of the circulation, a mild diaphoretic sedative,
like Dover's powder, will be of great service: it calms the irritability
of the system, and induces that state of quiet or actual repose to which
we have just alluded. If, on the other hand, the labour be much farther
advanced, the head approaching the pelvic outlet, and the soft parts well
dilated, a little assistance, by means of the forceps, will quickly
terminate the case, and free the mother and her child from farther
suffering and danger.
Where the uterus is enfeebled by lesion or change of structure, it becomes
very difficult to decide as to what course ought to be pursued: in some
cases, the soft passages partake in the loss of tone, and offer but little
resistance to the advance of the child; in others, however, the uterus is
so powerless as to give us no choice but of employing artificial delivery.
We have already pointed out the importance of paying the strictest
attention to the bowels shortly before and during labour, and how
frequently a neglect of this precaution acts as a means of perverting the
due action of the pains, and giving them that character, already described
under the head of _False Pains_. "After the labour has made much progress,
the rectum, if loaded, should be emptied by clysters; indeed, the utility
of clysters in almost every stage of labour is so apparent that it is to
be lamented they are not more frequently employed." (_Synopsis of
difficult Parturition_, p. 19.) We have seen cases where, although the
bowels had been opened at the commencement of labour, after a time, the
pains have gradually lost their dilating effect upon the os uteri,
although they have increased in severity; the os uteri has remained tense
and hard, and the labour has become very tedious and exhausting; the
administration of an enema, and removal of a quantity of fæcal matter from
the rectum, has been followed by an instantaneous change in all the
symptoms; the pains have become powerful and effective, the os uteri has
quickly dilated, and the whole labour has been completed in a very short
space of time. In like manner, vomiting during the early part of labour
produces the best effects; for it not only assists to relax the parts, by
the nausea which usually precedes it, but, by emptying the stomach of
unhealthy contents, it tends not a little to restore the uterus to its
natural activity.
Where the bowels are distended with flatus, and loaded with acrid and
unhealthy contents; we rarely see the pains become regular and effective
until these sources of irritation are removed: the abdomen is painful with
spasmodic colicky griping, and excites the uterus to partial and very
painful contractions of a cramp-like character, which entirely supersede
the regular pains, and thus exhaust the patient with protracted suffering
without at all advancing the labour itself. If this condition be allowed
to continue uninterfered with, the tenderness of the abdomen increases,
the circulation becomes excited, and inflammation, and fever of a most
serious kind will be the result.
In the management of primiparæ, who are pregnant either at a very early
age or considerably advanced in life, our chief attention must be directed
to the management of them for some little time before labour is expected,
in order that we may place them in as favourable a state of health as
possible, and thus enable them to meet the coming trial with safety.
Where the patient is very young, we should endeavour, by early hours,
regular exercise, good air, and simple nourishing diet, &c., to increase
her strength, and the general tone of health, and thus diminish that
irritability of the nervous system peculiar to females of this early age.
She should lead a country life, be as much as possible in the open air,
enjoy the absence of restraint and excitement, which are almost necessary
consequences of a residence in town, and, by agreeable occupation and
cheerful society, train herself, as it were, to that state of moral as
well as bodily health best adapted to ensure a favourable result. It is in
cases of this kind where the bodily powers have not yet ripened into adult
womanhood, that so much good may be effected by using the tepid or (if the
season permit) cold salt water bath; and we would beg to refer our readers
to our observations on this subject in the chapter on PREMATURE EXPULSION.
In a case which has recently come under our notice, we have had reason to
attribute the remarkably healthy and favourable labour of a young and
delicate primipara solely to the invigorating effects of regular exercise
and the daily use of sea-bathing, which she continued to within a very few
days of her confinement.
It is commonly supposed that women pregnant for the first time, and
advanced in years, always have severe labours: this is not necessarily the
case, although, at the same time, the greater rigidity of the soft parts
considerably increases the resistance to the expelling powers. It will be
equally important in this case, also, to improve her health and strength
as far as possible, and, by exercise, warm hip baths, &c., to give the
parts a greater degree of suppleness and elasticity.
Where the labour is protracted by a state of general plethora or local
congestion, the expelling powers are not only enfeebled by the engorged
state of the uterine circulation preventing effective pains, but the
resistance to the passage of the child is increased by a similar condition
of the soft passages, which are swollen and turgid with blood. It is in
these cases that bleeding effects such a sudden and complete change; the
pulse loses its oppressed character, and rises in point of strength, the
uterus loses the thick solid feel which it had before; its contractions
become active and powerful, the os uteri dilates, the passages become soft
and yielding, and the whole process assumes a different character. By
careful observation, this state can easily be discovered before labour has
actually commenced; in which case much useless suffering may be prevented
by previously reducing the circulation to a proper standard, and thus
fitting the uterus for the exertions it has to undergo: besides bleeding,
mild saline laxatives, with or without antimonials, will be of great
service. The nitrate of potass in these cases has the best effects, either
in farthering the effects of the bleeding, or removing the necessity of
using so powerful a remedy.
In treating rheumatism of the gravid uterus, our practice will differ but
little from that in cases of ordinary rheumatism in other parts: this
condition, we believe, is rarely excited, until the system had been
already predisposed to it by deranged digestion, and that general
prevalence of acid diathesis, which manifests itself in different
individuals and under different circumstances so variously; hence,
therefore, it will always be important to unload the primæ viæ effectually
by an active dose of calomel or some other mercurial, before prescribing
for the immediate symptoms of the complaint: beyond producing a little
occasional nausea, five grains of calomel will act much more comfortably
to the patient's feelings than a smaller dose; there will be less griping
and intestinal irritation, but the effect will be more complete and
general; not only will the bowels be thoroughly evacuated, but the liver
relieved of a large quantity of unhealthy acrid bile, the removal of which
cannot but be highly advantageous. We may now proceed to the use of
diaphoretics and opiates: of these, Dover's powder stands foremost; and if
given in doses of from ten to fifteen grains, accompanied with warm
diluent drinks, rarely fails to induce sleep and a pretty active
perspiration, which gives great relief. As the abdomen is usually more or
less tender on pressure, it should be covered with a piece of soft
flannel, or, still farther to ensure the full diaphoretic effect of the
remedies, a warm bath may be had recourse to. Where calomel in the above
dose has been premised, we seldom fail in procuring a free action of the
skin, and, according to our own experience, with far greater relief to the
system than where the perspiration has been induced merely by diaphoretics
and external warmth.
If this condition of the uterus has been neglected, and the contractions
are beginning to produce intense suffering; if the abdomen is rapidly
becoming more tender to the touch, it should be covered with a hot
poultice of linseed meal, made more stimulating by the addition of mustard
flour, and this should be continued until the skin is considerably
reddened. In the slighter cases of this affection, where the bowels have
been opened, friction upon the abdomen frequently produces the happiest
effects. We presume it is to these cases that Dr. Power alludes when he
says, "in some, the improper action will be removed almost instantly, and,
as it were, by a miracle; so that a case which has been protracted for the
greater part of a week, under the most intense suffering, without the
least progress, has been happily terminated in fifteen or twenty minutes
from the first commencement of the friction." (Power's _Midwifery_, 1819.)
Where inflammation of the uterus takes place during labour, the case
becomes one of the most serious character; for not only is the suffering,
which is produced by every contraction, of the most intense description,
but the presence of the child aggravates the state of inflammatory action,
and excites the uterus to still more violent efforts, while the swollen
and unyielding state of the os uteri, &c., precludes the chance of speedy
delivery. Under such circumstances, we must trust almost entirely to the
lancet in aiding this important object; for, until the circulation has
received an effectual check by fainting, the dilatation of the parts
cannot proceed, nor can any attempt be made to give artificial assistance.
The abdomen should be covered with a hot linseed meal poultice, as above
described, in the treatment of rheumatism of the uterus; warm decoction of
poppies should be thrown up the vagina, or, if this cannot be procured at
the moment, some thin gruel mixed with a little laudanum, or in which a
few grains of Extr. Conii or Hyoscyami have been suspended; the bowels
should be opened by a simple enema, after which a small opiate injection
will be desirable, in order still farther to allay irritation.
_Stricture of the uterus._ We have already had occasion to allude more
than once to that species of violent and continued contraction which we
have denominated stricture of the uterus, but have chiefly considered it
where it affects the os uteri; a somewhat similar condition of spastic
rigidity is occasionally, though rarely, seen in other parts of this
organ, and is capable of producing a most serious obstacle to delivery.
The uniform and regular action of the uterus disappears; its contractions
become partial, both in extent and effect, one part alone contracts whilst
the rest of the uterus is relaxed; its shape thus becomes altered; for, by
these partial contractions of its fibres, it may become elongated,
shortened, flattened, &c.: the spasmodic action frequently varies its
seat, and successively attacks different portions; thus, where it affects
the body of the uterus, it becomes contracted almost like an hour-glass,
having a transverse circular indentation, as if it had been tied with a
cord. Where the contraction affects one side of the organ, it alters the
shape of it materially; the fundus is pulled down equally, and the
position of the child, as we have shown in the first species of dystocia,
may be seriously affected. If the stricture has its seat in the os uteri,
this becomes tightly contracted, hard, unyielding, and painful upon
pressure: it does not dilate sufficiently, and the inferior segment of the
uterus is generally pushed downwards, whilst the os uteri itself is drawn
upwards. In cases of this kind, we find that although the uterus
contracts, the child does not advance, but rather retracts, during a pain;
the contractions are never general, but partial, and even where they are
general, the fundus does not attain its due preponderance over the os
uteri, so that the one contracts as much as the other does; in severe
cases, also, the uterus continues in a state of spasmodic action during
the intervals of the pains: this is frequently accompanied with a painful
and harassing sensation of tension and stretching, very different to that
produced by the action of regular pains upon the os uteri; and in the
worst cases we occasionally observe a peculiar state of the brain, which
manifests itself by attacks of insensibility, faintings, or even
convulsions.
Although the head does not advance in spite of the strongest pains, yet,
upon examination, we find no want of proportion between it and the pelvis;
if the intervals of uterine action be of sufficient duration to allow it,
we shall feel the head quite moveable in the pelvis, or, at any rate, with
plenty of room for the finger to pass round it, and yet when a pain comes
on, the head remains fixed, or if it does descend somewhat, it returns
again to its former situation as soon as the pain is over. This state of
things is usually seen where the body of the uterus is the seat of the
stricture, and is contracted transversely upon that of the child, which it
tightly encircles, and renders all farther advance impossible.
This state of spasmodic action is produced by whatever tends to irritate
the uterus and excite it to irregular action; thus, premature rupture of
the membranes, especially when it has been suddenly drained of a large
quantity of liquor amnii; the irritation arising from acrid matter in the
intestines, or from their being loaded with accumulations of fæces;
improper examination, and more especially, attempts to dilate the os uteri
by the fingers or hand; endeavouring to strain and bear down during the
early part of labour, and when the patient is not involuntarily compelled
to do so; attempting to apply the forceps when the os uteri is not fully
dilated, or whilst the instrument is very cold: malposition of the child,
especially after rupture of the membranes; and lastly, anxiety, fear, and
other affections of the mind. The circulation is generally in an irritable
state, the patient is of a delicate excitable habit, and is apt to be
nervous and hysterical.
The treatment in these cases will be precisely on the same general rules
as we have above described; the bowels must be relieved by a laxative or
by an enema; if necessary, the circulation must be reduced to the proper
standard by bleeding, and the irregular uterine action controlled by
opiates. Besides these means, the warm bath is of the utmost service, and
seldom fails to produce a favourable change. Where the action of the
uterus is impeded, or otherwise rendered faulty by organic disease,
lesions of its structure, &c., we shall in all probability be compelled to
use artificial assistance.
II. _Where the action of the abdominal and other muscles is at fault._
Where the faulty character of the labour arises from a faulty state of the
partly voluntary, partly involuntary, action of the abdominal muscles
which is destined to aid the uterus in expelling the child, this may
equally be a result of general debility from previous disease, exhaustion
from the long duration of the labour, from the abuse of spirituous
liquors, &c. It may also arise from various causes which tend to impede
the respiration; such as excessive corpulence, great deformity of the
spine, bronchocele, spasmodic asthma, rheumatism of the diaphragm,
ascites, hydrothorax, phthisis, pneumonia, aneurism of the aorta,
dilatation of the heart, &c.
Where the size is such as renders the patient very unwieldy, or the spine
is much deformed, we must place her in that position in which she can
exert herself with greatest effect, and at the same time experience the
least possible obstruction to her breathing: with deformed people, this is
of great importance; she should be propped up with pillows, &c. into
whatever posture she can lie with most comfort, and the practitioner must
manage to deliver her in this position. Patients suffering from pluerisy
or pneumonia are unable to bear the continued strong inflation of the
lungs which is necessary during the second stage: under these
circumstances, the pain and inflammation are greatly aggravated;
venesection must be used with great promptness, but it does not always
bring relief or remove the danger; for the disease is kept up by the
presence of labour, which, therefore, in all probability, will require to
be terminated by art. In some cases, however, as we have already
mentioned, especially where the disease is of an acute character, the
uterus appears to take upon itself the whole exertion of the labour, so
that the child is born apparently without any effort on the part of the
mother.
_Faulty state of the expelling powers after the birth of the child._ The
last stage of labour, which comprehends the expulsion of the placenta, may
also be retarded by a faulty state of the expelling powers. This not only
arises from the causes which we have already mentioned, but from those
connected with the labour itself; as from premature and immoderate
straining during the pains, misuse of medicines given to increase the
pains; also, where the uterus has been exhausted by the length and
severity of the labour, or where it has been thrown into a state of
inertia by the sudden evacuation of its contents, especially when
previously much distended. This condition is frequently induced by not
supporting the child sufficiently when the shoulders are about to pass
through the os externum; the main bulk of the child is therefore suddenly
expelled, and the uterus is at once thrown into irregular action by the
sudden shock of so great a change, or falls into a state of inertia. The
separation and expulsion of the placenta may be also retarded where the
labour has required the forceps, turning, or perforation, especially the
latter, on account of considerable pelvic deformity; the more so if there
has been considerable delay in giving assistance. Irregular and partial
action of the uterine fibres, after the expulsion of the child, may easily
render the last stage of labour dangerous; for, under such circumstances,
the portion of the uterus to which the placenta is attached may be in a
state of firm contraction in one part, while the other is quite relaxed,
so that incomplete separation of the placenta will be the result, and
hæmorrhage follow: hence we cannot be too cautious in avoiding every cause
which may at all influence the regular action of the uterus during the
last stage of labour, which is far more dangerous than the two others put
together.
In a case of this kind, we do not feel the uterus contracting into the
firm globular mass above the symphysis pubis, as might have been expected;
but if inertia uteri be present, it remains soft and large, the peculiar
pains of the last stage which indicate the speedy separation and expulsion
of the placenta do not make their appearance, or only in a very
insufficient degree. If it be contracting irregularly and only in part, we
shall feel this distinctly, from the unequal shape and hardness of the
uterus, which in some cases will have almost a lobulated feel; in others,
it presents a considerable depression either upon the fundus or anterior
wall.
_Hæmorrhage._ The danger here, chiefly depends upon the occurrence of
hæmorrhage: if the placenta be still attached by its whole surface to the
uterus, no hæmorrhage can ensue; but if the contractions have been of
sufficient power to detach more or less of it from the uterus, large
trunks, which have hitherto conveyed maternal blood into the placental
cells, are torn through, and a profuse discharge must be the result. The
degree of the hæmorrhage will in most instances furnish us with a
tolerable estimate of the extent to which the separation has taken place;
but it is far from easy to ascertain correctly the quantity of blood which
has been lost, and we must rather try to ascertain what are the effects
produced upon the system of the patient. The pulse becomes smaller and
quicker, the column of blood is evidently diminished, and the heart for a
time drives on its contents more rapidly; but as the loss increases, so
does it become enfeebled, and although beating with a very frequent
stroke, it now becomes so weak as to be scarcely or no longer capable at
the wrist of producing such a resistance to the finger as will give the
sensation of a pulse; the necessary consequence of this is, that the
patient at first complains of great weakness, the face becomes pale, the
lips white, the breathing anxious; this is followed by a sense of great
prostration, the perspiration breaks out upon the face and forehead,
tinnitus aurium, confusion of ideas, and sense of darkness before the eyes
succeed; the load at the præcordia, and the oppression of breathing,
become more insupportable; she tosses her arms about, and in some
instances has a sensation that the room is going round with her, or that
she is sinking through the bed; in other cases, the breathing becomes
gradually more feeble, until it is almost imperceptible; she every now and
then takes a deep sobbing grasp, which seems to rouse her to consciousness
for a moment, and then she relapses into a state verging upon
insensibility; the pulse is probably now no longer perceptible at the
wrist, the face is undergoing a rapid change, the features are
contracting, and there is a general expression of death-like collapse
which shows too truly the urgency of the danger. The alterations which are
taking place in the state of the brain and nervous system, vary in
different individuals: in some, there is strabismus; in others, temporary
mania, or at least, delirium; and in more unfavourable cases, even
convulsions; these last are especially formidable, as they not only show
that the system has been severely affected by the loss of blood, but are
apt, from their violence, to extinguish the little spark of life which is
left, or, in other words, to be followed by sudden death.
These are some of the many symptoms indicating a sudden and extensive loss
of blood; others also occur, depending on the external or internal
character of the hæmorrhage. The want of contraction and general
flaccidity of the uterus, as felt through the abdominal parietes, have
been already noticed; if the blood be prevented escaping by the contracted
state of the os uteri, by coagula, or the detached placenta, it begins to
collect in the cavity of the uterus, which therefore swells as the
accumulation continues to increase, so that it may even equal the size
which it had before labour, containing many quarts of blood, and the
patient may be in the most imminent danger of dying from hæmorrhage,
perhaps, without any blood having issued externally: this is the _internal
uterine hæmorrhage_, a form which is justly looked upon as peculiarly to
be dreaded, from the insidious character of its attack. In most cases, the
uterus fills to a certain extent only, and then, as if excited to
contraction by the distention of its parietes, or any slight concussion,
produced by coughing, &c. it expels a large quantity of coagula and half
coagulated blood, and returning to its former state of atony, again begins
to swell from fresh accumulation of blood in its cavity.
_Treatment._ So long as the inertia or atony of the uterus continues
without any symptoms either of external or internal hæmorrhage, we are not
justified in interfering directly, either for the purpose of exciting the
uterus, or still less of removing the placenta. This condition chiefly
occurs where the uterus has been previously much distended, or suddenly
emptied of its contents, where it has been exhausted by long and difficult
parturition, and also, as Leroux has observed, "in women of a phlegmatic
temperament and lax fibre, who, during pregnancy, have suffered much
ill-health, by which the tone of the solids has been weakened; who have
very large pelves, and a soft dilatable os uteri." (_Sur les Pertes de
Sang_, 1776.)
We must therefore give the uterus time to recover from the great and
sudden change which it has undergone, to collect its strength, to remodel
and arrange its forces, until it is at length able, not only to resume its
efforts, but to contract to that extent which shall both ensure the
expulsion of the placenta and the safety of the patient. Whilst this state
of inertia lasts, the patient should be kept as quiet as possible; she
should be placed in a comfortable posture, take a little cool drink from
time to time (as cold tea, toast and water, &c.,) in order to refresh
her;[131] or, if she has been much exhausted by her labour, a glass of
wine may be given with good effect. If, however, hæmorrhage appears, this
shows that a separation of the placenta from the uterus must have taken
place: our great object should now be to excite contraction of the uterus,
for by this means alone can we stop the discharge.
In ordinary cases, a little circular friction with the tips of the fingers
over the fundus will generally be sufficient. If the uterus begins to
swell, we may grasp it with a sudden but moderate degree of force; or we
may give the fundus every now and then a smart jog with our hand. Whilst
these measures are pursuing, a dose of secale cornutum (see DYSTOCIA, p.
330,) will be of great service; for even if it does not act soon enough to
aid the expulsion of the placenta, it contributes greatly to ensure the
contraction of the uterus afterwards. If the hæmorrhage nevertheless
continues profuse, it will be necessary to introduce the hand into the
uterus and remove the half-separated placenta: its contractions are too
feeble for that purpose of itself, and the presence of the hand in its
cavity, and the artificial separation of the placenta, act as a stimulus,
and rouse it to greater activity. The opinion that we only increase the
danger by thus increasing the bleeding surface does not hold good, when,
from the profuseness of the hæmorrhage, it has become evident that the
greater part of the placenta is already separated from the uterus; on the
other hand, where there is but a slight discharge, the case is very
different, and would not justify our having recourse to so strong a
measure.
If the contraction which has been excited by the artificial removal of the
placenta be but temporary, we must proceed to the use of other means for
the purpose of rousing the activity of the uterus. The sudden application
of cold is a most valuable means; it acts here solely by the _shock_ which
it produces at the moment, and not by lowering the circulation and
favouring coagulation. Thus we find that a cold wet napkin suddenly
flapped upon the abdomen has an immediate effect upon the uterus; but it
ought not to remain on long, and the skin should be dried with a warm
towel, in order that a fresh application of the cold may produce the
greater effect. A series of such _shocks_ may be produced by using another
wet napkin to the vulva, and a third to the sacrum and loins; an
assistant should remove them in the order in which they have been applied,
and dry the skin, for a repetition of the remedy, if necessary.
A still more powerful mode of producing a sudden shock, and thus rousing
the uterus to activity, is by a douche of cold water upon the abdomen.
This may easily be effected by a teapot or kettle held at some height
above, and slowly emptied upon the lower part of the abdomen; the uterus
will seldom refuse to obey such a stimulus as this, however great may be
the inertia into which it has fallen. The inefficiency of a prolonged
application of cold to the abdomen, however severe, and the efficiency of
the contrary practice, is admirably expressed by Dr. Gooch, in his
description of a dangerous case of hæmorrhage:--"Finding the ice so
inefficient, I swept it off, and taking an ewer of cold water, I let its
contents fall from a height of several feet upon the belly: the effect was
instantaneous; the uterus, which, the moment before, had been so soft and
indistinct as not to be felt within the abdomen, became small and hard;
the bleeding stopped, and the faintness ceased--a striking proof of the
important principle that cold applied with a shock is a more powerful
means of producing contraction of the uterus than a greater degree of cold
without the shock." (_An Account of some of the more important Diseases
belonging to women_, by Robert Gooch, M. D.)
Another mode of applying cold to induce uterine contraction, and little,
if at all, inferior to that above-mentioned, is the injection of cold
water into the uterus itself: this can only be effectually employed after
the removal of the placenta and membranes, and frequently proves of the
greatest assistance, being capable of rousing the uterus when many other
means have failed. If, from the sultriness of the weather, water cannot be
procured of sufficient coldness, or if the case be very urgent, vinegar
and water in equal parts may be used; but the injections of spirit and
water, which some have recommended, can scarcely be considered as a safe
proceeding.
These various means frequently require to be repeated several times before
the contraction of the uterus becomes permanent, nor must we be
discouraged by finding the uterus becoming soft again in a minute or two
after ceasing to use them; for we may feel assured, with few exceptions,
that if we can only keep the uterus, by this means, in a state of
tolerable contraction for half an hour, it will ultimately become
permanent, and remain so of itself.[132]
It is, in these cases, where pressure is of so much importance, not for
the purpose of producing uterine contraction, as of maintaining it when
once excited. By pressure applied at this moment, we may frequently keep
the enfeebled uterus in a state of contraction, which, but for this
support, would have yielded to the general force of the circulation, and
have again expanded. For the same reason, whenever the uterus begins to
swell again from internal hæmorrhage, and by the renewal of the above
remedies, it becomes hard, but does not diminish in size: this shows that
the contraction has not been powerful enough to expel the blood, which, in
all probability, has already begun to coagulate in its cavity: where this
is the case, the hand, or at least two fingers, should be passed, to
dislodge the clots, and assist in their expulsion; after which, a cloth
folded into a thick compress should be placed over the fundus, and firmly
bandaged upon the abdomen by a broad towel.
Where every means has failed to induce a sufficient or permanent degree of
contraction, we believe that the only certain means which remains, is
putting the child to its mother's breast. Under no circumstances do we see
the sympathy between the uterus and the breast so beautifully displayed as
here, and we may most truly affirm that we have never known it fail where
the mother was sufficiently conscious to know that it was her own child.
To a by-stander, ignorant of what was taking place, the sudden gush of
blood mixed with coagula, which follows the application of the child,
would be nothing less than a sign of renewed danger, while, in fact, it is
a proof that the uterus is beginning to contract and expel its contents.
If the pulse has been seriously reduced by the loss of blood which the
patient has sustained, a glass of wine, or a spoonful or two of brandy,
will be of great service in rousing the vital powers; and this must be
repeated or increased, according to the urgency of the circumstances; a
little weak beef-tea, given from time to time, frequently appears to rouse
the system, even more than the brandy, and is more refreshing to the
patient; it can also be taken in larger quantities, for when the
exhaustion is very great, stimuli appear to excite vomiting, which is by
all means to be avoided. Where, however, it occurs spontaneously, it need
not be looked upon in so formidable a light: thus Dr. Denman observes,
"when patients have suffered much from loss of blood, a vomiting is often
brought on, and sometimes under circumstances of such extreme debility
that I have shrunk with apprehension lest they should have been destroyed
by a return or increase of the hæmorrhage, which I concluded was
inevitable, after so violent an effort: but there is no reason for this
apprehension; for, though vomiting may be considered as a proof of the
injury which the constitution has suffered by the hæmorrhage, yet the
action of vomiting contributes to its suppression, perhaps by some
revulsion, and certainly by exciting a more vigorous action of the
remaining powers of the constitution, as is proved by the amendment of the
pulse, and of all other appearances immediately after the vomiting."
When a slight trickling of blood continues, although the uterus is
tolerably hard and contracted, it will be desirable to make an
examination, for we shall frequently find a long slender coagulum hanging
through the os uteri into the vagina, upon the removal of which, the
discharge will cease.
The application of the child to the breast is not less valuable for
preventing any return of the hæmorrhage than for stopping it in the first
instance: we are _never_ perfectly secure against hæmorrhage coming on
during the first few hours after delivery, even where every thing has
turned out as favourably as possible: the exhaustion from the length or
severity of the labour, the warmth of the bed, and in some cases, it would
even seem, the relaxing effects of deep sleep, are all liable to be
followed by inertia uteri and hæmorrhage. In no way can we ensure our
patient so completely against this kind of danger as by putting the child
to the breast; the uterine contraction which it excites is not only
powerful, but permanent; nor do we consider that a practitioner is
justified in leaving a patient in whom the uterus has shown a disposition
to inertia without having ensured her safety by this simple but effectual
safeguard.
There is a form of hæmorrhage after the birth of the child, which seems to
depend upon an over-distended state of the circulation, and where its
activity appears too great for the contractile power of the uterus; so
that, in spite of the uterus being tolerably firm and hard, a profuse
hæmorrhage is almost sure to follow the separation of the placenta. This
condition has been described by the late Dr. Gooch, and still more
recently by Professor Michaelis, of Kiel; to the former, especially, we
are indebted, not only for having first pointed out this important fact,
but for having placed it before us in the simplest and clearest light. "I
had now witnessed," says Dr. Gooch, "two labours in the same person, in
which, though the uterus contracted in the ordinary degree, profuse
hæmorrhage had nevertheless occurred: let me be understood--after the
birth of the child, I laid my hand on the abdomen, and felt the uterus
within, of that size and hardness, which is generally unattended by, and
precludes hæmorrhage; in both instances, the labour had been attended by
an excessively full and rapid circulation. I could easily understand that
a contraction of the uterus, which would preclude hæmorrhage in the
ordinary state of circulation, might be insufficient to prevent it, during
this violent action of the blood-vessels; and the inference I drew was,
that, in this case, the hæmorrhage depended not on a want of contraction
of the uterus, but on a want of tranquillity of the circulation; and that
if ever she became pregnant again, a mode of treatment which would cause
her to fall in labour with a cool skin and a quiet pulse, would be the
best means of preventing a recurrence of the accident." This will be
effected by an occasional venesection during the last weeks of pregnancy,
by the use of saline laxatives; and if there be still much disposition to
heat the surface, and excitement of circulation, by doses of nitre three
times a day, and by strict antiphlogistic regimen.