PRECIPITATE LABOUR.
_Violent uterine action.--Causes.--Deficient resistance.--Effects of
precipitate labour.--Rupture of the cord.--Treatment.--Connexion of
precipitate labour with mania._
The second division of Dystocia comprises those species of labour where it
becomes dangerous for the mother or child, without obstruction to its
progress. Of these we shall first consider precipitate or too rapid
labour, not only because it is liable to be followed by a great variety of
injurious results, but also because it has received little or no notice by
the obstetric authors of this country.
Precipitate labour depends on one of two conditions; either the expelling
powers exceed their ordinary degree of activity, or the resistance to the
passage of the child is less than usual. "Every normal labour has a
certain course, which is neither too slow nor too quick. The passages are
thus dilated gradually and without excessive suffering; the uterus is felt
alternately hard and soft; and the pains have certain and regular
intervals, which become very gradually shorter, during which both mother
and child are enabled to recover themselves." (Wigand, _Geburt des
Menschen_, vol. i. p. 68.)
_Violent uterine action._ In the present case the pains are extremely
violent from the very commencement of the labour; they produce great
suffering; each pain lasts a considerable time, and the intervals between
them are very short. During their presence, the patient is irresistibly
compelled to bear down and strain with all her force; the whole body
partakes of the general excitement: the patient is more restless and less
manageable than usual, her manner is altered and becomes strange; the head
is hot, the face flushed, and the pulse quick and full.
In some cases the intervals between the pains are scarcely perceptible,
for one pain has scarcely left off before the next has already commenced;
or the uterus falls into a state of continued violent contraction, which
does not cease until the child is driven into the world. The abdomen is
very hard during the pain, the whole body stiff and rigid; the patient
expresses her sufferings very loudly, or actually raves with pain. From
the constant and irresistible effort to strain, it seems as if she has
scarcely time to get her breath, for she continues to hold it so long that
respiration might be almost supposed to have stopped altogether. "As long
as consciousness remains, the impulse to lay hold of any object within
reach and pull by it is extraordinarily strong, until at length, in the
midst of a violent scream, or grinding of the teeth, covered with sweat
and with simultaneous evacuation of the rectum and bladder, she is
suddenly delivered." (Wigand, _op. cit._ vol. i. p. 71.)
_Causes._ This storm of uncontrollable uterine action "appears to depend
upon an unusually powerful influence of the nervous system upon the
contractile fibres of the uterus or upon a morbid degree of irritability."
(_Ibid._) In some cases it appears as an individual peculiarity, every
successive labour of the patient being remarkable for its violence and
rapidity. Precipitate labours of this kind are frequently observed to be
hereditary, and like an opposite and equally faulty condition of the
expelling powers, viz. slow and lingering uterine action, are sometimes
peculiar to certain families, the mother and the sisters of the patient
having had all their labours peculiarly rapid and violent.
The character of the catamenial periods before pregnancy is frequently
observed to bear a considerable relation to that of the labours in the
same individual; thus, if she has always suffered much pain and other
symptoms of uterine excitement just before or during these times, so much
so as even to require slight medical treatment to allay the periodical
suffering, the uterus almost invariably manifests a similar degree of
energy and irritability during labour. On the other hand, where the
menstrual periods produce so little suffering or derangement that, but for
the appearance of the discharge itself, the patient has scarcely any means
of determining their recurrence, the uterus betrays a similar want of
activity when labour comes on, which may therefore, _cæteris paribus_, be
expected to be slow and lingering.
Mental affections, which we have already shown to be capable of retarding
labour, occasionally have the opposite effect, and rouse the uterus to
violent action. It is well known that the dread of the forceps, which the
practitioner has declared would be required, has frequently been followed
by so much activity of the uterus as to render its application
unnecessary.
Where the patient is stout, robust, and plethoric, or of a nervous
hysterical habit, this state of unruly uterine action is frequently
attended with great cerebral excitement; during the pains she raves
wildly, and for some time becomes quite unmanageable, or in other cases
this state passes into actual convulsions.
In febrile diseases, especially of the eruptive kind, the labour is
usually of this character; the exertions of the uterus in such cases,
especially in scarlet fever, are sometimes quite extraordinary, so that
the child seems to be born without any effort on the part of the mother.
This is of great importance in inflammation of the lungs, &c. where the
patient would be unable to inflate the lungs to that extent which is
necessary for any violent efforts.
_Deficient resistance._ Where the rapidity of the labour arises from want
of that degree of resistance to the expelling powers which is natural, it
may depend on circumstances connected with the mother or the child; thus,
it may arise from too large a pelvis; the head, covered by the inferior
portion of the uterus, is forced down deeper into the pelvis than usual,
especially if, as is not unfrequently the case, this state be accompanied
with violent and powerful pains; the head may thus be actually forced
through the os externum before it has passed the os uteri: cases have been
recorded where nearly the whole uterus, has been thus protruded. In an
"extraordinary case," as Deventer justly terms it, "the head of the child
had passed the os externum as far as the shoulders, and only the summit of
it was visible, three-quarters at least of the head being still enclosed
in the uterus, although the head and neck had already passed." (_Novum
Lumen_, part. ii. chap. 3.)
In other cases the sudden expulsion of the child appears to depend merely
upon the great dilatability of the soft parts, and may occur quite
independently of any disease. We recollect a case of this sort where the
patient, a healthy woman, had only two pains--the first awoke her out of a
sound sleep and ruptured the membranes, the next drove the child with
great violence into the bed. Where the patient is weakened by previous
disease, and the soft parts are very relaxed and flaccid, they produce no
resistance to the advance of the head: this condition is very
unfavourable, "as it implies a greater state of relaxation, or want of
tone, than is compatible with the welfare of the patient: hence it is
seldom found to take place except when the unfortunate subject is sinking
under the last stage of debility, as in phthisis," &c. (Power's
_Midwifery_, p. 138.)
The want of due resistance to the expelling powers may depend upon the
size and hardness of the head; it is either smaller than usual, from the
child being premature, or, if of the full size, the cranial bones are
imperfectly ossified, the sutures are wide, the fontanelles large, and the
whole head very yielding and soft; or it may depend on some congenital
defect, in which the brain and cranial coverings are more or less
imperfect.
In the ordinary cases of precipitate labour the case depends generally on
a complication of violent pains, wide pelvis, and small child.
_Effects of precipitate labour._ Besides the mischief which may result
from the rapid expulsion of the child causing prolapsus uteri, laceration
of the vagina, perineum, and hæmorrhage from inertia coming on in
consequence of the uterus being so suddenly emptied, dangerous syncope,
or even asphyxia, may follow from the shock which the nervous system has
sustained, or in consequence of the sudden removal of that degree of
pressure which the gravid uterus had exerted upon the abdominal
circulation during pregnancy. Where the patient has been very unruly, and
has exerted herself with great violence, "emphysema of the face and neck
(says Dr. Reid) may suddenly occur during labour, and cause great alarm to
a young practitioner, as it alters and disfigures the countenance in an
extraordinary manner. Great straining or screaming may produce it, and it
probably depends on some partial rupture of the lining membrane of the
larynx. I have seen two or three cases of this description, and one which
occurred to a great extent in the case of an out-patient of the General
Lying-in Hospital, in whom this tumefaction spread to the shoulders and
chest." (_Manual of Pract. Midwifery_, by James Reid, M. D. p. 231.)
The _child_ also may suffer from a precipitate labour, where the pains are
excessively violent and run into each other, so that the whole labour is
effected during one continued storm of uterine action. If the membranes
have given way at an early period, so that the body of the child is
exposed to the immediate pressure of the pains, the abdominal circulation
suffers, and the child is destroyed in the same way as by pressure on the
cord itself; or it may be suddenly dashed upon the floor before the mother
has had time to reach her bed, or even put herself in a recumbent posture
upon the floor: in this way it may receive a severe injury upon the head,
or the cord may be lacerated, and the child die from hæmorrhage before
assistance can arrive: such accidents, however, are not so dangerous to
the child as have been supposed, a fact which has been proved by
medico-legal investigations. The direction of the pelvic outlet and vagina
is such as to expel the child obliquely downwards and forwards when the
mother is in the upright posture, so that the force of the blow is in a
great measure broken by this circumstance; the head also, as well as the
other parts of the body, are soft and yielding, and nearly preclude the
chances of injury taking place; the violence of the fall is generally
diminished in some measure by the patient being almost always compelled to
drop upon her knees at the moment of great suffering, whilst the child is
passing; her clothes also surround it more or less, and thus shield it
from any severe injury.
_Rupture of the cord._ The cord is liable to be torn in these cases,
showing that a considerable jerk had been applied to it, but neither the
child nor its mother have suffered from it. Ten or twelve cases of
ruptured cord have come to our own immediate knowledge, and in none of
them were any unfavourable effects produced. It can scarcely be imagined
possible that so much force could be applied to the cord, at the moment
when the uterus is so suddenly evacuated, without inversion or prolapsus
being the almost unavoidable result, the more so when we recollect that
the cord at the moment of birth requires considerable force to break it.
This circumstance may be partly attributed to the firmness with which the
uterus contracts at the moment that the child is expelled, but chiefly to
the fact that the axis of the brim is nearly at right angles with that of
the outlet, more especially if the fundus, as is usually the case, is
inclined somewhat forwards; the cord passes round the posterior part of
the symphysis pubis as upon a pulley, so that a considerable portion of
the force which is applied to it, is spent here before reaching the fundus
uteri. It is however remarkable, that the umbilicus of the child should
receive no injury from a jerk which breaks the cord, when, if we try
afterwards to break the remaining pieces of the cord, we find that it will
resist very powerful efforts: this fact, and the circumstance that the
cord usually ruptures at about two or three inches from the umbilicus, as
in some animals, seems to imply that this part is weaker than elsewhere,
as if intended by nature to give way with a moderate degree of force.
Wigand considers that patients are particularly disposed to have quick
labours, who are of a scrofulous, rheumatic, or arthritic diathesis; that
such patients are very liable to have adhesion of the placenta after the
birth of the child, with hour-glass contraction: the observation, however,
has not been confirmed by the experience of others, and certainly not by
the cases which have come under our own notice.
_Treatment._ Where, from the smallness of the child or unusual size of the
pelvis, the pains are forcing the lower portion of the uterus down to, or
through, the os externum, it will be necessary to support it carefully,
until the os uteri is sufficiently dilated to let the head pass. A case of
this kind occurred to Professor Naegelé, of Heidelberg, where, during the
patient's former labour, the pains had been so violent, and the uterus had
been detruded to such an extent, that actually the lower half of it
appeared between the labia: to prevent a similar accident occurring this
time, (as the pains were beginning to show the same disposition to violent
action as before,) he applied a broad T bandage very firmly upon her,
coming over the os externum, so as to prevent the uterus being prolapsed
beyond the labia; he cut a hole in it corresponding to the vagina, and the
child was born through this with perfect safety to the mother.
Where we have sufficient warning, opium in effective doses will probably
assist in lulling the irritability of the uterus: if the bowels have been
previously well opened, an opiate enema will be desirable; if not, a large
emollient enema should be premised.
The patient should be made to lie upon her side, and not only strictly
forbidden to resist to her very utmost, the urgent impulse which she feels
to strain and bear down, but must carefully avoid even holding by or
pushing against any fixed body with her hands or feet. Still farther, to
quiet the turbulence of the abdominal muscles, a broad bandage should be
fastened firmly round the abdomen; it not only gives the patient a
comfortable feeling of support, but tends greatly to calm the spasmodic
irritability of these muscles. These precautions will be of so much more
service if they can be used early, as in cases where we have been already
warned by the character of her previous labours: we can thus avoid the
premature rupture of the membranes, which is a thing by all means to be
avoided; the uterus acts with increased power where its bulk has been
diminished by the escape of the liquor amnii, and at the same time becomes
still more irritable and unruly from contracting immediately upon the
child; and not only is there imminent danger of its giving way in some
part, but the child is almost inevitably destroyed by the violence of the
pressure to which it is exposed.
In cases where the vehemence of the expelling powers appears to be quite
beyond our control, Wigand has recommended a copious bleeding to complete
syncope as the only means; in which suggestion, he has been followed by
Froreip: neither of these authors, however, appear to have had any
experience of this mode of treatment, and knowing how much more active the
uterus becomes after a smart bleeding in ordinary cases, and how
powerfully the state of syncope promotes the dilatability of the soft
parts, we should hesitate exceedingly to employ so doubtful a remedy.
Wigand also proposes, in cases of this desperate nature, to use effusion
with ice-cold water to the abdomen and lower extremities, and by this
powerful species of counter-irritation, produce a temporary calm for a few
minutes--a measure we should fear of as doubtful a character as bleeding.
_Connexion of precipitate labour with mania._ Lastly, we may observe, that
the subject of precipitate labour involves a medico-legal question of
great importance and interest, which has as yet excited little or no
notice in this country, viz. as regards acts of child-murder after labours
of this character. The state of mental excitement and frenzy into which a
patient is brought, by a labour of such violence and suffering, in many
cases falls little short of actual mania. We now and then meet with
instances, where, for the first half hour or so after a severe and rapid
labour, the patient takes a most insurmountable antipathy to her child,
and expresses herself towards it in so unnatural a manner, as to contrast
strangely with the tender and affectionate feelings which she had a short
time previously expressed for it. Cases have occurred where the patient
has been without assistance, during labour, and where, in a state of
temporary madness from mental excitement and pain at the moment of the
child's birth, she has committed an act of violence upon it, which has
proved fatal; a circumstance, which, from obvious reasons, would be more
liable to occur with single than with married women. These cases have been
very carefully investigated in Germany of late, and in many of them the
patient has been, we think, very properly acquitted, on the grounds of
temporary insanity, having herself voluntarily confessed the act with the
deepest remorse, at the same time declaring her utter incapacity to
account for the wild and savage fury which seized her at the moment of
delivery.