MECHANISM OF DELIVERY IN PRESENTATIONS OF THE TRUNK.
It has already been stated that in presentations of the Trunk it is
nearly always the right or left shoulder which occupies the passage. It
is stated, by some authors, that they have felt the back, and abdomen,
but others think they were mistaken; and most certainly such positions
are extremely rare, if they actually do ever exist.
There are two presentations of the Trunk, determined by the side on
which the fœtus lies, and denominated accordingly _right_ or _left
lateral presentations_.
Each of these presentations has two corresponding positions, determined
by the side on which the child's head lies. If the head be on the
mother's right side it is called the _right cephalo iliac position_,
and if it be on the left side it is denominated the _left cephalo
iliac position_. The mechanism of spontaneous delivery is the same in
them both, and in all their varieties, and so is the mode of rendering
assistance, so that a description of one will suffice.
Sometimes, when the labor has lasted long without assistance, one arm
will be forced down first, and even appear externally. This used to
be considered a separate presentation, and described as such, under
the name of _presentation of the hand and arm_. There is no reason for
describing it separately however, and no utility in doing so, as it
differs in no essential particular from ordinary presentation of the
shoulders, and must receive the same assistance.
What it is that produces presentations of the Trunk, and other
unfavorable parts, is not known, though they are generally thought to
be owing to excessive motion in the child, or obliquities of the Womb.
M. Lachapelle met with _sixty-eight_ cases of Trunk presentation in
_fifteen thousand six hundred and fifty-two labors_, which is nearly
the same as the face. The right side presents more frequently than the
left, and the head is on the left side oftener than on the right, as it
is in ordinary head presentations.
As a general rule assistance is always rendered in presentations of
the Trunk, and is generally considered absolutely necessary. It is
undoubtedly true however, that nature has effected delivery in such
cases unaided, though rarely, and such instances are considered as
extremely fortunate exceptions to the general rule. M. Chailly says
that the accoucheur should never leave such cases to nature alone, but
always aid her; but other authors trust to her a little more. The most
usual mode of rendering assistance is to _turn the child_, and bring
down the feet, a manœuvre which will be fully described hereafter.
In some cases the child turns itself, from the contractions of the
Womb, before it enters the upper strait; and in other cases, when very
small, or long dead, it will pass folded double. This self-turning
however, cannot take place after the escape of the waters, so that it
seldom occurs when the membranes are broken.
MECHANISM OF DELIVERY IN PRESENTATIONS OF THE TRUNK BY SPONTANEOUS
EVOLUTION.
This is the most usual mode for the fœtus to escape, in each
presentation, and in every position. By referring to the following
Plates, and the accompanying descriptions, it will be readily
understood.
[Illustration: PLATE XXXV.
_Position of the Fœtus in a presentation of the right shoulder, and in
the left cephalo iliac position._]
Previous to the rupture of the membranes the child's body lies
_across_, as formerly explained; but immediately after the rupture the
shoulders descend into the Pelvis, as seen in the above Plate, while
the head remains above the pubes; the arm frequently, but not always,
protruding externally.
The shoulder then continues to descend, the body following, bent up
against the face, as seen in Plate XXXVI.
[Illustration: PLATE XXXVI.
_Descent of the shoulder in a Trunk presentation, at a more advanced
period._]
Here the shoulder is protruded from the Vulva, the back being nearly
folded, and the knees turned up against the face.
[Illustration: PLATE XXXVII.
_Descent of the shoulder and trunk at a still later period._]
The whole Trunk is now fully delivered, folded almost double, and the
legs and feet are turned up against the face. They speedily follow
however, and then nothing is left but the head, and perhaps one or both
arms, placed against the sides of it, as shown in Plate XXXVIII.
[Illustration: PLATE XXXVIII.
_The Trunk has fully descended, and only the head is left, with one
arm._]
The arm is generally very easily brought down, or it may remain and
come with the head. The delivery of the head is effected the same
as in presentations of the pelvis, and is seldom attended with much
difficulty, the parts having been so much distended. The body always
rotates so that the back comes in front, and the chin passes into the
curve of the Sacrum.
This is the way in which the delivery is effected by nature in such
cases, and it will readily be conceived how dangerous it is to both
mother and child, and how seldom it can be accomplished. If the Fœtus
be of a full size, and the mother's pelvis no larger than ordinary,
it is almost impossible for this spontaneous evolution to take place;
and even when it does, it is with the greatest difficulty, the mother
suffering in an extreme degree, and running great risk, not only of the
most serious after results, but even of death. To the child the danger
is equally great, owing to the severe and long-continued compression
it receives, and the unnatural position it assumes. M. Velpeau tells
us that in _one hundred and thirty-seven_ such cases, _one hundred and
twenty-five_ of the children died. The number of the mothers also,
who either died or were made sufferers all their future lives, was
undoubtedly great, though unknown.
It is evident therefore, that presentations of the Trunk are the most
unfavorable known, and labor in them is but rarely spontaneous. Nature
can but very seldom effect the delivery of the Fœtus herself, and even
when she does it is with the greatest risk, both to it and the mother.
The accoucheur should _always_ assist therefore, if he can, because
even if nature can complete the delivery it is with such danger. The
means of assisting, by turning, will be described in another Chapter.
If the fœtus is not at full term, and of course is under the full size,
its expulsion may be left to nature safely, but not otherwise.
SECTION V.
THE PHYSIOLOGY OF SPONTANEOUS DELIVERY, OR CHILDBIRTH, AND THE MANNER
OF CONDUCTING A NATURAL LABOR.
Having now completed the description of the _Mechanism of Delivery_, in
all the various presentations and positions, it is necessary to explain
the physiological phenomena attending a natural labor, and the duties
of the accoucheur when conducting it, and to show what assistance he
can render, and when he should or should not interfere.
CHAPTER XV.
OF DELIVERY IN GENERAL.
DIFFERENT KINDS OF DELIVERY.
When the child is brought into the world by the unaided efforts of
nature, and without any accident to itself or the mother, it is called
a _Natural Delivery_. When it occurs by the efforts of nature alone,
but not advantageously for both, it is not called natural, but simply
_Spontaneous Delivery_. And when assistance is required it is called an
_Artificial_, or _difficult Delivery_. It is also called _precocious_,
or _tardy_, according as it comes before or after the full term.
CAUSES OF LABOR.
What it is that causes labor to commence, and proceed, is not fully
known. At the proper time the Uterus prepares to cast out the fœtus it
has so long retained, in the same manner that the tree casts off its
fruit, and from some efficient cause which we have not yet discovered.
It is probable that, when the fœtus attains a certain size, it presses
upon the nerves of the neck of the Uterus and irritates them, and
they react again upon the muscular fibres of the Womb and cause them
to contract, and so expel its contents. This is much the same action,
in fact, as vomiting. When any body very repugnant to the stomach
is swallowed, it irritates the nerves of that organ, and then they
excite its muscular fibres, which, by forcible contractions, expel the
offender.
It is possible, also, that the fœtus itself may instinctively assist in
bringing about its own delivery, as was supposed of old by Hippocrates,
and more lately by Harvey and others. It is certain that labor is both
more difficult, and more dangerous, when the child is dead; though it
may take place as usual after the death of the mother, providing the
child be still alive. Several instances of this kind have been known,
when the living child was expelled from the Womb, by the natural
process, sometime after the mother had ceased to breathe.
The contraction of the muscular fibres of the Womb however, must be
regarded as the immediate or efficient cause of fœtal expulsion, let
them be brought on how they may. The muscles of the Abdomen, and the
diaphragm, also assist, in the last stage, but are not essential.
The young of some of the lower animals are observed to perform certain
peculiar motions, during delivery, by which it is much facilitated;
and this is considered a proof, by some, that voluntary movements of
the fœtus assist in the process. Certainly if it be supposed, as we
have shown there is good grounds for doing, that the child assists in
placing itself in the best _position_, it is equally probable that it
also assists in its own expulsion, in other ways.
SIGNS OF DELIVERY.
_Premonitory Signs._--A few days before delivery the Uterus descends
much lower, so that the diaphragm and stomach are less pressed upon,
and the breathing and digestion becomes easier in consequence. The
ease which is thus experienced is sometimes so great that the female
becomes unusually animated and cheerful, and cannot think she is so
near her travail. This is not always the case however, for some on
the contrary feel very uncomfortable and melancholy. The lips of the
Vulva are also apt to swell and become painful, and the lower limbs
numbed and cramped, owing to the child's head pressing on the large
nerves. The neck of the bladder is also very liable to be compressed,
so that a constant desire is felt to urinate, and a similar trouble may
also be experienced in the Rectum. Most of these inconveniences, but
particularly the numbness and cramps in the limbs, are not likely to be
experienced except when the head presents, because no other part is so
formed as to be able to descend sufficiently low; when they are felt
therefore, the female may console herself by the reflection that they
indicate, with tolerable certainty, that the child is presenting in the
best position it can for a safe and speedy delivery.
Standing, or walking, usually become more difficult, and swelling of
the external parts, or piles, are apt to occur. With some females also,
a sudden diarrhœa, or vomiting, takes place, and troubles them up to
the period when labor commences.
Finally the Uterus begins to contract, though insensibly at first;
the Abdomen becomes unusually hard, and flying pains are experienced,
particularly with first children. This continues with more or less
of intermission, up to the actual period of labor, which is usually
divided into _three_ periods, each of which must be considered
separately.
CHAPTER XVI.
THE PROGRESS, PHENOMENA, AND DURATION OF NATURAL LABOR.
FIRST PERIOD.
On making 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:--
[Illustration: PLATE XXXVIII.--_a._
Fig. 1. Fig. 2.
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.
SECOND PERIOD.
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
natural efforts 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 delivery_ comprises 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 have just explained, and is attended with
similar phenomena, yet still we occasionally see marked exceptions.
This is particularly the case with regard to _pain_. 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 increase of 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 it _grinding_, _cutting_, and _burning_
pain. 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 the _false waters_, or
_shows_, and is not connected with the true waters at all.
The _general_ physiological phenomena of a natural delivery having thus
been explained, we have now to state its duration, and then proceed to
its conduct or management.
DURATION OF NATURAL LABOR.
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 can be 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, is _from 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 any _time_, and no well informed patient would _ask_ him to do
so, because she would know that it was out of his power.
CHAPTER XVII.
THE CONDUCT OR MANAGEMENT OF A NATURAL LABOR.
PRELIMINARY REQUISITES.
In most cases of natural labor there is not much assistance needed.
The assistant should, however, possess a certain _tact_, or _manner_,
calculated to make a favorable impression on the patient. This is
especially needed _when a man officiates_. It must be recollected,
that the situation of the female at such times is a very peculiar one,
and that the presence of one of the other sex, however necessary, must
be more or less objectionable to her. He should, therefore, carefully
exhibit in his behavior the most refined delicacy, combined with a
warm sympathy and kind consideration; thus soothing her scruples and
enlisting her gratitude. He must also appear perfectly self-possessed
under all circumstances, and then she will have full confidence in
his skill and judgment. It may seem scarcely necessary to state
these things, but I have often known men officiate without such
qualifications, and also be perfectly unaware of their deficiencies.
Such accoucheurs never officiate well; they may be skillful and
attentive, but yet unsuccessful, and unappreciated. They are only
_tolerated_, but not respected, and are never fully confided in.
When requested to see a woman supposed to be in labor, it is always
advisable to be prompt in paying the visit, because delivery sometimes
comes on suddenly and unexpectedly, and both mother and child may be
in great danger if no one is near to assist.
Some time before the event is expected, it is advisable to provide
certain articles, which will or may be needed at the time, and which
should not have to be looked for at the last moment. A pair of sharp
scissors, with a piece of strong thread or cord, are indispensable, and
a female catheter may be needed. A quill with the feather part on, may
also be useful; and some pure lard or sweet oil is frequently called
for. The professional accoucheur will also find it a good precaution
to have his stethoscope in his pocket, and a lancet, if he ever relies
upon bleeding in any contingency. A small box of extract of Belladonna
also, may often be of great and immediate service.
PRELIMINARY PROCEEDINGS.
The first thing required when visiting the patient, is of course
to ascertain positively whether she be pregnant, and whether labor
is really commenced, and if so how far it has progressed. This
necessitates an examination, the proposal and making of which require
the most delicate tact, particularly if it be with a comparative
stranger, or in a first labor. No allusion to it should be made to the
patient herself by the assistant; he should converse with _her_ about
indifferent matters, or merely upon her health, and state his wishes to
the _nurse_ or female friend, and then retire. This gives them time to
inform her of what is required, and to make the necessary preparation.
On entering the room again, he should not proceed abruptly, but resume
the conversation, and make some of the necessary arrangements while
carrying it on. He should seat himself by the side of the bed, with
his right hand next her, and his face opposite hers. Then passing
his hand under the bed clothes, after having lubricated it with lard
or oil, he can proceed with the examination as if it were a simple
ordinary proceeding. By exhibiting no hurry, and appearing to think it
nothing unusual or in any way strange, the female herself will cease to
think it so, and will not be flurried or shocked.
The hand must be passed under the female's right thigh, her knees being
elevated. She should, of course, lie on her back, and as near to the
edge of the bed as convenient. Not the slightest exposure is necessary,
nor allowable under ordinary circumstances.
The fore-finger being introduced, _ballotment_ may be practised, to
ascertain if pregnancy really exists; and if the evidence from this
source is not sufficient, auscultation must be resorted to. After
being satisfied on this point, the mouth of the womb must be carefully
examined, and its degree of dilatation noticed. If the female has
pains, their character and frequency must also be noticed, and the
effects they produce on the parts. It will generally be possible by
these means, to discover how far the labor has progressed, and even
to form an opinion how long it is likely to last. The general form of
the parts and their size, should also be noticed; particularly of the
pelvis, so that any deformity or deficiency may be discovered. And
lastly, the _presentation_ should be ascertained, if possible, so that
it may be known in time whether nature will be sufficient herself or
will require helping. The _position_ need not be cared for at present,
because it is of little consequence when the presentation is favorable.
The time required to make the examination need not be long, and should
always be as short as possible.
While conversing with the patient, much useful information may be
gained. The general state of her health, the nature of her pains, and
the time they first commenced, should all be known; and if she has
had children before, it will be highly useful to know what kind of a
labor she had; whether it was long or short, easy or difficult, and
particularly if attended with any accident likely to occur again.
It need scarcely be remarked that great caution is needed in these
cases, many eminent men having been deceived as to the patient's
condition, as already stated in our chapter on the signs of pregnancy.
And many times the doctor has been summoned under the supposition that
labor had begun, while it was yet far off. The pains may be false ones,
such as frequently occur towards the end of pregnancy, and may all
pass away. These false pains, however, can usually be distinguished,
being continuous and irregular, while the true ones intermit with
periods of almost perfect ease, and are tolerably regular. The false
pains are also felt in various parts, while the true ones are chiefly
fixed in the uterus and vagina. Sometimes, however, the difficulty
in distinguishing them is very great, and the accoucheur has often
waited for several hours and even days; the labor meanwhile making
no progress; and eventually all has passed off, and the patient has
risen again from her bed. I know one case, where a gentleman attended
nearly _three days_, at the end of which time the patient _rose and
walked down stairs_. She was not put to bed till _six weeks after_.
I can scarcely think, however, that these mistakes can happen very
frequently, if the examination be properly conducted.
PREPARATIONS FOR THE DELIVERY.
If it appears from the examination that labor has really commenced, or
is about to do so, everything should be at once prepared. All useless
persons should leave the room, and also those who would be likely to
alarm or grieve the patient by uttering cries, or exhibiting fear; but
no objection should be made to any one being present whom she wishes
to see, unless they cannot be depended upon. Thus some females always
wish to have their husbands with them, but others do not, though they
are averse to saying so. In these cases the accoucheur, if he be
an attentive observer, will soon see what is really desired by his
patient, and will manage matters accordingly.
The dress of the female should be perfectly loose, consisting of a
wrapper or night-gown, but sufficiently complete and warm to allow
of her getting up to walk in the chamber, if she desires it, as some
do. No corsets, garters, or other tight bandages, however, should be
allowed.
The bed should be prepared by placing the mattress on the top, or by
removing all from it; and then placing a thick layer of blankets or
quilts, with a folded sheet over them. This is to provide a firm level
surface, in which the body will not sink, and also to prevent the
fluids soaking through. It is an excellent plan, if the material can
be obtained, to place a thin oil-skin or India-rubber cloth under the
folded sheets, as this keeps all perfectly dry underneath. Some persons
also place another folded sheet, or a cushion, under the pelvis, to
keep it elevated; but this is not necessary, unless the bed sinks in
very much. It is also advisable to leave a foot-board or other firm
body, against which the female can press her feet when bearing down;
and a long towel folded lengthways should be passed under the back, so
that it can be raised up by a person lifting at each end. This will
often be found a better mode of _pressing the back_, which nearly all
patients call for, than by merely forcing the hand against it, which is
both tiresome and insufficient. Another towel may also be firmly fixed
to the bottom of the bed, so that she can _pull_ by it, at the same
time that she pushes with her feet.
Some persons are confined on a cot, but this is not a very good
arrangement, because it sinks in too much in the middle, and is not
sufficiently large and firm. It is advantageous in one respect,
however, as it can be placed by the side of the bed, into which the
patient can be lifted when all is over, and be comparatively dry and
comfortable. This is the most frequent plan in France. If the bed be
properly arranged however, the under sheet can be withdrawn, and clean
warm napkins then passed under the body, which will be equally as good.
The covering should consist of a sheet, with blanket or coverlid,
according to temperature, and should, of course, never be removed,
except under peculiar circumstances.
The chamber itself should be as quiet as possible, _well ventilated_,
and not too warm. Nothing distresses the patient more than a close, hot
atmosphere.
The accoucheur need not, of course, be present while these arrangements
are being made; and when he retires he should suggest to the nurse that
the female may attend to the bowels and bladder during his absence.
This precaution may both facilitate the labor, and prevent much future
annoyance. It would even be advisable to administer an injection if
necessary, of thin starch and a little castor oil, rather than leave
the bowels unmoved.
In regard to nourishment, nothing is needed or proper in the shape of
solid food; because all the energies of the system are concentrated
in the uterus, and as digestion cannot therefore go on, it would only
be an evil. If the labor is much protracted however, some broth or
soup may be taken, or a little milk. As a general rule, no spirituous
liquors or stimulating drinks of any kind should be taken; because they
impart no real strength, and may produce inflammation, or congestion on
the brain. Some females always prefer tea to drink, others lemonade,
toast water, gruel, or barley water, and others again simple cold
water, which is perhaps the best of all. In cases of great exhaustion
it is sometimes advisable, and even necessary, to give a little wine,
or brandy and water, but it should always be cautiously administered.
In some parts it is customary for the female to lie on her side during
delivery, with a pillow between the knees; some even choose this mode,
and others will desire to stand, or place themselves on their knees.
The most frequent position however, and certainly the most convenient,
is on the back, though it may often be changed with advantage under
peculiar circumstances. In the early stages of labor she can lie, or
move about, as she chooses, or even rise if more agreeable.
ATTENDANCE AFTER THE PREPARATIONS ARE MADE, AND DURING THE DELIVERY.
When everything is arranged the assistant should take his seat on the
right hand of his patient and repeat the examination. If the head
presents, he need not concern himself much further at present, but
if it be any other part, he should prepare at once to change it, or
assist, as the case may be. At this second examination the parties
present, and the female herself are usually anxious to know if the
child is _coming right_, and how long the labor is likely to last. The
answer to these inquiries should be guarded and circumspect in regard
to the duration, because of its uncertainty, but if the presentation
is right, it is well to say so at once, because this gives great
comfort and encouragement. If it be unfortunately wrong, it is best not
to say so abruptly, but remark that it is rather obscure, or cannot
yet be fully distinguished, and so keep up the spirits of the female
while you await the proper time, or make the necessary arrangements,
to interfere; and then tell her there is a little difficulty which
requires to be righted, but which will not be serious, nor cause much
delay.
If the labor steadily progresses it is necessary to remain with the
female and attend to it; but if it be delayed, and everything remains
natural, she may be left for a time with advantage. When the second
stage is fairly commenced however, and especially after the membranes
are broken, the attention should be unremitting. The state of the parts
should be ascertained frequently, so that the actual progress may be
known, and any necessary assistance rendered. The state of the bladder
especially should be observed, and if it be full and the female unable
to urinate, the catheter should be passed. Neglect of this precaution
may lead to serious accidents. While making the examinations, the hand
should be introduced with great care, so as not to bruise or lacerate
the parts, and it should not remain longer than absolutely necessary.
Many females exhaust themselves unnecessarily by bearing down, and
straining, with great force, from the very commencement of labor,
under the mistaken idea that it is necessary to do so, or will assist.
They should be told not to do so however, till after the membranes are
broken, and not even then unless the neck of the womb begins to dilate.
They should also be told not to make any effort except _during a pain_,
as it will not assist at any other time.
No attempt should be made, under ordinary circumstances, to rupture the
membranes, or dilate the mouth of the womb, even though nature may be
slow in doing so. Patience must be practised, both by the female and by
her assistant, and sometimes it is severely tried.
When the waters have escaped, and the orifice is opened, an examination
must be made, to discover whether the cord has descended, or either of
the arms, as is sometimes the case, and if so, they must be returned if
possible.
As the head descends to the bottom of the pelvis it compresses the
rectum, and produces a feeling as if the bowels must be moved, or even
causes them to be so. This is apt to distress the female, and make her
wish to rise, which cannot be permitted. If anything of the kind occurs
no notice should be taken of it, or she may even be assured she is
mistaken, while a clean napkin may be interposed. This, as Dr. Chailly
observes, will soothe her delicacy. Such an accident is very apt to
occur towards the end of the labor.
When the head has rotated, and presents at the external opening, or
vulva, and begins to distend it, the greatest care is required. This
is a critical period, during which the accoucheur can render more real
assistance than at almost any other. There is danger at this time, as
formerly explained, of the head passing through too quickly, before
the parts are sufficiently relaxed, and so causing them to rupture.
This is particularly the case with the perineum, against which the head
presses with great force. It is necessary therefore to _support the
perineum_, as it is termed, to prevent this accident. This is done by
passing the right arm under the patient's right thigh, and placing the
palm of the hand flat against the perineum, with the thumb encircling
one side of the vulva, and the forefinger the other. The hand is then
gently, but firmly, pressed against the part during every pain, so as
to prevent the head passing too quickly, and also to _elevate it_, and
thus relieve the perineum of part of the strain, and throw the occiput
under the pubes.
Some practitioners also pass the left hand over the thigh, at the same
time, and grasp the back of the head with it, thus holding the head as
it were between the two hands, so as to direct it at pleasure.
The manner of doing this is represented in plate XXXIX.
PLATE XXXIX.
The manner of supporting the perineum, during the passage of the head.
The right hand is placed underneath, so as to push the head gently
back, when it presses on the perineum too forcibly, before it is
dilated; and also to elevate it towards the pubes.
The left hand is seen above, grasping the top of the head, to assist.
This may be done or not, according to the necessities of the case, or
the custom of the assistant.
[Illustration: Plate XXXIX.
The manner of supporting the perineum, during the passage of the
head.]
It is also necessary to request the female at this time to moderate her
efforts, and not bear down too strongly. If however she be too excited,
and eager to do so, more care must be used, and the head pressed back
still more forcibly, till the parts are fully relaxed. For want of
these precautions there is often serious lacerations of the perineum
and vulva, particularly in first labors, and when the parts are
unusually rigid. If proper care be bestowed however, these accidents
ought to occur but seldom, even in the worst cases, and nothing can
be more hurtful to the reputation of an accoucheur than for them to
happen. Sometimes it is necessary to support the perineum for hours,
and to bestow constant attention the whole time. It is often useful
to keep applying a little simple ointment, or lard, in the intervals
of the pains, mixed with the extract of Belladonna, which will soften
and relax the parts. Dr. Lee also advises the application of a sponge,
dipped in warm water, and which would probably do much good in many
cases.
It will of course be understood that the pressure only needs to be
made _during the pains_; when the head draws back the ointment or warm
sponge may be applied. The knees of the female should be held up by
some one, if she bears down too much, so as to prevent her from doing
so too powerfully.
When it is felt that the parts are fully relaxed, and sufficiently
distended, the head is left at liberty, during a strong pain, and it
immediately passes the outer ring, or is born.
It should then be held up, towards the pubes, and the mucus should be
cleaned from the mouth with one of the fingers, so that the child may
breathe. A careful examination should also be made round the neck,
to see if the umbilical cord is around it. If it be so, but is not
tight, it may be left alone, or pulled a little over one shoulder, or
even passed clean over the head, if it can be _easily_ drawn out long
enough. When it is very tight, and cannot be eased, it must be cut
through, or it will strangle the child.
In most cases the shoulders follow immediately after the head, the
uterus resting only a few moments; but if they do not the head may
be _slightly_ drawn upon, or the fore-finger of the right hand may
be linked under the arm, and a _little_ force employed, though very
carefully. It is better however to wait even two or three minutes, and
only resort to these means when there is evidently a partial suspension
of the natural efforts. Sometimes also the contractions may be brought
on again by merely pressing the hand over the fundus of the uterus, and
this should therefore be tried first. In all cases it being better to
let the uterus expel the child than to bring it away by manual force.
During the passage of the shoulders the perineum needs as much care as
during the passage of the head, and must be supported in the same way.
Indeed some authors are of opinion that most cases of laceration are
caused by the shoulders.
After the shoulders are expelled the limbs and body speedily follow.
The child should be received in the hands of the accoucheur, and laid
on its side, at a little distance from the vulva, so that it may not
be suffocated by the discharged fluids. He should then take a strong
ligature and pass it _twice_ round the umbilical cord, about two inches
from the navel, and also at about four inches, and then cut the cord
through, between the two bands, with a pair of sharp scissors. The
child may then be handed to the nurse.
The tying of the cord is by some deemed unnecessary, and in most cases
probably is so, but as children have been known to bleed to death,
when it was not done, it should never be neglected. Some practitioners
only tie it once, leaving that part open which is still attached to
the placenta, and they suppose this is advantageous, inasmuch as it
partly empties the placenta of its blood, and so helps to detach it.
There is little or no fear, as some suppose, that this bleeding can be
extensive enough to hurt the female, or second child if there be one,
and even if it were likely to be so it could soon be stopped; it has
the inconvenience however of soiling the bed more, and this is probably
one great reason why the second ligature is applied, which certainly is
not _necessary_.
In my directions I have said that the cord may be tied about two inches
from the abdomen, and this will be sufficient if the child breathes;
but if not it should be left about four inches long, so as to give room
to cut it again, which is occasionally needed, as will be seen further
on. The knot should be drawn very tight, and great care must be taken
never to tie it so near as to pinch the skin of the abdomen, which
passes a little distance up it. A small portion of the intestine will
enter the cord sometimes, and swell it out for an inch or more; this
must be pressed back with the thumb and finger, and carefully avoided
by the ligature. Some practitioners cut the cord first and tie it
after, but I think the other plan is decidedly the safest and the best.
After this is accomplished the accoucheur should place his hand again
over the fundus of the uterus, to discover whether it contracts, and
also to judge whether there be another fœtus. If the womb is felt
drawn up into _a hard round ball_, in the middle of the abdomen, all is
right, and no apprehension need be felt; but if it remains unaltered in
size, and is soft, _flooding_ is to be feared, and the hand should be
firmly pressed, or kneaded, over the fundus, to bring on contraction.
If there be another fœtus, the womb will remain much the same as before
labor, and the child may also be felt. It is better however to make
an examination internally, and then, in most cases, the membranes and
presenting part of the second fœtus will be found at the upper strait.
If there be any doubt after this it is even better to carry the hand
a little way into the womb, than to remain in ignorance on such an
important point. The delivery of the second fœtus usually follows close
upon the first, though sometimes there will be a delay of some hours,
or even days. And in general there is little or no difficulty with the
second, owing to the parts having been already prepared; but the longer
it is delayed the less easy it becomes.
Immediately the birth is fully effected the female feels, as most of
them express it, _in heaven_; there is an almost instantaneous change,
from the most agonizing pain to a state of perfect ease. She ceases
her cries, and falls into a quiet and pleasing languor, strikingly at
variance with the state of intense excitement she was in but a few
moments before. This repose however, does not last long; the Placenta
yet remains, and a new effort is required to expel that.
DELIVERY OF THE AFTER BIRTH, OR PLACENTA AND MEMBRANES.
Unlike the Fœtus the Placenta is fast to the walls of the Womb, and can
only become separated from them by the contraction of their substance,
which usually commences soon after the birth of the child, and is
indicated by new pains, and a slight discharge of blood. In about a
quarter of an hour, or twenty minutes, the accoucheur should enquire
of the patient whether she has felt any of these pains, and he should
also examine whether the Placenta has reached the mouth of the Womb, or
Vagina, so that he may remove it. If the pains have not yet come on,
and the Placenta is not in the passage, he should press one hand on
the fundus of the Womb, to promote its contraction still further, and
then gently draw upon the cord with the other, holding it as high up as
possible, either by a piece of linen around it, or by looping it around
the finger. It should be pulled very gently, but steadily, downwards
and backwards. If it be snatched, or drawn too hard, it may break,
and cause great trouble; or it may _pull down the Womb_, and either
invert it or bring on falling of the Womb afterwards. The hand placed
over the fundus can detect this accident, and if the uterus be felt to
_sink down_ the cord must not be drawn upon any longer. Pulling away
the Placenta too soon, and with rudeness, has often led to deplorable
accidents. In nearly every case it will gradually separate itself, and
be delivered in about half an hour, and should only be assisted by
_slight_ drawing on the cord, and by pressing the fundus.
When the Placenta is completely detached there is seldom any difficulty
in its passing the neck of the Womb, and down the Vagina, but it
usually requires to be drawn through the external opening by the hand.
In doing this the membranes may be twisted round the cord, so as to
wind them altogether, and strengthen the cord.
In case the separation does not take place we must wait, and continue
the slight strain on the cord and the friction over the fundus. It is
not reckoned safe however, by most authors, to wait more than an hour;
and if there is no sign of its coming by that time artificial delivery
is resorted to. This is accomplished by carrying the hand carefully
up into the Womb, and separating the Placenta from its walls with the
fingers, and then bringing it down at once.
When the afterbirth has passed the Vulva, a careful examination should
be made of it, to see that no part is left behind; and for still
greater security it is advisable to explore the Vagina thoroughly, so
that any detached portion may be removed. The membranes are very apt to
become broken, and fragments of them left, which though ever so small
may cause trouble. The finger should also be passed into the mouth of
the Womb, so as to clear it; for sometimes a large clot of blood, or a
piece of the membranes, will remain and keep it open, and thus cause
severe flooding.
It is generally considered, by those who have bestowed attention on the
subject, that assistance should always be rendered, if the afterbirth
does not come very soon. There is danger, if it be left too long, of
the mouth of the Womb contracting and retaining it; in which case it
becomes absolutely necessary to abstract it, but exceedingly difficult,
and even dangerous, to do so. Dr. Lee says it should never be left
more than _an hour_ at most, and that it is best never to delay
removing it even so long as that.
When left purposely, for observation, it is found to be expelled
spontaneously, and soon, only in a few cases; usually it remains
several hours, and most frequently it requires to be removed by hand.
No doubt it is _natural_ for it to be expelled unaided, but it must be
borne in mind that our females are usually too weak, and deficient in
energy, to perform any unusual natural function without assistance. The
accoucheur must use great caution, so as neither to intrude his help
when not required, nor yet to refuse it when really needed; and above
all he must not substitute _violence_ for _skill_.
When the afterbirth is brought away, a bandage should be passed round
the body of the female, made of soft linen, twelve or fourteen inches
wide. It should be drawn moderately tight, and fastened securely. If it
pass round twice it will be all the better, and it should be drawn down
as near the pubes as possible. I know many ladies who prefer the India
Rubber bands, recently invented, as they press more equally and firmly,
and are put on with less trouble, being all in one piece and drawn over
the feet and limbs.
Some accoucheurs put on the wrapper immediately the child is born,
before the afterbirth passes away; but I think this is not the best
plan. When properly adjusted, the supporting band gives great comfort
to the female, and is very useful.
Some ladies provide a curious kind of _corset_ to put on, invented for
the purpose, which however, as a celebrated author recently remarked,
"Are usually stiff and unyielding, like the prejudices of their
patrons, and often prove injurious." None of them are equal to the
simple contrivances above-mentioned.
ATTENTIONS TO THE FEMALE AFTER THE DELIVERY OF THE AFTERBIRTH.
When the afterbirth is removed the patient should be left to repose
herself for about a quarter of an hour, during which time most of the
blood escapes, and then she must be made as comfortable as possible.
In France, and with many persons here, it is customary to cleanse the
patient with a sponge dipped in warm water, pass a clean warm sheet
under her, and then put on clean linen, after which she is lifted into
the clean bed, previously well warmed; the accoucheur himself carrying
her there. Most frequently however, the sponging is dispensed with
till some time after, and also the changing of beds--the under sheet
merely being withdrawn, and a warm dry one passed in its place, while
the female's limbs are gently wiped. In either case the female should
be disturbed as little as possible, particularly if there be danger
of flooding, and she should be carefully guarded from cold. When the
soiled and wet clothes are removed, as completely as possible, warm
napkins should be placed under the Pelvis and between the limbs, to
soak up the discharge, and they should be carefully changed as often
as needed, without uncovering the patient. If she be disposed to sleep
however, and is much exhausted, these attentions need not be pressed
too much till she is recovered a little.
Many persons here have a dread of using the sponge immediately, and
of being carried to another bed; but there is no danger from either
practice, in ordinary cases, when carefully performed; and it is so
productive of _comfort_, that I never knew one but what was pleased
with and benefitted by it, and desirous of its being done in their
subsequent labors.
Some females will even rise and take a _cold bath_, or be wrapped
in a _wet sheet_, not only without evil effect but with _positive
advantage_. I would not advise any one to do this however,
_particularly if they are the least timid at it_, _or doubtful of its
propriety_. Without the mental stimulus of _faith_ and _hope_ it may be
hazardous. It shows however, that many of the popular notions, as to
the requirements and susceptibilities of females, in this state, are
entirely unfounded.
The patient may either experience great comfort after being thus
attended to, or she may complain very much. Some will even be attacked
with a kind of chill. Their teeth will chatter, and their hands and
feet grow quite cold. This however usually passes off, and she falls
asleep. The accoucheur ought to remain for an hour or two, even though
she sleeps soundly, and appears quite well, because she may become
suddenly worse, or flooding may set in with such violence as to
endanger life in a few minutes, when unchecked.
If the patient desires any nourishment she may take a little simple
soup, or gruel, but nothing stimulating, unless a little wine be needed
from extreme exhaustion.
ATTENTIONS TO THE CHILD.
_Inspection when born_.--As soon as the child is born its mouth and
nose should be cleared from mucus, if that has not been done already;
and if it has not breathed, means should be resorted to immediately
to make it do so. Sometimes the whole head is covered with a thin
membrane, called the _caul_, or _veil_, which is most probably only a
portion of the Amnion, and which may cause suffocation. I remember a
case of this kind in my own practice, in which the caul was unnoticed
at first, and the child came near dying from it. Nothing could be seen,
and as it bent before the finger, when pressed into the mouth, it was
totally unobserved. The nurse however, called out that the child did
not breathe, and a close examination as to the cause soon revealed why.
On passing the finger under the edge of the membrane, which was round
the neck, it came off like a cap, and the child cried immediately.
_Washing the child._--The cleansing of the child may usually be safely
committed to the nurse, or other female attendants, though some of
them have very absurd and injurious practices in this respect. Thus
I have known them rub the whole body over with _whiskey_, or _raw
spirits_, before washing it, which must cause great coldness from its
evaporation, and also great irritation. The only thing required is
_perfect cleanliness_, and this should be effected in the _quickest_
and _simplest_ manner. Some very mild soap, and moderately warm water,
is all that is really needed, though a little sweet oil, or fresh lard,
or butter, rubbed on first, appears to facilitate the operation. The
drying should be done as quickly as possible, after all the mucus is
washed off, and with great care; the napkin being as soft as it can
be, and never _rubbed_ hard, for it takes but little force to remove
the skin. Many persons take great trouble, and are a long time over
this infantile wash without succeeding well with it. They are deceived
by the tough mucus slipping under the hand, but still clinging to
the body, where they leave it even after using the napkin; it then
dries on and forms a hard skin, very difficult to remove, and very
irritating. This can be avoided with care, and by using the oil first,
which appears to soften the mucus. Some persons use _flour_, or _Indian
meal_, and others _starch_, but none of these are so good as the simple
means we have described.
_Dressing the child._--After the washing and drying is completed the
child must be _dressed_, and this is a process in which comfort and
utility is frequently sacrificed to mere fashion and prejudice, as
it is in adults. The article next the skin should be of soft line
linen, which may be followed by others of warmer material, according
to the temperature. They should all be perfectly loose in their make,
and quite soft to the feel. As far as possible they should all be
fastened with _strings_, rather than _pins_. These metallic points
are troublesome to fix, and often injure the child, in spite of every
precaution. They are also apt to be referred to as the cause of the
child crying, and thus prevents other causes being sought for, which
frequently exist.
Some people put a thick flannel cap on the head, over a linen one, but
others leave this part altogether uncovered, which I think is the best
plan. At most there should only be the linen covering; the head being
better rather cool than otherwise.
The dressing of the cord is the next duty, and this is done by taking
several pieces of soft linen, oiled a little, and cutting a small round
hole in the middle of each, through which the cord is passed. The
linen then lies flat on the abdomen of the child, and the cord on the
top of that, the holes being just large enough for it to pass easily
through. Five or six pieces are usually put on, but very frequently
only one is used, and is found quite sufficient. It should be very
fine, and soft. When this is done another layer is laid over the cord,
and then a bandage of soft linen, about four or five inches wide, is
passed two or three times over it, and round the body. This completes
the dressing, and the child may now be wrapped up warmly and laid down
to sleep--remembering, as Dr. Chailly remarks, that if it be laid on a
chair, or sofa, it may be accidentally sat upon and killed, an accident
which has happened.
ACCIDENTS WHICH MAY HAPPEN.
Before these dressings are needed however, there are frequently
other things of more importance to be attended to. If the labor has
been long, or the presentation unfavorable, the child may be born
_apoplectic_, from the pressure it has received. The face will be
puffed up, and of a blue color; the body will be swollen, and the limbs
without motion, while the pulsation will scarcely be felt, either over
the child's heart or in the cord. It will feel warm, and the limbs will
be quite flexible, but still there will be no signs of life. In this
case it should be exposed naked to the cool air, and even blown upon;
and if that does not resuscitate it the cord may be cut through below
the ligature, so as to let out two or three tea-spoonfuls of blood.
After this it generally revives, and begins to move, while its face
assumes a natural color, and the swelling goes down. The mouth and
throat should also be carefully cleaned with a quill feather, of all
mucus.
A more frequent accident is _Asphyxia_, or want of breathing, in which
case the surface of the body is cold and pale, and no breath whatever
is drawn, though the heart beats quite naturally. Very weak children,
or those born before their time, are most likely to become asphyxiated,
or those delivered by instruments. The first thing to be done is to
carry the child to the open window, if it be not exceedingly cold, and
expose its head and chest to the air, while the rest of the body is
wrapped up warm. This will often make it gasp, but if it does not a
little cold water may be dashed on its face and chest, and the throat
may be tickled with a feather. The breech may also be smartly slapped,
and the chest well rubbed with the cold hand. When it begins to breathe
a little it may be put into a warm bath up to the middle, and a warm
injection may be given to it. In most cases these means will speedily
bring it round, but if they do not the attendant should place his mouth
close over that of the child and breathe into it, so as to fill the
lungs, and then press down the chest to empty them again, repeating
the process several times. This may be called artificial breathing,
and if it succeed once only there is a probability of its effecting
the desired object. The breath however, must not be blown in too hard,
or it may injure the child's lungs, nor too rapidly. Sometimes a tube
is used, which is passed down into the throat; but it is troublesome,
and not much better than the mouth, if any at all. These efforts may
be repeated twenty or thirty times if necessary, or even more. In some
cases it is requisite to continue using some, or all of these means,
for an hour or two without intermission, before the child begins to
breathe freely. I knew an instance even, where the nurse continued to
do so for _five hours_, and at last fully recovered the child, though
all present, including the doctor, had given it up. She said she did
not despair while it continued _warm_, though it was doubtful whether
the heart beat or not. This may show that the attempt should not be
abandoned too soon.
In cases of asphyxia no blood should be lost at all, but on the
contrary the cord should be carefully examined to see if it is tied
fast; the bleeding from it frequently aggravating the evil.
_Congenital weakness._--Some children are born extremely weak, and
remain constantly debilitated and cold. This is very apt to be the
case when they are born before the full term, or when the mother is
diseased. They should be carefully wrapped in cotton, or very soft
flannel, and kept warm by bottles of warm water. Many instances are on
record of these weak children becoming afterwards extremely robust, so
that they need not be regarded with unmixed apprehension, nor neglected
from a supposition that they must die.
_The child may be deformed._--The accoucheur should also carefully
examine the child, to see if it be deformed in any way, or has met with
any accident, because in some of these cases assistance is required
immediately, and may be rendered at once.
_The child's capability of endurance._--The capability of the new-born
infant to endure extremes of cold is almost as great as that of its
mother, and sometimes even it is benefitted by them. With many persons
it is customary to plunge it in cold water, immediately when born; and
in Russia, we are told, it is even _rolled in the snow_. In some cases
these extremes may be beneficial, but in others I have no doubt they
prove fatal. A medium course is best, in most instances, leaving the
extreme to be resorted to when we wish a sudden stimulus.
When all these matters are carefully attended to, and both mother and
child have remained for an hour or two without any unpleasant symptom,
they may be left to the care of the ordinary attendants, giving them
strict orders to send for proper assistance _immediately_, if anything
unusual transpires.
SUBSEQUENT ATTENTIONS TO MOTHER AND CHILD.
_The Bladder._--One of the most important points to attend to is the
urine. A few hours after the delivery is fully effected, unless the
female is reposing, she should be asked whether she has any desire to
urinate; and, if she has, the convenience should be at once afforded
to do so. There is always more or less danger of retention of urine,
from the pressure that has been exerted on the bladder; and if it be
allowed to continue too long its removal becomes exceedingly difficult.
If on making the attempt the urine does not flow, the catheter must be
used, and the sooner the better. The pain arising from retention of the
urine has often been supposed to arise from inflammation of the womb,
or bowels--neither patient nor physician knowing its real source, till
the passage by the catheter gave relief. There have even been instances
of females dying, merely from an overcharged bladder, while their
attendants were industriously treating them for uterine inflammation.
This accident therefore, should always be suspected, and a very little
attention will prevent any mistake in regard to it. When allowed to
become too full the swollen bladder may be felt, just above the pubes,
hard and tender, so that the least pressure upon it causes great pain.
If not relieved it will at last burst.
_The Bowels._--If the bowels are not opened naturally, it will be well,
the following day, to administer an injection of thin starch and water,
or to prescribe a small dose of castor oil, or a seidlitz powder. This
should also be repeated for two or three days, till the natural power
is restored.
_The Food._--But little solid food should be taken, and nothing
stimulating. Gruel, milk, toast and water, Indian meal, light puddings,
or broth, should be the chief articles for some time. Roast apples are
also very good, being pleasant and relaxing. For refreshing drinks, if
there be any fever, lemonade or tamarind tea may be taken.
_The After Pains._--After the expulsion of the after-birth most females
experience, more or less, severe pains, almost like those of labor,
arising apparently from the further contraction of the uterine walls
to expel the coagulated blood. These pains are seldom or never felt in
first labors, but afterwards they are often most acute. I have known
many patients suffer _much more_ from them than they did during labor.
They sometimes last only a few hours, or a day, and sometimes even
extend to six or eight days. Nothing that we know of can prevent them,
though many means are known of mitigating their severity. If there
be no tendency to flooding, a large poultice may be placed over the
abdomen, or it may be fomented, or covered with cloths wrung out in hot
water. An injection may also be used, either in the Vagina or Rectum,
consisting of warm thin starch, with about twenty drops of laudanum;
or either of the following recipes may be used internally:--_Pills of
Gum Camphor_, two, about the size of ordinary pills, to be repeated,
if necessary, in an hour.--Or, _Syrup of Poppies_, two drachms;
_Mucilage of Gum Arabic_, two ounces; and _Solution of Sulphate of
Morphia_, ten drops; to be made into a mixture, _one-half_ of which may
be taken at first, and the remainder in _two hours_, if the patient is
not relieved. This seldom fails.--It is necessary to bear in mind that
the pains arising from _inflammation_ have been mistaken for ordinary
after-pains, and serious consequences have resulted from the error. The
after-pains however, are concentrated, and _intermittent_, while the
sensations from inflammation are more diffused and constant, and are
also usually attended by fever.
_The Lochial Discharge._--From the time of delivery until the uterus
has returned to its ordinary condition, there is poured from it a
discharge, at first like blood, and afterwards thin and light colored,
called the _Lochia_. The duration of this discharge varies from one
week to a month, and its quantity from one ounce to six or eight
ounces, daily. It gradually diminishes however, and frequently stops
for a few days altogether. In women who do not nurse it is both more
abundant, and lasts longer, than in those who do. The bloody color
usually disappears after the first or second day, though sometimes it
will show itself again, even when the discharge has nearly ceased,
particularly if the female exert herself too soon.
It appears that this discharge is essential to health, and great
attention should therefore be bestowed on the patient, if it be too
small, or cease too soon, or too suddenly. In most cases it ceases
naturally during the _milk fever_, and of course its disappearance then
need not excite alarm. Sometimes also, it does not attain its full
quantity till some days after its commencement. If however, it remains
small past the _third_ day, or does not appear when the milk fever
is over, means should be taken for increasing it. The best means for
this purpose are _warm poultices_ and _fomentations_ over the abdomen,
and injections in the rectum of simple warm water. Some practitioners
advise _two drachms of powdered Camphor_ to be sprinkled on each
poultice, and probably it is an excellent addition. Occasionally the
lochia is very offensive, and in that case a simple cleansing injection
may be frequently used of thin starch, or Chammomile tea.
During the whole period of the Lochia in fact, even in ordinary
cases, the female will be all the more comfortable, and better, for
an occasional injection, and frequent washing. This is very much
neglected, though it never ought to be so. The only care required is
not to expose her to cold, which is quite unnecessary.
_The Milk Fever._--About the second or third day there usually
commences a peculiar temporary excitement in the system, called
the _milk fever_, which requires to be described because it may be
confounded with something more serious. It is generally ushered in by
headache, flushed face, and a hot dry skin; the pulse beats slowly, and
the breasts become hard, while the veins upon them appear very full. In
a short time however, the pulse becomes quicker, a perspiration breaks
out, and the breasts become still larger and fuller, so that the female
can scarcely bring her arms to her body. These symptoms last about a
day, or two days at most, and seldom become much aggravated.
Occasionally the milk fever is preceded by a slight chill, or by a
furred tongue, or sick stomach, but not very frequently.
The precise causes of this temporary fever are unknown, though probably
it is connected with the full establishment of the secretion of milk,
and hence its name. It is seldom very severe in those who nurse, and
frequently does not appear at all. During its continuance, and for some
time after, the female must carefully avoid exposure to cold, and keep
herself quiet; her diet should also be rather restricted, and light and
unstimulating. An occasional seidlitz powder may also be of service, or
a simple injection.
_Making the Bed._--It is not customary to disturb the female, for the
purpose of making her bed, till the milk fever is passed; or, if that
does not appear, till the tenth or twelfth day; and then it should be
done with care, and so as not to expose her unnecessarily.
_First sitting up, and Going out._--This must of course be determined
more by the condition of the patient, and the state of the weather,
than by any rules. It may be as well to remark however, no matter how
the patient may _feel_, that the _first attempt_ should always be
made with care. Very frequently she thinks herself stronger, and more
capable, than she really is, and premature or undue exertion may do
great injury. In most cases the female is allowed to rise within the
first week, and sit for a short time in an arm chair; after which she
begins to walk slowly about the room. The first going out is fixed,
_by fashion_, at one month. Many females however, are unfit to leave
the house till long after that time, and others should by no means be
confined to it _so long_. Of course these proceedings should depend,
as already remarked, upon the patient's strength and inclinations,
and upon the state of the weather, and not upon any fashionable
observances. Some females are quite able to rise, and even walk out, in
a few days, with benefit to themselves; and it exhibits as great a want
of correct feeling, or common sense, for any one to make disparaging
remarks on them for their early appearance, as it would if they were to
blame the poor invalid for keeping her bed.
The apartment should be kept constantly _well ventilated_, particularly
if the female is confined to it, and all soiled linen, or other sources
of foul air, should be removed as quickly as possible. There is reason
to believe that inattention to this, and to properly cleansing the
_person_ of the female, frequently produces _child-bed fever_.
_Attentions to the Child._--If the infant's bowels are not opened by
the end of the first day it should have a little sugar, or molasses
and water, given to it, and if this does not succeed about half a
tea-spoonful of syrup of Rhubarb may be added. This is however but
seldom needed, if it be put to the breast within a few hours, as the
first secretion of the milk possesses sufficient laxative power itself.
It should also be observed whether it has urinated, and if not it
should be placed in a warm bath immediately.
Some persons prefer to let the child wait till the milk fever is
established, before they let it nurse, but this is very improper. The
early feeding does it no good, and the purgatives it requires are
injurious. As soon as the female is sufficiently reposed, if there is
nothing special to forbid it, the child should go to the breast.
Sometimes the child will remain sleepy and dull, and not seem to
require food at all, for several days, and even die at last of
starvation, unless aroused. If this lethargy continues it should be
put in a warm bath, and afterwards well rubbed, while a little sugar
and water is poured down its throat. These attentions may be required
to be repeated for some time.
About the fourth or fifth day the portion of the cord above the knot
usually separates and falls off, if it has not already done so. If
the navel is inflamed, or suppurates, a little simple ointment may be
rubbed on, and it should be regularly and carefully washed. In some
infants it swells out very much, in which case a pad should be made of
soft linen, and laid upon it, over which the ordinary bandage may be
drawn. The complete healing of the part does not occur till about the
twelfth day, and the bandage must be carefully worn till then at least,
and is better continued a little longer, particularly if there is any
swelling, or if the child cries much, or strains.
CONCLUDING REMARKS.
From the explanations given above of an ordinary natural labor, it
will be evident that but little manual assistance is required, either
to the mother or the child, and also what really is called for is of
so simple a character as to be easily rendered. It would undoubtedly
be improper, and cruel, to leave females at such times without aid
altogether; but it is also equally improper and injurious to interfere
too much. Excepting in cases of disease and deformity, or of very
unfavorable presentations of the fœtus, Nature herself will nearly
always effect the delivery; and much better, in most cases, when left
to herself. Numerous females and infants have been _killed_, and still
more have been grievously injured for life, by rude and uncalled for
manipulations; so that it has been a question with some accoucheurs, of
great experience, whether as many would die, or seriously suffer, from
receiving _no assistance_, as do now from being improperly handled.
Without going so far, it is undoubtedly true that great mischief is
done in this way, which can only be prevented by both accoucheur and
patient bearing in mind that _Nature herself is usually competent_,
and at most only requires skillful and gentle _assistance_. Some
practitioners seem to think that labor is a mere _mechanical_ process,
like the removal of a block of stone, and hence they depend altogether
upon _force_; overlooking altogether the wonderful vital powers
inherent in the system, which operate with such certainty, and yet so
safely; and which frequently succeed of themselves when brute force is
completely foiled.
The nature of the assistance proper to be given, in any particular
stage of labor, will be evident on inspecting the structure of those
parts, of both mother and child, which are brought in connection at
the time, and by considering how their mutual relations require to
be changed and modified. If those relations are already such as are
required, and the system retains sufficient force, nothing _can_
be done with any advantage--we must _wait_, and let Nature operate
herself. Even many unfavorable conditions may be spontaneously
corrected, and it should always be a matter of consideration, when the
means of assistance are not very obvious, whether it will not be better
to rely upon the natural powers than to interfere. Great evil has
resulted from teaching females that labor _cannot_ terminate, safely,
without a great deal of assistance, which can only be rendered properly
by those who possess a vast amount of skill and experience. They are
thus led to think themselves totally dependent upon the accoucheur,
and many of them actually seem to believe that he is as necessary to
deliver the child as a dentist is to extract a bad tooth. If they were
better informed they would feel more confidence in their own natural
powers, and would not be so unnecessarily alarmed when unforeseen
difficulties occur, or when professional aid cannot be immediately
procured.
In most cases there is more danger _after the labor is over_, from
_puerperal fever_, various local inflammations and other causes, than
there was during its progress. Indeed the real danger may be said
properly to commence several days after, and the physician is really
needed then more than at the time.
SECTION VI.
PROTRACTED AND DIFFICULT LABORS.
The causes which may impede a labor, and increase its difficulties,
are numerous, and they are of several different kinds--some depending
upon the mother, and others upon the child. Some of these may be easily
removed, or modified, but others present more serious difficulty. It is
therefore necessary to enumerate and explain them separately.
CHAPTER XVIII.
THE CAUSES AND CONSEQUENCES OF PROLONGED LABOR TO BOTH MOTHER AND CHILD.
THE CONSEQUENCES OF PROLONGED LABOR.
A labor is usually called protracted or difficult, if the head
presents, when it is not completed in about _twenty-four hours_ from
its actual commencement. There are many labors however, that last much
longer, and yet terminate quite favorably, and many that are over
much sooner and yet are very difficult. Still, generally speaking,
the danger and difficulty increases as the time progresses, and it is
seldom prolonged beyond twenty-four hours without serious inconvenience.
It appears, from the statistics of the Dublin Lying-in Hospital, that
in _seventy-eight thousand deliveries_, one out of every _ninety-two_
of the mothers died, and one out of every _eighteen_ of the children
was stillborn. Of those mothers who were in labor with first children,
from _thirty to forty hours_, one in every _thirty-four_ died, and one
child in every _five_ was stillborn. Of those who were in labor from
forty to fifty hours, one died in every _thirteen_. Of those who were
in labor from fifty to sixty hours, one died in every _eleven_. And of
those who were in labor from sixty to seventy hours, one died in every
_eight_, and nearly _one-half_ of the children. It is evident therefore
that, as a general rule, the danger increases with the length of time.
CHAPTER XIX.
CAUSES CONNECTED WITH THE MOTHER WHICH MAY IMPEDE LABOR, OR MAKE IT
DIFFICULT.
INERTIA, OR WANT OF SUFFICIENTLY POWERFUL CONTRACTION IN THE WOMB.
This is most likely to occur in delicate females, and in those who are
debilitated by disease. The contractions are very feeble, and, as the
nurses say _do not tell_; the mouth of the womb dilates but slowly, and
the head descends with difficulty into the passage.
In many cases in fact the labor is so tedious, from this cause, that
the female becomes completely worn out, and finally sinks, while the
child is exposed to the greatest hazard from the delay.
It is in these cases that the patient's strength needs supporting, and
that stimulants may be useful. A little wine, or brandy and water,
will often rouse the failing energies, and bring on a series of strong
contractions that will end the labor at once.
The most usual resort however is to the drug called _Ergot_, or _Secale
Cornutum_, a fungus growth which is sometimes found on ears of rye.
This possesses the peculiar property of exciting the womb to contract,
the same as an emetic excites the stomach to vomit, and it seldom fails
in its effect; but still there are many objections to its use. It
not unfrequently causes _delirium_, great restlessness, and anxiety,
sickness, headache, and convulsions, or complete prostration, from
which the female may be long in recovering. It is also supposed by
some to be not altogether free from danger to the child. If however
no other means were known of making the womb contract, in such cases,
all the probable evils should be risked, because the labor _must_ be
completed at all hazards; but other means _are_ known, which succeed
even more certainly than ergot, and without any danger. The application
of _Galvanism_, explained in my "_Neuropathy_," and "_Practical
Facts_," will almost invariably cause the womb to contract, and
speedily bring the labor to a safe termination, without the slightest
risk or inconvenience, to either mother or child. Simple friction over
the abdomen will also succeed in many cases, and gently rubbing the
mouth of the womb with the finger in others. These simple means should
therefore always be used in preference to the ergot, but in case they
cannot be resorted to, or fail, the drug must be administered, and I
will therefore explain the manner in which this is done. When gathered
the ergot is in large irregular lumps, and should be so kept. When
wanted for use a single drachm should be finely powdered, and divided
into three parts; one of these parts to be taken first in a glass of
sugar and water, and the others at intervals of ten minutes, unless the
effects of the first are very powerful. It is often thrown from the
stomach however even in still smaller quantities, and is then given,
by some, as an injection by the rectum, in which mode it seems more
powerful, so that a smaller dose is sufficient.
Great caution should always be observed in using this powerful drug,
as it will sometimes act so energetically as to _burst the womb_; or
expel the child so suddenly as to lacerate the perineum and other
parts. The contractions produced by it are different from the natural
ones, being almost constant, without any interval, and gradually
increasing in force. They usually come on in about ten or fifteen
minutes after the last dose, and continue about an hour and a half.
Some practitioners depend almost altogether on the ergot, in every
protracted case, and even use it to bring on _premature labor_, when
that is required. Thus M. P. Dubois was once called to a dwarf, whom he
delivered with instruments, the first time, but with great difficulty
and risk. The next time she became pregnant he determined to bring on
premature labor, and accordingly he administered ergot, when she was
about _eight months_ gone. This brought on natural labor, and she was
delivered without difficulty. M. Chailly says he believes it will bring
on uterine contraction at any time, and that he has never known it to
fail. I consider however that there is always more or less risk in its
use, and I should certainly prefer any of the other means, particularly
_Galvanism_.
It is of the first importance however to be certain, before using _any
forcing means whatever_, that there is no _physical impediment_. If
the pelvis should be deformed or small, if the child's head should
be unusually large, or dropsical, or if the soft parts of the mother
should be undilated and rigid, the most serious consequences must ensue
from violent uterine contractions. In like manner if the presentation
be unfavorable, particularly if it be one of the trunk, the danger
is equally great. In every case the passage of the child must be
_physically possible_, before it is attempted to force it away. A
neglect of this rule has frequently led to fatal results. The ergot
has been given and the uterus forced to contract, while the pelvis
was too small for the child to pass through; and the consequence has
been _rupture of the uterus_, or complete exhaustion, with death to
both mother and infant. In other cases the delivery has resulted so
suddenly, from the violence of the expulsive efforts, that the vagina
and perineum have been lacerated in the most shocking manner.
The ergot is also especially dangerous to very nervous women, or to
those who are disposed to congestion, apoplexy, or inflammation.
Among the special causes which often paralyze the action of the womb,
may be mentioned a full habit of body, great distention of the uterus
from accumulations of fluid, and extreme thickness of the membranes.
In some cases in fact, the membranes will be so strong that the most
violent contractions fail to break them, and the uterus completely
exhausts itself to no purpose. It is in such cases as these, when the
mouth of the womb is fully dilated, that the accoucheur should rupture
the membranes artificially. This is usually done with the finger nail
by pinching them. Some practitioners however use a pointed instrument,
or a sharp quill; but there is always more or less danger of injuring
the child or the mother by such means. The best time for breaking
them is during a strong pain, when they are fully distended. The mere
scratching, or pushing on them will frequently suffice. I have known
cases however in which they were so strong that an instrument was
actually necessary to open them.
The death of the infant also seems sometimes to check uterine
contraction, though probably not from the mere circumstance of its
being dead, but because the womb suffers from the same morbid cause
which produced its death.
Any strong moral impression may also produce the same state of things.
Thus in some females the womb will instantly cease its contractions,
and the labor be arrested, from _fright_, or from strong repugnance
to somebody, or something, in the room. Instances have been known of
women being so alarmed on first seeing the accoucheur, or so displeased
because he was not the one they wished, that the uterine efforts
immediately ceased, and could not be again brought on for a long time.
The presence of some person who is a subject of dislike may also
have a very prejudicial effect, and if this is known they should be
immediately removed. Dr. Merriman tells us of a female who was seized
with a fit, from which she died, simply from seeing a strange doctor
enter the room.
Whatever may be the cause which paralyzes the action of the womb we
should endeavor, if possible, to discover and remove it. If however
it be beyond our reach, the patient's strength must be supported as
much as possible, and the simplest means of exciting the contractions
tried first; if these fail the more powerful ones must be tried,
always preferring the safest. Finally, if all fail, the hand must be
introduced into the womb, the child turned, and brought away by the
feet; or the forceps must be used if absolutely necessary.
RIGIDITY OF THE MOUTH OF THE WOMB, VAGINA AND VULVA.
Sometimes the mouth of the womb or other soft parts, will not give way,
but remain obstinately rigid, so as to render the continued expulsive
efforts of the womb of no avail. If this state continues too long the
parts become swollen, hot, and dry, and extremely painful, so that
the slightest touch causes acute suffering. The abdomen also becomes
exquisitely tender, fever sets in, with cold sweats, the head begins
to wander, the features express great anxiety and suffering, and the
voice alters so that it can scarcely be recognized. These symptoms will
sometimes be established, and become rapidly worse in a remarkably
short time, so that the patient will appear to pass suddenly from a
condition of comparative ease and safety to one of extreme peril and
suffering. The child also suffers in an equal degree, the continued
pressure upon its head having a most injurious effect. The bones
overlap to a great distance, the scalp is engorged with fluid, and all
its blood-vessels are ready to burst; the brain is severely compressed;
the circulation in it is suspended, and apoplexy frequently ensues.
Even when one of these protracted cases eventually terminates without
immediate mischief, there is much subsequent evil to be feared. The
bruised parts frequently slough away, so that fistulas are formed, and
the whole remain so permanently weak that they can never afterwards
retain their places.
The most usual resort in these cases of obstinate rigidity is
_blood-letting_. This frequently induces relaxation immediately,
and also checks the tendency to inflammation and fever. In many
cases however, if not in all, it may be dispensed with, and should
always be so if possible. Very frequently it produces as much evil
as good, by alarming the patient, and by creating a debility which
cannot afterwards be removed. Simple warm _fomentations_ will often
make the rigid parts give way; and so will lubricating them with
soothing ointment, or better still anointing them with the _Extract of
Belladonna_. This frequently acts like a charm, and opens the rigid
os tincæ in a few minutes. Injections of thin starch and laudanum are
also excellent, and may be advantageously administered before applying
the Belladonna. The _Galvanic Battery_ may also be employed, it having
induced relaxation in many cases, when all other means failed; as will
be seen by the cases quoted in "Practical Facts."
If the labor really does progress though slowly, it is generally best
to have patience and let it take its course. If however the patient is
likely to sink before it is completed, or if it is at a stand still,
and cannot be accelerated, artificial delivery may be necessary. It is
seldom however that all of the above mentioned means fail.
OBLIQUITIES OF THE WOMB.
Sometimes the womb is so much inclined in a particular direction that
its mouth does not present to the middle of the passage. Thus it may
lean over so much to the right side that the mouth may open against the
left wall of the Pelvis; or it may lean to the left side, or to the
front. In all these cases the expulsion of the child may be totally
prevented, because it is forced against the walls of the passage
instead of down its axis.
Obliquity is sometimes righted spontaneously, but more frequently it
requires the interference of art. The mode of rendering assistance is
to support the womb on the side to which it falls, particularly during
the pains, so that its mouth may be directed towards the middle of the
passage.
PROLAPSUS UTERI.
Falling of the womb may retard labor, but is not likely to make it more
than usually difficult, nor dangerous. It is requisite, however to bear
in mind that the head of the child may, by this displacement, be found
in the vagina, and even at the vulva, before it has passed through the
mouth of the womb, because the neck itself is already in the passage.
The head may therefore be felt low down, and the accoucheur may think
the labor will soon be completed, when in reality it has scarcely
begun. In such cases it merely requires patience and _non-interference_.
In my work on _the Diseases of Women_, will be found many curious
cases of pregnancy and delivery, occurring during partial or complete
prolapsus uteri; and also much information regarding obliquity, and
other similar derangements.
SMALLNESS OR DEFORMITY OF THE PELVIS.
These constitute by far the most serious obstacles to delivery, and are
most to be dreaded. In treating upon them it will be first necessary to
explain the chief kinds of deformities, and the cause from which they
arise, after which it can be shown how they interfere with the progress
of labor, and how they can be best remedied.
Deformities of the pelvis may either be congenital, or they may be
produced by certain diseases in after life, and also by bad physical
education. The principal causes however are two diseases, _Rachitis_,
or _Rickets_, and _Malacosteon_, called also _Mollites Ossium_, or
softening of the bones. Rachitis usually attacks children somewhere
between nine months and two years of age, and produces a variety of
well marked symptoms; such as large head and belly, protrusion of the
breast-bone, flattening of the ribs, emaciation of the limbs, and
various deformities of the bones. The patient may recover from the
disease, but the deformity of the bones often remains, and therefore no
female should become pregnant, who has had rickets, till the shape and
dimensions of her pelvis are known, or it may cost her life.
Malacosteon or softening of the bones, may come on at any period
of life, and frequently occurs without any serious constitutional
disturbance. It consists in a gradual absorption from the bones of
all their solid matter, so that they become soft, and may be bent or
twisted like horn. Sometimes this state will be reached very soon, but
at other times the disease progresses very slowly. The causes of it are
unknown, and it is incurable. I have seen a patient who could bend the
bone of her leg _nearly double_, as if it were a piece of rope.
In my work on the Diseases of Woman, I have spoken upon various other
causes which may deform the bones in young females, such as wearing
corsets, improper attitudes in sitting, and want of sufficient
_unconstrained_ exertion of the body in the open air.
The deformities may be of various kinds, and may either alter the
general appearance and the walk, or may not be discoverable except on
examination. Sometimes the pelvis is _too large_, so that the womb and
other parts are continually falling down into its cavity, but this is
very rarely seen; more frequently it is either too small, or irregular
in its form.
In all cases where the irregularity in form, or diminution in size,
is such as to prevent the passage of the child an operation becomes
necessary, either upon the mother or her infant, and great danger is
consequently incurred by both.
It is therefore the duty of every mother, if she has the slightest
suspicion that her daughter is deformed, though it may not be apparent,
to have her examined before she is allowed to marry. _Many have lost
their lives for want of this precaution._ Severe blows or falls in
early life may also create a pelvic deformity, and this, as a possible
consequence of such accidents, should always be borne in mind. The
means by which the form and size of the pelvis are ascertained, as
before stated, are simple, and such as need not in any way be feared.
To enumerate all the varieties of deformed pelvis, as described by
different authors, is unnecessary, and would not be useful here. I
shall therefore only refer to them generally. Sometimes the pelvis
is regular enough in its form, but singularly small altogether, not
larger perhaps than that of a child eight or nine years of age. More
frequently, however one part only is small, while the others are full
sized, or the different parts are not in a proper position in regard to
each other. Thus sometimes the pubic bones will be flattened backward,
near to the sacrum, so as to narrow the antero posterior diameter of
the upper strait; at other times one of the sides will be flattened
towards the other, as if crushed in, and thus diminish all the
diameters; and at other times one side will sink down lower than the
other, and thus effect similar changes in another way.
By referring to the description of the perfect pelvis, given in the
early part of the work, the nature of these changes will be readily
understood, particularly if the plates given there are compared with
those given here.
PLATE XL.
Represents the _standard_ form, with which the rest must be compared.
PLATE XLI.
Represents a pelvis which resembles that of the male in its form, and
is therefore called _masculine_. It is deeper, and less capacious
altogether than the standard one. This form is occasionally met with
in females of a peculiar general conformation, and temperament,
approaching that of the other sex. It is not a sufficient deviation
from the natural form to create any great difficulty, though it may
cause delay.
[Illustration: Plate XL.
Represents the _standard_ form of the Pelvis.]
[Illustration: Plate XLI.
Masculine Pelvis.]
PLATE XLII.
Represents the peculiar deformity most frequently produced by
_Mollites Ossium_. The different parts are stretched out as it were,
and crushed inwards toward each other. The size of each strait is
diminished in nearly every diameter, and the whole form is very
unfavorable to delivery. This is sometimes called a _cordiform_
pelvis. Observe the difference between it and the standard one.
PLATE XLIII.
This is called an _Ovate_ Pelvis. It appears as if it had been
crushed by a heavy weight, from above downward, the sacrum being
depressed below the plane of the pubes. In this case the antero
posterior diameter of the upper strait is so much lessened that the
two halves appear nearly separated, and form almost a figure of eight
(8).
[Illustration: Plate XLII.
Represents the peculiar deformity most frequently produced by _Mollites
Ossium_.]
[Illustration: Plate XLIII.
This is called an _Ovate_ Pelvis.]
PLATE XLIV.
This is another kind of deformity, in which one side is sunk down
below the other, while both are twisted as it were round the sacrum.