Natural; 2d. Preternatural, is sufficiently comprehensive, while it
forcibly recommends itself by its simplicity and perspicuity. Natural
labor supposes four things: 1st. That the vertex presents; 2d. That
there is sufficient room in the pelvis to admit of the ready descent of
the head of the child in that direction which permits the occiput to
emerge under the arch of the pubis; 3d. That there is parturient energy
adequate to the expulsion of the contents of the uterus without manual
interference, and without danger either to the mother or child; and,
4th. That the process of parturition is completed within a moderate
time.
“Preternatural labor embraces all the varieties not comprehended in the
class of natural labor, whether they respect difficulty, duration, or
danger, and may be included in the following six orders: 1st. Protracted
labors; 2d. Those labors in which any other part than the head may
present; such as the breech, feet, hands, penis, etc.; 3d. Labors with a
plurality of children; 4th. Labors attended with convulsions; 5th.
Labors with uterine hemorrhage; 6th. Labors in which laceration of the
uterus or contiguous parts may occur.”
Dr. Denman’s division of labors is probably as good as any one, and has
the recommendation of being simple and easy to comprehend. It consists
of the following classes: 1. Natural; 2. Difficult; 3. Preternatural; 4.
Anomalous.
Under one or other of these distinctions, every kind of labor which can
occur, is to be placed.
Natural labor “is that which consists in a gradual enlargement of the
mouth of the womb, and the diametus of the vagina, so as to suffer the
child to pass away when urged from above by a repetition of expulsatory
contractions of the uterus and all the surrounding muscles.” This kind
of labor is by far the most frequent, and indeed takes its name from its
frequency; and in the great majority of labors there is no danger
however painful and distressing they may be. Natural labor lasts usually
from two to twelve hours, seldom happening sooner than the first or
later than the last. Dr. Good places the average at about six hours. If
I were to speak of the average duration of labor from memory, in regard
to the cases which I have attended, I should consider that six hours was
too low a number, and should think that eight or ten would be a nearer
approximation to it.
Dr. Maunsel, of Dublin, has given the records of 839 cases of labor
which occurred in the Wellesley Institution. In these,
347 terminated in 6 hours.
300 „ 12 „
87 „ 18 „
59 „ 24 „
37 „ 48 „
3 „ 56 „
5 „ 60 „
1 „ 72 „
IS PAIN A NATURAL CONDITION OF LABOR?
I am here led to make a digression on the subject of pain. There are
some nowadays who contend that labor is naturally a painless process,
and that through the voluntary habits of the individual it is possible
to make it so even at the present day.
I must humbly dissent from this doctrine. I am willing to admit, or,
rather, I do emphatically affirm, that the safety of parturition, the
ability to pass with comparative comfort through the period of
pregnancy, and the recovery from childbirth, are very much under the
influence of the voluntary habits of the individual, and may be modified
to an almost indefinite extent. If I did not believe all this most
fully, I would never have written these letters, and probably not have
practiced the healing art. But all this is a very different thing from
that of bringing forth a child without pain.
I do not care even if some of your sex who have borne children, too,
should themselves tell me that they passed through labor without
experiencing any suffering whatever. I could hardly trust their word if
they should tell me so, because I know too well that they may deceive
themselves, and that it is a matter of striking benevolence in the
Creator, who has formed woman’s nature in such a way that she soon
forgets the agony after it has passed. How many of you all to whom I
address myself would ever consent to bring forth a second child, if
there should always be present in your minds the consciousness of the
agony, not to say the pain, the real agony, which labor actually cost
you?
See, too, the animals which we hear so much about. Some will tell you
that they do not suffer when they bring forth their young. But I say to
you these pretended philosophers do not know of what they affirm. Take
the healthiest animals—not the sickly, stall-fed ones of our cities, but
those of the country—and such as never manifested any signs of sickness
whatever; do they not suffer pain when they bring forth? I speak from a
knowledge of the facts when I tell you they do. They sometimes even die
in the process, and they _always_ manifest signs of distress, even as a
premonitory symptom when labor is about to come on. How, indeed, could
there be such a displacement of living, vital parts as occurs in a labor
without there being pain? As to _danger_, that is another thing.
I would, therefore, not have you carried away with that foolish notion,
which some would instill into your minds, that labor can be without
pain. I trust I have said and shall say some things in these pages which
will go to encourage you somewhat in reference to childbirth; but all
along my desire is to tell you the truth. It is better for you that you
should know it, and for me that I should speak it. _We ought never to be
afraid of the truth._
But perhaps some of you are ready to ask, what is the meaning of that
passage of Scripture which reads:
“Unto the woman God said, I will greatly multiply thy sorrow and thy
conception; in sorrow shalt thou bring forth children; and thy desire
shall be to thy husband, and he shall rule over thee.”
I can tell you what I think it does _not_ mean, which is, that the
Almighty did not order that human beings should have no agency in regard
to the pains and perils of childbirth. He did not say, that if a woman
chooses, when pregnant, to go to balls, parties, theaters, and the like
places, become excited, and, for example, dance, that she could not
thus, of her own voluntary acts, bring on abortion or some worse
ailment. He did not order, that if she will persist in drinking tea and
coffee, that her nerves will not be injured thereby. And so of all other
rules of health. If we obey God’s physiological laws, health will be
better in proportion to the extent of that obedience; if we disobey
them, we must inevitably suffer in consequence thereof. Nor is there any
thing in the Word of God, when rightly understood, which at all
conflicts with this doctrine.
ETHER AND CHLOROFORM.
Holding, as I do, that pain is a natural condition of the puerperal
state, you can understand why it is that I am opposed to the use of
ether and chloroform under such circumstances. We ought never to
counteract a law of nature. If we do, we are certain of being injured to
a greater or less degree; and it is no wonder at all to me that people
sometimes lose their lives in the use of these anesthetic agents. The
only wonder is that they do not oftener sink under them. I am not now
saying that I would never recommend even the risk of using chloroform,
but only that I would not recommend it in labor, because that is a
natural process, and one which should not be unnecessarily interfered
with by art.
LETTER XXV.
MANAGEMENT OF LABOR.
Its Premonitory Signs—Progress of Labor—Its Different Stages—Age as
Affecting it.
It is very common for women to experience a manifest improvement in all
their symptoms some days before labor is about to come on.
Some days previous to its commencement, a remarkable subsidence of the
abdomen and diminution in the size of the body takes place. This is
occasioned by the sinking of the womb, and, of course, its contents with
it move into the brim of the pelvis. It is possible, likewise, that the
walls of the uterus begin at this time to bring themselves into closer
contact with the child, thus rendering the abdomen somewhat smaller. At
all events we know, that the fact does occur in most cases, and the
circumstance is always to be looked upon as a favorable one.
Just before labor a sort of general distress arises in the patient’s
mind, owing, no doubt, in part, to the state of the body, and in part to
the natural apprehensions of pain and the danger which she is to pass
through. “This,” as Dr. Denman observes, “does not seem to be confined
to the human species, but to be common to all creatures, as they
universally show signs of dejection and misery at this time, though they
suffer in silence; and even those animals which are domesticated, strive
to conceal themselves, and refuse all offers of assistance.”
STAGES OF LABOR.
Labor may be appropriately divided into three stages, which are the
following:
1. That which includes “all the circumstances which occur, and all the
changes made, from the commencement of the labor to the complete
dilatation of the os uteri (mouth of the uterus), the rupture of the
membranes, and the discharge of the waters.”
2. This stage includes those circumstances which occur between the first
stage and the expulsion of the child.
3. The third stage includes all that relates to the separation and
expulsion of the placenta or after-birth.
As labor is about to come on, and even for some days previously to it,
an increased mucous discharge takes place from the vagina, which for a
day or two at the last is apt to become streaked with blood, forming
what is termed the _show_. This arises from a partial detachment of the
placenta, at which time it might perhaps with propriety be considered
that labor had actually commenced, although in a slight degree.
This show, however, does not always appear, for, as Dr. Denman observes,
“in many cases there is no colored discharge in any period of the labor,
and then the dilatation proceeds more slowly; for the discharge is not
only a sign that the parts are in a state disposed to dilate, but it
also improves that state.”
If the bladder is at all irritable, the woman at this time suffers from
strangury, more or less. This is in consequence of the pressure of the
womb upon the neck of the bladder, or upon the urethra. If the rectum is
in a similar condition, there is apt to be tenesmus, or a bearing-down
feeling at the lower bowel, as if something should be discharged, but
which the woman is not able to accomplish. All these are common
symptoms; but in some cases labor begins, as it were, suddenly, without
any warning whatever.
Not unfrequently, in the beginning of a labor, the woman experiences one
or several rigors, which may be in connection with or without a sense of
cold. These are supposed to arise in consequence of the system rallying
its energies to concentrate them upon one important object, namely, that
of effecting the dilatation of the uterus and the expulsion of the
fetus. They are evidently not attended with any danger, and should
therefore give the patient no alarm.
_State of the Bowels._—It is not uncommon for patients to have one or
more loose discharges from the bowels at the beginning of or during
labor. This symptom occurs in consequence of the sympathy that exists
between the womb and the lower part of the alimentary tract. There
appears to be in the minds of most women a great prejudice against bowel
complaints through the different stages of pregnancy, and at the time of
labor, and, as a consequence, there is a willingness, and often anxiety,
on their part to use such means as are supposed to have an effect in
suppressing them. But in most cases of diarrhea under these
circumstances, the patient is relieved by it rather than made worse, and
should therefore take no special means of counteracting it, unless,
indeed, under the guidance of a medical attendant who should deem such a
course necessary.
_Nature of the Pains._—It is an object to know how you may distinguish
between the true pains of labor and those which are false.
The true pains of labor usually begin in the back and loins, and shoot
round to the upper part of the thighs; or they may commence first in the
lower part of the abdomen, as if in the region of the bladder, passing
backward toward the spine. Some women commence being sick, as if they
had eaten something that disagreed with them; and I have repeatedly
known them to attribute the pains of the commencement of labor to this
cause. A little time in such cases is sufficient to convince them of
their error.
Periodicity is, in most cases, a symptom showing that the pains are not
false. The interval between them may vary in different cases from one
minute to thirty, forty, or more, according to the action of the uterus,
on which they depend. The more the pains are multiplied the better it is
to be regarded for the patient, and for the reason, that if an effort of
great importance to the constitution is to be produced, the more slowly
and gradually it is done the better, if the slowness is not the effect
of disease. A sudden and violent labor is never to be looked upon as
being so safe as one which happens in a more gradual manner. “It is an
old observation,” says Dr. Denman, “confirmed by daily experience, that
after the completion of slow or lingering labors, patients usually
recover better than after those which are quick; not to mention that
they are less liable to the untoward accidents which precipitation may
immediately produce.”
A considerable difference exists in the character of the pains,
according to the stage of labor in which they occur. The earlier pains
are termed cutting or grinding, from the fact that uterine fibers alone
are principally concerned in them. Afterward the pains get to be lower
down, and are of a more bearing-down nature. When these pains exist, the
woman is instinctively led to bring her abdominal muscles into powerful
action, causing her, at the same time, to hold in her breath, so that
after the pain has ceased, or partially so, she utters a deep groan. In
the earlier part of the labor, the cries are more shrill, so that an
experienced observer will often be able to judge of the stage of the
labor merely by hearing the manifestations made. In some cases, however,
the patient does not exhibit any of the aforementioned signs of
distress, until the moment when the child is about to pass into the
world. She is then obliged to put forth an expression of agony, which
proves but too well how much it is her lot to endure.
THE LIQUOR AMNII, OR WATERS.
In order that you may the better understand the first stage of labor, I
will here make some remarks on the nature and office of the fluid
above-named. By _liquor amnii_, or _waters_, is meant that fluid which
is contained within the membranes surrounding the child.
The quantity of the waters, when compared with the size of the child, is
greater in the earlier parts of pregnancy. At the time of labor it is
found to vary a good deal in different cases, amounting in some to four
or five pints, and in others to scarcely as many ounces. It is thought
to be largest in case the child has been for some time dead, as also
when it is very feeble.
In regard to the office of this fluid, some have imagined that the fetus
is nourished by it, the liquor being swallowed into the stomach. But in
answer to this doctrine, it is to be remarked, that there are many
examples of children having been born without any passage to this organ.
There have also been born children of a full size and well-formed shape,
all except the head, which was wanting. These facts make it clear that
the child must be nourished in some other way than by the waters
surrounding it.
Some also have supposed this fluid to be an excrementitious substance;
but this belief is not now generally adopted, or rather, no physiologist
of any eminence regards it as such at the present day.
The liquor amnii “is generally transparent, often milky, and sometimes
of a yellow or light-brown color, and very different in consistence; and
these alterations seem to depend upon the state of the constitution of
the parent. It does not coagulate with heat, like the serum of the
blood; and chemically examined, it is found to be composed of phlegm,
earthy matter, and sea-salt, in different proportions in different
subjects, by which the varieties in its appearance and consistence are
produced.”
It has been supposed that the liquor amnii may, all of it, be discharged
as early as the sixth month of pregnancy, without producing injury to
either mother or child; but this cannot be true, it would appear, since
it is well known, that when the membranes are broken intentionally, so
that all of the waters are discharged, the uterus never fails to
contract itself until abortion or the birth comes on. A discharge from
the vagina, somewhat resembling the waters, however, may appear for
weeks, and even months, before the delivery takes place; but in such
cases it has been observed, that no diminution in the size of the
abdomen occurs, from which circumstance it is known that the real liquor
amnii does not pass off.
The normal purposes of this fluid in the system appear to be to afford
the fetus a safe and easy lodgment in the uterus. If it were not there
to protect the embryo, it would constantly be in danger of being
destroyed by mechanical violence; besides which, it would be almost
certain of adhering to the inner surface of the womb in such a way that
the birth could not possibly take place. At the time of labor, too, we
see the advantages of the “bag of waters,” for as it is protruded in
advance of the child, it forms a soft, yielding wedge, as it were, which
gradually dilates the soft parts, without overstretching or tearing
them, which would not be the case if the comparatively hard head of the
child was the first to present itself.
The rupture of the membranes, which ends the first stage of labor, may
take place a very short time before the expulsion of the child, or it
may happen prematurely, as it were; that is, many hours, or even days or
weeks before the child is born. In such cases the occurrence is to be
considered as an accident or exception to the general rule. It does
happen, however, every now and then, and in many cases it seems to make
no difference whatever in regard to the future progress and safety of
the delivery.
The greatest agony, as I have remarked, is experienced at the time the
child is brought into the world; but if I could make plain to you the
mechanism of labor, you would be struck with admiration, I am sure, at
the wonderful marks of benevolence and design which are exhibited in the
_manner_ in which a child is expelled from the uterine cavity.
You may ask why it is that a woman should be made to suffer pain at all
in bringing forth a child, and why did not the Creator form the system
of woman in such a way that a child could be expelled without causing
any of that agony which is well known to be a natural circumstance of
childbirth. I answer, it was not possible for God to create woman in
such a way. Suppose He had made her pelvis larger, and the soft parts
more yielding; she would have been constantly subject to the misfortune
of miscarriage; or rather, it would not have been possible for her to
carry a child at all.
But see the beautiful, and at the same time wonderful operation of
nature in the mechanism of parturition. At first, some days before labor
is to come on, the abdomen begins to subside, showing that the uterus,
with its contents, is gradually sinking downward in preparation for the
greater struggle that is to take place at the birth. Probably, too, the
womb at the same time begins to contract itself more firmly upon the
child, and, as it were, begins to gather strength for the contest which
it is about to engage in, namely, that of forcing the child into the
world. After this there appears a greater discharge of mucous than
ordinary from the womb and vagina, which serves to soften and lubricate
the parts in preparation for the terrible distension which is to take
place. Gradually, also, in the first stage of labor, the womb dilates,
for too sudden a distention of this important part would be very apt to
cause a fatal rupture of the organ. In the second stage, the head of the
child is driven through the os uteri into the vagina. As the pains
continue, the face of the child is turned into the hollow of the sacrum;
that is, toward the back of the mother, the wider part of the head being
in the wider part of the pelvis, just as a wise mechanician would
naturally place it; but in the beginning of labor, when the child’s head
is at the upper part of the pelvis, it lies more to the side of the
mother, corresponding to the wider diameter of this upper strait.
Look at a skeleton, I repeat, that bugbear of our childhood, that grim
yet beautiful remnant of our mortality; and when you see and understand
how admirably adapted the form and shape of the pelvis is to the ends
for which it was created, tell me if you do not recognize in this
adaptation the most unmistakable evidences of the work of an Almighty
hand.
In cases of first children, the first or dilating stage usually occupies
from six to thirty or more hours. It is natural to expect that a woman
must suffer greater pain, and bear a more tedious labor with her first
child than with the subsequent ones. “I have heard a voice as of a woman
in travail, and the anguish as of her that bringeth forth her first
child,” saith the prophet Jeremiah. The difference in the length of the
first and subsequent labors, however, is not usually in proportion to
the number of children that have been borne. If a woman be twenty-four
or thirty-six hours in labor with her first child, she may be only six
or eight with her second, and in the subsequent labors only three or
four hours. There will, of course, be many deviations from any
calculation of this kind that can be made, but the practitioner will,
however, often be able to form a tolerably accurate opinion of the
probable duration of a labor, if the woman have had a number of children
previously. But even here there will be a good deal of liability to
error, since the fifth, sixth, or tenth labor may prove a very tedious
and difficult one, because of some mal-position of the child. I had an
example of this kind in my own practice some months ago, in which a lady
suffered incomparably more with the birth of her third child than with
both of the former together, and the labor was protracted to thirty
hours, which was a much longer period than either of the former had
been. This happened in consequence of the face of the child, that is,
the wider part of the head, presenting forward in the narrower part of
the outlet of the pelvis, whereas in almost all cases the reverse of
this takes place, as I before remarked. Such cases are, however,
fortunately very rare, the exception only to the general rule.
You will readily understand why the first labor is apt to be somewhat
more difficult than subsequent ones, when you recollect that all the
soft parts, such as the womb, vagina, the external organs, etc., are
more rigid and unyielding in the first labor than they afterward are.
The bones, recollect, are the same at all times; they do not give or
separate, as many of you have supposed; they are bound so firmly
together that it is not possible for them to be separated, in their
natural and healthful state, by any such force as that which is exerted
in the birth of a child, although this force is a great one. It is
necessary that the bones of the pelvis should be thus strongly bound
together, otherwise they would not be sufficiently firm to answer the
purposes for which they are intended.
THE AGE AS AFFECTING LABOR.
If the patient be considerably advanced in years at the time of her
first pregnancy, the labor is apt to be, or rather, must necessarily be,
a more difficult one than would occur earlier in life.