parturition, Dr. Smellie says, “That of 1000 women in childbed, 920
of them will be delivered in the ordinary way, with little or no
accocheur trouble, skill, or assistance: 70 more of the thousand will
be difficult labours, or slow and tedious, when often some skill and
aid of the accocheur will be necessary; and the remaining ten of
the thousand will be preternatural labours.” There will, therefore,
according to this author, be about 8 _per cent._ of slow, laborious,
preternatural, and anomalous labours, which, in different gradations,
will be more tedious, difficult, and dangerous than in the usual
process of nature.
It is a proposition not uninteresting in Obstetricks, and in medical
jurisprudence, and in many instances it is material to the medical
character, to observe that, in the preceding list, during seventy-five
years in London, there were brought forth alive and christened,
1,220,656; that the abortives and stillborn in the same period were,
46831, or as 1 of 26. But, as we just now remarked, that the chrisoms
and infants who die in the threshold of life, and previous to baptism,
are excluded from the registered births and christenings; on that
account we may venture to calculate the abortive list to those who are
ushered alive into the world, as 1 of 27 or 28; perhaps more, or about
3 _per cent._ Were we, however, to add the abortions and miscarriages
of diminutive embryos, in the early months of pregnancy, and which are
much more frequent than in the latter months, the abortive catalogue
would be prodigiously swelled.
Dr. Short attempted to ascertain the proportion between single births,
twins, and tergemini, from a register of three large parishes, during
a series of years, in which the single births amounted to 11,415; the
twins and tergemini to 311, or about one of thirty-five.
Lastly, Let us examine what were the several diseases during pregnancy
and parturition, and afterwards which occasioned this childbed
mortality, and in what arithmetical ratio were the fatality of those
respective puerperal diseases and casualties. This inquiry demands a
previous analysis of pregnancy and parturition.
_Conception and Pregnancy._ In some instances, there is not a more
puzzling problem in midwifery, than to decide the simple question,
whether or not a woman is pregnant? The symptoms in the beginning
are various and obscure, not only in different women, but even in
the same woman at different times, and are fallible until the end of
the fourth month of gestation. In the beginning, one or more of the
following indications sway our decision: a slight titillating pain, or
unusual disturbance about the womb and navel; nausea and reaching to
vomit in the mornings, loss of appetite, sudden unnatural cravings and
longings of the stomach, heartburn, drowsiness, slothfulness, chagrin,
capriciousness, dislike, moroseness, aversion to venereal dalliance,
headach, tooth-ach, increased secretion of saliva, tawny circle round
the eyes, and some perceptible alteration of countenance. But the
most unerring signs of pregnancy are by the touch and feel of the
accocheur’s finger introduced into the vagina, or rectum.
The womb, a small bag, in shape and size like a pear, situated within
the pelvis, between the bladder and rectum, and terminated at its
lower part by a soft tube, from three to six inches in length, called
the Vagina, begins in pregnancy to be enlarged. About the third month
of gestation, the womb is closely locked up, and the menses cease to
flow: but in some very rare cases, there is a serous gleet during
pregnancy, and in others plethoric, a small sanguineous discharge at
the usual menstrual periods. About the fourth or fifth month, the womb
is considerably distended, and its upper part ascends above the brim
of the pelvis; by the finger it is felt weighty and enlarged, its neck
shorter, and raised higher up in the pelvis; and the abdomen begins to
be distended above the pubis. About this period also, the mother begins
to be sensible of the infant’s motion. For although the heart and
arteries of the embryo, from its earliest, rudiments, are in action,
yet the other muscular efforts of the fœtus are seldom perceptible by
the mother until the third or fourth month, increasing in strength and
frequency to the end of pregnancy. Before the end of the fifth month,
the womb reaches up half-way between the pubis and navel; in the sixth
month, to the navel; in the eighth month, half-way between the navel
and stomach; in the ninth and last month, to near the lower part of the
stomach, filling up the whole anterior part of the abdomen. The uterine
enlargement is then not only perceptible to the hand pressed on the
abdomen, but is also obvious to the eye of the spectator. In different
women, however, the size of this protuberance is various. Towards the
latter stages of pregnancy, the mother’s breasts begin to enlarge, and
the circle or areola round the nipples, is of a brown colour.
Nine solar months, or thirty-nine weeks, or 273 days, reckoning from
the time of conception, is the usual period of uterine gestation in the
human species. But, as conception is often obscure, unless the limited
congress of the sexes can be ascertained, we must be guided by probable
conjectures respecting the ultimate completion of uterine gestation;
in which women themselves often err days and weeks. The usual way of
regulating puerperal books, or reckonings, is by going backwards, and
computing from the middle space between the last menstruation, and the
immediately succeeding menstrual period which should appear, but is
interrupted to support the fœtus. Some women are delivered of living
children considerably earlier than the end of the ninth month; and
others, probably, a little later.
The comparative growth of the fœtus infinitely surpasses that of its
whole future existence. But the exact age of uterine embryos, and of
abortives, is, in some degree, conjectural. Before the seventeenth
day after conception, its rudiments are not even visible to the naked
eye: the glary ovum has then slidden down from the ovarium, through
one of the lateral tubes into the womb. The size of an abortion,
comprehending the fœtus, its membranes, waters, and placenta, at the
end of six weeks, does not exceed in size that of a pigeon’s or hen’s,
and in three months, a goose’s egg. About the end of the fourth month,
its different viscera are formed; and its length between four and five
inches. At the end of the ninth month, the homunculus length, from head
to foot, is from sixteen to twenty-one, and in some even twenty-six
inches: its weight, from six to ten pounds. Some extraordinary fœtal
giants, however, have been seen, from ten to twenty pounds in gravity.
Its usual dimensions, so necessary to obstetrical knowledge, is, from
the forehead to the hindhead, four inches and a half; from each temple
the lateral dimensions three inches and a half; the circumference of
the head from twelve to fourteen or fifteen inches; the breadth of
the shoulders five or six inches, and of the breech nearly the same;
the circumference of the shoulders and of the breech, from fifteen
to eighteen inches. We might also have observed, that in gravity,
exclusive of placenta, membranes, and waters, the mature fœtus
exceeds considerably that of the whole menstrual blood, were it to be
accumulated throughout pregnancy.
In the womb, the fœtus is folded together into a round oval form; and
its usual position is with the head downwards, presenting at the upper
brim of the pelvis, and at the mouth of the womb; the chin resting on
its breast; one ear turned to the back part of the mother, the other
forwards; the face and hindhead to the mother’s sides; the thighs bent
up along the belly; the legs again bent backwards, with the heels to
the buttocks; the arms laid along the infant’s sides, or before its
breast. Thus folded together in a globular heap, it is wrapped up in
four delicate transparent membranes, and is immerged in water, which
continues decreasing throughout pregnancy, and at parturition is
various in quantity, from one to six pints. By its blood vessels united
into what is termed the navel-string, the fœtus is attached to a flat
round cake, resembling a firm coagulum of blood, called the placenta,
and which is closely cemented with the mother’s womb. In this natural
posture the mature fœtus lays above the pelvis, and totally within the
abdomen.
Previous to parturition, the fœtus must descend “inter scyllam et
charybdin,” through that ossious circumvallation, or bony cavity of the
mother, called Pelvis. This cavity is open, both above and below, and
is inclosed between the hips, groin, and lower part of the spine. The
female pelvis, for obvious reasons, is more capacious than in males.
In a well formed and proportioned woman, the common standard is at the
upper part of the brim, from the back part of the spine, or sacrum,
four inches and a half; laterally, or from side to side, five inches
and a half; below, at the lower opening of the pelvis, these dimensions
are exactly reversed. But as in parturition, the os coxcygis, or lower
bone of the spine, is elastic and moveable, on pressure backwards by
the infant’s head, the diameter of the pelvis below is thereby enlarged
in all its dimensions. The ossious depth of the pelvis, from the top
of the os sacrum to the extremity of the os coxcygis, is five, or
five inches and a half; at the sides four; before, or in the interval
between the groins, two inches. In some deformed and ricketty women,
the dimensions of the pelvis are either throughout, or in particular
parts, greatly contracted, and most commonly at the upper part.
Of _Parturition natural_, _laborious_, _preternatural_, _complex_, or
_anomalous_. Natural labours are all those in which the infant’s head
presents at the orifice of the womb; which are probably ninety-nine
out of every hundred labours. But in this presentation of the infant,
some are natural and easy, and a small number lingering and difficult
labours. Preternatural labours are either all those wherein any other
part of the fœtus spontaneously presents at the orifice of the womb, or
where, notwithstanding the natural presentation of the head, yet it is
necessary to turn the infant by force, and to deliver it by the feet
foremost. Complex and anomalous labours are those, whether natural or
preternatural, accompanied with extraordinary symptoms and danger, such
as floodings, convulsions, &c.
Labour or parturition is a salutary effort of nature, to expel
the contents of the womb by its own muscular contraction, and the
collateral assistance of the muscles of the abdomen, diaphragm, thorax,
back, and extremities. These exertions commence at intervals, called
Paroxisms, or Labour Pains, which are various in strength and duration,
from one to several minutes, and recurring at irregular intervals of
one minute, an hour, or more. The symptoms naturally preceding and
accompanying real parturition are, anxiety, shivering, violent pains,
shooting from the loins to the lower part of the abdomen or womb,
and extending down to the thighs; trembling of the thighs and legs;
frequent micturition, tenesmus, diarrhœa, and involuntary stools,
colick; the countenance and visage florid and red from the violence of
the muscular efforts, with profuse perspiration and sweats; softness
of the breasts, sinking of the abdomen in size, gradual dilatation
of the orifice of the womb, protrusion of the membranes through its
orifice in the form of a soft gut or bladder: in the absence of the
labour pains the membranes and waters are retracted, at length are
ruptured, when the fœtus may be felt with the finger introduced: next
ensue the spiral descent of the infant’s head through the pelvis,
dilatation of the external parts round the orifice of the vagina,
expulsion of the infant, its membranes and waters; separation of the
placenta, exclusion and extraction, together with some sanguineous
discharge. Natural labours are generally terminated within a few hours,
from 2 to 12 of real labour efforts; sometimes in a few minutes, and
with a trifling exertion or pain. In some warm climates labours are
alledged to be particularly easy.
But there are specious, or False labour pains, which are vague and
irregular in frequency and force, and do not produce any sensible
enlargement of the uterine orifice, and are not attended with any
mucous discharge: they are generally confined to the lumbar region and
abdomen, without extending down the thighs; they are most troublesome
towards night, and are relieved by clysters and opiates. They generally
are excited by one of the following causes, stretching of the womb,
erect posture, spasm in the intestinal canal, colick, costiveness,
distention of the bladder with urine, &c.
Of laborious, lingering, tedious, or difficult parturition. Every
labour in which the process is prolonged beyond 24 hours, may be
classed under this head, notwithstanding the natural presentation of
the infant. Sometimes the labour may continue several days, either from
the head not entering the pelvis, or, which is much more frequent,
from some impediment during its descent through that ossious cavity.
In these cases the woman becomes hot, thirsty, anxious, restless,
low-spirited; is afflicted with headach, nausea, sickness, vomiting,
incontinence, and difficulty of urine; she tosses incessantly, and
finds no comfort in any posture. During this struggle, the infant’s
head advances slowly, or stops at various parts in its descent; and
the intervals of labour paroxisms are various. It is by no means
necessary that childbirth pains should be incessant, or without
intervals of respite and rest. In some cases, tedious and difficult
labours may continue two, three, and even four days and nights, when,
after reiterated paroxisms, the infant may at length be excluded by
the efforts of nature alone: in some of these cases also, the mother’s
recovery is surprisingly expeditious, as if she had been delivered
in half the time; and unless some dangerous symptoms indicate, no
manual assistance will be necessary. It is an obstetrical axiom, that
in labours with the head presenting, the labour pains continuing
strong, the woman not deformed, the pelvis sufficiently capacious, the
constitution sound, not exhausted by labour pains nor weak, there is
the strongest reason to expect that nature will be adequate to the task
of delivery.
Indeed, the obstetrical cases, where instruments are required, are very
rare; and in such emergencies there is often much greater difficulty to
determine the ultimate propriety of employing instrumental aid, than in
the mode of using the few implements peculiar to the obstetrick art;
consisting principally of forceps, crotchet, and scissars. The danger
of the mother, from tedious and difficult parturition, is discernible
from her natural constitution, her debility, pulse, respiration, voice,
countenance, the duration of the labour, the weakness of the pains, or
their perseverance and severity, the space elapsed from the entrance of
the head into the pelvis, and from the rupture of the membranes. The
danger of the fœtus may be predicted from the time its head has been
pressed into the pelvis, and the violence of that pressure, especially
on the yielding cranial bones.
Preternatural labours are these wherein any other parts but the
infant’s head present at the orifice of the womb; such as the feet,
breech, shoulders, arms, and so on; besides those other cases in
which, although the fœtal presentation may be natural, yet, for
variety of reasons, and in dangerous emergencies, it is necessary to
turn the infant in utero, and to extract it by the feet. The signs
of the preternatural position of the fœtus are uncertain, until the
accocheur can touch the presenting part. But in all cases, natural
and preternatural, before the rupture of the membranes and evacuation
of the waters, it is often extremely difficult to distinguish by the
finger what part is felt. Preternatural postures of the infant may be
suspected, if the pains from the beginning are lingering, tardy, weak,
making little impression on the orifice of the womb, consequently
tedious labours; if the membranes are either soon ruptured, or are
pinched up into a conical form, like the finger of a glove; if no
part of the infant can even be touched until the uterine orifice is
moderately dilated, which remains high up in the pelvis, and when any
part of the fœtus can be reached, it is indistinct and irregular, and
generally small.
In some preternatural presentations delivery may be easy; but in
general, they are always precarious, often difficult and troublesome
to the mother and accocheur. After some continuance of labour the
membranes break; but still no bulky part descends, nor is the mouth
of the womb sufficiently dilated: at length the labour pains abate
in strength and frequency; sometimes they intermit during a few
hours, and, in some instances, a day or more. When we compare the
size of the fœtus and of the pelvis, the reason is obvious why in
cross postures, where the infant descends double, and is expelled
by the natural efforts of the mother, such cases will be difficult,
especially in first labours; and unless the child is very small, it
will often be born dead. It is true, Providence has wisely provided,
as far as possible, against puerperal compression, by the softness
of the buttocks, belly, and shoulders, and by the over-lapping of
the parietal bones of the infant’s head. Infants in the womb, we may
presume, are subject to diseases as well as casualties; but probably
the most frequent causes of mature abortives and stillborn, originate
from laborious, preternatural, and complex parturition; which cases,
as we observed, may be estimated at about _eight_ per cent.; but the
abortives and stillborn are not altogether three per cent.
In a pelvis not two inches wide at the brim, it is impossible for the
fœtus to descend alive through such a narrow passage. Deformity at the
brim of the pelvis is more difficult to detect than at the lower part.
Some pelvises have been seen not altogether one inch in diameter either
above or below: but, happily, such instances of deformity very rarely
occur. We have but eight examples on record during the last hundred
years in this island, three of them in London, and five in Edinburgh,
wherein it was thought necessary to have recourse to the dreadful
alternative of the Cesarian operation; that is, of cutting out the
infant by an incision made through the mother’s abdomen and womb; and
all these women died. During the above long interval of time, including
three generations, of fifty or sixty puerperal women in London, whose
pelvises were remarkably small and deformed, notwithstanding the
unavoidable necessity of recurring to obstetrical instruments, in order
to diminish and tear away the infant, yet not above five or six died.
We have instances, almost miraculous, where, after five days strong
labour, and a pelvis deformed and contracted in all dimensions, yet,
by obstetrical perseverance and skill, the woman has been delivered,
and has recovered. Instructed by these precedents, we may reasonably
expect, that two barbarous and ineffectual operations, the Cesarian,
and the modern attempt at improvement, by severing the anterior
cartilaginous juncture of the bones of the pelvis, will both hereafter
be for ever exploded, at least in this enlightened island.
Anomalous, or complex labours, are either natural or preternatural:
but at the same time are accompanied with uterine hemorrhage, with
convulsions, or with two or more fœtuses; and to these some add the
cases of instrumental delivery. It is natural and usual for the human
species, and for all large animals, to bring forth one at a birth:
twins often occur; tergemini are rare: four, or at least five, are
not perhaps seen in some millions of births. Plurality of fœtuses are
seldom attended with peculiar circumstances of danger. Twins do not
occasion much difficulty: they are generally small; and the remaining
fœtus is seldom discovered before the exclusion of the first, by which
the passage is stretched. Neither the number nor size, and much less
the sex of fœtuses, can be predicted: a large quantity of uterine
waters will sometimes produce a more prominent belly than twins,
especially if the infant is at the same time large.
The predisponent and occasional _causes_ of difficult, laborious,
lingering, preternatural, and complex parturition, are, on the part
of the mother, ricketty formation, and deformity of the pelvis; this
narrowness generally begins in infancy, and the common obstruction or
protuberance is at the jetting forward of the lower lumbar vertibra,
or of the os sacrum; the pelvis may also be too small, without any
deformity or projection; it may be too narrow from the fore to the
back part, above and below, and at the sides: the os coxcygis rigid;
too great resistance and rigidity of the uterine orifice, which
is a frequent cause; rigidity of the vagina and surrounding soft
parts; first child; the mother in years, or long intervals between
parturition; the womb too much distended and stretched, its irregular
contraction, oblique position; the membranes too soon ruptured by
nature or art, and the womb contracting closely before the infant’s
shoulders; the membranes rigid; the mouth of the womb strait, callous,
inert, irritable; its spasmodic constriction; the bladder distended
with urine; hardened feces collected in the rectum; piles; weakness
of the mother; tedious labour and fatigue; passions of mind; terror
and fear of the event; the mind and spirits broken, irritable; the
mother delicate, fat, torpid, plethoric; diarrhœa, profuse evacuations,
floodings, convulsions; heat, cordials, strong liquors; improper
fatigue and torment during labour, with fruitless and officious
endeavours in the accocheur to dilate the parts, and to expedite
delivery: the mother’s belly pendulous; tumours and cicatrices blocking
up the vagina; rupture of the womb; stone in the bladder. From the
fœtus erroneous in position, and different to the natural; in laborious
cases with the head detained at the brim, or after its descent into
the pelvis: such postures are vertebral, occipital, auricular, mental,
oral, facial. Of the preternatural and cross positions authors
enumerate; the neck, breast, shoulders, arms, hands, back, loins,
buttocks, breech, sides, belly, knees, feet. The fœtus may also be
detained by the whole being monstrous in size, or only in particular
parts; such as the head, shoulders, belly; the head dropsical; the
cranial bones ossified, and not yielding in its descent: the fœtus
dead, emphysematous, and blown up with putrid air: the navel string
twisted round its neck; two or more fœtuses entangled; twins growing
together; deformed monsters.
Having now finished the various processes of parturition, with the
perils and difficulties that encompass our immediate exit from the
shell, I shall return back to pregnancy, to explore the different
inconveniences and maladies that ensue in consequence of that state,
both before and after parturition: many of these are merely temporary
morbid symptoms; some of them rarely occur; others are attended with
trifling danger; and a few only with imminent hazard. We may include
all these troublesome symptoms, accidents, and diseases, under the
following heads; proceeding progressively from the beginning of
conception to the end of parturition, with all its train of evils.
These are nausea, indigestion, vomiting, pains in the stomach,
acidity, unusual cravings, headach, vertigo, costiveness, difficulty
and incontinence of urine, piles, varix, pains in the back and loins,
cramp, colick, fainting, œdematous legs and thighs, difficulty and
labour in breathing, retroverted womb, extra uterine conception,
superfœtation, graviditas perennis, moles and false conceptions,
rupture of the womb, protrusion or too low descent of the womb or
vagina, miscarriage and abortion, dead fœtus, uterine hemorrhage,
convulsions, irregularity of the lochia, including obstruction,
suppression or excess, inflammation of the womb, puerperal fever, milk
fever, weed, inflammation of the breasts, excess and defect of milk,
insanity.