COMPLICATIONS IN LABOR (Cont’d)
=Vomiting= in labor frequently occurs near the end of the first stage.
It is due to the sympathetic excitement of the nerves of the stomach as
the last fibers of the os uteri give way. It requires no treatment.
Hyperemesis in labor is very rare, but when it does occur, the delivery
should be expedited.
=Hæmorrhages= may occur either before, during, or after labor.
Hæmorrhage is always serious.
Hæmorrhage before labor arises either from a premature detachment of a
normally implanted placenta or from placenta prævia. The first is
sometimes called “accidental hæmorrhage” to distinguish it from the
latter, or “unavoidable hæmorrhage.”
=Accidental hæmorrhage= may be the result of an injury or a blow, but in
many cases, there is no such history. The hæmorrhage is most frequent in
the later months of pregnancy, and may be without any apparent cause.
The hæmorrhage may be entirely inside the uterus (concealed hæmorrhage)
or it may appear externally.
The hæmorrhage, when concealed, takes place back of the placenta or
between the membranes and the uterine wall. If the hæmorrhage is
concealed, it is usually followed by an attempt to expel the child. If
the hæmorrhage is pronounced, systems of shock appear.
_The diagnosis_ is made by the symptoms which are summarized in
differentiating this condition from placenta prævia (p. 231).
From this affection, nearly all the children and half the mothers die.
[Illustration: Fig. 99.—Various forms of placenta prævia compared with
normal attachment of the placenta. (American Text Book—Williams.)]
When the hæmorrhage is external and slight, the _treatment_ may possibly
be expectant for twelve hours, if carefully watched, but usually the
symptoms become so serious that immediate emptying of the uterus is
required either by the Vorhees bag, digital dilatation, version and
extraction, or Cæsarean section, the method chosen being dependent upon
the amount of the hæmorrhage, the vigor of the mother and the condition
of the cervix, os, pelvis, and child.
=Placenta prævia= is the name given to a placenta that is attached low
down in the uterus so that its margin or a large part of its mass
overlies the os. This happens through the action of the egg which embeds
itself too far down on the endometrium—too close to the cervix.
Three different kinds are known and named from their manner of
encroaching on the os, as marginal, partial, or central implantation of
the placenta.
The hæmorrhage is from a loosening of the placental attachment owing to
the stretching and growth of the uterus.
_There is only one symptom of placenta prævia—sudden, painless,
causeless hæmorrhage._ The bleeding seldom appears before the
twenty-eighth week, and no suspicion of a placenta prævia may arise
before the appearance of hæmorrhage, which, as a rule, _is soon
repeated_.
Labor frequently comes on prematurely and malpresentations naturally
result from the inability of the presenting part to fit itself into the
pelvis.
There is no bag of waters, hence the first stage is longer and bloodier
and fraught with much danger.
Interference is regularly indicated to save the life of the mother,
while the child also has a high mortality. Puerperal infection is not
uncommon.
Placenta prævia is always an emergency. If the patient can be kept under
observation in a good hospital, one may temporize, but under other
conditions the uterus must be emptied at once, even if only a single
hæmorrhage has developed. The indications are, (a) to control the
bleeding, and (b) to empty the uterus. The life of the child must be
disregarded and the mother alone considered.
If the contractions have not begun, they should be stimulated by the
introduction of a Vorhees bag, which, at the same time, dilates the
canal and mechanically shuts off the bleeding vessels by compression. In
introducing the bag, the membranes may be ruptured so the bag will pass
into the uterine cavity. When the implantation is central, the finger
must tear a hole through the placenta, and through this opening pass the
bag inside the uterus.
If the os is partially dilated, version may be done, and a foot brought
down. The leg may then be pulled upon until it compresses the bleeding
area and the traction maintained with a slowly developing pressure
sufficient to check the hæmorrhage, until dilatation is advanced enough
for delivery. Occasionally good results are obtained by tightly packing
the cervix and vagina with gauze or cotton. (See Vaginal Tampon, p.
204.)
Cæsarean section may be done in the interests of the child, as well as
the mother.
The fœtal mortality in placenta prævia is said to be 60 per cent and the
maternal 10 per cent.
_Differential diagnosis between_
_Accidental hæmorrhage_ _and_ _Placenta prævia_
Usually occurs in later months. Any time after the twenty-eighth
week.
May be concealed or open. Always open and external.
Soon followed by labor pains. Labor need not occur.
Uterus becomes larger if bleeding Uterus remains same size.
is concealed.
Uterus hard and woodeny. Uterus, normal consistency.
In severe cases, signs of shock In severe cases, signs of shock
whether hæmorrhage is external or follow the invariable external
internal. hæmorrhage.
No placenta can be felt. Placenta can be felt through the
os.
Hæmorrhage continues. Hæmorrhage intermittent.
No history of previous attack. Possibly history of previous
attack.
No contractions after labor begins Contractions as usual.
in serious cases.
No bogginess of cervix. Cervix boggy.
Hæmorrhages may occur _during labor_ from retention of the major part of
the placenta while a portion is detached. This may be due to
pre-existent disease, such as endometritis, or from uterine inertia.
Normally the placenta will separate and be discharged within an hour
after labor and in the absence of hæmorrhage it may go even longer than
this with safety. The occurrence of severe hæmorrhage, however, requires
the immediate cleaning out of the uterus by inserting the hand and
peeling the placenta from its attachments.
=Post partum hæmorrhage= includes all hæmorrhages that occur after the
delivery of the placenta.
The “flooding” as it is called by the laity, is most apt to come on
either immediately or within an hour or so after labor. If it comes on
_after_ the first twenty-four hours, it is called secondary hæmorrhage.
Such predisposing causes as over-distention from twins may be present,
but the hæmorrhage may follow a perfectly easy and apparently normal
labor so suddenly and so profusely that the woman may die in half an
hour.
There are four causes for post partum hæmorrhage: namely, (a) uterine
exhaustion (atonia uteri); (b) mechanical obstacles to retraction, such
as clots or retention of pieces of placenta or membrane; (c) and
lacerations of some part of genital passage, such as the vulva, vagina,
cervix, or lower uterine segment; and (d) the systemic condition known
as hæmophilia.
“Bleeders” (hæmophilias) are women whose blood lacks coagulability,
owing to the absence of fibrin-producing elements.
Post partum hæmorrhage is usually an external hæmorrhage, but the woman
may bleed to death into her own uterus.
Besides the external signs, the patient may show the symptoms of acute
anæmia, such as the rapid pulse, hurried, shallow respiration, pallor,
cold sweat, yawning, dizziness, etc.
Nearly all these cases can be saved by prompt recognition and efficient
_treatment_.
The first step is to grasp the uterus. If the hæmorrhage is due to a
tear low down, the uterus may be hard, but generally it is relaxed and
requires vigorous massage with both hands before it shows any signs of
contraction. In the absence of the doctor, the nurse must know how to
undertake this maneuver. The uterus, after labor and especially when
relaxed, is sometimes difficult to identify and the nurse can only make
deep massage in the pelvis until the organ responds and its hard
globular mass can be appreciated. As soon as the uterus contracts, clots
and contained blood are expelled, and in many cases its bleeding ceases
at once. (See Conduct of Third Stage, p. 149.)
It may be necessary to keep the uterus contracted by manual massage in
this way for several hours. As soon as possible, the nurse, or someone
whom she directs, prepares a hypodermic of pituitrin—10 to 15 ♏︎. An
injection of ergot may follow because its effect is more lasting than
pituitrin. Next, a hot douche is made ready and the materials for
packing the uterus are assembled.
When the doctor arrives, he sterilizes his hands, puts on gloves and
introduces two fingers or the whole hand into the uterus to remove clots
or any retained fragments of placenta.
The hot intrauterine douche may follow, and if the contraction is not
firm and the hæmorrhage checked, the uterus must be packed with gauze.
If hæmorrhage comes from cervix, it should be grasped with long forceps,
pulled down, and sutured. If from perineum, pack first, and afterward
sutures may be introduced.
If the patient is exsanguinated, the foot of the bed is raised, coffee
given by mouth, camphorated oil hypodermically, and normal saline
transfused under the breasts.
Pituitrin may be continued in larger doses. 1 c.c. will raise the blood
pressure very definitely. Adrenalin also may be employed for this
purpose.
The following summary may be found convenient:
=Post Partum Hæmorrhage=
_Etiology, Functional.—_
Atony of the uterus, especially after rapid artificial or natural
emptying of the organ.
More common after uterus has previously been greatly distended.
Premature version and extraction.
Hydramnios and twins.
Imperfect development of uterine musculature.
Precipitate labors.
Haste or improper management of third stage.
_Etiology, Mechanical.—_
Retention of placenta—partial, total or solitary cotyledons.
Inversion of the uterus.
Placenta succenturiata.
Inflammation of decidua serotina.
Conduct of third stage, i.e., wait until placenta separates.
_Etiology, Systemic, Hæmophilia.—_
_Kind of hæmorrhage._
Hæmorrhage _before_ expulsion of placenta due to laceration of the
soft parts, or
Partial release of placenta and failure of uterus to contract, or
Placenta may be attached to periphery or to one side.
Attempts to expel placenta without waiting for uterine contraction
are sometimes productive of hæmorrhage.
Hæmorrhage _after_ expulsion of placenta.
Hæmorrhage in interval between pains—comes from placental site.
Hæmorrhage in stream not checked by uterine contraction is due to
laceration of the canal.
Hæmorrhage in abnormal quantities at beginning of pains.
Pure atony—comes early.
Hæmophilia again.
_Diagnosis.—_
Palpation of uterus through abdomen.
Placental site excluded from contraction (paralysis).
View of vulva.
Injuries. Flow continuous, fluid and bright red, shows arterial
origin, probably from cervix. Examine.
Atony—bleeding at intervals, clotted and dark.
Hæmorrhage from a tear begins at once.
Uterus contracted and hæmorrhage continues. Look for tear.
If hæmorrhage does not begin within ten or fifteen minutes after
labor it is not from a tear.
Always have hæmophilia in mind.
_Management.—_
Third stage must be conducted properly.
Before expulsion of placenta—early expression.
Credé or manual removal—then secure contraction by massage.
Pituitrin, Ergot, or both.
_After Third Stage.—_
Restore an inverted uterus. Repair lacerations. See that cavity is
clear and clean.
Massage, intrauterine hot water douche, hand in uterus and hand
outside and rub, ergot.
Pituitrin hypodermically. Pack uterus with sterile gauze or weak
iodoform gauze. Strict asepsis for all intrauterine maneuvers.
_Treat_ anæmia with transfusion, elevation of foot of bed, coffee,
external heat, hot rectal enemas, stimulation, bandaging of
legs.
Strychnine sulphate, adrenalin, or camphorated oil may be required
in usual dosage.
Hypodermoclysis. (See Minor Operations, p. 206.)
After the bleeding stops, the food must be most nutritious—milk, eggnog,
rich soups, chicken and mutton broths, oyster stew, and beef steak as
soon as she can take it. A diet of fluids and stimulating foods that
raise the blood pressure will most quickly relieve the symptoms.
[Illustration: Fig. 100.—The knee-elbow posture. (Bumm.)]
[Illustration: Fig. 101.—The knee-chest posture.]
=Eclampsia= occurs in the last three months of pregnancy as a rule, and
most frequently just before or during labor.
In about one sixth of the cases only, the attack may follow labor. The
attack is characterized by violent convulsions, which come on with
little or no warning unless the urine has been carefully watched.
[Illustration: Fig. 102.—The exaggerated lithotomy position obtained
with a sheet sling. (American Text Book.)]
[Illustration: Fig. 103.—The improvised Trendelenburg position.
(American Text Book.)]
The _prodromal symptoms_ have already been described under albuminuria
in pregnancy (p. 77). The marked features may be repeated for emphasis:
_persistent headaches_, _disorders of vision_, spots before the eyes,
blindness, edema of cheeks, eyelids, feet and hands, _pain at the pit of
the stomach_, _dizziness_, _nausea and vomiting_ and ringing in the
ears. Suddenly the convulsion occurs, the facial muscles twitch, then
the limbs and body are shaken by violent muscular spasms. The body
becomes rigid, the tongue protrudes and the face is livid and cyanotic.
The spasm usually lasts from one to five minutes and is succeeded by
coma that lasts an hour or more. In some instances there is no return to
consciousness before the next attack, which comes on every hour or half
hour, though occasionally only one seizure is noted.
[Illustration: Fig. 104.—The dorsal position with stirrups. (Dorland’s
Dictionary.)]
The blood pressure is greatly increased and the urine is diminished, the
temperature rises to 101° or 102° F. When death ensues, it is most
frequently due to edema of the lungs or cerebral hæmorrhage.
The greater the number of convulsions, the more serious the outlook as
to life, and it is said that after twenty seizures fifty per cent of the
mothers die. Under the best treatment approximately fifty per cent of
the babies die.
[Illustration: Fig. 105.—Dorsal position across the bed. (Bumm.)]
There is no routine treatment for eclampsia.
The principles of management for the attack are (1) to empty the uterus,
on the theory that the disease is a toxæmia of gestational origin, (2)
to eliminate the poison, and (3) to control the convulsions.
The albumin in the urine and other eclamptic symptoms demand urgent
attention in prophylaxis.
For the pre-eclamptic period (see Albuminuria of Pregnancy, p. 77) a
rigid milk diet is indicated. The bowels, kidneys, skin and blood
vessels must all be brought into service.
In the full blooded patient, venesection may be done and after drawing
off ten or twelve ounces of blood, an equal amount of normal saline may
be poured into the same vein.
[Illustration: Fig. 106.—Flexed dorsal position with feet on the table.
(American Text Book.)]
Subcutaneous transfusion or the submammary introduction of saline
solution may be done. The skin is stimulated by hot wet packs and the
bowels by saline cathartics and frequent irrigation of the colon.
During the attack, the patient must be kept from injuring herself. A
spoon wrapped in gauze or a small, long roller bandage should be slipped
between the teeth to keep the tongue from injury. The clothing must be
loosened or removed. No food, but only water is given by mouth, until
the patient is conscious.
The convulsions are controlled by morphine, chloral, or both.
Morphine sulphate, ¼ gr. is given hypodermically, followed in an hour by
30 gr. of chloral by mouth. Two hours later the morphine is repeated and
six hours after the first dose of chloral, it is repeated. In this
method (Stroganoff’s), four doses of chloral and six of morphine are
given in twenty-four hours. That is all. When the stomach will not
retain the chloral it may be given by rectum in milk. If a general
anæsthetic is used, it should not be chloroform, but ether.
[Illustration: Fig. 107.—The Sims position. (Kelly.)]
The labor, if begun, should be expedited by forceps, or version and
extraction. Bleeding during delivery should be looked upon as desirable.
If more rapid measures of delivery seem demanded and obstacles exist,
such as pelvic contraction, imperfect dilatation, or the prospect of a
prolonged first stage, Cæsarean section or forcible delivery
(accouchment forcé) may be attempted.
If the labor has not begun, when the convulsion occurs and a quick
delivery by the normal passage does not seem feasible, then the Cæsarean
operation may be the best treatment.