The Matron's Manual of Midwifery, and the Diseases of Women During Pregnancy and in Childbed / Being a Familiar and Practical Treatise, More Especially Intended for the Instruction of Females Themselves, but Adapted Also for Popular Use among Students and Practitioners of Medicine

by Frederick Hollick

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.

Plate XL.

Represents the standard form of the Pelvis.

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).

Plate XLII.

Represents the peculiar deformity most frequently produced by Mollites Ossium.

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.

PLATE XLV.

This is a section of a Pelvis to show the effect of a corroding disease of another kind. The whole of this is such a mass of disease and deformity as to preclude any particular description.

Plate XLIV.

This is another deformity, in which one side is sunk below the other, and both twisted round the sacrum.

Plate XLV.

The effect of corroding disease.

Curvature of the spine sometimes affects the pelvis, when low down, and therefore if any female is affected with it she should not marry before being examined. Several diseases and lesions of the hip-joint, and of the thigh, may also do the same, and should therefore be suspected.

In the great majority of cases, deformities of the pelvis remain unknown, till the period of delivery, and all that can be then done is to combat in the best possible way the difficulties they create. It is evident that the amount of difficulty depends entirely on the disproportion between the head of the child, and the passage through which it has to be born. If the head be large and the passage small the difficulty will be greatest, but if the head be small it may pass through the pelvis though under its average size. The development of the head cannot be ascertained however, before birth, except when it is unusually large from dropsy, and it is therefore always assumed to be of an average development, and the pelvis is compared accordingly.

The kind of assistance required in these cases depends chiefly on the measure of the pelvic diameters, though it may be modified somewhat by other considerations.

When the smallest diameter of the pelvis measures from three inches and a half to three inches, it is customary to leave the expulsion of the fœtus to nature, and it is generally effected, though slowly and with difficulty. If however the patient becomes exhausted, or the head be unusually large, the forceps are generally used after waiting five or six hours. In these cases the head often becomes firmly fixed in the upper strait, so that great force is needed to dislodge it. The upper part passes through, owing to the overlapping of the bones, and the scalp then bulges out like a large tumor, from being engorged with blood and serum, but the lower being more unyielding remains behind. It is therefore impossible for the head to move either way, as it is formed like a figure 8, and held by the narrow part, as will be seen by the following plate.

PLATE XLVI.

This Plate represents the head fixed, or impacted, at the upper strait of a narrow pelvis.

When the smallest diameter is not more than from three inches to two and a half, the birth is sometimes effected by nature, but with extreme difficulty. The accoucheur waits four or five hours, as in the former case, and then if no progress is made he applies the forceps, using great care in doing so. If the extraction is found impossible, with reasonable force, the head must be opened and made smaller, even though the child be living, because it is more proper to sacrifice it than to risk the life of the mother. In a case like this however, no one person would like to decide, unless in a great emergency; there should always be a consultation if possible.

A dwarf, named Lepratt, who used to perform at the theatres, was delivered with the forceps by M. Dubois, though the pelvis only measured three inches. She perfectly recovered, though the child was born dead: it was of fair average size.

It is contended by some that the delivery may be effected, under peculiarly favorable circumstances, when the passage measures only two and a half inches, and at all events the effort should be made; but for the sake of the mother such cases should not be left long, as the chance is so small, and the risk of delay so great. When the passage is less than two and a half inches, spontaneous or artificial delivery is allowed to be impossible, and the only alternatives then are to dismember the child or open the mother. Which of these should be done depends on circumstances. Whenever the child can be brought away by the natural passages, though it be piecemeal, it always is so brought, unless the danger to the mother be greater than by the cesarian operation, in which case that operation is resorted to. By means of an instrument called the Cephalotribe, which crushes the head, the child may be brought away, unless very large, when the pelvis only measures two inches. When the passage is less than two inches, the only resort is to the cesarean operation, which sometimes succeeds, and saves both mother and child, though more frequently the mother sinks.

The necessity for all these frightful operations is now much less than formerly, and may be done away with altogether. This important fact should be known universally, and also the means to be resorted to. In the first place, every young female should be examined, before marriage, by a competent person, if there be the slightest reason to suspect deformity; and in case the deformity is found to exist, the consequences if she becomes pregnant, must be laid before her. If, after being told this, she will marry, or has already done so, the means of avoiding conception should be placed at her disposal, so that she may not be made, of necessity, a helpless victim. These means need not be described here, though I have no hesitation in referring to them. When I know that the life, or life-long health, of a female, depends on her not becoming pregnant, I consider it my duty to put such means at her disposal, if she desires it. In many instances I have known females suffer, several times, the most frightful tortures, merely to bring into the world the mangled fragments of a dismembered child, with the greatest risk to their own lives; and in others I have known them in constant dread of becoming pregnant, because they were conscious it would be their death warrant. In such cases I leave it to humanity, and common sense, as to whether such information should be withheld? I could not reconcile it with my notions of duty to withhold it.

In case pregnancy has occurred before the deformity is discovered, and it is then found that a full grown child cannot be born, premature delivery must be brought on; or, in other words, the Uterus must be made to expel the child before the full term, while it is yet small enough to pass through the Pelvis. This operation is of course only allowable when needed to preserve life, or to escape great suffering and danger. It must always be decided upon by the medical man, and performed by him, so that a description of it is uncalled for here. In Europe it is quite common, and nothing has tended so much to do away with those disgusting and horrid operations, on mother and child, which were formerly absolutely necessary in cases of deformity. If it is found at the first delivery of a female, or before, that she cannot bear a living child at full term, artificial delivery is accomplished at seven or eight months, thus avoiding all the danger to the mother, and frequently preserving the child. In the case of the dwarf before referred to, when she became pregnant the second time, M. Dubois brought on premature delivery, and the child was born alive, with but little difficulty. According to statistics it appears that, when artificial premature delivery has been induced, in one hundred and sixty-one cases only eight mothers have died, and all but forty-six of the infants were born alive. Of the whole number of children seventy-three continued to live; and of the eight mothers five died from other causes, leaving but three whose death resulted from the operation. Now when the fearful number of deaths from instruments, and other operations, necessary at full term, is recollected, the advantage of this practice will be evident. In the Cesarian operation for instance, which is often the only remaining resort, but one female out of six recovers.

The delivery should be postponed as long as possible, so as to give the best chance for the child living. This must of course be decided upon after the size of the pelvis is ascertained. Seven months is the earliest time at which the fœtus is viable, and it is much better left till eight, if the size of the parts will allow of its birth then. In case they are so small that it cannot be born even at seven months, we have our choice, as M. Chailly remarks, between the dreadful Cesarian operation at full term, and producing early miscarriage.

M. Dubois seems to recommend premature delivery in nearly all cases, if the smallest diameter is under three inches; because, as he remarks, spontaneous delivery at full term is then a very rare exception, and the danger and suffering to the mother is so great. He also recommends it when there are tumors, and even when the female is afflicted with any acute disease. Of course it is always necessary, before operating, to be sure that the child is alive.

I knew a lady myself who had given birth, at full term, to seven children, all of which were torn from her with instruments, dead, owing to the smallness of the pelvis. When pregnant with the eighth, premature delivery was brought on, at my suggestion, at about seven months and a half. The fœtus was born with comparative ease, and lived. But for this operation she probably would never have been blessed with a living child at all. Since then she has avoided conception.

TUMORS IN THE PELVIS.

Tumors of various kinds are met with, both in the bones of the pelvis and attached to the soft parts. They frequently offer the most serious impediments to delivery, and baffle the skill of the most experienced obstetricians. In fact they differ so much in their structure, their size, and their situation, that but few general directions can be given as to their management. In every case where one exists pregnancy should never occur, if possible to be prevented, before it is removed; for though it may cause no inconvenience at other times, yet during delivery it may necessitate very serious operations, or even cause death. Some of these tumors are mere vesicles, or bags, filled with fluid, and may be punctured and their contents let out, so as to make them less. Others are more or less solid but moveable, and may often be supported above the upper strait till after the child is born. When they are so large as to block up the passage, and are either fixed or cannot be carried up into the Womb, there is often no other choice than to either cut them out or open the child's head; the practice being determined by the circumstances of the case. In some instances the bladder itself, distended with urine, has impeded delivery, and been mistaken for a tumor; and in other instances stones in the bladder have caused the same error.

A specimen of one of these tumors is represented in Plate XLVII, and one of a Polypus in Plate XLVIII.

PLATE XLVII.

This represents an Ovarian Tumor, which has descended before the head of the child, and completely blocked up the passage. The delivery, it will be seen, is utterly impossible in such a case, unless the Tumor can either be pushed away, or reduced in size.

Plate XLVII.

Case of Tumor.

PLATE XLVIII.

This Plate represents a case which occurred in the practice of Dr. Ramsbotham, and which terminated favorably. The polypus had a very long neck, and was forced out of the external opening by the child, which was then born with ease. I once saw a case myself, in which the labor was completely arrested by a large hard tumor about the middle of the Vagina; it could not be moved, and delivery was evidently impossible while it remained. In consultation it was decided to cut it out, as there seemed but little circulation of blood in it, and its situation was favorable for the operation. This was accordingly done with but little trouble, and the child was born without difficulty in about twenty minutes after. The mother perfectly recovered.

Plate XLVIII.

Case of Polypus.

TUMORS EXTERNALLY.

Sometimes tumors exist externally, on the lips, or in the Vulva, but as they seldom offer much obstruction, and are easily detected and managed, but little need be said about them. They should always however be attended to, if discovered, before labor comes on, or better still before pregnancy.

In some instances the veins around the Vulva become much enlarged, and resemble tumors, and sometimes even impede delivery. It is usual then to open them, and let out the blood, but not till the head is sufficiently low to press upon it and prevent dangerous bleeding.

OBSTRUCTIONS IN THE VAGINA, AND NARROWNESS OR OBSTINATE RESISTANCE OF THE VULVA AND PERINEUM.

The Vagina may be partly closed by its sides growing together, or it may be united by bands and membranes stretching across; and these obstructions may be sufficient to impede or prevent delivery. Most usually they give way, and are gradually broken down by the pressure of the child's head; but if they prove too strong, after waiting a reasonable time, they must be cut through. Cases have even been known in which the hymen has been found perfect at delivery, and even offered considerable resistance, so as to necessitate its being cut through before the child could be born. In such cases this membrane is unusually strong, and conception occurs without its being broken.

When the perineum or Vulva remains rigid and hard, so that the opening cannot be enlarged sufficiently for the child to pass, it may also be necessary to operate with the knife. But this should never be done till after every means of relaxation has been tried, and the head has been kept back as long as prudent. It is however, always better to open a passage than to let one be torn, because it may be made in the most favorable place. When the perineum is allowed to be torn, the most serious consequences often ensue, and the patient is made a miserable sufferer for life. The Vagina and Rectum may be torn into one, or the power of retaining the contents of the intestine, or bladder, may be for ever lost. When an incision is made none of these evils follow; the wound speedily heals, and in a little time no trace of it can be seen. It has even been necessary to cut the neck of the Womb, when it would not open, to prevent the organ from being ruptured; and this has been done with perfect safety. A celebrated practitioner in this city had to perform such an operation very recently, on a female who had injured herself, and made the mouth of the Womb grow together, by violent attempts to produce abortion. The delivery took place with comparative ease, and no unpleasant results whatever followed, either to the mother or the child.

CHAPTER XX.

CAUSES CONNECTED WITH THE CHILD, OR CHILDREN, WHICH MAY IMPEDE DELIVERY, OR MAKE IT DIFFICULT AND DANGEROUS.

PROCIDENTIA OF THE UMBILICAL CORD.

This means the escape of a portion of the cord before the child itself. It is most frequent in the irregular presentations, as they do not so fully close up the mouth of the Womb, and it is most likely to occur at the commencement of labor, though not impossible at a later stage. Very often the cord descends when the membranes break, being carried down by the rush of the waters; and sometimes it is already in the sack, or bag, before the rupture takes place. This accident is comparatively frequent, being found to occur as often as once in about three hundred cases.

The causes which produce procidentia of the cord, are most likely these:—A large quantity of liquor amnii, and its sudden discharge,—Unnatural presentations,—Deformities of the superior strait of the Pelvis,—A very long cord,—and rupturing the membranes too early. But it may also happen from other causes with which we are unacquainted.

There is seldom much difficulty in detecting this accident, because if the membranes are broken it protrudes into the Vagina, and if they remain whole it can be felt within the sack, and its pulsation will be quite distinct. Sometimes, it is true, it may be so firmly compressed, between the fœtus and the walls of the pelvis, that its pulsation may be very indistinct, or even totally suspended for a time; but this only necessitates a little extra care.

Procidentia of the cord may be very serious for the child; in fact, it is a frequent cause of its death. The reason of this will be evident when the functions of the cord are borne in mind. The circulation in it is as necessary for the life of the child before birth, as breathing is after, and when protruded first it can seldom escape being so pressed upon as to stop its circulation, and hence the danger. To the mother it makes no difference whatever, unless it be told and alarm her; or unless violent efforts are made to correct it. She had therefore better not know if it occurs.

If assistance is not rendered in this accident the consequences are almost always fatal to the child, though in some instances the cord has remained hanging from the Vulva several inches, for an hour or more, and still the infant has been saved.

If the fallen cord is detected before the membranes are broken, it may frequently be put back into the Womb without much difficulty. The accoucheur must wait till the mouth of the Womb is fully dilated, and then watch his opportunity, in an interval between two contractions, to push the cord upwards, between the fœtus and the uterine walls. If he succeeds in this, as is usually the case, he must then break the membranes during the next pain, and this will bring the presenting part at once into the upper strait, and so block up the passage. To effect this manœuvre it is requisite to introduce two or three fingers, and sometimes even the whole hand. It must never be attempted till the mouth is fully dilated, otherwise the membranes may be ruptured too soon, and the delivery be delayed, thus increasing the danger.

After the rupture of the membranes the replacing of the cord becomes a much more difficult matter, and frequently cannot be effected at all; particularly if the head be descended far down. Every effort however must be made, and if unsuccessful the delivery should be hastened as much as possible. In many such cases the forceps are applied, and the child brought away at once, because every moment's delay increases the risk to its life.

Several different kinds of instruments have been invented to return the cord, but they are seldom at hand when needed, and none of them are so good as the hand itself.

If the return of the cord cannot be effected, and the progress of the labor will allow of it, the hand is introduced and the child turned, unless the position of the head will allow of the advantageous application of the forceps, in which case they are mostly resorted to. The only general rule is, to terminate the labor as speedily as possible, consistent with the welfare of the mother. In spite of all that can be done the pulsation is often found to cease, and when the child is born it is either quite dead or breathes but a few times.

A very frequent indication that the fœtus suffers from compression of the cord, is a greenish color of the water discharged, owing to the discharge of Meconium from the child's bowels. This is brought about, most probably, by its straining, and its efforts to relieve itself.

SHORTNESS OF THE CORD.

The cord is sometimes too short, and this may operate very unfavorably in many ways. It may keep the fœtus up in the Womb, and prevent it from descending to the bottom of the Vagina,—it may cause the placenta to be torn away too soon, and so lead to serious flooding,—it may pull down and invert the Womb,—or it may make the labor very tedious, and cause the death of the child.

Unfortunately there are but few signs of this accident, even after the rupture of the membranes, and none at all before, that can be depended upon. If the head has descended properly, and the parts be fully relaxed, but still the expulsion is delayed from no obvious cause, it may reasonably be supposed that shortness of the cord exists; and if so there is very soon given a proof of it by a discharge of blood. This is owing either to the breaking of the cord, or to the separation of the placenta, and is frequently the first intimation the assistant has of the accident. All that can be then done is, to conclude the delivery as soon as possible, and in the best way that circumstances will allow.

In some cases the cord is not too short absolutely, but is made so by being twined round the body or limbs of the child, which are often cut off by it. M. Tasil saw a case where the cord round the neck had nearly severed the head; and Montgomery gives several instances in which the limbs had been amputated in this way. Two of these are represented below:—

PLATE XLIX.

Fig. 1.

Fig. 2.

Limbs cut off by the Cord.

Occasionally the cord can be slipped over the head, or limbs, when wound round them, and the strain upon it be thus removed. If this cannot be done however, and the danger increases, relief may be obtained by cutting the cord, particularly if it be absolutely short. But this must not be done till everything indicates that the labor will probably soon terminate; and the end connected with the child must be carefully held, or tied.

DESCENT OF OTHER PARTS WITH THE HEAD.

One Arm.—The descent of one arm along with the head may cause some delay and difficulty, but Nature nearly always overcomes the impediment. It is seldom that the arm can be reduced, and therefore but little can be done at first; if the delivery be evidently arrested by it the accoucheur must at last assist in the most feasible manner. Sometimes even it is necessary for him to apply the forceps.

The Two Arms.—Even this difficulty is often overcome spontaneously, though much more rarely than the former one. As soon as it is detected, the accoucheur must endeavor to return one or both of the limbs, if the labor has not proceeded too far; and if he cannot succeed the delivery must be accomplished as soon as possible, either by turning or with the forceps, unless there be reasonable ground for delay.

The Feet.—Either one or both of the feet may also descend with the head, at first, though they usually recede and allow the head to be born alone. When they are so impacted as to prevent the delivery being completed, the accoucheur must interfere. In most cases he will find it quite easy to push the feet above the head, and allow that to descend alone; but if this is not possible he must introduce one hand, grasp the feet with it, and pull them down, while the other pushes the head up. This will turn the child, and if it be in no immediate danger, and the mother is not suffering, the rest may be left to nature; but if the contrary is the case, the delivery must be finished as speedily as possible. When the head is very low down it may be necessary to use the forceps, but great care must be observed not to grasp the feet along with the head when using them.

A Foot and Arm.—The proceeding is the same as with the foot alone. If the limbs cannot be returned the head and arm must be pushed up, while the foot is brought down.

TWINS AND TRIPLETS.

In most cases where there are two or more children the delivery is easier than with one, because they are generally small, and the first one so prepares the way that the rest are born without difficulty. It is also a fact that twins are nearly always born before full term, and consequently are not quite grown.

The expulsion of the second fœtus usually takes place, immediately after the first, though sometimes the Womb stops contracting, and it is not born for half an hour or more, and it may even remain for hours or days. It is a question whether, in such a case, the second delivery should be left for Nature to finish, or whether the accoucheur should terminate it sooner artificially. The most general practice is to wait only about half an hour, and then, if the Womb is still inert, use friction, or other necessary means, to excite it, and accomplish the second delivery as soon as possible. If there be more than two the proceeding is still the same.

Some difficulties may arise however with twins, which it is necessary to be prepared for. Thus the two heads may come together, and mutually impede each other. In this case the one which moves the easiest must be pushed up till the other is descended sufficiently low. One head may also descend with one or two feet; in which case, if the feet cannot be returned, the head must be pushed up, and they must be brought down. The force exerted however, must not be very great at first, because one may belong to each of the children, and much injury may be done; a little gentle traction will soon detect this however, with ordinary care. If two arms, or one arm and a foot descend, the same care is also required, before pulling upon them, to ascertain that they are not parts of the two children. Sometimes when the head of one twin descends along with the feet of the other they may, if small, descend together. But if this is impossible, and interference is needed, we must first try to push up the head; and if this cannot be done, it must be drawn upon, not the feet; because if the feet were drawn down the two children would soon occupy the passage together, body and head, and would perhaps become firmly wedged. In nearly every case one of the twins presents by the head and the other by the feet, as formerly shown.

EXCESSIVE SIZE OF THE FŒTUS, OR THE DISEASED DEVELOPMENT OF CERTAIN PARTS.

Fœtus too large.—It is very rarely the case that the Fœtus is so large as not to pass easily through a well-formed Pelvis, though such cases have been known. The mode of proceeding is of course precisely the same as if the pelvis were too small. If no means will succeed in abstracting the Fœtus whole, it must be made less; but Nature should be first allowed full time to act with all her force.

Hydrocephalus.—This consists of an accumulation of water in the head of the child, and is usually termed watery head. The bones of the cranium will sometimes be widely separated by it, and the head be made so large that it cannot possibly be born till made less. The causes which produce this disease before birth are unknown.

In cases of hydrocephalus the head does not descend into the straits, owing to its size, and is felt to be full and firm, during a pain, but soft and yielding during the intervals, especially at the fontanelles and sutures, which are also very large. The bones are usually very wide asunder, or even totally separated, as if floating in the fluid.

In some cases, when the quantity of fluid is but small, the delivery may terminate spontaneously; the head lengthening, from being so soft, and thus adapting itself to the size and form of the strait. Most frequently however, assistance is rendered in such cases, either by the forceps, which will sometimes succeed, or by puncturing the head, and letting out the fluid. This operation has been performed and the child saved, though such an occurrence can never be reasonably anticipated. Such instances however, show that great care should be taken not to injure the brain, as that would destroy the small chance there is.

Dropsy may also occur in the chest, or abdomen of the child, causing similar difficulty with dropsy of the head. If the natural or artificial expulsion of the child cannot be effected without, the part must be carefully punctured, and the fluid evacuated.

Tumors on the Fœtus.—Sometimes various kinds of tumors form on the child's body, but they are rarely so large as to prevent delivery, though they may delay it. If they should be too large however, it will be necessary to remove them, as in the case of tumors in the Pelvis.

OSSIFICATION OF THE HEAD.

Occasionally the bones of the head will be so hard, and so closely united, that they will not overlap, in which case the labor may be very difficult, unless the head is small, or the pelvis very large. If after waiting a reasonable time, there be no prospect of the labor terminating naturally, and the female is exhausted, it must be terminated artificially, as if it were a case of deformed pelvis. It is seldom however, that the head does not eventually give way.

VARIOUS PRESENTATIONS AND POSITIONS OF THE FŒTUS, FROM WHICH THE LABOR MAY BE DIFFICULT OR PROTRACTED.

Presentations of the Face.—These are usually more difficult, and longer, than those of the head. They will nearly always however, terminate spontaneously, or with ordinary assistance; but, if they should not, artificial delivery must be practised, either by turning, if the case be not too far advanced, or with the forceps. Some of the most celebrated authors recommend that all these cases should be treated like cases of natural labor. Dr. Merriman says that in some very favorable instances turning may be practised with safety and advantage; but Dr. Lee says, "My firm belief is, that the child, even under such favorable circumstances, would have a far better chance to be born alive if the labor were left wholly to Nature; or, if the natural powers were inadequate, to be extracted with the forceps." In such cases there is often too little patience, and too much interference.

The forehead inclined against the Pubes.—In this position the labor may be long delayed, and difficult, and most practitioners endeavor to turn the head round, if they cannot bring down the feet, or else apply the forceps at once. Dr. Lee however remarks, and very properly, "From all that I have seen of these cases, I am disposed to believe that it is best to leave them to the natural efforts, and to avoid all interference, all attempts to change the position, while the pains continue regular, and the head advances, however slowly." If the labor does not progress at all, or the female becomes exhausted, of course artificial delivery is necessary.

Several varieties of head and face presentations may also retard labor considerably, but Nature nearly always overcomes the difficulty; or if she cannot do so mere ordinary assistance is required.

PRESENTATIONS OF THE LOWER EXTREMITIES.

It has already been remarked, in another place, that breech presentations mostly terminate spontaneously, and that but few of them require interference. In some of them even, when the pelvis is large, or the fœtus small, the delivery is effected quite rapidly. Still such presentation occasionally causes delay and difficulty, and necessitate more or less assistance.

As soon as the mouth of the Womb is opened sufficiently, unless the labor is rapidly progressing without it, one of the fingers may be introduced and hooked over the groin, and a little gentle force exerted upon it. This will assist very much, and will often be all sufficient. If the pelvis is too small, or the fœtus too large, and the delivery is evidently arrested, the breech must be pushed up, if possible, and the feet be brought down, as in turning. The remarks of Dr. Lee on this presentation are so plain and practical, and marked with such good sense, that I think a better explanation of what should be done in such cases-could hardly be given, I will therefore quote his remarks in full:—

"Having ascertained that the nates present, whatever the position of the fœtus may be, whether the abdomen look backward or forward, we cannot alter it with safety, and no change can be required to be made till the nates and lower extremities are expelled. The os uteri dilates slowly in most cases of nates presentation, but we cannot employ any means with advantage to accelerate the delivery, and in most cases, if we do not interfere, but wait patiently, they are gradually pressed lower and lower into the pelvis, and at last escape from the vagina without any assistance. If the os uteri and vagina are imperfectly dilated, and the nates are drawn down or pass rapidly through the pelvis, the child is often lost. The membranes should not be ruptured, and the expulsion of the nates should be left entirely to the natural efforts, unless the labor is protracted and exhaustion takes place. Except supporting the perineum, nothing is required in a great proportion of these cases before the nates and lower extremities have been expelled, when it becomes necessary to ascertain precisely the relative position of the child to the pelvis, to rectify this if it is unfavorable, and artificially extract the superior extremities and head, to prevent the fatal compression of the umbilical cord. If we find, after the expulsion of the nates and lower extremities, that the toes are directed forward, or that the child is in the position represented in the second figure, with its abdomen applied to the anterior part of the uterus, and that its back lies along the spine of the mother, we should wrap the nates and sides in a soft napkin, and turn the child very gently round during a pain, observing to which side the feet are inclined to turn, till its abdomen is to the spine of the mother, and the toes are directed backward to the hollow of the sacrum, or to the side of the pelvis. In many cases the nates turn round in the passage spontaneously, so that it is not required artificially to alter the position. It is necessary always to recollect that it is possible to turn the body of the child round without turning the face round into the hollow of the sacrum, and that the chin may be over the symphysis pubis when the front of the chest and abdomen are turned backward. After the lower extremities and body of the child have been expelled, and placed in the most favorable position for the extraction of the superior extremities and head, it is necessary to proceed without loss of time to draw these through the pelvis, that the child may not be destroyed by compression of the umbilical cord. As pressure upon the cord for a very short time will in some cases kill the child, it is proper to watch closely the pulsations of its arteries. Draw the body of the child forward as far as the arm-pits, and place it over the palm of your right hand and fore-arm, and gently draw the body towards the left thigh of the mother; then pass the fore and middle fingers of your left hand along the back part of the left arm of the child to the elbow-joint, and press down the arm with your lingers along the thorax of the child, and extract it. Then transfer the body of the child and left arm to your left hand and fore-arm for support, and with the fore and middle fingers of your right hand disengage and bring down, in the same way, the right arm of the child; then pass the fore and middle fingers of your left hand into the mouth of the child, or rather over the lower and upper jaw, and at the same time place the fore and middle fingers of your right hand over the back part of the neck and occiput, and with the fingers of the two hands thus applied extract the head, in the line of the axis of the pelvis. The perineum is very rigid in some cases of nates presentation, where it is the first child, and it will be torn if the head is extracted hastily, and not drawn forward to the symphysis pubis. When you feel the pulsations of the cord beginning to cease, you may be tempted to employ greater extracting force than the neck of the child and perineum can bear, and both may be destroyed. The only method of obviating this is to press back the edge of the perineum, that the air may gain admission into the mouth of the child, and the respiration go on, when the circulation in the cord has been arrested, until the perineum is sufficiently dilated to slide back over the face, and allow the head to pass. I have seen from twenty minutes to half an hour elapse in some cases, after the cord had ceased to pulsate, before the perineum would allow the head to escape, during which time the respiration was regularly performed. This is not a new practice; it has been alluded to by some of the older accoucheurs, and some others; and the advantages to be derived from it were fully pointed out some years ago by Dr. Bigelow, in a paper published in the American Journal of the Medical Sciences, 'On the means of affording Respiration to Children in Reversed Presentations.' The object of Dr. Bigelow in this paper is to show that in many cases the life of the child may be saved by forming a communication between the mouth and atmosphere previous to the delivery of the head. If the head be low down, the fingers alone can give the necessary assistance; but if it is high in the pelvis, and is reached with difficulty, the assistance of a tube may be necessary. He recommends a flat tube, which is to be guarded, and kept within the fingers of the inserted hand.

"Where the pelvis of the mother is small or distorted, and the child large and unfavorably situated, the efforts of nature may be insufficient to expel the child, either alive or dead. The nates may become so firmly impacted in the pelvis, that they cannot advance without artificial assistance. A finger should be passed up to one of the groins, and when a pain comes on a considerable extracting force may be exerted with it, without injuring the child; or a soft handkerchief may be passed between the thigh and abdomen, and the nates drawn down; but this cannot be done unless they have descended low into the cavity of the pelvis. Where these means fail, and it is impossible to extract the child alive, the blunt hook or crotchet must be employed. In cases of nates presentation, where the pelvis is distorted, after the extraction of the trunk and extremities, it is necessary to perforate the back part of the head, and complete the delivery with the crotchet. In presentations of the feet and knees the treatment does not essentially differ from that required in presentations of the nates."

PRESENTATIONS OF THE SHOULDER.

These are the most dangerous of all the presentations, and most frequently require assistance; in fact the delivery can seldom be terminated naturally when the shoulder presents.

Sometimes the child will pass doubled up, as formerly explained, but this must not be too confidently expected. Dr. Lee says—

"It is now a general rule, established in all countries where midwifery is understood, that in cases of preternatural labor, where the shoulder and superior extremities of the child present, the operation of turning ought to be performed. But the hand must not be forced into the uterus, if the orifice is rigid and undilatable; it should be dilated nearly to the size of half-a-dollar piece or more, or the margin ought to be very thin, soft, and yielding, if it is expanded to a smaller extent than this when turning is attempted. If the os uteri will not admit the extremities of the fingers and thumb in a conical form to be introduced without much force, if it is thick, hard, and unyielding, some delay is necessary, that the parts may relax, death being almost always the consequence of thrusting the hand with violence through the orifice of the uterus in a rigid and undilatable condition, whether the membranes be ruptured or not. But as soon as it will admit of the safe introduction of the hand, where you have ascertained that an arm presents, no time should be lost in completing the delivery, otherwise the membranes may give way, the liquor amnii be evacuated, and a case of little difficulty and danger be suddenly converted into one equally hazardous to the mother and child. In all cases of labor, where the first stage is far advanced without the nature of the presentation being positively determined, or a superior extremity is felt through the membranes, the patient should be kept in the horizontal position, that they may not be ruptured; and you should remain in constant attendance upon the patient, and be prepared to interfere the instant the necessity arises."

Speaking of the operation of turning in these cases he remarks as follows:—

"In some favorable cases of shoulder and arm presentation, the uterus is widely dilated before the membranes are ruptured and the liquor amnii discharged; and no difficulty is experienced in passing the hand into the uterus, laying hold of the feet, and extracting the child by the operation of turning. If the uterus is not contracting strongly and at short intervals, little resistance is offered to the introduction of the hand, and the delivery may be speedily accomplished with safety both to the mother and child. But if the membranes have burst, the liquor amnii escaped, and the uterus has been contracting firmly upon the child many hours before the operation of turning is attempted, the child is often destroyed by the pressure, and the coats of the uterus exposed to great danger from contusion and laceration in passing up the hand and bringing down the feet. The shoulder and thorax become so strongly impacted in the pelvis, that great force is required to introduce the hand to grasp the feet, and much exertion necessary before the position can be changed.

"In other cases of shoulder and arm presentation, the membranes burst and the liquor amnii escapes at the commencement of labor, and the os uteri is rigid and undilated, so that the hand cannot be passed into the uterus after the labor has continued many hours. The difficulty and danger of these cases is greatly increased when the uterus is contracting with violence, and the pelvis is distorted, or a disproportion exists between the child and pelvis from any other cause. The greater number of women, if abandoned to the efforts of nature under these circumstances—the uterus having no power to alter the position of the fœtus—would ultimately die undelivered, from exhaustion or rupture of the uterus and vagina."

Fortunately these cases are very rare, and when assistance is rendered early, the difficulty is readily overcome. This is a strong reason why all women especially should know what to do, because a little timely help may save much suffering, or even life.