Midwifery and the diseases of women

by Joel Shew

THE MEMBRANES.

These are expanded from the edge of the placenta, in connection with which they form a complete involucrum of the fetus and waters, and at the same time a lining for the uterus. The membranes grow and expand in the same proportion as the fetus, and when expelled after the birth has taken place, are, in connection with the placenta, termed the secundines.

There are three of these membranes, which are found surrounding the fetus. “There is first the outer, or connecting membrane, which is flocculent, spongy, and extremely vascular, completely investing the whole ovum, and lining the uterus; secondly, the middle membrane, which is nearly pellucid, with a very few small blood-vessels scattered over it, and which form a covering to the placenta and funis, but does not pass between the placenta and uterus; thirdly, the inner membrane, which is transparent, of a firmer texture than the others, and lines the whole ovum, making, like the middle membrane, a covering for the placenta and funis. With the two last the ovum is clothed when it passes from the ovarium into the uterus, where the first is provided for its reception. These membranes, in the advanced state of pregnancy, cohere slightly to each other, though in some ova there is a considerable quantity of fluid collected between them, which being discharged when one of the outer membranes is broken, forms one of the circumstances which has been distinguished by the name of by, or false waters.”

It seemed necessary that I should make these preliminary remarks concerning the physiology of the placenta and the membranes, in order that you might the better understand the third process of labor, or that which consists in the expulsion of these growths, the secundines, as they are called.

I have now some practical remarks to make, which I hope you will study faithfully, for it not unfrequently happens that a child is born before you can obtain the assistance of a physician; and after the child has been expelled, what to do in reference to the after-birth; that is a question which, under such circumstances, puzzles your sex more a great deal than it need or ought to do.

Suppose, then, that a child is born suddenly, or at least before the medical man or woman whom you would employ, comes to your aid, and the placenta remains undelivered.

I shall tell you, in another place, not to be in such a flurry, as women too often are, in regard to separating the umbilical cord. So, too, I say in regard to the after-birth; be in no hurry.

Have you not often heard people say that the after-birth has grown fast and sticks? Women sometimes say this, and so do the doctors, some of them; such, for example, as are not honest enough to tell the truth, if they know it, and would make you believe that they are doing a great thing when they get away the after-birth, if it sticks.

Now please remember that it is right that the placenta should grow fast to the womb; that is, to its inner surface. It is always grown fast, and should be; but it is possible for it to adhere more firmly in some cases than in others; and in some cases, too, the uterus seems to be so weak that it has not power sufficient to expel it.

In cases when the womb is very active after the birth of the child, the placenta may be expelled very quickly.

But it is more commonly the case that after the uterine contractions have forced the child into the world, the womb reposes itself for a half hour, less or more. After this, periodical pains begin to occur, so that the after-birth may be completely thrown forth into the world; but far oftener it is either wholly, or in part only, into the vagina, where it remains for a time at least.

At what time, and under what rules, should manual aid be administered in helping away the after-birth? By different practitioners different rules have been instituted. A rule of Dr. Hunter’s was to wait till four hours after the birth of the child. If the placenta come away of itself, before this time have elapsed, it is well; but if, on the other hand, it still remain in the cavity of the uterus, manual aid may become necessary.

Another rule is, to judge by the pains, without any regard to the length of time that has elapsed since the delivery of the child; pains, it is said, accompany the contractions; the contractions expel the placenta; the pains, therefore, indicate the time at which artificial assistance should be interposed.

Another rule is, first to determine the situation of the womb before any manual attempt is made for helping away the after-birth. If, on examination, the placenta is found lying in the upper part of the vagina, and through the os uteri, and more especially if the union of the umbilical cord with the placenta can be felt, it is considered proper to remove it. But if the umbilical cord ascend high into the womb, and no part of the placenta can be felt, it is considered best to wait.

Still another rule is, to act according to the feeling and condition of the uterus, without any regard to the length of time after the birth, the pains, or the situation of the placenta. If, on examination externally, it is found that the womb is yet large, uncontracted, and pulpy, the placenta should not, according to this rule, be interfered with. But if, on the other hand, there is an opposite state of things—that is, if the uterus is found hard and contracted, feeling like a child’s head in the abdomen, and if it remain so for some time permanently, it is considered safe and best at once, in a proper manner, to remove the viscus. A skillful practitioner will bear in mind all these circumstances, and form a rule out of all of them, as it were, to guide him in each individual case; and I wish you to remember, that although you may consider the principal part of delivery is accomplished at the time when the child comes into the world, it is to be remembered that its real danger has not yet commenced, and that the birth of the placenta is a most important part of the process.

Into all the niceties and difficulties of this part of the accoucheur’s art, I do not, you will remember, attempt to induct you. It is my object to give you some general ideas of the matter, such as may be of use to you in an emergency, and prevent a great deal of unnecessary anxiety and alarm in some cases. My remarks will also, I trust, go to impress upon your minds how very necessary it is, under such circumstances, to have the aid of a physician—a man or woman, I care not which—who understands well the art. You may say that nature is sufficient in most cases to perform her own tasks unaided and alone. That, I admit, may all be true, especially with those who have good constitutions, and who observe well the laws of life. But remember that these circumstances do not always exist. Any one of you would rather incur the expense of having a physician a thousand times, when he is not needed, than to suffer danger for his want in a single instance.