Morphine, which is used to prevent pain, is the chief drug in the twilight sleep method, and it is greatly intensified in action by the presence of scopolamine. When, however, morphine and scopolamine are given to a pregnant woman hypodermically, these drugs are at once carried by the blood to the fetus. Children for years after birth all withstand the action of morphine badly, and a fetus in utero may be overwhelmed by it. Just in this fact lies the chief moral crux in the use of the twilight sleep method of obstetrical delivery. The woman may go on to the end more or less safely in competent hands, but if constant watch is not kept at the bedside by a skilled observer the infant is liable to be killed, and the danger comes to it not solely from the drug directly—it may be drowned in the amniotic fluid, its condition may be masked by the restlessness of the mother, which prevents proper observation: when a woman is plunging all over the bed, as is extremely common in twilight sleep, the pulse-rate of the baby cannot be properly watched.
If the mother happens to be particularly susceptible to scopolamine or morphine, the first will cause delirium and the second coma; or the respirations may become arhythmic and be reduced to only five or six a minute. The kidneys may be affected by the morphine so as to bring on total suppression of urine. Labor is prolonged, and it may be very much prolonged. In some women uterine atony is induced by the morphine, with very dangerous consequent post-partum hemorrhage. Morphine relaxes all musculature, and it relaxes the muscle of the arterial walls and so disposes to hemorrhage. There is little or no premonitory symptom of these idiosyncrasies (except in the case of an injured kidney) to inform the physician that he should avoid the scopolamine-morphine treatment.
Dr. Polak, professor of obstetrics at the Long Island College Hospital, reported[204] on 155 cases of the twilight sleep method, and he is in favor of it under several restrictions. He uses the drugs from ampules which contain one two-hundredth of a grain of scopolamine and half a grain of narcophin, which is a proprietary drug said to be composed of the meconate of morphine with the meconate of narcotin in molecular proportion. Morphine itself is a tribasic meconate, and narcotin, of course, another opium derivative. The American Council on Pharmacy and Chemistry was unable to accept the claims made for narcophin.[205] Polak says he finds no difference between morphine and narcophin.
In the twilight sleep treatment the patient, especially if she is a primipara, should be definitely in labor before any injection is given. She should have pains occurring at regular intervals, preferably every four or five minutes, before the first injection of scopolamine and morphine is administered; that is, the first stage of labor should be well advanced. Gauss gives one-sixth of a grain of morphine at the first injection, and Polak nearly three-fourths of a grain of narcophin, with one two-hundredth of a grain of scopolamine. If the woman is a multipara, Polak begins the treatment at the very beginning of the pains. The patient is kept in bed, in a darkened room, removed from all noise and excitement. Some stop the ears and blindfold the patient, and, according to Baer of Chicago, the women are put into restraining sheets as a routine practice in certain clinics to keep them from infecting themselves. The ordinary practice is to give a half dose of scopolamine an hour after the first dose and about every two hours thereafter, according to the indications. The morphine may be discontinued, or used approximately every six hours in a long labor. Smaller doses are required if the first is given early in the labor, and larger if the pains have been well developed. In these latter cases the danger to the child is, of course, greater.
The condition of the patient's pulse, respiration, pupillary reaction, and the frequency and character of the uterine contractions are constantly watched, to guard against poisoning. Fonyo[206] reported two fatal poisonings by the scopolamine-morphine method as used in surgery. Both were operations for the delivery of women by laparotomy, and in each case the centre of respiration was overwhelmed. In each of these operations only one-hundredth of a grain of scopolamine and one-third of a grain of morphine had been used, but chloroform was administered later. Robinson recently reported the fatal poisoning of a negress by scopolamine, and Chandler of Philadelphia two more where one thirty-third of a grain of scopolamine had been used. One-ninetieth of a grain given hypodermically has caused severe toxic disturbance which lasted for twenty-eight hours, and Root[207] reported a case where one three-hundredth of a grain given by mouth poisoned violently.
In Freiburg, Gauss tests the consciousness of the women about every half hour by showing them some object, and if they remember having seen this object he gives an additional dose of scopolamine. Polak says this memory test is not necessary: even if the patient gives outward evidence of pain by cries and motion, she is apparently but very dimly conscious in his opinion.
The progress of the delivery must be constantly watched by repeated extraäbdominal or rectal examinations, following the fetal shoulder as it rotates—and not by vaginal examinations—to avoid sepsis. The fetal heart must be auscultated every half hour at most, between and during the pains. If the child's pulse grows arhythmic or slow between pains, these are bad prognostic signs. All use of the drugs is to be discontinued, and the child is to be delivered at once to save its life, by the most suitable method and route.
Polak holds that the solutions of the drugs must be absolutely pure, and that hyoscine cannot be substituted for scopolamine, but that narcophin is no better than morphine: the American preparations have produced delirium. As I have shown, no one can possibly tell the difference between hyoscine and scopolamine, even by chemical analysis. All we can do is to take the druggist's word that the drug at hand was made from Scopolia and not from Hyoscyamus niger. It does not make any difference which is the source of the supply.
Polak says the morphine shortens the first stage of labor by softening the cervix, but that the treatment lengthens the second stage. Other observers have not found that it shortens the first period. He tells us that if this second stage—that is, the time from the full dilatation of the os until the delivery of the child—lasts over an hour in multiparae, or over two hours in primiparae, delivery must be effected by the Kristeller expression or by low forceps. In the Kristeller expression the child is pushed out of the canal by the hands of the physician applied to the fundus uteri. It should be a method of last resort, because there is danger of rupturing the uterus, of tearing the placenta loose, or of crushing an ovary.