A System of Midwifery

by Edward Rigby

The action of labour forcing the head of the child against these contractions and adhesions is frequently sufficient ultimately, to effect the necessary degree of dilatation; where, however, this is not the case, they require to be divided by the knife. The proper moment for doing this is during a pain, when the parts are put strongly on the stretch: we can now feel exactly where there is the greatest resistance, and where an incision will produce the most effect. In this state also the incision can be effected with most ease, for the stricture being firmly distended, the knife will more readily divide it than where it is relaxed; the patient also at this moment is not sensible to the cutting of the knife. The lower part of the blade well armed with lint or tow should be cautiously introduced along the side of the finger during an interval of the pains: in this way the necessary number of incisions may be made: this is usually followed by a good deal of bleeding, which tends still farther to relax the parts; and when the head has advanced low enough, a cautious attempt may be made with the forceps to deliver it.

In recommending dilatation by means of the knife, it must be distinctly understood, that a sufficient time should be allowed in order to see how much can be effected by the uterine efforts, for in many of these cases the stricture has at length yielded after severe and protracted suffering.[128] In cases of this kind, also, the effects of bleeding are by no means inconsiderable, and must not be neglected.

The unruptured hymen has been said to be capable of impeding the progress of the head, but this can only be where the membrane is of unnatural strength and thickness. It has more than once occurred to us at the commencement of labour, to find the hymen uninjured; but it has broken down under the finger, even during examination, and we are convinced would have produced no obstacle whatever to the child. Where its structure is abnormal, and the advance of the labour is evidently retarded by it, division is the simplest and easiest remedy.

Bands of firm fibrous or almost ligamentous tissue are sometimes found stretched across the vagina or os externum. We described a remarkable case of this sort in the Medical Gazette, Sep. 26, 1835, where it extended from the symphysis pubis backwards to the perineum; it had resisted the pressure of the child’s head so powerfully as to produce a deep indentation along the cranial bones; it was divided by a bistouri, and the head was immediately expelled.

The perineum can rarely, if ever, prove a serious hindrance to the labour in primiparæ so long as its structure is healthy, even although it may be unusually broad. With patience and due management the necessary degree of dilatation may be obtained by the pressure of the head; and proposals to dilate it artificially, or even to make a slight incision into it, do not deserve a moment’s consideration. Where, however, it has been extensively lacerated in a previous labour, and has healed again throughout its entire length (by no means a common occurrence) or when there has been much sloughing, the cicatrix thus formed may render it incapable of relaxation, and thus produce much resistance to the passage of the head. Even here we may do a great deal by warm hip baths, fomentations, and especially by bleeding; an incision through the callous portion is by no means desirable where it can be possibly avoided, as it only endangers a farther laceration during the expulsion of the head. Cases nevertheless, occur where the contracted ring of the os externum is so unyielding and gristly as to make this operation necessary.[129] In all these cases, where, either the adhesion and contractions have given away, or have been divided during labour, great care should be taken to prevent them forming again during the process of healing, by using sponge tents well greased, and other appropriate means.

Varicose and œdematous swellings of the labia and nymphæ also deserve mention, although they rarely interfere with the progress of labour to any great extent. Varicose labia seldom annoy the patient during her pregnancy; the veins of the part may have become somewhat dilated and the labium swollen; but it is generally not until the commencement of labour, that they become hard and knotty: at first they feel like a bunch of currants imbedded in the cellular tissue of the labium, and as labour advances, and the return of blood from the part is still more impeded, the swelling continues to increase in size, and frequently obstructs the os externum very considerably. The danger here is not so much from its acting as an obstacle to the passage of the child, as from its bursting during labour and causing loss of blood and other serious consequences. The tumour seldom bursts directly externally, but first gives way beneath the skin, producing extravasation, after which, in consequence of still farther distention, the labium itself ruptures. In some cases the hæmorrhage is not very profuse externally, while the extravasation internally, amounts to some pounds, extending not only to the vagina and perineum, but also to the groin; and instances have occurred where it has spread to a great distance over the glutæus muscles.

“The extravasation,” says Mr. Ingleby, “usually happens during the pain which expels the child; but sometimes at an early period of labour, as in the example of severe hæmorrhage here annexed. I had just left a patient to whom I had been called, in consequence of the difficult transmission of the child’s head through a distorted pelvis, in connexion with an inordinate varicose enlargement of the labia pudendi (especially the left,) when a messenger overtook me urging my immediate return. It appeared that during the violence of the straining, the tumour on the left side had suddenly burst at the edge of the vagina posteriorly. The patient lay in a little lake of blood; and as the bleeding recurred in gushes with the return of every pain, it became essential to complete delivery, and a child weighing fifteen pounds was extracted with the forceps. A large slough separated at the end of the third week.” p. 109.

Where no laceration has taken place externally, it is seldom that an opening for the purpose of removing the effused blood will be of use; on the contrary, the access of external air cannot but be prejudicial in many cases. The action of the absorbents is generally sufficient for this purpose, and may be increased by friction with stimulating liniments, and most remarkably of all by the application of electricity. Where the extravasation extends beneath the lining membrane of the vagina, so much swelling may be produced as nearly to close the passage; this, however, generally takes place after the birth of the child, the rupture of the varicose vessel having occurred whilst it was passing.

On perceiving, at the commencement of a labour, that there are varicose veins in the labium, which are beginning to increase in size and hardness as the head advances, it will be as well to compress them as much as possible during the intervals of the pains, when there is less impediment to the blood returning from them: we can, by thus squeezing out their contents to a certain degree, lessen the size of the swelling, and thus prevent it from gaining that extent which might endanger laceration. We may instantly know when this injury has taken place, by the livid tumefaction of the parts, and our being no longer able to feel the knotty portions of the varix. In order to check the effusion of blood as much as possible, we must apply cold, and thus favour its speedy coagulation beneath the skin. Where the distention is very great, it may become necessary to evacuate the effused fluid; but, generally speaking, it is deeper beneath the surface than might, at first sight, be expected. “It has been proposed,” says Mr. Ingleby, “that the swelling should be punctured, provided there has been no delay, and the puncture is made whilst the blood is still liquid. On one occasion I promptly carried this suggestion into effect, but without success; and, considering the structure of the labium, it is probable that the greater part of the blood will coagulate almost as rapidly as it is effused.” (Ingleby, op. cit. p. 109.)

A considerable degree of suffering and annoyance to the patient may arise from œdematous swelling of the labia and nymphæ, both previous to and during her labour. The labia are occasionally so distended as not only to close the os externum, but to require that the legs should be kept as wide asunder as possible, to prevent the swollen parts being crushed: the patient is thus rendered very unwieldy and helpless, if she were not already so previously by an anasarcous state of the lower extremities, which frequently accompanies this condition.