Treatment. The causes of insufficient uterine action are so numerous that the modifications to which they give rise are almost endless, and demand no little variety of treatment. A great deal may be done to avoid this state by attention to the patient’s health shortly before labour; and by so carefully regulating it as to ensure a healthy condition of the whole system. Lingering labour from feeble uterine activity is seen most frequently in young primiparæ of delicate form and nervous irritable habit; the pains produce much fruitless suffering, and greatly exhaust the patient. If the cause continues, the case becomes much protracted, and serious consequences may ensue; such as hysterical symptoms, or even convulsions, inflammation of some organ, general fever, or complete and dangerous exhaustion, hæmorrhage, retained placenta, or hour-glass contraction of the uterus. In a slight degree this condition is not of unfrequent occurrence, whether from an enfeebled uterus or general debility, and requires general, rather than special treatment for its removal. Change of posture, walking about the room, gentle friction of the abdomen, and occasionally taking some refreshing or mildly nutrient drink, as tea, wine and water, or beef-tea, &c., prove serviceable in such cases; friction of the abdomen, if well applied, frequently produces a great alteration in the character of the pains, and greatly assist the progress of labour: if it be still in the first stage (the os uteri not yet fully dilated,) an enema will not only clear the rectum of any fæcal matter which may be lodging there, but assist in rousing the uterus to greater activity.
Where we can satisfy ourselves that none of the above-mentioned causes are present to protract the labour, we may proceed to the use of those remedies which are considered to have the power of exciting the uterine contractions, such as secale cornutum, borax, cinnamon, and the several diffusible stimulants. This state of uterine inactivity is, however, rare; and we would earnestly warn young practitioners against too readily concluding that it is present. They will find that the more carefully they investigate such cases, the less frequently will they require these remedies. In using the secale cornutum, we give the preference to the powder: it should be carefully kept from moisture, air, or light: from twenty to thirty grains, mixed in cold water, will be the proper dose, and this may be repeated two or three times, at intervals of half an hour, or rather more. Borax is also another remedy which appears to possess a peculiar power in exciting the activity of the uterus: although it is scarcely ever used for such a purpose in this country, its effects upon the uterus have been long known in Germany; and in former times, both it and the secale cornutum entered largely into the composition of the different nostrums which were used for the purpose of assisting labour. We have combined these two medicines with the best effects, and generally give them in the following manner:—℞ Secalis Cornuti ℈ i—ij; Sodæ Subborat. gr x; Aq. Cinnamomi ℥ jss. M. Fiat haust. Cinnamon, which is a remedy of considerable antiquity, has also a similar action upon the uterus, although to a less degree.
Our own conviction with regard to the use of these remedies is, that they are seldom required during labour, except in nates, or footling presentations, or in cases of turning, where the head is about to enter the pelvis, and where, at this critical moment, the action of the uterus is apt to fail, when it is important to the safety of the child that there should be brisk pains to force the head through the pelvis and internal parts with sufficient rapidity. The chief value of these remedies is for the purpose of exciting uterine contraction after labour, and thus to promote the safe expulsion of the placenta, where there is a disposition to inertia uteri, and ensure the patient against hæmorrhage.
Where the contractile power of the uterus is so enfeebled that it becomes nearly powerless, we deem it much safer and better to apply extractive force to the head by means of the forceps, and thus overcome the natural resistance of the soft parts, to using medicines which excite uterine action, and thus stimulate the exhausted organ to still farther efforts. The mere cessation of uterine action, however, where the labour has been tedious and fatiguing, is no proof that the uterus is exhausted, and incapable of farther efforts: so far from its sinking into a state of quiescence, being a symptom of exhaustion, experience shows that, in labours of this character, it indicates a very opposite condition, being nothing more than a state of temporary repose, during which nature affords it an opportunity of recruiting its own powers, as also those of the whole system. The interval of ease which is thus given to the patient is accompanied by refreshing sleep; the skin grows moist; a gentle diaphoresis creeps over her; the circulation becomes calm; and after a time, the uterus awakes again to renewed and astonishing exertions; thus, Wigand has remarked, “the pains during the same labour may cease once, twice, or even oftener, and yet after a little rest will return with renewed strength.” (Geburt des Menschen, vol. ii. p. 242.) On the other hand, where the pains, in spite of their becoming more and more ineffective, continue to exhaust the patient with fruitless suffering, and prevent her from enjoying that repose which is so desirable under such circumstances; when the uterus, from increasing irritability, scarcely ceases to contract even for a moment, but continues tense and more or less tender during the intervals of the pains, we can have little or no reasonable expectation that such a labour can be terminated by the natural powers. If the head be not far advanced in the pelvis, or the passages fully dilated, if the bowels have been relieved before labour, and there is no febrile excitement of the circulation, a mild diaphoretic sedative, like Dover’s powder, will be of great service: it calms the irritability of the system, and induces that state of quiet or actual repose to which we have just alluded. If, on the other hand, the labour be much farther advanced, the head approaching the pelvic outlet, and the soft parts well dilated, a little assistance, by means of the forceps, will quickly terminate the case, and free the mother and her child from farther suffering and danger.
Where the uterus is enfeebled by lesion or change of structure, it becomes very difficult to decide as to what course ought to be pursued: in some cases, the soft passages partake in the loss of tone, and offer but little resistance to the advance of the child; in others, however, the uterus is so powerless as to give us no choice but of employing artificial delivery.
We have already pointed out the importance of paying the strictest attention to the bowels shortly before and during labour, and how frequently a neglect of this precaution acts as a means of perverting the due action of the pains, and giving them that character, already described under the head of False Pains. “After the labour has made much progress, the rectum, if loaded, should be emptied by clysters; indeed, the utility of clysters in almost every stage of labour is so apparent that it is to be lamented they are not more frequently employed.” (Synopsis of difficult Parturition, p. 19.) We have seen cases where, although the bowels had been opened at the commencement of labour, after a time, the pains have gradually lost their dilating effect upon the os uteri, although they have increased in severity; the os uteri has remained tense and hard, and the labour has become very tedious and exhausting; the administration of an enema, and removal of a quantity of fæcal matter from the rectum, has been followed by an instantaneous change in all the symptoms; the pains have become powerful and effective, the os uteri has quickly dilated, and the whole labour has been completed in a very short space of time. In like manner, vomiting during the early part of labour produces the best effects; for it not only assists to relax the parts, by the nausea which usually precedes it, but, by emptying the stomach of unhealthy contents, it tends not a little to restore the uterus to its natural activity.
Where the bowels are distended with flatus, and loaded with acrid and unhealthy contents; we rarely see the pains become regular and effective until these sources of irritation are removed: the abdomen is painful with spasmodic colicky griping, and excites the uterus to partial and very painful contractions of a cramp-like character, which entirely supersede the regular pains, and thus exhaust the patient with protracted suffering without at all advancing the labour itself. If this condition be allowed to continue uninterfered with, the tenderness of the abdomen increases, the circulation becomes excited, and inflammation, and fever of a most serious kind will be the result.
In the management of primiparæ, who are pregnant either at a very early age or considerably advanced in life, our chief attention must be directed to the management of them for some little time before labour is expected, in order that we may place them in as favourable a state of health as possible, and thus enable them to meet the coming trial with safety.
Where the patient is very young, we should endeavour, by early hours, regular exercise, good air, and simple nourishing diet, &c., to increase her strength, and the general tone of health, and thus diminish that irritability of the nervous system peculiar to females of this early age. She should lead a country life, be as much as possible in the open air, enjoy the absence of restraint and excitement, which are almost necessary consequences of a residence in town, and, by agreeable occupation and cheerful society, train herself, as it were, to that state of moral as well as bodily health best adapted to ensure a favourable result. It is in cases of this kind where the bodily powers have not yet ripened into adult womanhood, that so much good may be effected by using the tepid or (if the season permit) cold salt water bath; and we would beg to refer our readers to our observations on this subject in the chapter on Premature Expulsion. In a case which has recently come under our notice, we have had reason to attribute the remarkably healthy and favourable labour of a young and delicate primipara solely to the invigorating effects of regular exercise and the daily use of sea-bathing, which she continued to within a very few days of her confinement.
It is commonly supposed that women pregnant for the first time, and advanced in years, always have severe labours: this is not necessarily the case, although, at the same time, the greater rigidity of the soft parts considerably increases the resistance to the expelling powers. It will be equally important in this case, also, to improve her health and strength as far as possible, and, by exercise, warm hip baths, &c., to give the parts a greater degree of suppleness and elasticity.