A System of Midwifery

by Edward Rigby

Where the labour is protracted by a state of general plethora or local congestion, the expelling powers are not only enfeebled by the engorged state of the uterine circulation preventing effective pains, but the resistance to the passage of the child is increased by a similar condition of the soft passages, which are swollen and turgid with blood. It is in these cases that bleeding effects such a sudden and complete change; the pulse loses its oppressed character, and rises in point of strength, the uterus loses the thick solid feel which it had before; its contractions become active and powerful, the os uteri dilates, the passages become soft and yielding, and the whole process assumes a different character. By careful observation, this state can easily be discovered before labour has actually commenced; in which case much useless suffering may be prevented by previously reducing the circulation to a proper standard, and thus fitting the uterus for the exertions it has to undergo: besides bleeding, mild saline laxatives, with or without antimonials, will be of great service. The nitrate of potass in these cases has the best effects, either in farthering the effects of the bleeding, or removing the necessity of using so powerful a remedy.

In treating rheumatism of the gravid uterus, our practice will differ but little from that in cases of ordinary rheumatism in other parts: this condition, we believe, is rarely excited, until the system had been already predisposed to it by deranged digestion, and that general prevalence of acid diathesis, which manifests itself in different individuals and under different circumstances so variously; hence, therefore, it will always be important to unload the primæ viæ effectually by an active dose of calomel or some other mercurial, before prescribing for the immediate symptoms of the complaint: beyond producing a little occasional nausea, five grains of calomel will act much more comfortably to the patient’s feelings than a smaller dose; there will be less griping and intestinal irritation, but the effect will be more complete and general; not only will the bowels be thoroughly evacuated, but the liver relieved of a large quantity of unhealthy acrid bile, the removal of which cannot but be highly advantageous. We may now proceed to the use of diaphoretics and opiates: of these, Dover’s powder stands foremost; and if given in doses of from ten to fifteen grains, accompanied with warm diluent drinks, rarely fails to induce sleep and a pretty active perspiration, which gives great relief. As the abdomen is usually more or less tender on pressure, it should be covered with a piece of soft flannel, or, still farther to ensure the full diaphoretic effect of the remedies, a warm bath may be had recourse to. Where calomel in the above dose has been premised, we seldom fail in procuring a free action of the skin, and, according to our own experience, with far greater relief to the system than where the perspiration has been induced merely by diaphoretics and external warmth.

If this condition of the uterus has been neglected, and the contractions are beginning to produce intense suffering; if the abdomen is rapidly becoming more tender to the touch, it should be covered with a hot poultice of linseed meal, made more stimulating by the addition of mustard flour, and this should be continued until the skin is considerably reddened. In the slighter cases of this affection, where the bowels have been opened, friction upon the abdomen frequently produces the happiest effects. We presume it is to these cases that Dr. Power alludes when he says, “in some, the improper action will be removed almost instantly, and, as it were, by a miracle; so that a case which has been protracted for the greater part of a week, under the most intense suffering, without the least progress, has been happily terminated in fifteen or twenty minutes from the first commencement of the friction.” (Power’s Midwifery, 1819.)

Where inflammation of the uterus takes place during labour, the case becomes one of the most serious character; for not only is the suffering, which is produced by every contraction, of the most intense description, but the presence of the child aggravates the state of inflammatory action, and excites the uterus to still more violent efforts, while the swollen and unyielding state of the os uteri, &c., precludes the chance of speedy delivery. Under such circumstances, we must trust almost entirely to the lancet in aiding this important object; for, until the circulation has received an effectual check by fainting, the dilatation of the parts cannot proceed, nor can any attempt be made to give artificial assistance. The abdomen should be covered with a hot linseed meal poultice, as above described, in the treatment of rheumatism of the uterus; warm decoction of poppies should be thrown up the vagina, or, if this cannot be procured at the moment, some thin gruel mixed with a little laudanum, or in which a few grains of Extr. Conii or Hyoscyami have been suspended; the bowels should be opened by a simple enema, after which a small opiate injection will be desirable, in order still farther to allay irritation.

Stricture of the uterus. We have already had occasion to allude more than once to that species of violent and continued contraction which we have denominated stricture of the uterus, but have chiefly considered it where it affects the os uteri; a somewhat similar condition of spastic rigidity is occasionally, though rarely, seen in other parts of this organ, and is capable of producing a most serious obstacle to delivery. The uniform and regular action of the uterus disappears; its contractions become partial, both in extent and effect, one part alone contracts whilst the rest of the uterus is relaxed; its shape thus becomes altered; for, by these partial contractions of its fibres, it may become elongated, shortened, flattened, &c.: the spasmodic action frequently varies its seat, and successively attacks different portions; thus, where it affects the body of the uterus, it becomes contracted almost like an hour-glass, having a transverse circular indentation, as if it had been tied with a cord. Where the contraction affects one side of the organ, it alters the shape of it materially; the fundus is pulled down equally, and the position of the child, as we have shown in the first species of dystocia, may be seriously affected. If the stricture has its seat in the os uteri, this becomes tightly contracted, hard, unyielding, and painful upon pressure: it does not dilate sufficiently, and the inferior segment of the uterus is generally pushed downwards, whilst the os uteri itself is drawn upwards. In cases of this kind, we find that although the uterus contracts, the child does not advance, but rather retracts, during a pain; the contractions are never general, but partial, and even where they are general, the fundus does not attain its due preponderance over the os uteri, so that the one contracts as much as the other does; in severe cases, also, the uterus continues in a state of spasmodic action during the intervals of the pains: this is frequently accompanied with a painful and harassing sensation of tension and stretching, very different to that produced by the action of regular pains upon the os uteri; and in the worst cases we occasionally observe a peculiar state of the brain, which manifests itself by attacks of insensibility, faintings, or even convulsions.

Although the head does not advance in spite of the strongest pains, yet, upon examination, we find no want of proportion between it and the pelvis; if the intervals of uterine action be of sufficient duration to allow it, we shall feel the head quite moveable in the pelvis, or, at any rate, with plenty of room for the finger to pass round it, and yet when a pain comes on, the head remains fixed, or if it does descend somewhat, it returns again to its former situation as soon as the pain is over. This state of things is usually seen where the body of the uterus is the seat of the stricture, and is contracted transversely upon that of the child, which it tightly encircles, and renders all farther advance impossible.

This state of spasmodic action is produced by whatever tends to irritate the uterus and excite it to irregular action; thus, premature rupture of the membranes, especially when it has been suddenly drained of a large quantity of liquor amnii; the irritation arising from acrid matter in the intestines, or from their being loaded with accumulations of fæces; improper examination, and more especially, attempts to dilate the os uteri by the fingers or hand; endeavouring to strain and bear down during the early part of labour, and when the patient is not involuntarily compelled to do so; attempting to apply the forceps when the os uteri is not fully dilated, or whilst the instrument is very cold: malposition of the child, especially after rupture of the membranes; and lastly, anxiety, fear, and other affections of the mind. The circulation is generally in an irritable state, the patient is of a delicate excitable habit, and is apt to be nervous and hysterical.

The treatment in these cases will be precisely on the same general rules as we have above described; the bowels must be relieved by a laxative or by an enema; if necessary, the circulation must be reduced to the proper standard by bleeding, and the irregular uterine action controlled by opiates. Besides these means, the warm bath is of the utmost service, and seldom fails to produce a favourable change. Where the action of the uterus is impeded, or otherwise rendered faulty by organic disease, lesions of its structure, &c., we shall in all probability be compelled to use artificial assistance.

II. Where the action of the abdominal and other muscles is at fault. Where the faulty character of the labour arises from a faulty state of the partly voluntary, partly involuntary, action of the abdominal muscles which is destined to aid the uterus in expelling the child, this may equally be a result of general debility from previous disease, exhaustion from the long duration of the labour, from the abuse of spirituous liquors, &c. It may also arise from various causes which tend to impede the respiration; such as excessive corpulence, great deformity of the spine, bronchocele, spasmodic asthma, rheumatism of the diaphragm, ascites, hydrothorax, phthisis, pneumonia, aneurism of the aorta, dilatation of the heart, &c.

Where the size is such as renders the patient very unwieldy, or the spine is much deformed, we must place her in that position in which she can exert herself with greatest effect, and at the same time experience the least possible obstruction to her breathing: with deformed people, this is of great importance; she should be propped up with pillows, &c. into whatever posture she can lie with most comfort, and the practitioner must manage to deliver her in this position. Patients suffering from pluerisy or pneumonia are unable to bear the continued strong inflation of the lungs which is necessary during the second stage: under these circumstances, the pain and inflammation are greatly aggravated; venesection must be used with great promptness, but it does not always bring relief or remove the danger; for the disease is kept up by the presence of labour, which, therefore, in all probability, will require to be terminated by art. In some cases, however, as we have already mentioned, especially where the disease is of an acute character, the uterus appears to take upon itself the whole exertion of the labour, so that the child is born apparently without any effort on the part of the mother.