Faulty state of the expelling powers after the birth of the child. The last stage of labour, which comprehends the expulsion of the placenta, may also be retarded by a faulty state of the expelling powers. This not only arises from the causes which we have already mentioned, but from those connected with the labour itself; as from premature and immoderate straining during the pains, misuse of medicines given to increase the pains; also, where the uterus has been exhausted by the length and severity of the labour, or where it has been thrown into a state of inertia by the sudden evacuation of its contents, especially when previously much distended. This condition is frequently induced by not supporting the child sufficiently when the shoulders are about to pass through the os externum; the main bulk of the child is therefore suddenly expelled, and the uterus is at once thrown into irregular action by the sudden shock of so great a change, or falls into a state of inertia. The separation and expulsion of the placenta may be also retarded where the labour has required the forceps, turning, or perforation, especially the latter, on account of considerable pelvic deformity; the more so if there has been considerable delay in giving assistance. Irregular and partial action of the uterine fibres, after the expulsion of the child, may easily render the last stage of labour dangerous; for, under such circumstances, the portion of the uterus to which the placenta is attached may be in a state of firm contraction in one part, while the other is quite relaxed, so that incomplete separation of the placenta will be the result, and hæmorrhage follow: hence we cannot be too cautious in avoiding every cause which may at all influence the regular action of the uterus during the last stage of labour, which is far more dangerous than the two others put together.
In a case of this kind, we do not feel the uterus contracting into the firm globular mass above the symphysis pubis, as might have been expected; but if inertia uteri be present, it remains soft and large, the peculiar pains of the last stage which indicate the speedy separation and expulsion of the placenta do not make their appearance, or only in a very insufficient degree. If it be contracting irregularly and only in part, we shall feel this distinctly, from the unequal shape and hardness of the uterus, which in some cases will have almost a lobulated feel; in others, it presents a considerable depression either upon the fundus or anterior wall.
Hæmorrhage. The danger here, chiefly depends upon the occurrence of hæmorrhage: if the placenta be still attached by its whole surface to the uterus, no hæmorrhage can ensue; but if the contractions have been of sufficient power to detach more or less of it from the uterus, large trunks, which have hitherto conveyed maternal blood into the placental cells, are torn through, and a profuse discharge must be the result. The degree of the hæmorrhage will in most instances furnish us with a tolerable estimate of the extent to which the separation has taken place; but it is far from easy to ascertain correctly the quantity of blood which has been lost, and we must rather try to ascertain what are the effects produced upon the system of the patient. The pulse becomes smaller and quicker, the column of blood is evidently diminished, and the heart for a time drives on its contents more rapidly; but as the loss increases, so does it become enfeebled, and although beating with a very frequent stroke, it now becomes so weak as to be scarcely or no longer capable at the wrist of producing such a resistance to the finger as will give the sensation of a pulse; the necessary consequence of this is, that the patient at first complains of great weakness, the face becomes pale, the lips white, the breathing anxious; this is followed by a sense of great prostration, the perspiration breaks out upon the face and forehead, tinnitus aurium, confusion of ideas, and sense of darkness before the eyes succeed; the load at the præcordia, and the oppression of breathing, become more insupportable; she tosses her arms about, and in some instances has a sensation that the room is going round with her, or that she is sinking through the bed; in other cases, the breathing becomes gradually more feeble, until it is almost imperceptible; she every now and then takes a deep sobbing grasp, which seems to rouse her to consciousness for a moment, and then she relapses into a state verging upon insensibility; the pulse is probably now no longer perceptible at the wrist, the face is undergoing a rapid change, the features are contracting, and there is a general expression of death-like collapse which shows too truly the urgency of the danger. The alterations which are taking place in the state of the brain and nervous system, vary in different individuals: in some, there is strabismus; in others, temporary mania, or at least, delirium; and in more unfavourable cases, even convulsions; these last are especially formidable, as they not only show that the system has been severely affected by the loss of blood, but are apt, from their violence, to extinguish the little spark of life which is left, or, in other words, to be followed by sudden death.
These are some of the many symptoms indicating a sudden and extensive loss of blood; others also occur, depending on the external or internal character of the hæmorrhage. The want of contraction and general flaccidity of the uterus, as felt through the abdominal parietes, have been already noticed; if the blood be prevented escaping by the contracted state of the os uteri, by coagula, or the detached placenta, it begins to collect in the cavity of the uterus, which therefore swells as the accumulation continues to increase, so that it may even equal the size which it had before labour, containing many quarts of blood, and the patient may be in the most imminent danger of dying from hæmorrhage, perhaps, without any blood having issued externally: this is the internal uterine hæmorrhage, a form which is justly looked upon as peculiarly to be dreaded, from the insidious character of its attack. In most cases, the uterus fills to a certain extent only, and then, as if excited to contraction by the distention of its parietes, or any slight concussion, produced by coughing, &c. it expels a large quantity of coagula and half coagulated blood, and returning to its former state of atony, again begins to swell from fresh accumulation of blood in its cavity.
Treatment. So long as the inertia or atony of the uterus continues without any symptoms either of external or internal hæmorrhage, we are not justified in interfering directly, either for the purpose of exciting the uterus, or still less of removing the placenta. This condition chiefly occurs where the uterus has been previously much distended, or suddenly emptied of its contents, where it has been exhausted by long and difficult parturition, and also, as Leroux has observed, “in women of a phlegmatic temperament and lax fibre, who, during pregnancy, have suffered much ill-health, by which the tone of the solids has been weakened; who have very large pelves, and a soft dilatable os uteri.” (Sur les Pertes de Sang, 1776.)
We must therefore give the uterus time to recover from the great and sudden change which it has undergone, to collect its strength, to remodel and arrange its forces, until it is at length able, not only to resume its efforts, but to contract to that extent which shall both ensure the expulsion of the placenta and the safety of the patient. Whilst this state of inertia lasts, the patient should be kept as quiet as possible; she should be placed in a comfortable posture, take a little cool drink from time to time (as cold tea, toast and water, &c.,) in order to refresh her;[131] or, if she has been much exhausted by her labour, a glass of wine may be given with good effect. If, however, hæmorrhage appears, this shows that a separation of the placenta from the uterus must have taken place: our great object should now be to excite contraction of the uterus, for by this means alone can we stop the discharge.
In ordinary cases, a little circular friction with the tips of the fingers over the fundus will generally be sufficient. If the uterus begins to swell, we may grasp it with a sudden but moderate degree of force; or we may give the fundus every now and then a smart jog with our hand. Whilst these measures are pursuing, a dose of secale cornutum (see Dystocia, p. 330,) will be of great service; for even if it does not act soon enough to aid the expulsion of the placenta, it contributes greatly to ensure the contraction of the uterus afterwards. If the hæmorrhage nevertheless continues profuse, it will be necessary to introduce the hand into the uterus and remove the half-separated placenta: its contractions are too feeble for that purpose of itself, and the presence of the hand in its cavity, and the artificial separation of the placenta, act as a stimulus, and rouse it to greater activity. The opinion that we only increase the danger by thus increasing the bleeding surface does not hold good, when, from the profuseness of the hæmorrhage, it has become evident that the greater part of the placenta is already separated from the uterus; on the other hand, where there is but a slight discharge, the case is very different, and would not justify our having recourse to so strong a measure.
If the contraction which has been excited by the artificial removal of the placenta be but temporary, we must proceed to the use of other means for the purpose of rousing the activity of the uterus. The sudden application of cold is a most valuable means; it acts here solely by the shock which it produces at the moment, and not by lowering the circulation and favouring coagulation. Thus we find that a cold wet napkin suddenly flapped upon the abdomen has an immediate effect upon the uterus; but it ought not to remain on long, and the skin should be dried with a warm towel, in order that a fresh application of the cold may produce the greater effect. A series of such shocks may be produced by using another wet napkin to the vulva, and a third to the sacrum and loins; an assistant should remove them in the order in which they have been applied, and dry the skin, for a repetition of the remedy, if necessary.
A still more powerful mode of producing a sudden shock, and thus rousing the uterus to activity, is by a douche of cold water upon the abdomen. This may easily be effected by a teapot or kettle held at some height above, and slowly emptied upon the lower part of the abdomen; the uterus will seldom refuse to obey such a stimulus as this, however great may be the inertia into which it has fallen. The inefficiency of a prolonged application of cold to the abdomen, however severe, and the efficiency of the contrary practice, is admirably expressed by Dr. Gooch, in his description of a dangerous case of hæmorrhage:—“Finding the ice so inefficient, I swept it off, and taking an ewer of cold water, I let its contents fall from a height of several feet upon the belly: the effect was instantaneous; the uterus, which, the moment before, had been so soft and indistinct as not to be felt within the abdomen, became small and hard; the bleeding stopped, and the faintness ceased—a striking proof of the important principle that cold applied with a shock is a more powerful means of producing contraction of the uterus than a greater degree of cold without the shock.” (An Account of some of the more important Diseases belonging to women, by Robert Gooch, M. D.)
Another mode of applying cold to induce uterine contraction, and little, if at all, inferior to that above-mentioned, is the injection of cold water into the uterus itself: this can only be effectually employed after the removal of the placenta and membranes, and frequently proves of the greatest assistance, being capable of rousing the uterus when many other means have failed. If, from the sultriness of the weather, water cannot be procured of sufficient coldness, or if the case be very urgent, vinegar and water in equal parts may be used; but the injections of spirit and water, which some have recommended, can scarcely be considered as a safe proceeding.