A System of Midwifery

by Edward Rigby

Treatment. The sooner we endeavour to return the uterus the better, for we shall seldom experience much difficulty in effecting our object, if done immediately upon the occurrence of the accident; indeed, we know of a case where, under these circumstances, it was successfully returned by a midwife. If, on the other hand, some hours are permitted to elapse before the attempt at reduction is made, it will be attended with great difficulty, or even prove entirely abortive; the os uteri contracts powerfully, the uterus swells from the obstructed return of the circulation, inflammation rapidly follows, and diminishes still farther our chances of success. Dr. Denman says, “The impossibility of replacing it, if not done soon after the accident, has been proved in several instances, to which I have been called so early as within four hours, and the difficulty will be increased at the expiration of a longer time.” Still, however, we must not despair of success, for numerous cases have been recorded by different authors where the reduction has been effected after a much longer period.

There has been a considerable discrepancy of opinion as to the management of those cases where the placenta is still adhering to the uterus, viz. whether it is not safer to reduce the fundus with the placenta, and excite the uterus to throw it off afterwards in the usual way, or whether we ought not to separate the placenta before making the attempt at reduction. Mr. Newnham, the author of almost the only monograph upon this subject, recommends the former mode of practice. “It has been recommended by several respectable authorities to remove first the placenta, in order to diminish the bulk of the inverted fundus, and thus facilitate the reduction. But it is surely impossible that this proceeding can be attended with any beneficial consequences, whilst the irritation of the uterus will necessarily tend to bring on those bearing down efforts, which would present a material obstacle to its reduction; and would increase the hæmorrhage at a period when every ounce of blood is of infinite importance, besides returning the placenta while it remains attached to the uterus; and its subsequent judicious treatment as a simply retained placenta will have a good effect in bringing on that regular and natural uterine contraction, which is the hope of the practitioner and the safety of the patient.” (Essay on the Symptoms, Causes, and Treatment of Inversion of the Uterus, by W. Newnham, Esq. p. 14.)

On the other hand, many authorities, especially of modern times, advocate a very opposite practice, and recommend that the placenta should be removed before attempting to reduce the fundus; as by so doing it will pass back much more easily than where the bulk of the placenta is added to it. There can be no doubt that this practice is correct in cases of complete inversion, where, as we have already observed, there is little or no danger from hæmorrhage, and where it is of the greatest importance to avail ourselves of every advantage by lessening the size of the inverted uterus as much as possible: where, however, it is a case of partial inversion, it is generally accompanied with hæmorrhage; and here, therefore, it becomes a question how far we are justified in detaching the placenta, and therefore increasing the flooding, either before we are certain that we are able to reduce the fundus, or before we have placed the uterus in a condition in which it is capable of contracting. In Mr. Mann’s case, quoted by Dr. Radford (op. cit.,) the inversion was evidently complete, for the uterus was found to have “passed externally from the vagina, and the placenta attached to it.” “I first peeled the placenta from the fundus uteri, and then grasping the extruded part with my hand, I did not find it very difficult to re-introduce it into the vagina, and to carry it through the os uteri. I followed with my hand, or rather pushed it forward, when I observed it suddenly start from me as a piece of India rubber would.”

Dr. Merriman, who candidly owns that he has altered his opinion on this point, since the last edition of his work on difficult parturition, in favour of removing the placenta, distinctly proves that the presence of this mass was the chief cause of the difficulty. “I tried,” says he, “to effect the reduction without removing the placenta, but could, by no possibility, accomplish it till I had first separated the placenta: this being effected, I succeeded to my entire satisfaction in re-inverting the fundus.” (Synopsis of Difficult Parturition.)

In reducing the fundus, we must not thrust our fingers collected into a cone against the tumour, as has been recommended by most authors; for, by so doing, we only produce a depression in it, and, as it were, re-invert or double the uterus upon itself, and thus add considerably to the bulk of the mass, and the difficulty of the reduction. We should grasp the tumour firmly, and push it bodily upwards in the direction of the pelvic outlet: at first little or no change is produced, until it has ascended so far, that the vagina which had been dragged down is returned again to its natural situation; the hand must follow the tumour, and now that the lower part of the uterus is fixed, by the vagina being put upon the stretch, the pressure which is applied to the fundus will act with so much greater effect. We should endeavour to “return, first, that portion of the uterus which was expelled last from the os uteri.” (Newnham, op. cit. p. 616.) As the hand rises into the cavity of the pelvis, and is no longer able to grasp the tumour, so far from contracting the points of our fingers into a cone, it will be desirable to spread them at equal distances round it, and thus apply the pressure over a larger space: it was to attain this object that Leroux recommended the application of a cloth to the fundus, as by this means the force applied to it was more equally divided. (Sur les Pertes de Sang, § 218.) The hand, however, will be far preferable. We must gradually alter the direction in which we press up the tumour as it ascends, guiding our hand in the axis of the pelvic cavity, and lastly bringing it upwards and forwards in that of the superior aperture. When once the fundus has repassed the os uteri, it usually recedes suddenly from the hand, as already described in Mr. Mann’s case: if we feel the uterus through the abdominal parietes well contracted, there will be no need of passing the hand into its cavity; but if it be still flaccid and soft, the hand should be introduced, not only for the purpose of guarding against any return of the inversion, but of exciting more active contractions by its presence. The patient should avoid making any sudden efforts to raise herself, or to cough, strain, or by any means excite the abdominal muscles to exert pressure upon the fundus, for it is occasionally observed, that the disposition to inversion continues some time after the reduction has been effected.

Where some little time has elapsed before any attempt is made to reduce the fundus, the inverted portion begins to swell from obstruction to the return of blood, especially where the inversion is partial, and, therefore, tightly girded by the os uteri; the passages grow hot and dry, and the chances of reducing the tumour diminish in proportion. “Is it not reasonable,” as Mr. Newnham observes, “to suppose that the first effect of the accident will be to bring on inflammatory action and tension of the parts, and this very state will in itself be a sufficient obstacle to success.” (Op. cit. p. 18.) If, under these circumstances, we find that the attempts at reduction is attended with considerable difficulty, or is evidently impossible, it will be necessary to wait until the excitement of the circulation, and the congestion and swelling of the parts are reduced, and the passages duly relaxed by bleeding; besides this, the external parts should be well fomented, the patient should use the warm hip bath, or sit over the steam of hot water, and throw up emollient and sedative enemata as recommended in our treatment of inflammation of the uterus; the operation, which was during the state of inflammation and feverish excitement in which the patient was, strongly contra-indicated, now becomes practicable and safe, and the difficulties, which before would have rendered it nearly or quite impossible, are now in a great measure removed.

Wherever the uterus is completely inverted, and there is reason to expect considerable difficulty in reducing it, we shall find great benefit in adopting the mode of practice recommended by Mr. C. White, of Manchester, viz. of firmly grasping the tumour until we have succeeded in considerably diminishing its size, and thus removing the chief obstacle to its reduction. “I grasped the body of it in my hand,” says Mr. W., “and held it there for some time, in order to lessen its bulk by compression. As I soon perceived that it began to diminish, I persevered, and soon after made another attempt to reduce it, by thrusting at its fundus; it began to give way. I continued the force till I had perfectly returned it, and had insinuated my hand into its body: it was no sooner reduced, than the pulse in her wrist began to beat: she recovered as fast as we could wish.” (White, on Lying-in Women, case, 19. Appendix, p. 429, 2d edit.)

Where the fundus is partially inverted, and the os uteri girds it very tightly, so as not only to produce very frightful symptoms arising from the strangulated condition of the organ, but also to render its reduction a matter of great difficulty, or even impossibility, Dr. Dewees has advised that, so far from attempting to push up the fundus, we should rather try to bring it down, and thus render the inversion complete; by this means, the “pain, faintness, vomiting, delirium, cold sweats, convulsions, extinct pulse,” &c. will not only be relieved, but the farther danger from hæmorrhage prevented.

“The propriety and safety of this plan is, it must be confessed, predicated upon the happy result of a solitary case, but, from its entire and speedy success in this instance, it is rendered more than probable that it will be of equal advantage if employed in others; “all reasoning upon the subject” is certainly in its favour; and experience, so far as a single case may be entitled such, is equally so. The patient is to be placed upon her back near the edge of the bed, and have her legs supported by proper assistants; the hand is to be introduced along the interior part of the vagina, but sufficiently high to seize the uterus pretty firmly; it is then to be drawn gently and steadily downward and outward, until the inversion is completed: this will be known by a kind of jerk, announcing the passing of the confined part through the stricture. Traction should now cease, and the part be carefully examined; if the inversion be complete, the mouth of the uterus will no longer be felt, and there will be an immediate cessation of pain and other distressing sensations.” (Dewees, Compendious System of Midwifery, § 1318.)

Chronic inversion. Where some time has already elapsed since the occurrence of the accident, and the more distressing symptoms have subsided, the inversion now passes into a chronic state, which, although not immediately dangerous to life, will ultimately be not less fatal. The form of the tumour gradually alters; it assumes a more polypoid shape, from the increasing contraction of its mouth narrowing the upper part of it; and now the diagnosis from polypus sometimes becomes exceedingly difficult, the more so as the pressure produced by the os uteri diminishes the sensibility of the fundus. Hence, as Mr. Newnham observes, we may conclude, “that it is always difficult and sometimes impossible, with our present knowledge, to distinguish partial and chronic inversion of the uterus from polypus; since, in both diseases, the os uteri will be found encircling the summit of the tumour, and, in either case, the finger may be passed readily around it. And if, in order to remove this uncertainty, the entire hand be introduced into the vagina, so as to allow the finger to pass by the side of the tumour to the extremity of the space remaining between it and the os uteri; and if we find that the finger soon arrives at this point, it will be impossible to ascertain whether it rests against a portion of the uterus which has been inverted in the usual way, or by the long-continued dragging of the polypus upon its fundus. And if, under these embarrassing circumstances, we call to our assistance our ideas concerning the form of polypus, its enlarged base and narrow peduncle, we must also recollect the abundant evidence to prove that the neck of such a tumour is often as large, and sometimes larger, than its inferior extremity, and we shall still be left in inexplicable uncertainty.”