A System of Midwifery

by Edward Rigby

Mental affections, which we have already shown to be capable of retarding labour, occasionally have the opposite effect, and rouse the uterus to violent action. It is well known that the dread of the forceps, which the practitioner has declared would be required, has frequently been followed by so much activity of the uterus as to render its application unnecessary.

Where the patient is stout, robust, and plethoric, or of a nervous hysterical habit, this state of unruly uterine action is frequently attended with great cerebral excitement; during the pains she raves wildly, and for some time becomes quite unmanageable, or in other cases this state passes into actual convulsions.

In febrile diseases, especially of the eruptive kind, the labour is usually of this character; the exertions of the uterus in such cases, especially in scarlet fever, are sometimes quite extraordinary, so that the child seems to be born without any effort on the part of the mother. This is of great importance in inflammation of the lungs, &c. where the patient would be unable to inflate the lungs to that extent which is necessary for any violent efforts.

Deficient resistance. Where the rapidity of the labour arises from want of that degree of resistance to the expelling powers which is natural, it may depend on circumstances connected with the mother or the child; thus, it may arise from too large a pelvis; the head, covered by the inferior portion of the uterus, is forced down deeper into the pelvis than usual, especially if, as is not unfrequently the case, this state be accompanied with violent and powerful pains; the head may thus be actually forced through the os externum before it has passed the os uteri: cases have been recorded where nearly the whole uterus, has been thus protruded. In an “extraordinary case,” as Deventer justly terms it, “the head of the child had passed the os externum as far as the shoulders, and only the summit of it was visible, three-quarters at least of the head being still enclosed in the uterus, although the head and neck had already passed.” (Novum Lumen, part. ii. chap. 3.)

In other cases the sudden expulsion of the child appears to depend merely upon the great dilatability of the soft parts, and may occur quite independently of any disease. We recollect a case of this sort where the patient, a healthy woman, had only two pains—the first awoke her out of a sound sleep and ruptured the membranes, the next drove the child with great violence into the bed. Where the patient is weakened by previous disease, and the soft parts are very relaxed and flaccid, they produce no resistance to the advance of the head: this condition is very unfavourable, “as it implies a greater state of relaxation, or want of tone, than is compatible with the welfare of the patient: hence it is seldom found to take place except when the unfortunate subject is sinking under the last stage of debility, as in phthisis,” &c. (Power’s Midwifery, p. 138.)

The want of due resistance to the expelling powers may depend upon the size and hardness of the head; it is either smaller than usual, from the child being premature, or, if of the full size, the cranial bones are imperfectly ossified, the sutures are wide, the fontanelles large, and the whole head very yielding and soft; or it may depend on some congenital defect, in which the brain and cranial coverings are more or less imperfect.

In the ordinary cases of precipitate labour the case depends generally on a complication of violent pains, wide pelvis, and small child.

Effects of precipitate labour. Besides the mischief which may result from the rapid expulsion of the child causing prolapsus uteri, laceration of the vagina, perineum, and hæmorrhage from inertia coming on in consequence of the uterus being so suddenly emptied, dangerous syncope, or even asphyxia, may follow from the shock which the nervous system has sustained, or in consequence of the sudden removal of that degree of pressure which the gravid uterus had exerted upon the abdominal circulation during pregnancy. Where the patient has been very unruly, and has exerted herself with great violence, “emphysema of the face and neck (says Dr. Reid) may suddenly occur during labour, and cause great alarm to a young practitioner, as it alters and disfigures the countenance in an extraordinary manner. Great straining or screaming may produce it, and it probably depends on some partial rupture of the lining membrane of the larynx. I have seen two or three cases of this description, and one which occurred to a great extent in the case of an out-patient of the General Lying-in Hospital, in whom this tumefaction spread to the shoulders and chest.” (Manual of Pract. Midwifery, by James Reid, M. D. p. 231.)

The child also may suffer from a precipitate labour, where the pains are excessively violent and run into each other, so that the whole labour is effected during one continued storm of uterine action. If the membranes have given way at an early period, so that the body of the child is exposed to the immediate pressure of the pains, the abdominal circulation suffers, and the child is destroyed in the same way as by pressure on the cord itself; or it may be suddenly dashed upon the floor before the mother has had time to reach her bed, or even put herself in a recumbent posture upon the floor: in this way it may receive a severe injury upon the head, or the cord may be lacerated, and the child die from hæmorrhage before assistance can arrive: such accidents, however, are not so dangerous to the child as have been supposed, a fact which has been proved by medico-legal investigations. The direction of the pelvic outlet and vagina is such as to expel the child obliquely downwards and forwards when the mother is in the upright posture, so that the force of the blow is in a great measure broken by this circumstance; the head also, as well as the other parts of the body, are soft and yielding, and nearly preclude the chances of injury taking place; the violence of the fall is generally diminished in some measure by the patient being almost always compelled to drop upon her knees at the moment of great suffering, whilst the child is passing; her clothes also surround it more or less, and thus shield it from any severe injury.

Rupture of the cord. The cord is liable to be torn in these cases, showing that a considerable jerk had been applied to it, but neither the child nor its mother have suffered from it. Ten or twelve cases of ruptured cord have come to our own immediate knowledge, and in none of them were any unfavourable effects produced. It can scarcely be imagined possible that so much force could be applied to the cord, at the moment when the uterus is so suddenly evacuated, without inversion or prolapsus being the almost unavoidable result, the more so when we recollect that the cord at the moment of birth requires considerable force to break it. This circumstance may be partly attributed to the firmness with which the uterus contracts at the moment that the child is expelled, but chiefly to the fact that the axis of the brim is nearly at right angles with that of the outlet, more especially if the fundus, as is usually the case, is inclined somewhat forwards; the cord passes round the posterior part of the symphysis pubis as upon a pulley, so that a considerable portion of the force which is applied to it, is spent here before reaching the fundus uteri. It is however remarkable, that the umbilicus of the child should receive no injury from a jerk which breaks the cord, when, if we try afterwards to break the remaining pieces of the cord, we find that it will resist very powerful efforts: this fact, and the circumstance that the cord usually ruptures at about two or three inches from the umbilicus, as in some animals, seems to imply that this part is weaker than elsewhere, as if intended by nature to give way with a moderate degree of force.