A System of Midwifery

by Edward Rigby

The form or size of the pelvis can have, we think, but little effect upon the cord, so long as the uterine action is of the right character and the child alive. Most authors enumerate a large pelvis or small fœtal head as a cause, why should we not, therefore, have prolapsus of the cord in every case of precipitate labour which arises from such circumstances? Nor are we at all disposed to consider deformed pelvis as capable of producing it, so long as the uterus is not immoderately distended and acting naturally: we do not deny that the cord is occasionally found prolapsed in cases of dystocia pelvica, but this is chiefly where the child has died from the severity of the labour, and where the flaccid pulseless cord has gradually slipped down during the intervals of the pains.

So long as the uterus exerts but a moderate degree of pressure round the head, it is impossible for the cord of a living child to descend, particularly as, according to Dr. Michaelis, the circular contraction of the portio vaginalis commences from below upwards, and would rather push back the cord if a portion of it had descended during the moments of uterine relaxation. The pulsating turgor of the cord when the child is alive will also assist much in preventing its descent, even where the uterus does not surround the presenting part so closely as usual.

The unusual length of the cord is also a very doubtful cause of its prolapsus, and will evidently, in great measure, depend upon the causes we have already alluded to.

We may also allude to another cause of prolapsus of the cord, which, although noticed nearly a century ago by Levret, and also by two or three authors after him, had nearly fallen into oblivion until lately, when it excited the attention of Professor Naegelé, junior. Levret, from the result of numerous observations on the insertion of the cord into the placenta, was led to suppose that the lower the situation of the placenta in the uterus, the lower also was the insertion of the cord into the placenta, so that if the edge of the placenta touched upon the os uteri, the cord was usually inserted into that part of its edge which corresponded with the os uteri.

Although it is certain that the situation of the placenta close to the os uteri, is by no means necessarily attended by insertion of the cord into its edge, and, therefore, by prolapsus of it when the membranes give way, inasmuch, as under such circumstances we ought to have every case of partial placenta prævia accompanied with the cord presenting: still, however, there is no doubt that cases of the above-mentioned complication do every now and then occur, and must necessarily incur no inconsiderable danger of prolapsus.

“There is no doubt that the situation of the placenta in the vicinity of the os uteri, may be looked upon as one of the predisposing causes of the cord presenting during labour; an accident which is the more to be feared, the nearer the cord is inserted into the inferior edge of the placenta. If its edge extends quite down to the os uteri, and the cord is inserted into it, or the umbilical vessels divide, as in the cases we have described, at some little distance from it, viz. in the membranes, the cord will present as a necessary result, and prolapse as soon as the membranes give way.” (Die Geburtshülfliche Auscultation, von Dr. H. F. Naegelé, p. 114.) The two cases referred to by Professor Naegelé, jun., of prolapsus of the cord from this cause, occurred so near after each other, as to render the circumstance the more remarkable. The fact was noticed by Giffard as early as in 1728, in a case of flooding from partial placenta prævia; but he does not appear then to have drawn any inferences from the position of the placenta, which he did not consider was attached, but was “in part, if not wholly, separated from the uterus.”[137]

Prolapsus of the cord is fortunately not a circumstance of frequent occurrence. Dr. Churchill, of Dublin, in a valuable paper, (Edin. Med. and Surg. Journal, Oct., 1838,) has collected the results of no less than 90,983 deliveries, amongst which the cord presented in 322 cases, being in the proportion of one in 282¼.[138] That prolapsus of the cord occurs most frequently in foot presentations, as supposed by Professor Naegelé, senior, is disproved by the results of Mauriceau’s large experience, as well as of many others since; thus, out of 33 cases which occurred in labour at the full term, (or nearly so,) 17 presented with the head, 1 with the face, 1 with the feet, 9 with the hand or arm, 3 with the hand or foot, 1 with the hand and breech, and 1 with the hand and head. In the 16,652 births which have been recorded by Dr. Collins, at the Dublin Lying-in Hospital, the cord prolapsed in 97 instances. “Twelve of the 97 occurred in twin cases, and in seven of the 12 it was the cord of the second child. Nine occurred where the feet presented, (not including two met with in twin children,) which was in the proportion of one in every fourteen of such presentations. Two only where the breech presented, which was in the proportion of one in every 121 of such presentations: this approaches nearly the proportional average in all deliveries, which is one in 171½. Four occurred where the shoulder or arm presented: this is in the proportion of one in nine of such presentations. Seven occurred where the hand came down with the head. Seven of the children were born putrid; three of the 97 were premature, viz. two at the seventh and one at the eighth month.” (Collins’s Practical Treatise on Midwifery, p. 346.) We may, therefore, conclude with safety, that presentations of the head are by far the most common.

Treatment. Left to itself prolapsus of the cord is almost certain destruction to the child, for unless the labour comes on very briskly, and the head passes rapidly through the pelvis, the cord is pressed upon so long as to render it impossible for the child to be born alive. Still, however, where the passages are yielding, and the pains active; where the head is of a moderate size, the pelvis spacious, and the cord in a favourable part of it, viz. towards one of the sacro-iliac synchondroses; where also the membranes remain unruptured until the last moment, there will be a very fair chance of the child being born alive. Under no circumstances is it of such paramount importance to avoid rupturing the membranes as in these cases, for the bag of fluid which they form dilates the soft passages and protects the cord from pressure.

“Many methods of relief have been recommended, such as turning, delivering with the forceps, pushing up the funis through the os uteri with the hand, and endeavouring to suspend it on some limb of the child, collecting the prolapsed cord into a bag, and then pushing it up beyond the head, pushing up, the funis with instruments of various kinds, endeavouring to keep it secured above the head by means of a piece of sponge introduced; these and many other similar expedients have been resorted to.” (Collins, op. cit. p. 344.)

The first two of these means have been chiefly used in cases of prolapsed funis, the others having, for the most part, been found entirely inefficient. Thus Mauriceau, in the 33 cases which he has recorded, turned 19 times: the children were all born alive, except one, which was dead, but required turning as it presented with the arm. In later times, turning or the forceps have been preferred, according to the period of labour at which the prolapsus was discovered or occurred. Thus Madame Boivin has recorded 38 cases, 25 of which occurred at the commencement of, and 13 during labour, the former were all turned; in the latter the forceps was used; 29 children were saved, seven were lost, and the two others were putrid.