A System of Midwifery

by Edward Rigby

The longer the patient has still to go, the more desirable is it that we should, if possible, control the symptoms, and prevent them from proceeding to such extent as to require artificial delivery. It is of the utmost consequence that we should take such measures as will enable the pregnancy to go on safely, if not to the full time, at least to a later period, for by this means the uterus will have attained such a degree of development as will enable the turning to be undertaken with ease to the practitioner and with safety to the mother; the child also will have so far advanced towards maturity as to give it a better chance of surviving the operation.

Wherever hæmorrhage has occurred during the last three months of pregnancy, which has come on suddenly and without any assignable reason, we should earnestly warn the patient and her friends to summon the practitioner the moment there are any symptoms of its return; for if it be a case of placental presentation, it assuredly will return, and as certainly much more profusely than at first.

Where the patient has gone nearly or quite to her full time, the first attack is much more alarming; the hæmorrhage frequently appears with a sudden gush, and in a few minutes a serious and even dangerous quantity of blood is lost; thus a patient whom we had seen but a few hours previously in perfect health, was suddenly seized with profuse flooding as she was standing at the door of her house speaking to a person, and before she could move, a large pool of blood had formed at her feet; in another case, the patient while standing at her tea-table was attacked in a similar manner, and in a moment the floor was deluged with the discharge.

Although artificial delivery by turning the child is required in every case of central presentation of the placenta during the latter periods of pregnancy, it is evident that this will not apply during the earlier months, when the uterus from its size will preclude the possibility of such an operation. Dr. Rigby has established a valuable axiom on this point, viz. “that when the uterus is too small for the admission of the hand, the expulsion of the placenta and fœtus will happily be timely effected by nature. It is well known that in the early months, instances of fatal termination by floodings have been very rare, as abortion sooner or later puts a stop to the discharge. It has been likewise before observed, that in floodings at any period of pregnancy, women seldom die, at least not in the first instance, unless a considerable quantity of blood has been suddenly lost. Now, as the danger of a great and sudden loss must obviously depend upon the size of the uterine vessels, and as the enlargement of the vessels is in exact proportion to the increased size of the uterus, it becomes probable that when the vessels have acquired such a magnitude, that when detached from the placenta they would bleed largely and suddenly, the uterus itself must have attained to such a capacity as to admit the hand for artificial delivery.” (Op. cit. p. 48, 6th ed.) He farther observes, “that as the most material increase of the uterus does not take place until the end of the sixth month of pregnancy, a hæmorrhage before that period will seldom require artificial delivery; and after that period, should it become necessary, that it is probable the hand may then be admitted for that purpose.” (Ibid. p. 51.)

In almost every case where the patient is some time short of her full time, the os uteri will be found unyielding and but little dilated; it will, therefore, seldom be possible, and scarcely ever proper, to introduce the hand into the uterus under such circumstances; the os uteri either entirely resists our efforts, or if we do overcome it, the degree of force required to effect this has been so great, as will in all probability have been attended with serious injury to the part itself. In no case is it proper or safe to force delivery by artificially dilating the os uteri, when it is contracted and unyielding (see Turning;) but where the placenta is presenting, it is peculiarly dangerous, for even slight laceration of the os uteri will be followed by serious consequences. Where the placenta is situated in the upper part of the uterus, it is of very little consequence if the edge of the os uteri has been torn somewhat during labour; but in the present case it is very different; the os uteri now plays the part of the fundus, its vessels are immensely dilated, and large ones are ruptured, which cannot be closed by the firmest contraction of the uterus.

“In recommending early delivery, I think it right, however, to express a caution against the premature introduction of the hand, and the too forcible dilatation of the os uteri before it is sufficiently relaxed by pain or discharge; for it is undoubtedly very certain that the turning may be performed too soon as well as too late, and that the consequences of the one may be as destructive to the patient as the other.” (Rigby, op. cit. p. 37.) Cases have occurred where the os uteri has been artificially dilated, where the child was turned and delivered with perfect safety, and the uterus contracted into a hard ball; in fact, every thing seemed to have passed over favourably; a continued dribbling of blood has remained after labour, which resisted every attempt to check it; friction upon the abdomen and other means for stopping hæmorrhage by inducing firm contraction of the uterus were of no use, for the uterus was already hard and well contracted; the patient has gradually become exhausted, and at last died; on examination after death, Professor Naegelé has invariably found the os uteri more or less torn.

“It must be acknowledged, indeed,” says Dr. Rigby, “that it may sometimes happen that at the very first coming on of the complaint, if the discharge be small, and more especially, if it be the patient’s first child, and the parts be close and unyielding, the admission of the hand into the vagina, as I have directed, will be attended with the utmost difficulty, and, perhaps, be almost impracticable: in this case let us wait (but let it be with the patient) till the discharge increases, and has continued long enough to relax the parts; for certainly, if the woman be able to bear losing a little blood, which at first she may safely do, the examination will be thereby rendered more easy, and the turning of the child, if necessary, be more practicable and safe.” (Op. cit. p. 36.)

We have already shown (see Turning, p. 236.) that there is no means of rendering a rigid os uteri yielding and capable of admitting the hand equal to the relaxation produced by loss of blood: wherever the powers of the system have already suffered from the effects of hæmorrhage, we may feel almost certain that we shall find the os uteri capable of dilating, even if it be so little open as barely to admit the finger. Where the patient has become faint or fallen into actual syncope, the relaxation of the soft parts is very striking, and frequently to an extent which could scarcely be believed by those who have not felt it; all resistance seems to be at an end for the time, and the hand enters the flaccid passages with scarcely a sensation of pressure from them, but rather (as has been aptly compared, to that of some wet bladder wrapped around it.)

“It has been advised (observes Dr. Rigby) never to introduce the hand till nature has shown some disposition to relieve herself by the dilatation of the os uteri to the size of a shilling, or a half-crown; and this rule is certainly founded on a rational principle, for when it is so much dilated, there is no doubt but the turning may be easily and safely effected; but from some of the annexed cases it appears that a dilatation to this degree sometimes does not take place at all; and that even when the woman is dying from the great loss of blood, the uterus is very little open; the reason for which, seems to be, that when the discharge has been considerable, and more particularly when much blood has been suddenly lost, such a faintness is brought on, that though the uterus be totally relaxed, and might, therefore, be opened by the most gentle efforts, yet nature is unable to make use of these efforts; and, moreover, if there be slight pains, the adhesion of the placenta to the internal surface of the mouth of the womb, counteracts their influence, and thereby hinders its giving way to a power, which would otherwise, probably, very easily open it.” (Op. cit. p. 39.)

Plug. Where, however, the case is at that doubtful period of early pregnancy, when even under the most favourable circumstances, as above-mentioned, the hand must experience considerable difficulty in entering the os uteri, and yet the expulsion of the child cannot be safely trusted to the natural powers, it becomes necessary, as in certain cases of premature expulsion, to have recourse to such means as shall enable the os uteri to go on dilating without the danger of farther hæmorrhage; in other words, we must plug the vagina. “If, after the commencement of a flooding, we favour the formation of a coagulum by means of a plug, are we not aiding nature? It brings on labour much sooner, and the os uteri has time to dilate without farther loss of blood.” (Leroux, Sur les Pertes de Sang. § 309.) By means of the plug, we enable the patient to go on with perfect security until the pains have produced a sufficient dilatation of the os uteri to admit the hand; after a time we may withdraw it, and if then not satisfied with the state of the os uteri, it must be again introduced until our object be effected. (For directions as to the use of the plug we must refer to p. 152.)