A System of Midwifery

by Edward Rigby

Cervix uteri in the eighth month.

In the eighth month, the fundus has risen half way between the umbilicus and the scrobiculus cordis. The abdomen has increased considerably in size, and has become more convex; the umbilical depression in primiparæ has entirely disappeared. The portio vaginalis is still shorter, being barely a quarter of an inch in length. The os uteri is so high up as not to be reached without difficulty; the presenting part of the child can be distinctly felt.

Cervix uteri in the ninth month.

In the ninth month, the fundus has reached nearly to the scrobiculus cordis, and by the end of the month is quite in it; this is more especially the case with primiparæ: the anterior parietes of the abdomen not allowing the fundis to incline so strongly forwards, the oppression of breathing is therefore more marked in them than in multiparæ, for the fundus uteri rising so high prevents in great measure the action of the diaphragm, so that the chest is expanded by other muscles; hence the shortness of breath and inability of moving, so frequently complained of at this period of utero-gestation. The portio vaginalis is still shorter, and in the primipara forms little more than a soft cushiony ring which marks the os uteri. The inferior part of the uterus is becoming more spherical, and is usually occupied by the presenting part of the child: this latter is no longer so moveable as before, its size as also its weight being evidently increased. That portion of the uterus which extends between the symphysis pubis and os uteri is now not only more convex but lower in the pelvis than the os uteri itself.

During the last four weeks of pregnancy a considerable change is observed. The fundus is now lower than it was in the preceding month, being about half way between the scrobiculus cordis and umbilicus; the abdomen has, as it is called, fallen; and from the diaphragm being now able to resume its functions the breathing becomes more easy, and the female feels more comfortable and capable of moving about. On examination per vaginam the anterior portion of the inferior segment of the uterus will be felt still deeper in the pelvis: if the head presents it distends this part of the uterus, so that, in many cases, we have to pass the finger round it before we can reach the os uteri, which is now in the upper part of the hollow of the sacrum. All traces of the cervix have now disappeared, it having been required to complete the full development of the uterus; the situation of the os uteri itself is marked merely by a small depression or dimple; there is no longer any distinction between the os uteri internum and externum; the edges of the opening are so thin as to be nearly membranous, but remain closed in primiparæ until the commencement of labour.[16]

In women who have had several children, a considerable difference is observed as regards the state of the cervix and os uteri: the cervix does not undergo that shortening during the latter half of pregnancy, which is the case in a primipara, a portion of it at least remaining up to the full term of utero-gestation: in many cases, especially where the female has had a large family, it is nearly an inch long at this period; nor is the lower portion of the uterus so spherical as in the primipara; to this circumstance may probably be attributed the fact of the head not descending so deep into the pelvis just before labour. In multiparæ the os uteri is also very different: instead of being perfectly round with its edges smooth, it is irregular and uneven, and seldom loses altogether the lip-like shape of the unimpregnated state in consequence of the greater thickness and elongation of its lips from former labours; its edges here and there is uneven and knotty, from little callous cicatrices, where it has been torn; moreover it does not remain closed till the commencement of labour, but the os uteri externum (commonly called os tincæ,) and sometimes even the os uteri internum will be more or less open during the last three or four weeks of pregnancy. These peculiarities are of great importance in coming to a conclusion as to whether a patient be in her first pregnancy or not: although not invariable in the utmost sense of the word, still their occurrence, even after a single labour, is sufficiently frequent to make them worthy of careful observation. Indeed, on more than one occasion, we have known them occur even after a miscarriage, a circumstance on the strength of which the patient had ventured to deny that she was pregnant. On the other hand, we sometimes meet with the os uteri in a second pregnancy so little altered by the effects of the previous labour, that it would be extremely difficult to come to a decision.

When labour is over, the uterus contracts very considerably, and, in a few days after, its parietes will be found at least an inch in thickness. It now gradually diminishes in size, and continues to do so for some weeks; the blood-vessels contract, and losing the peculiarly loose spongy structure of pregnancy it becomes harder, firmer, and more compact. It nevertheless remains softer and larger than in the virgin state, and does not attain its original size and hardness until an advanced period of life.

The os uteri, which in the latter months of pregnancy had formed a circular opening, resumes its former shape, except that its lips, especially the posterior one, which are more or less irregular and uneven, are thicker and longer than in the virgin state. For the first weeks after labour, the os uteri is high in the pelvis, soft, and easily admits the tip of the finger; at the end of the second week it is much lower in the pelvis, and no longer permits the finger to pass. Immediately after labour, the contracted uterus forms a hard solid ball, the size of a new-born child’s head; this state of contraction is not, however, of long continuance: in the course of half an hour, or even less, it begins to increase in size, becoming softer and larger, and continuing to increase slowly for some hours, when it again gradually diminishes, until, as before observed, it approaches its original size in the unimpregnated state. The state of powerful contraction in which the uterus is felt immediately after labour, after a time gradually relaxes; its spongy texture, from which the blood had been forcibly expelled by the violent action of its fibres, becomes again filled with blood; the organ swells and becomes softer and more bulky, and the orifices of the vessels which open into the cavity of the uterus are again partly pervious, and emit a sanious fluid called the lochia. This state lasts for two or more days after delivery, when the vessels begin to recover their former caliber, and lose that degree of dilatation peculiar to the gravid state. The lochia become less and less coloured, and now, and not before the uterus undergoes that gradual diminution of size and bulk which we have just alluded to.