A System of Midwifery

by Edward Rigby

No conscientious practitioner, who has clear and enlarged views of the process and mechanism of natural labour, would feel himself justified in interfering with its course, merely because some portion of it has extended beyond a certain fixed period; but would rather guide his conduct by the habit and strength of the individual, and by the effects which the labour has upon her. We have before stated, that no two labours are alike; we may also add, that no two individuals are similarly affected by the same degree and duration of labour, nor indeed are any two labours exactly alike in the same person: hence it will be evident, that what to one patient would prove a protracted and exhausting labour, to another would be nothing more than a perfectly regular labour, natural both in its character and progress. Among other injurious effects which premature efforts on the part of the patient will have, is, that the membranes are liable to give way too soon—this is by all means to be avoided, for nothing is so likely to render the first stage protracted as the occurrence of this accident; the course of the labour frequently undergoes an immediate change; the pains lose their regular and effective character; the os uteri remains thin, tense, and unyielding, and the process of dilatation is greatly retarded.

Prognosis as to the duration of labour. There are few subjects upon which an accoucheur is so frequently importuned, or about which it is so difficult to give a decided opinion, as the probable duration of labour. It is natural enough that both she and her friends should be anxious to know how long this process of suffering is likely to last: nothing, however, is more hazardous than a prognosis in these cases; and we would warn our junior brethren to be cautious how they commit themselves by venturing an opinion, which the result of the labour may prove to have been founded upon guess-work or ignorance. The character of the labour during the second stage, is frequently very different to that of the first, so that the mode in which the labour commences is by no means a criterion for its latter part. A labour which has commenced briskly and regularly, and with every promise of a rapid progress and termination, frequently becomes exceedingly lingering during the second stage, so that the expelling powers may, perhaps, even fail altogether in making the head pass through the os externum; whereas, on the other hand, a labour, the first stage of which has been slow and protracted, frequently experiences a complete alteration of character, and advances with a degree of quickness and energy, which could scarcely have been anticipated from the manner in which it commenced. In primiparæ, especially, it is particularly difficult to foretell, with any thing like certainty, the duration of labour: hence it is, that unguarded assertions in this respect are not only liable to disappoint the patient, but destroy her confidence in the practitioner.

Wigand’s views. The celebrated Wigand of Hamburgh considered that the form of the vagina would frequently furnish the means of a pretty certain prognosis, as to the duration of labour: thus, if it were wide and yielding throughout its whole length, the labour would be quick, both at its beginning and termination; if, on the other hand, it were small, rigid, and contracted throughout, the labour might be expected to be of a very opposite character. If on examination the vagina is found roomy and well dilated at its upper part, but contracted and rigid near the os externum, the labour will be probably quick and easy during the first half, but slow and difficult afterwards; on the contrary, where the os externum is yielding and wide, but the upper portion of the vagina narrow, the labour may be expected to be slow at first, but to be brisk and active afterwards. We have already stated, that the course of labour varies in every possible way; in some cases the same peculiar character of labour shows itself through two or three successive generations: hence it has been observed, that very tedious or very violent and rapid labours sometimes seems to be hereditary; the mother, daughters, and grand-daughters, being all remarkable for their lingering or rapid labours.

Diet during labour. The diet of the patient during labour should be simple and unirritating; if every thing is going on naturally and briskly, some gruel or tea, with or without a little biscuit or bread and butter, will be quite sufficient; but if the process is becoming tedious and exhausting, some beef-tea, broth, or any other mild nourishment of this sort will be required to support the strength.

During the first stage of labour there is no need for the practitioner to be constantly in the room, nor even during the early part of the second, unless the pains are very violent and protrusive; for, by taking frequent opportunities of quitting the patient for a few minutes, she is left more free from restraint, and the presence of the practitioner becomes less irksome when it is really necessary; whereas, if he continues at the bed-side, she is justified in expecting that the labour must be advancing rapidly to demand so unremitting an attendance, and, therefore, becomes disappointed and impatient to find that his presence has been of so little use to her. The conversation should be light and cheerful, and every means taken to encourage her and keep up her spirits.

Supporting the perineum. As the head approaches the os externum our attention must be directed to giving the perineum such a degree of support, as shall secure it from any serious degree of laceration during its passage. The greatest danger of ruptured perineum is in primiparæ, for the soft parts never having been subjected to such a degree of dilatation before, do not yield so readily as in multiparæ. The anterior margin of the perineum, called frænulum, is, we believe almost invariably ruptured in every first case; but the laceration ought not to extend farther. The more gradual the advance of the head is through the os externum, the better will be the dilatation of the soft parts: hence therefore, when the pains are violent, and the head is thrust with great force against the perineum, it will be desirable to restrain it in some degree, until the parts shall have had sufficient time to yield; on the other hand, where the pains are more gradual, the perineum and os externum may receive the whole dilating force of the head, and every succeeding pain will show that a progressive advance is taking place.

The increasing thinness of the perineum itself, and the frænulum becoming tense during the height of a pain, may be looked upon as warnings that the expulsion of the head is not far distant, and now the support of the hand will be needed to prevent laceration; for this purpose the position on the left side is peculiarly convenient, besides having the additional advantage of relaxing the external parts more completely. If the pains be violent, and the impulse to strain very considerable, we must desire the patient to lie as passive as she can, and do her best not to bear down, for otherwise the head is sometimes driven through the os externum with a single effort, and the mischief done in spite of all our care.

The support of the perineum has been variously directed by different authors; we prefer using the left hand, because then we have the right at liberty for any manipulations which may be necessary, such as examining if the cord be round the child’s neck, &c. &c. It is awkward at first, because it requires the hand to be considerably twisted, and makes the wrist ache a good deal; but a very little practice soon conquers this slight difficulty, and the superiority of the mode will then be apparent. As our object is not merely to support the perineum, but to direct the head as much forwards under the pubic arch as possible, in order that the anterior portions of the os externum should undergo their share of dilatation, and thus in some measure spare the perineum, the chief pressure should be applied near to the sphincter ani, gradually diminishing it up to the frænulum perinei in front: for this purpose the left hand protected by a napkin (partly for the sake of cleanliness and partly for the purpose of having a firmer hold upon the parts, and preventing it slipping) should now be applied with the palm in the vicinity of the sphincter ani, so that the tips of the fingers should project somewhat beyond the frænulum; the whole should be laid as flat and close to the part as possible. In order that we may be sure of the hand being applied exactly along the raphe of the perineum, we should guide it by the examining finger of the right hand, bearing in mind, that when we place this against the posterior margin of the os externum, and bring the middle finger of the left hand in contact with it, we shall hold the left hand in the desired direction.

It is desirable also to hold the examining finger of the right hand against the frænulum perinei when a pain comes on, because then we know exactly when the tension of the perineum is becoming such as to endanger its integrity, and when the head is about to pass out. Until this moment the frænulum is seldom on the stretch, although the rest of the perineum is: hence we need not apply our support until now, and thus give the parts the full benefit of the dilating force, which the head exerts upon them, until the very last instant. To relax them still farther, the patient’s knees ought not to be separated by a pillow or cushion placed between them, as is usually done, although it must be confessed that in some cases she is relieved by it.

In applying the left hand to support the perineum, it should be placed somewhat more backward than the spot which we intend to support: for by this means we are enabled to push the soft parts somewhat forwards, and thus relax them. By this means, also, we not only direct the head against the other parts of the os externum but avoid the danger of its perforating the perineum. When the moment of greatest distension arrives, the process cannot be too slow; we must therefore desire the patient not to bear down, and endeavour, if possible, to make the head remain in the state of crowning until the next pain comes on: the os externum having been held for some moments at its utmost dilatation, permits the head to pass with greater ease and safety. As the globe of the head passes forwards and emerges through the os externum, we feel the posterior portions of the perineum become soft and lax, while the forehead, followed by the face, and lastly the chin glide over the anterior margin of it.