A System of Midwifery

by Edward Rigby

The passage of the head is not the only moment of danger to the perineum, for laceration is even still more liable to be produced during the expulsion of the shoulders; any slight rupture of the anterior edge is now apt to be converted into a considerable laceration, unless the support be continued until the thorax be expelled. We have already stated that the frænulum perinei is generally torn through in the first labour; but the laceration ought not, if possible, to extend farther, because serious injury may be produced either to the vagina, or even to the sphincter rectum. To say, however, that laceration of the perineum need never happen, would be preposterous; because cases every now and then occur, where, from the contracted and unyielding state of the os externum, and from the size of the child, it is nearly impossible that the perineum can escape without injury; fortunately, although considerable lacerations are by no means uncommon, they are seldom observed to extend into the sphincter ani, the direction of the rent being usually to one side. Under the ordinary circumstances of perineal laceration, little more than mere attention to cleanliness is required; for the parts contract so astonishingly after labour, that what was a wide rent of an inch and a half long, in a couple of days will be scarcely more than two or three lines in length. Rest, great cleanliness, and gentle-relaxed bowels, constitute the chief treatment.

Treatment of perineal laceration. Where, however, the laceration extends into the rectum, the case becomes exceedingly troublesome and difficult to cure, and the patient is liable to be rendered a miserable object for life; for the action of the sphincter being entirely destroyed, she is unable to retain fæces or flatus in the rectum; besides which, from the injury to the posterior wall of the vagina, prolapsus uteri is an almost certain consequence. In these cases the slightest movement of the thighs upon each other alters the position of the lips of the wound, and thus tears it open afresh, so that at length the edges of the wound become callous and refuse to heal. A great deal in these cases depends upon the patience and good conduct of the patient herself; for if she have the resolution to lie perfectly still for at least a week, she will have every chance of a perfect cure. If there be much swelling of the edges, and a disposition to slough, a warm poultice of chamomile flowers should be applied, and the bowels kept in a nearly liquid state by gentle and repeated doses of salines, in order to prevent distension of the rectum when the evacuation is passing; she should preserve the supine posture, and have her knees confined together by a piece of tape, as is done with patients after the operation of lithotomy. Straps of adhesive plaster are seldom or never of any use, but if the rent be very severe a suture or two may be required. The great fault in applying these means for bringing the edges of the wound together is the attempting to unite them throughout their whole length; for by so doing the tension of the parts is increased, and therefore there is less disposition to unite; and even if we succeed in effecting complete union of the whole wound, the perineum is so contracted and unyielding from the cicatrisation, that it can scarcely escape a repetition of the injury in succeeding labours. It is, therefore, much better that we should content ourselves with uniting merely the posterior half of the laceration; the parts heal much more readily, and the os externum is left of a sufficient size to escape all danger of laceration on future occasions.

Where the edges have become callous and refused to unite, they require to be pared and brought together again; this, however, does not always succeed, and the case becomes very difficult and protracted: under these circumstances, the treatment adopted by Dr. Dieffenbach, of Berlin, is well worthy of attention. Having pared off the callous edges of the wound, he brings them into the closest opposition by transfixing them with needles in several places, as is done for the operation of hare-lip; and in order to isolate the wound as much as possible from the surrounding parts, and prevent any tension, he makes a free incision through the integuments, parallel with the wound, at a little distance from it, and nearly of the same length; by this means, every cause which might tend to separate the edges is removed; whilst the parallel cuts, being fresh incised wounds, soon close by granulation.[68]

It sometimes, although rarely, happens that the perineum, instead of being torn from before backwards, is perforated through its centre by the head, so that the child is not born through the os externum, but through a lacerated opening in the body of the perineum. This accident may arise from a variety of circumstances: the direction of the pelvic outlet may be faulty, or the inclined plane formed by the lower part of the sacrum, by the sacro-sciatic ligaments, &c. may be insufficient to guide the head forwards under the pubic arch; or the perineum may be unusually broad; in which cases the power of the uterus being directed against the centre of it, the head becomes enveloped in a bag of protruded perineum; and if the pains are violent, and the head not properly supported, it at length bursts its way through the centre without even injuring the frænulum. The treatment of this form of ruptured perineum is the same as that of the more common species; the bowels must be kept open, and a fomentation of chamomile flowers applied to the wound, which, from the gradual contraction of the surrounding parts after labour, diminishes remarkably, so that in the course of a short time it will have entirely or nearly closed.[69]

Besides the above-mentioned advantages in supporting the perineum, we may mention another which is not generally noticed, and which is sometimes of considerable service. In cases where the head has completely descended upon the perineum, and begins to protrude somewhat through the os externum, the pains occasionally fail at this moment, the labour becomes very lingering, while the advance of the head and state of the parts show that two or three active pains would bring the child into the world; firm pressure applied at the lower end of the sacrum, in a direction forwards, materially adds to the effect of each pain in bringing the head through the os externum, and seems also to excite the patient to make a more powerful effort with the abdominal muscles. On several occasions we have thus assisted the expulsion of the head, when otherwise the labour would have been very protracted, or would have even required the forceps to disengage it. Madame La Chappelle is the only authority in midwifery, as far as we know, that has noticed this fact.

Cord round the child’s neck. As soon as the head is born, we must examine whether the cord be twisted round the child’s neck; and here the advantage of supporting the perineum with the left hand becomes evident: it is ready to support the shoulders when they begin to pass, while the right hand is at liberty to perform any manipulations which may be necessary. If it be important to support the head during its passage over the perineum, still more so will it be to support the shoulders; for if a small laceration has already been produced, it is invariably converted into a wide rent at this moment, if great care be not taken: indeed, we are justified in saying that most of the cases of severe perineal rupture are produced by the shoulders, not by the head.

Passage of the shoulders. If the pains cease for a time, or the child be large, the shoulders do not pass immediately: in this position the face swells and grows purple from the pressure upon the neck, although it does not necessarily result from the cord being round it; if, however, we find that this is the case, we can in most instances loosen it somewhat by the finger, and as the shoulders advance, slip it first over one and then the other: we must recollect that the shoulder, which is forwards, passes out first, and that, therefore, we must slip the cord over it first.

It is seldom necessary to assist the shoulders by applying any extractive force to the head, for in the course of a minute or two the uterus generally resumes its activity and expels it: on the other hand, when the shoulders pass through the os externum, the right hand should be in readiness to prevent the body of the child from being born too rapidly: the uterus can scarcely be emptied of its contents too gradually, for by this means it contracts equably, powerfully, and permanently, and throws off the placenta without difficulty; whereas, if suddenly evacuated, it frequently becomes powerless for a time, or if contraction does take place, it is so irregular and incomplete as to endanger partial separation, retention of the placenta, and hæmorrhage.[70] If, however, the cord be twisted exceedingly tight round the child’s neck, and imbedded so deeply into the skin, as to render it impossible to push the coil over the shoulder, it may become necessary to divide it in order to let the child pass, in which case the practitioner must seize the divided ends as well as he can, and apply a ligature the instant the child is born. We believe that this is rarely, if ever, necessary; for in proportion as the child advances, so does the fundus descend, and thus relieves, in some measure, the tension to which the cord is exposed. This subject, however, belongs rather to the third species of dystocia, to which we must therefore refer.

Birth of the child and ligature of the cord. As soon as the child is born, we must place it in such a position as will enable it to breathe with ease. The sudden exposure to the external air is generally sufficient to excite respiration; if not, a gentle pat on the nates, or blowing suddenly in the face, will usually succeed: if, however, the child still remains insensible, recourse must be had to those means which are recommended under the head of Asphyxia neonatorum. The cord should not be tied until it has ceased to beat, for unless the circulation be well established in its new course, the breathing is apt to stop, and the child relapse into insensibility: the cord should be tied about three inches distant from the umbilicus; it should be applied tightly, because otherwise it is apt to become loose, as the cord grows flaccid. In tying the ligature, one hand should be supported against the other to prevent giving the cord any jerk in case the ligature breaks; we are able also by this means to tie it more firmly.

The cord should be divided at some little distance from the ligature, so as to prevent all chance of its slipping off, and it should be done with a pair of blunt scissors, by which means the vessels of the cord are so bruised as to be rendered nearly impervious. There is no need to apply two ligatures; in fact it is better not, for, as Dr. Dewees justly observes, “the evacuation from the open extremity of the cord will yield two or three ounces of blood, which favours the contraction of the uterus and expulsion of the placenta.” It has been recommended, in case of twins, to apply a second ligature, to prevent all chance of the second child bleeding through the cord of the first. There is, however, no connexion between the two placentæ, although they usually form what appears to be one mass. We only know of one case where the umbilical arteries of one cord anastomosed with those of the other, an anormality of very rare occurrence: still, however, it is better to apply a second ligature upon the cord, where we find that twins are present, as a precaution: and also to prevent it being said, in case the second child is still-born, that it had died from no ligature having been applied upon the placental extremity of the cord. It has been questioned whether it was really necessary to tie the cord before separating the child from the mother, from the well known fact that nothing of the sort is required in animals; and that, in cases of rapid labour, where the child has been unexpectedly dashed upon the floor and the cord broken, no hæmorrhage has resulted. This arises from the bruised and lacerated condition of the cord under these circumstances: animals not only bite the cord, but also draw it through their teeth several times, so as to contuse the vessels for a considerable extent; whereas, if it was merely divided with a sharp instrument, there is no doubt but that the new-born animal would quickly bleed to death.[71]