A System of Midwifery

by Edward Rigby

Presentation of the hand and feet. We sometimes also meet with cases where the hand presents with one or two feet; but these complications merely exist at the commencement of labour, where the uterus has been greatly distended with liquor amnii, and where its contractions have not yet begun to press the child into the brim. Cases of this nature sooner or later are sure to terminate in presentations of the nates or shoulder, unless the process of labour has been interfered with.

Presentation of the head and feet. Presentations of the head and one or both feet have also been described: these, however, have only occurred during the operation of turning, when the feet have been brought down into the pelvis before the head had left it, and, therefore, must be considered as having been made by unskilfulness on the part of the practitioner. Where this is the case it may be necessary to premise blood-letting, &c., on account of the inflamed condition of the parts from the previous unsuccessful attempts to turn: after this, a fillet should be passed round the feet in order to secure them, and then the head may be safely pushed out of the pelvis.

Rupture of the uterus. Of the injurious results arising from protracted or neglected cases of arm or shoulder presentation none can compare in point of danger with those where the uterus has given way or burst. This state may also be produced by deformity of the pelvis, tumours, and other causes of obstruction to the passage of the child, by which the uterus is excited to unusually violent efforts in order to overcome the impediment during which the laceration is effected. It may also arise from injuries to the uterine tissue without undue exertions, as from exostosis of the pelvis, sharp projecting edges of the promontory or brim, and also from organic disease: thus, “when the rent speedily follows the accession of labour, before the pains have become severe, or the uterus has scarcely begun to dilate, its structures will probably be found diseased.” (Facts and Cases in Obstetric Medicine, by I. T. Ingleby, p. 176.)

Usual seat of the laceration. The part of the uterus in which laceration is most frequently observed to occur is near to or at the junction of the uterus with the vagina: this happens rather more frequently behind than before, but the difference in this respect is very trifling. Thus in 36 cases which were collected by Mr. Roberton, of Manchester, “in 1 the cervix was separated from the vagina except by a thread: in 11 the laceration was posterior, in 8 it was anterior, in 5 lateral, in 3 anterior-lateral, and in 3 posterior-lateral.” (Edin. Med. and Surg. Journal, vol. xlii. 1834, p. 60.) In 34 cases which occurred at the Dublin Lying-in Hospital, “in 13 the injury was at the posterior part; in 12 anteriorly; in 2 laterally; in 1 the mouth of the womb was torn, and in 6 the particular seat of the laceration was not described.” (A Practical Treatise on Midwifery, &c., by Robert Collins, M. D., 1835, p. 244.)

The nature and extent of the laceration varies a good deal: in the worst cases the uterus is torn completely through, and the child escapes either partly or wholly into the abdominal cavity; whereas, in many, the peritoneum has not given way, the laceration being confined entirely to the tissue of the uterus itself. Thus, in 9 of the 34 cases recorded by Dr. Collins, “the peritoneal coat of the uterus was uninjured, although the muscular substance of the cervix was extensively ruptured.” In other instances the peritoneum has been cracked or torn in numerous places without any injury to the subjacent tissue.

From the greater degree of resistance to the passage of the child, in cases of first labour, we might naturally suppose that rupture of the uterus would be more frequently seen among primiparæ: this, however, is not the case, for of 29 cases mentioned by Mr. Roberton, only one of them was a primipara; a larger (and as an average probably more correct) proportion, viz. 7 in 34, has been given by Dr. Collins: of the multiparæ, 5 were in their sixth pregnancy, 2 in their tenth, and 2 also in their eleventh pregnancy.

Experience also shows that in a large proportion of these cases, the duration of the labour has been very far from being longer than usual; indeed, in a considerable majority, the mischief has taken place very few hours after the commencement of active labour. Thus, the average duration of it in the 36 cases recorded by Mr. Roberton, was 15 hours: in 24 of those by Dr. Collins, it was 17 hours: but if we take merely the majority of them we shall have a much smaller average: thus, in 20 of Mr. Roberton’s cases it was 9 hours, and in 15 of Dr. Collins’s it was only 6 hours.

Causes. A large proportion of cases where the uterus gives way during labour, are connected with more or less deformity of the pelvis, and where, from previous severe and difficult labours, its structure has been injured, and rendered incapable of bearing that degree of tension, which even the ordinary exertions of the uterine fibres would require. In many others, the impediment produced by the contracted pelvis, or malposition of the child, has roused the uterus to those violent efforts which have produced the laceration. Organic diseases of the uterus, or cicatrisations of the soft passages from extensive injuries in former labours, either render its powers of resistance defective, or, by increasing the resistance, excite it to unusual violence. “The operation of turning is not unfrequently a cause of laceration of the vagina or mouth of the uterus, particularly, where it is performed previous to the soft parts being sufficiently dilated to admit the easy passage of the hand, or where great haste is employed. The same consequences may ensue from rash or violent attempts to remove a retained placenta. I have also known the mouth of the womb to be torn by the imprudent use of the forceps when not sufficiently dilated.” (Dr. Collins, op. cit. p. 242.) “The sex of the infant, it would appear, may also have some share in occasioning this very distressing occurrence.” (Practical Remarks on Lacerations of the Uterus and Vagina, by Thomas M’Keever, M. D., p. 4.) Thus, of 20 cases reported by Dr. M’Keever, 15 were delivered of boys and 5 of girls; of the 34 cases described by Dr. Collins, “23 of the children were males. This is satisfactorily accounted for by the greater size of the male head, as proved by accurate measurement made by Dr. Joseph Clarke.”

Another circumstance which influences to a certain extent the frequency of rupture of the uterus, is the rank of the patient: in private practice, especially among the better classes of society, it is an extremely rare occurrence; but in the lower grades of life several causes concur to render it more frequent. They are “much more exposed to falls, bruises, and other accidental injuries during pregnancy, in consequence of which the uterus may be either ruptured at the time they have sustained the violence, or may be so weakened in structure at some particular point, as readily to give way during its efforts to accomplish delivery. Lastly, they are more liable to fall into the hands of ignorant inexperienced midwives, who not unfrequently, with a view of expediting the process of delivery, rupture the membranes at an early period of the labour; in consequence of which, the firm unyielding head of the child is prematurely brought in contact with the passages, exciting by its pressure, swelling, inflammation, and an interrupted state of the circulation in the uterus and adjacent parts. In such a case should there unfortunately exist any disproportion between the parts of the mother and the head of the infant, or should proper measures not be employed to obviate distressing symptoms, and that the labour pains continue to recur with extreme violence, there is great risk of the uterus giving way, the laceration being of course most likely to occur at that part where the greatest pressure has been sustained.” (M’Keever, op. cit. p. 3.)

The premonitory symptoms of rupture of the uterus are not always sufficient to warn us of the impending danger, for in many cases nothing unusual has occurred until the actual injury has been produced, and it has then been inferred by the alarming change observed in the patient’s appearance. In many cases, especially where the muscular substance only of the uterus was torn, the pains have continued with a sufficient degree of power to expel the child; in others the mischief has been attended with so little suffering at the moment, and for the time with so little constitutional derangement, as to excite no suspicion, either on the part of the patient, or her attendant. “Farther, as on some occasions, the uterus has been known to give way during the very pain which effected the delivery of the child, instances of which may be found in the works of Crantz and Guillimeau.” (Ibid. p. 15.)