Part 12 (1/2)

_Duration of the first stage._ The duration of the first stage of labour varies exceedingly, both in primiparae and those who have had several children; nor is it at all easy to determine with precision the exact moment when labour commences. The sensation of pain to the patient is no guide whatever, for what is attended with much suffering in one patient is scarcely sufficient to excite the notice of another. The dilatation of the os uteri as marking its commencement, must also be taken with some caution: in primiparae, where it generally remains closed until the contractions are becoming painful, it would obviously be wrong to date the commencement of labour from the moment that the os uteri opens, as regular uterine contractions have been evidently present for some hours previously, although not of sufficient force to produce actual pain. On the other hand, in women who have already had several children, the os uteri is found open some days and even weeks before labour comes on. As a general rule, we may state that regular and genuine contractions of the uterus, sufficiently powerful to produce pain, seldom require more than six hours to effect the full dilatation of the os uteri; in many cases a much shorter time will be sufficient; whereas, in others, the first stage of labour may last for more than quadruple this period before it is completed: in neither can it be considered as abnormal; and we usually find that where the pains of the first stage have been slow and lingering, they become remarkably quick and active during the second stage. This agrees with the experience of Dr. Churchill, in his report of the Western Lying-in Hospital at Dublin, viz. that, ”no evil consequences resulted, and they (the labours where the first stage was so protracted) were amongst those in whom the remaining stages of labour were shortest.”

The first stage terminates with the full dilatation of the os uteri; the rupture of the membranes is a change which is necessarily more or less uncertain, as to the precise period of labour at which it takes place.

Thus, in primiparae, it frequently occurs before the first stage is completed; whereas in other cases the membranes sometimes do not give way until the head approaches or has even pa.s.sed through the os externum; generally speaking, however, they burst at this period of the labour, and usually effect a remarkable change in the whole process. The pains are now of longer duration and more powerful, the intervals between them are shorter, and yet, although the suffering is actually more severe, it is more tolerable to the patient than that of the first stage. During the first stage they are chiefly confined to one spot in the loins; and as they must necessarily continue for some hours without any distinct evidence of the labour being advanced by them, the patient feels discouraged and gets a little impatient at the endurance of so much apparently useless suffering: but as soon as the gush of liquor amnii takes place, she feels that a great alteration has been produced; the abdomen becomes smaller: the pains a.s.sume a very different character, and every thing combines to a.s.sure her that she has made progress, and encourages her to patience and resolution.

_Description of second stage._ The os uteri has now disappeared entirely, so that the v.a.g.i.n.a and uterus form one continuous ca.n.a.l, and is thus admirably adapted for the easy pa.s.sage of the head: the anterior lip, however, dilates much more slowly than the other parts of it, and this is especially the case in primiparae, for, being pressed between the head and pelvis it becomes oedematous, and swells to a considerable size: if the pains be strong, it is pushed down more or less before the head, and may be frequently felt beneath the symphysis pubis, and occasionally it is detruded so far as to be visible between the l.a.b.i.a. According to Wigand, the swelling of the anterior lip sometimes attains such a size as makes it liable to be mistaken for the bladder of the membranes (_op. cit._ vol.

ii. p. 308;) it seldom produces much obstacle to the advance of the head, and with a little patience gradually disappears of itself. All attempts to push it up above the head are objectionable, because, in the first place, the finger cannot reach sufficiently high to effect this object, and therefore the swelling descends again to its former situation; and, secondly, the efforts to push it up only tend to inflame it and increase the swelling. Those who imagine that they can push up the anterior lip of the os uteri above the head deceive themselves; and even if they do succeed, it merely shows that had they let it alone, it would have gone up very shortly of itself.

_Straining pains._ As the head enters the v.a.g.i.n.a, not only do the contractions of the uterus become much more powerful, but now another set of forces are called into action, and the half involuntary efforts of the abdominal and other muscles come to aid the uterus in expelling its contents. The sole object of this stage is the expulsion of the child, and even the v.a.g.i.n.a by its contractions contributes to effect it. The head is therefore subjected to considerable pressure; hence we may now feel the cranial bones overlapping each other at the sutures, and the fontanelles diminished in size; and, from the tightness with which the head is embraced by the v.a.g.i.n.a, the circulation in the scalp is more or less impeded, and a large oedematous swelling, called _caput succedaneum_, forms on that part of the head which presents.

Each pain is attended with a violent and irresistible impulse to bear down, and every muscle which can a.s.sist in effecting this object is now brought into play. The tone of the patient's voice, the expression of her face, the hurried breathing and sudden inspiration, stopping short the moment a pain comes on, in order that she may add still greater power to the efforts which she is about to make, all betoken a very different process to that of the first stage, and one which requires a powerful struggle of muscular strength and energy for its completion. Hence it is that the sound of the patient's voice during the pain is frequently of itself sufficient to inform us how far labour is advanced, for ”we never see the really powerful straining pains come on (the head may be never so low in the pelvis,) so long as the os uteri is not fully dilated.”

(Wigand, _op. cit._ vol. ii. p. 310.) This is a wise provision of Nature, for by this means it prevents the danger of laceration to which the os uteri would be otherwise exposed, and shows the importance of not permitting a patient to strain and bear down until the os uteri be fully dilated. In those cases where a patient has been induced to exert herself prematurely, the efforts being voluntary are never so powerful, and soon produce much fatigue.

Several reasons have been a.s.signed why the straining pains should come on at this stage. It cannot be owing to the pressure of the head upon the parts of the pelvis, as has been supposed and especially the r.e.c.t.u.m, thus producing the sensation of a violent desire to evacuate the bowels, because, in almost every case of first labour, the head for several days before the actual commencement of labour is sufficiently deep in the pelvis to produce these effects. It evidently arises from a sympathetic connexion ”between the os uteri and v.a.g.i.n.a on the one hand, and the abdominal and other muscles on the other. We see this connexion most distinctly in those difficult labours where the head is pushed down deeply in the pelvis even to the very outlet, and where the os uteri which is but little dilated is protruded before it. In such cases we never see the really powerful and continued action of the abdominal muscles excited, let the head press never so forcibly upon the r.e.c.t.u.m; but as soon as the os uteri (perhaps after much suffering) has retracted over the head, the whole auxiliary action of the abdominal muscles commences.” (_Ibid._ vol.

ii. p. 467.)

There is the same relation between these muscles and the v.a.g.i.n.a, as there is between them and the r.e.c.t.u.m: the moment the v.a.g.i.n.a becomes distended, it begins to contract upon the distending body, and like the r.e.c.t.u.m excites them to strong and involuntary action. The tenesmus of dysentery is a sympathetic action of the same nature; the r.e.c.t.u.m is highly irritated by the acrid nature of its contents, and excites an irresistible disposition to bear down. The patient wishes for the next pain and yet she dreads it, from the suffering it creates, and the tremendous effort which it compels her to make; the pulse is quicker, and is not only so during the intervals, but undergoes a greater increase of rapidity during the pains themselves than in the first stage; the face becomes red, swollen, and bathed in perspiration; the breath is hurried; the lips are apart; the eyes are wild; every thing betokens a state of the highest excitement.

When a pain comes on, she catches hold of whatever she can reach, plants her feet upon any thing which is firm, and, by thus fixing her extremities, she is enabled to bear down with greater power and effect.

During the struggle the face often changes its expression surprisingly, so much so, that even her own attendants would scarcely recognise her.

_Dilatation of the perineum._ As pain succeeds pain, gradually increasing both in force as well as duration, the head descends along the v.a.g.i.n.a, and begins to press against the perineum; the r.e.c.t.u.m becomes flattened; the sphincter ani dilated, and therefore any faecal matter which may have been lodging there is unavoidably expelled; the anterior wall of the r.e.c.t.u.m is pressed close against the a.n.u.s, and where the pressure is very great, even protrudes somewhat through it; the haemorrhoidal veins are frequently much distended, and form a roll of cus.h.i.+ony swelling around the a.n.u.s. A small quant.i.ty of liquor amnii dribbles away from time to time, but is neither during a pain, nor during the absence of a pain, for in the former case the pressure of the head acts as a plug and prevents its escape, and in the latter there is no uterine contraction present to expel it: the liquor amnii dribbles away only at the moment when a pain is coming on or going off.

_Expulsion of the child._ As the head descends farther it begins to press more powerfully on the perineum, and during each pain pushes it out like a large ball; and then, as a contraction goes off, and the resiliency of the soft parts regain their superiority, it retires again. The breadth of the perineum (viz. from the a.n.u.s to the v.u.l.v.a) increases, whilst it diminishes considerably in thickness, especially towards its anterior margin. Whilst pa.s.sing through the inferior aperture or outlet of the pelvis, the head advances more or less forwards under the pubic arch, and begins to distend the os externum; during a pain it separates the l.a.b.i.a, and protrudes between them, and again retires as the pain goes off; a larger and larger portion of the head gradually forces itself through the os externum as this dilates; the perineum becomes still thinner, so that at length it is scarcely thicker than parchment. When more of the head has pa.s.sed through, it does not now recede when the pain goes off; the os externum and perineum are at their greatest distension, for the largest diameter of the head, which is presented to the os externum is now encircled by it; the next pain brings the head into the world.

This is the moment of greatest pain, and the patient is frequently quite wild and frantic with suffering; it approaches to a species of insanity, and shows itself in the most quiet and gentle dispositions. The laws in Germany have made great allowances for any act of violence committed during these moments of phrenzy, and wisely and mercifully consider that the patient at the time was labouring under a species of temporary insanity. Even the act of child-murder, when satisfactorily proved to have taken place at this moment, is treated with considerable leniency. This state of mind is sometimes manifested in a slighter degree by actions and words so contrary to the general habit and nature of the patient, as to prove that she could not have been under the proper control of her reason at the moment. It is a question how far this state of mind may arise from intense suffering, or how far the circulation of the brain may be affected by the pressure which is exerted upon the abdominal viscera.

A short cessation of pain succeeds the birth of the head. The violent distension of the os externum has ceased for a time, and the patient feels comparatively easy; but in the course of a few minutes the pains return as before, although not quite so severe: first, the shoulder, which is turned forwards, pa.s.ses under the pubic arch, followed by the other which sweeps over the perineum. The rest of the child is expelled with comparative ease, and as soon as its pelvis has pa.s.sed through the os externum, a gush of the remaining liquor amnii, which had been retained in the upper portions of the uterus, follows; the whole abdomen instantly sinks and becomes flaccid, while the uterus contracts into a firm globe upon the placenta, which is shortly to be expelled. A most delightful and perfect calm succeeds, and the sense of freedom from suffering, and joy for the termination of her trial, are expressed in the liveliest terms of grat.i.tude.

_Third stage._--_Expulsion of the placenta._ The period between the birth of the child and expulsion of the placenta varies considerably. Sometimes it follows the child very rapidly, so that, apparently, they are both expelled by the same effort of uterine action; at others, the interval is more considerable. There is generally an interval of ten or fifteen minutes, and then pains of a totally different character make their appearance: these are supposed to denote the separation of the placenta from the uterus, and, from their being usually attended with discharge of more or less blood, have been termed _dolores cruenti_ by many of the foreign writers. The expulsion of the placenta is attended with little or no suffering; it descends into the v.a.g.i.n.a inverted, _i. e._ with its foetal or amniotic surface turned outwards: whether or not this is produced by pulling at the cord is perhaps a question.

_Twins._ If there be twins, the placenta of the first child is seldom expelled until after the birth of the second child. The membranes of the second ovum become distended with liquor amnii, project into the v.a.g.i.n.a and burst as in a common single labour; the pa.s.sages have been sufficiently dilated and prepared by the birth of the first child, so that, when the uterus begins to contract, the expulsion of the second will be readily and easily effected. The uterus may resume its efforts for this purpose in twenty minutes after the birth of the first child, or it may remain quiescent for several hours without at all disturbing the regular and natural course of the process which will be precisely the same as in the previous case.

The placentae of twins are usually expelled together, forming one large placentary ma.s.s; their vessels, however, are distinct from each other, so that with care one placenta can be peeled away from the other. In other cases, they are separated from each other by an intervening s.p.a.ce of membranes; and in one rare instance of triplet placentae the umbilical arteries of two placentae anastomosed with each other, before dividing into smaller branches.

Upon the expulsion of the placenta, the uterus, being now emptied of its contents, contracts into a firm hard ball, which may be felt behind the symphysis p.u.b.es, or sometimes a little to one side, of about the size of a full grown foetal head. This state of hard contraction gradually disappears, and a discharge of blood called lochia follows, which having continued for a few days becomes colourless, and at length ceases altogether. For a description of the changes which the uterus and pa.s.sages undergo in returning to their former condition as in the unimpregnated state, we refer to the chapter on the FEMALE ORGANS OF GENERATION.

CHAPTER II.

TREATMENT OF NATURAL LABOUR.

_State of the bowels.--Form and size of the uterus.--True and spurious pains.--Treatment of spurious pains.--Management of the first stage.-- Examination.--Position of patient during labour.--Prognosis as to the duration of labour.--Diet during labour.--Supporting the perineum.-- Treatment of perineal laceration.--Cord round the child's neck.--Birth of the child, and ligature of the cord.--Importance of ascertaining that the uterus is contracted after labour.--Management of the placenta.--Twins.--Treatment after labour.--Lactation.--Milk-fever and abscess.--Excoriated nipples.--Diet during lactation.--Management of lochia.--After-pains._

This is a subject of great extent as well as importance, because it comprehends the whole ma.s.s of rules for the management of a woman, not only just previous to and during, but also after, her confinement. On nothing does the course of a natural labour depend so much, as upon the careful removal of every source of irritation which may tend in any way to derange or interrupt the regular progress of that series of changes or phenomena which const.i.tutes the great process of normal parturition. It will be necessary that the reader should have made himself thoroughly master of the subjects discussed in the last chapter, before commencing those of the present one. With each change there mentioned, the state of the system and its functions should be carefully watched, and every slight deviation from the natural course of things checked by appropriate dietetic or medical treatment. Hence, therefore, the more a woman can follow her usual avocations, and take that degree of exercise to which she has been accustomed at other times, the better; for by so doing the circulation is equalized, the digestion is kept in full activity, and the tone and general strength of the system maintained.

It would almost seem, by rendering a woman more capable of moving about during the last weeks of pregnancy (which has already been shown to be produced by the sinking of the fundus, enabling the respiration to act more freely,) that Nature intended she should use exercise at this period, and thus prepare her, by increased health and strength, for a process which requires so much suffering and exertion.

Her hours should be regular and early, her meals light and moderate, and by agreeable and cheerful occupation she should fit herself, both in body and mind, to meet the coming trial.