Part 12 (2/2)

_State of the bowels._ Attention to the state of the bowels is of first importance, and must never be neglected. It is a subject nevertheless upon which women are remarkably careless, and they will frequently, when not attended to, allow labour to come on with their bowels in a very loaded and highly improper condition.

There is, perhaps, no one circ.u.mstance which is found to exert such a prejudicial influence on the course of a natural labour, in so many different ways, as deranged and constipated bowels. Where the contents are of an unhealthy character, the irritation which they produce in the intestinal ca.n.a.l is quickly transmitted to the uterus, and tends not a little to pervert and derange the due and healthy action of this organ: hence arises one of the most fertile sources of spurious pains, a subject which will shortly come under our consideration. Where the bowels are loaded, in consequence of the pressure upon the ascending cava, considerable obstruction to the free return of blood from the pelvic viscera is produced, the vessels of which become considerably engorged. No organ feels these effects more than the uterus: from the immensely dilated condition of its veins, a state of local plethora is engendered, which, from the congested state of the uterine parietes, considerably interferes with the free and regular action of its fibres, and not unfrequently predisposes to haemorrhage.

Moreover, the r.e.c.t.u.m being distended with faeces, diminishes proportionally the capacity of the pelvis, and prevents the ready descent of the head into it; occasionally it forms, at the beginning of labour, a solid cylinder of indurated faeces, so hard, as, at the first touch, almost to induce the suspicion of a projecting sacrum. As a measure of common cleanliness, the bowels ought always to be attended to before labour, for, besides the more serious effects now enumerated, the labour may be rendered exceedingly filthy for the patient, and not less disgusting for the pract.i.tioner; for, as the sphincter ani loses all power of contraction when the head advances deeper into the pelvis, it follows that whatever faecal matter may have been lodging in the r.e.c.t.u.m will now be unconsciously pressed out.

Hence, therefore, for the last few days of pregnancy, the bowels should be regularly opened (unless they are so spontaneously, which is seldom the case) by castor oil or other mild laxatives: and if labour has already commenced before this measure has been taken, and if, therefore, there is not sufficient time for the operation of the medicine, an enema should be given.[66] In Germany it is a rule to throw up some chamomile infusion at the commencement of every labour, by which means the process is rendered more cleanly than is frequently the case in this country; and also, for the reasons already given, the early stage is less apt to be tedious from spurious and ineffective pains.

_Form and size of the uterus._ The more regular the first precursory pains are, the more symmetrical and uniform will be the shape of the uterus; and again, on the other hand, the more uniform its shape, the more regularly and effectively will it act.

It is these slight but early contractions, which, although they produce little or no effect upon the os uteri, exert a very important influence over the first half of labour; for it is by their action, in great measure, that the form of the uterus is determined, as also the correct position of the child. Hence, therefore, some pract.i.tioners lay considerable stress on ascertaining the precise form of the abdomen as a means of determining what sort of labour the patient will have.

In a woman pregnant for the first time, and in a state of perfect health, the uterus is of an oval or rather elliptical form at the beginning of labour: when seen in profile, the abdomen presents nearly a uniform degree of convexity. In this state the child lies with its long axis parallel to that of the uterus, that is, with its head or inferior extremity turned towards the brim of the pelvis; and if the fundus has already sunk in the manner above-mentioned, the pract.i.tioner may very confidently prognosticate that the head presents, even before making an examination per v.a.g.i.n.am.

In a perfectly healthy primipara there is scarcely any inclination of the uterus either to one side or forwards, its median line corresponding with that of the abdomen: whereas, in the multipara, the axis of the uterus is seldom straight, inclining more or less to one side, or, from the greater relaxation of the abdominal parietes, being somewhat pendulous. The size of the uterus should also be taken into consideration, especially in first pregnancies; a large uterus shows that either its parietes are gorged with too much blood, or that its cavity is distended with an unusual quant.i.ty of liquor amnii, or that the child is very large, or that there are twins.

Whatever may be the cause of the distension, it interferes with the regular and effective contractions of the uterus, and tends to make the labour (at least the first part of it) tedious. A moderate sized uterus is much more capable of active exertion, for its fibres not being put so much upon the stretch are enabled to contract better.

_True and false pains._ If the patient is already beginning to suffer pains, it is of great importance to ascertain whether they be genuine or spurious; upon the correct diagnosis of which, the favourable or unfavourable course of the labour not unfrequently in great measure depends.

A genuine labour pain comes on at tolerably regular intervals, rises gradually to a certain degree of intensity, remains at that point for a few seconds, and then subsides as gradually; the body and the fundus of the uterus increase in hardness, and the os uteri in tenseness, in proportion as the pain rises, and vice versa; the pain is seated in the back and loins, and is of a dull aching character: but with the spurious pains it is quite the reverse; they come on and go off suddenly and irregularly, the pain is in the abdomen, and produces a sharp twinging sensation, and the hardness of the uterus and tenseness of its mouth bear no proportion to the pain.

Spurious labour pains are the early contractions of the uterus perverted and rendered irregular, spasmodic, and painful by irritation, congestion, or inflammatory action; they sometimes come on several days before actual labour commences, and if not recognised and removed, may expose the patient to considerable suffering and exhaustion. Derangement of the stomach and bowels is one of the most frequent causes of spurious pains, for by the irritation which is thus produced, the uterus is almost sure to sympathize, and to have its action more or less disordered. This may arise from unhealthy irritating contents of the bowels producing spasmodic, griping, and colicky pains, or from diarrhoea with tenesmus arising from exposure to cold, or from irritation caused by the pressure of the gravid womb. Spurious labour pains of this character also frequently occur in patients who are accustomed to indulge in the luxuries of the table, or in the lower cla.s.ses, who are addicted to the use of spirituous liquors.

Constipation has been already mentioned as a cause of this condition. The state of plethora, congestion, or inflammation, acting as a cause of spurious pains, may arise from various sources: it is frequently observed in strong healthy young women, especially those pregnant for the first time; the pains do not a.s.sume the proper character of genuine labour pains, and exhaust the patient by continued but useless suffering. The os uteri probably dilates somewhat, but its edge remains thin and tense, and the pains appear to have no effect in dilating it any farther. The mucous secretion of the v.a.g.i.n.a is not of the character described at the beginning of labour in the preceding chapter. The pulse is strong and more or less excited, and the flushed face, and generally increased heat of skin indicate the condition upon which those symptoms depend. The inflammatory form of spurious labour pains is not unfrequently of the rheumatic character, a condition which has not been much noticed in this country, but which is capable of exerting a very considerable influence upon the course and progress of the labour. It is usually produced by exposure to cold and the other common causes of rheumatism in other parts of the body, and is generally accompanied with more or less derangement of the stomach and bowels. In this state each contraction of the uterine fibres is attended with much suffering, although the contraction itself may be so slight as to produce little or no effect upon the os uteri. Most of these conditions, in a severe degree, form that species of dystocia which arises from a faulty state of the expelling powers, for the farther consideration of which we must refer to our chapter upon that subject. In a minor degree they produce these slight derangements of uterine action, which we are now considering under the name of _spurious pains_.

_Treatment of spurious pains._ The indications of treatment depend in great measure upon the cause; and we cannot impress it too strongly on the young pract.i.tioner, as a rule never to be lost sight of, that, whatever is wrong in the state of the circulation or of the bowels must be first rectified before having recourse to opiates. Where the stomach is much deranged at the beginning of labour, nature frequently induces spontaneous vomiting, with considerable relief to the patient, and mitigation of the pains; if not a gentle emetic may be administered. Where the bowels are loaded, the treatment already mentioned must be put into practice, after which [Symbol: minim] xx of Liquor Opii Sedativus and of antimonial wine in peppermint water, or gr x of Dover's powder may be given. When there is diarrhoea with a good deal of griping and tenesmus, a dose of castor oil with Liquor Opii Sedativus in any aromatic water may be administered; and if the labour be not yet commenced, gr v of Pil. Hydr. and Dover's powder may be also given at night. If there be a plethoric or even inflammatory condition, the lancet will be of the greatest service; it reduces the temperature of the body, relaxes the soft parts, brings on copious secretion of mucus, and by relieving the congested state of the uterine parietes, enables the fibres to contract with more regularity and effect.

In the rheumatic form, laxatives followed by diaph.o.r.etics, the warm bath, and even venesection will be necessary.

By thus treating the spurious pains according to their cause, they will usually subside readily enough, and be either followed immediately by pains of a more genuine and effective character, or leave the patient perfectly free for several hours, or perhaps even days. It is by inattention to, or ignorance of, these conditions, that patients have been allowed to remain for several days in suffering, during which they have been treated as if they had been in natural labour, until at length they have become so exhausted that, when labour really made its appearance, they were incapable of undergoing the exertions which this process demands.

_Management of the first stage._ The preparatory pains of labour, which form the first stage, do not require that the patient should take to her bed at this early period; and this is especially the case in primiparae, where the first stage is usually somewhat tedious. Until nearly the end of the first stage, she ought rather to be induced to suppose that actual labour has scarcely yet commenced, and that she may still sit up or walk about the room as best suits her feelings, taking care at the same time that every thing is in readiness against the moment when it shall become necessary for her to lie down. A nurse who understands her business will of course duly arrange all these matters, but it behoves the accoucheur, nevertheless, to pay attention to these little details, and to see that every thing is properly prepared: that the bed is ready, and guarded either by several folds of sheeting, or by a leather for the purpose, to prevent the blood and other discharges during labour from soaking into the bedding beneath; this must be done either on the right side or at the foot of the bed, in order that the patient may be better within the reach of the accoucheur: that the patient should be partially undressed, and covered with her dressing-gown: that all the linen should be well aired: that there should be towels, napkins, hot and cold water in readiness, and also a bottle of vinegar, and one of spirit in the room, in case of hemorrhage, suspended animation in the child, &c. &c. These and many other arrangements of less importance are by no means beneath his attention, and require but a moment's glance to a.s.sure him that every thing is properly prepared.

By encouraging the patient to sit up as long as she can, or even to move about occasionally, the pains are rendered more tolerable as well as more effective; the time pa.s.ses more agreeably and quickly; and by the time that it has become necessary for her to lie down, the labour has made so much progress that the rest of its course seems to be much quicker than was at first expected. On the contrary, where the pract.i.tioner at an early period of the first stage, informs her that she must stay up no longer, that she must go to bed and remain lying on her left side, her mind is solely occupied with her pains, which become wearying and irksome; the time pa.s.ses heavily away; she becomes impatient and therefore dispirited; and is much disappointed, that, after remaining in this state for some time, the termination of the labour appears to be as far off as ever.

Nothing eases the pains of the first stage, or increases their effect, so much as frequent change of position and moving about; when, however, they are severe or of long continuance, and the patient becomes fatigued, she will require rest, and this opportunity, afforded by her lying down, should be seized for the purpose of making an examination.

_Examination._ The manner in which this operation should be proposed to the patient cannot be too delicate: it should, as Dr. Dewees has justly observed, always if possible be done by means of a third person, such as the nurse or any elderly female friend who happens to be present. If the accoucheur has proposed it with that degree of gentleness and good feeling which it ought to behove every one to show under such circ.u.mstances, he will rarely, if ever, experience the slightest unwillingness to accede to his request: the better the patient's rank in life is, the more docile will she prove at these times, and the more resolute to undergo whatever she is told it is necessary to submit to. The object of an examination is to determine whether the child presents rightly, whether the labour is far advanced, and to form some degree of prognosis as to its course and duration, &c.: these are points which are of such importance as well as interest to ascertain, that the dread which a patient feels at undergoing an operation so repugnant to her feelings is generally merged more or less in the intense anxiety to know if all is right.

An examination at an early period of labour is important in many respects.

We ascertain the condition of the v.a.g.i.n.a, whether it be soft, cool, relaxed, and well lubricated with mucus, as described at the beginning of the last chapter; whether the os uteri be dilated; whether its edge be thin and tense, or already becoming soft, cus.h.i.+ony, and yielding; whether the membranes are ruptured; whether the presentation be a natural one, and whether the pelvis be rightly formed. In cases where the umbilical cord is prolapsed, it is particularly desirable to ascertain the existence of this displacement as early in labour as possible.

It is usually directed to examine during a pain, because at this moment we feel the os uteri tense, and therefore more distinct to the finger; but it is far better to examine during the interval between the pain: the os uteri being now relaxed, admits the finger more easily; the membranes being loose are not so liable to be ruptured; and, from their not being distended, we shall feel the presenting part more distinctly.

Wherever the os uteri is nearly or fully dilated, or from its condition and the effect which the pains have upon it shows a disposition to dilate with rapidity, the patient should go to bed, as we cannot be sure when the membranes may rupture, more especially in primiparae, in whom this usually takes place early. It is equally desirable, also, in those who have already had children, that the patient should be upon her bed at this moment; because, if the pains be strong, and the os uteri yielding, the head is apt to follow the discharge of the liquor amnii, and sudden expulsion of the child might result at a moment when the patient is unprepared for such an occurrence.

The accoucheur should always examine when the membranes give way, because not only will he be able to feel the presenting part now more distinctly, but if the cord has prolapsed, a coil of it will come down into the v.a.g.i.n.a and cannot escape his notice; in fact, if there is any thing unusual about the presentation, he will be now able to distinguish it with greater certainty. In women who have had large families, the head remains very high in the pelvis until this moment, so that it is frequently extremely difficult to reach it and to ascertain its position: the same is observed with presentations of the nates and of the shoulder, which seldom descend into the pelvis until the liquor amnii escapes.

_Position of the patient during labour._ The position which the patient should take during the actual process of labour has been a subject of considerable discussion, and even at the present day varies exceedingly in different countries. In the earliest periods of history, women appear to have been delivered in a sitting posture, as is described in the first chapter of _Exodus_: this mode was revived in comparatively modern times; thus Ambrose Pare, in 1573, speaks of a labour chair with an inclined back, which he preferred to a common bed. Labour chairs were brought into very general use upon the Continent in the beginning of the last century by Hendrick van Deventer of Dort in Holland, and although they have been in great measure discontinued in modern times, there are still some districts of Germany where they continue to be used. It is a species of chaise percee furnished with straps, cus.h.i.+ons, &c. by which the patient can fix her extremities, and thus enable the abdominal muscles to act with the greatest power. This is the very reason which renders labour chairs objectionable. The presenting part of the child is forced through the soft pa.s.sage with great violence, before they have had time to yield and to dilate sufficiently; hence it has been noticed that lacerations of the perineum are of very frequent occurrence in those countries where labour chairs have been in general use. In some remote parts of Ireland, and also of Germany, the patient sits upon the knees of another person, and this office of subst.i.tute for a labour chair is usually performed by her husband. Labour chairs, as far as we are acquainted with their history, were never used in this country, nor have they been used for the last century in France, where the patients are usually delivered in the supine posture, on a small bed upon the floor, which has not inaptly been termed _lit de misere_. A modification of the labour chair is the labour cus.h.i.+on first used by Nuger, and afterwards by the late Professor von Siebold of Berlin and Professor Carus of Dresden; it is a species of mattress, with a hollow beneath the nates of the patient for receiving the discharges which take place during the labour. The patient is compelled to lie upon her back during the greater part of labour, and thus maintain the same posture for some time, which must necessarily become irksome and even painful to her. In this country and in Germany the patient is delivered upon a common bed, prepared for the purpose as above mentioned: in England she is placed upon her left side, the nates projecting to the edge of the bed, for the greater convenience of the accoucheur: in Germany, except in Vienna and Heidelberg, where the English midwifery has in great measure been introduced by Boer and Naegele, the patient is delivered upon her back.[67] In former times the supine posture was also used in this country, but for about a century the position on the left side has been preferred; the patient lies more comfortably to her own feelings; her face is turned from the pract.i.tioner who sits behind her, and who, from this posture, is able to examine or to perform any other necessary manipulation without her feelings being annoyed by seeing what is going forward. It is decidedly the easiest position during the last moments of tremendous suffering and exertion; when the presenting part is pa.s.sing she is not able to exert an undue degree of violence, and from the knees being kept together, there is less danger of the perineum being torn. The left side seems moreover to be the natural position for a woman at the moment of parturition, for if accidental circ.u.mstances have occurred, such as sudden labour, &c. by which she is deprived of all a.s.sistance at this moment, she will almost invariably be found upon the ground lying on her side supporting herself with one hand. In some cases she will remain during these moments upon her knees, into which posture she has gradually dropped from that of standing: in by far the majority of cases she will take the position upon her side, as above mentioned.

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