Part 20 (1/2)
When a full-grown child has presented with the arm or shoulder, and nothing has been done to a.s.sist the delivery of it, the results are usually as follow:--After the membranes have burst, and discharged more liquor amnii than in general where the head or nates presents, the uterus contracts tighter around the child, and the shoulder is gradually pressed deeper into the pelvis, while the pains increased considerably in violence, from the child being unable, from its faulty position, to yield to the expulsive efforts of nature. Drained of its liquor amnii, the uterus remains in a state of contraction even during the intervals of the pains; the consequence of this general and continued pressure is, that the child is destroyed from the circulation in the placenta being interrupted, the mother becomes exhausted, and inflammation or rupture of the uterus or v.a.g.i.n.a are almost the unavoidable results.
Another although much rarer consequence of malposition of the child, is that peculiar mode of expulsion which was first noticed by Dr. Denman in 1772. From the supposition that the shoulder receded and the nates came down into the pelvis, in which position the child was born, he called it ”_the spontaneous evolution of the foetus_;” but the term _spontaneous expulsion_, as proposed by Dr. Douglas in 1811, is much better adapted, it having been shown by that gentleman that the explanation of this process as given by Dr. Denman was not correct. (_An Explanation of the real Process of the spontaneous Evolution of the Foetus_, by J. C. Douglas, M.
D. 2nd ed. 1819, p. 28.,) but that whilst the shoulder rested against the p.u.b.es, the side of the thorax and abdomen, followed by the nates, pa.s.sed in one enormous sweep over the perineum, leaving the head and other arm still to be extricated.
The shoulder and thorax thus low and impacted, instead of receding into the uterus, are at each successive pain forced still lower, until the ribs of that side, corresponding with the protruded arm, press on the perineum, and cause it to a.s.sume the same form as it would by the pressure of the forehead in a natural labour. At this period, not only the entire of the arm but the shoulder can be perceived externally, with the clavicle lying under the arch of the p.u.b.es. By farther uterine contractions the ribs are forced more forwards, appearing at the os externum, as the vertex would in a natural labour, the clavicle having been by degrees forced round on the anterior part of the p.u.b.es with the acromion looking towards the mons Veneris. ”The arm and shoulder are entirely protruded with one side of the thorax, not only appearing at the os externum, but partly without it: the lower part of the same side of the trunk presses on the perineum, with the breech either in the hollow of the sacrum or at the brim of the pelvis, ready to descend into it, and, by a few farther uterine efforts, the remainder of the trunk, with the lower extremities, is expelled.”
(Douglas, _op. cit._ p. 28. 2nd ed.)
Farther experience has confirmed the correctness of Dr. Douglas's views (_Med. Trans. of the Royal Coll. of Physicians_, vol. vi. 1820;) and, indeed, the original case as related by Dr. Denman himself tends to prove that nothing like an ”evolution” of the foetus takes place. I found the arm much swelled, and pushed through the external parts in such a manner that the shoulder nearly reached the perineum. The woman struggled vehemently with her pains, and during their continuance _I perceived the shoulder of the child to descend_.
Some years afterwards, the late Dr. Gooch had the opportunity of observing a case of spontaneous expulsion with great accuracy, and came to the same conclusion as Dr. Douglas had done. ”Resolved to know what became of the arm, if this (the spontaneous expulsion) should happen, and thus fit myself for a witness on this disputed point, I laid hold of it with a napkin and watched its movements: so far from going up into the uterus when a pain came on, it advanced, as well as the shoulder, still forwarder under the arch of the p.u.b.es, the side of the thorax pressing more on the perineum and appearing still more externally; it advanced so rapidly that in two pains, with a good deal of muscular exertion on the part of the patient, but apparently with less suffering than attends the birth of the head in a common first labour, did the side of the chest, of the abdomen, and of the breech, pa.s.s one after the other in an enormous sweep over the perineum till the nates and legs were completely expelled.” (_Ibid._)
The celebrated Boer, has, however, detailed a case where the arm had prolapsed into the v.a.g.i.n.a, the hand appearing externally; and on introducing his hand for the purpose of turning, he felt the hand distinctly receding, and the breech beginning to occupy the cavity of the pelvis. This is very different to a case of spontaneous expulsion: ”the child lay completely across, with its abdomen towards the back of the mother;”[110] it had, in fact, not yet begun to press against the brim, or to a.s.sume any definite position, there having been as yet but little uterine contraction, and both r.e.c.t.u.m and bladder being considerably distended. When these were evacuated the pains increased: the breech being nearest to the brim, descended, and the arm in consequence receded. Dr.
Gooch considers it most probable that ”it was only a breech presentation, the hand having accidentally slipt down into the v.a.g.i.n.a.”
Although in cases of malposition where turning has become excessively difficult and dangerous, the spontaneous expulsion must be looked upon as a most fortunate process by which nature effects delivery, still, however, we must never venture to wait for it without making such attempts to turn the child as the state of the patient may justify. It is always more or less dangerous to the mother, and almost certainly fatal to the child.
Indeed, it is our opinion, that the spontaneous expulsion can rarely, if ever take place, except where the child has been already dead some time, or where it is premature. ”Nor can any event,” says Dr. Douglas, ”ever be calculated upon than that of a still-born infant. If the arm of the foetus should be almost entirely protruded with the shoulder pressing on the perineum, if a considerable portion of its thorax be in the hollow of the sacrum with the axilla low in the pelvis, if with this disposition the uterine efforts be still powerful, and if the thorax be forced sensibly lower, during the presence of each successive pain, the evolution may with great confidence be expected.” (_Op. cit._ p. 42.)
On the other hand, if either from the rigidity, &c. of the child or of the pa.s.sages, but little material advance is made in the manner above-mentioned, if the soft parts are become swollen and inflamed, and the powers of the patient are beginning to flag, and exhaustion coming on, if turning has been attempted as far as could be done with safety, and still without success, we have no choice left but that of embryotomy; the chest and abdomen must be evacuated of their contents as already directed under the head of PERFORATION, and in this manner the child delivered.
_Malposition with deformed pelvis, or rigidity of the uterus._--Where the pelvis is deformed, or the uterus (from the early escape of the liquor amnii) spasmodically contracted upon the child, and the os uteri in a state of rigidity, the difficulties and danger of the case are greatly multiplied: in the former complication the embryotomy must be carried much farther, in the latter we must have recourse to bleeding, opium, warm-bath, &c. as recommended under the head of TURNING.
_The prolapsed arm is not to be put back or amputated._--Where the arm has been some time prolapsed, and, from the pressure of the soft parts, much swollen, it fills up the v.a.g.i.n.a so completely that it would seem almost impossible to introduce the hand, unless we push up the arm first: experience however confirms the valuable rule of La Motte, viz. that we must slide our hand along the arm into the uterus; we shall rarely find, where the pa.s.sages are in a proper state for undertaking the operation, that the prolapsed arm presents any serious obstruction to the pa.s.sage of the hand. ”An arm presenting,” says Chapman, ”and advanced as far as the armpit, is not to be returned, but the hand is to be introduced (which, as Deventer justly observes, is often found to penetrate with much more ease when the arm hangs down than when it is thrust back again) and the feet to be sought for, which, when found, the arm will prove no great hindrance in turning the child.” (Chapman's _Midwifery_, p. 46. 2nd. ed., 1735.)
In no case is it necessary to separate the arm at the shoulder, ”for I have found it,” says Dr. Denman, ”a great inconvenience, there being much difficulty in distinguis.h.i.+ng between the lacerated skin of the child and the parts appertaining to the mother.” (_Essay on Preternat. Labours_, p.
32.)
Dr. Meigs, of Philadelphia, has added another powerful argument against this practice, viz. that cases have occurred where the arm had been cut off and where the child was nevertheless born alive.
As to how far it is possible or advisable so to alter the position of the child as to make it present with the nates or head, this has already been considered in the chapter upon TURNING.
The _presentation of the arm with the head_ is of very rare occurrence, so much so that some have doubted if it really existed: two cases of this kind have come under our own notice, in both of which the child was born in this position, although with some difficulty.
”Independent of the awkwardness of position which the head may a.s.sume, from the circ.u.mstance of the hand or arm descending with it into the pelvis, there will be so much increase in the bulk of the part as to render its pa.s.sage slow and difficult; yet if the case be not interrupted by mismanagement, it will terminate favourably, for this complication of presentation seldom happens but in a wide pelvis.” (Merriman's _Synopsis_, p. 48, last ed.)
It is by no means uncommon to feel the hand lying upon the side of the head or on the cheek; but this produces no impediment to the labour, for as the head descends through the brim of the pelvis the hand usually slips up: in the other case we have felt the arm bent over the head, and pressing the ear on the opposite side.
_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 pract.i.tioner.
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 pa.s.sed 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 pa.s.sage 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 v.a.g.i.n.a: 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 v.a.g.i.n.a 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.