Part 23 (1/2)

As this was the first time we had attended this patient, and from the history she gave of her former labours, in which she represented her abdomen being in all equally pendulous, with the exception of the first, we waited several hours (she being placed upon her side) for the accomplishment of the labour. During the whole of this period the head did not advance a single line; nor could it, as the direction of the parturient efforts carried it against the projection of the sacrum. We had several times taken occasion to recommend her being placed upon her back, but to which she constantly objected, until we urged its being absolutely necessary. She at length reluctantly consented to the change of position; when upon her back it was found that it did not advance the os uteri sufficiently towards the centre of the superior strait. The abdomen was therefore raised, and a long towel placed against it, and kept in the position we had carried it by the hands, by its extremities being firmly held by two a.s.sistants; at the same time we introduced a finger within the edge of the os uteri, and drew it towards the symphysis pubis, and then waited for the effects of a pain. One soon showed itself, and with such decided efficacy, as to push the head completely into the inferior strait, and three more delivered it.” (_Compendious System of Midwifery_, -- 224.)

This peculiar displacement of the uterus, which has been called by some anteversion of the gravid womb, has occasionally given rise to the suspicion that there was no os uteri, from its being tilted upwards and backwards towards the promontory of the sacrum: it has been said, in some cases, to have even contracted adhesions with the posterior wall of the v.a.g.i.n.a, from the firmness with which it was pressed against it, and thus tended still farther to increase the deception. ”Within our knowledge,”

says Dr. Dewees in the paragraph preceding the one just quoted, ”this case has been mistaken for an occlusion of the os uteri, and where upon consultation it was determined that the uterus should be cut to make an artificial opening for the foetus to pa.s.s through. They thought themselves justified in this opinion, first, by no os uteri being discoverable by the most diligent search for it; and, secondly, by the head being about to engage under the arch of the p.u.b.es covered by the womb. Accordingly, the l.a.b.i.a were separated, and the uterine tumour brought into view. An incision was now made by a scalpel through the whole length of the exposed tumour down to the head of the child, the liquor amnii was evacuated, and in due course of time the artificial opening was dilated sufficiently to give pa.s.sage to the child. The woman recovered, and, to the disgrace of the accoucheurs who attended her, was delivered per vias naturales of several children afterwards, a d.a.m.ning proof that the operation was most wantonly performed.” Where, in addition to the anteversion, strong adhesions have taken place between the os uteri and posterior wall of the v.a.g.i.n.a, no trace of os uteri will be felt, and the operation above-mentioned does become sometimes necessary.

_Rigidity of the os uteri._ The chief way in which the uterus can obstruct the pa.s.sage of the child, is, by an undilatable state of its mouth: this may arise from a variety of causes, which may be chiefly brought under the two heads of functional and mechanical. Under the first head comes rigidity of the os uteri, either from a spasmodic contraction of its circular fibres, or from irregularity or deficiency in the contractions of the longitudinal fibres of the whole organ. In a slight degree this is frequently met with, especially in first labours, where the patient is young, delicate, and irritable, and where, in all probability, there is some source of irritation in the primae viae which tends to disturb and divert the proper and healthy action of the uterus. We see it also in robust plethoric primiparae; the os uteri dilates to a certain degree, perhaps an inch in diameter, and remains tense and firm, with its edge thin; the contractions of the uterus produce much suffering, and to all appearances are very violent; but they are chiefly in front, and produce little or no effect upon its mouth; the v.a.g.i.n.a is hot and dry, the patient becomes exhausted with fruitless pains, and fever or inflammation would quickly follow, if nothing be done to relieve this state. As this subject, however, belongs rather to the next species of dystocia, viz. that arising from a faulty condition of the expelling powers, we shall delay the consideration of the treatment.

_Belladonna._ It has been recommended, and not very judiciously, to apply belladonna to the os uteri in cases of great rigidity: it was repeatedly tried by the celebrated Chaussier in the Maternite, at Paris, and, according to his observations, it produced a considerable effect upon it.

”The knowledge of the extraordinary powers which this drug possesses in causing dilatation of the iris, led to its employment for the object of enlarging the aperture of the uterus; but there is certainly no similarity in the structure and office of the two organs, and no a.n.a.logy can be drawn between their functions. It is not likely that this means will produce the relaxation we require; and if no good results from its use, it must be injurious; not in consequence of the poisonous quality resident in the drug itself, but in the friction which is necessary for its efficient application. The mucus which naturally lubricates the part must be wiped away, and this irritation must predispose the tender organ to take upon itself inflammatory action.” (_Dr. F. H. Ramsbotham's Lectures, in Med.

Gaz._ May 3, 1834.)

For our own part we must confess, that, although we have seen this application tried repeatedly, it has never produced the desired effects, but has invariably brought on very troublesome and distressing symptoms, such as sickness, faintness, headach, vertigo, &c.

There is a condition of the os uteri which is occasionally met with, and which presents a degree of rigidity which we have never seen except where there have been adhesions and callous cicatrices from former injuries. It has nothing of the thin edge put strongly on the stretch during the pains; but it is thick and firm, presenting nothing of the elastic cus.h.i.+ony softness of the os uteri in a favourable state for dilatation; it dilates to about an inch across, tolerably regularly, and without much apparent difficulty, but no efforts of the uterus can dilate it farther. We have already alluded to two extreme cases of this when speaking of ruptured uterus, and where in each instance the os uteri entirely separated from the uterus and came away. Whether there is something peculiar in the structure of the part which renders it thus undilatable, or whether it required even still more powerful measures than those employed, is not very easy to decide.

_Edges of the os uteri adherent._--_Cicatrices_, &c. A serious impediment to the pa.s.sage of the child may be produced by adhesions of the sides of the os uteri to each other; by hard callous cicatrices resulting from ulcerations, lacerations, &c. in former labours; by abnormal bands, or bridles, as they have been called; and by tumours and other morbid growths. Where the structure of the os uteri has been much injured by previous injuries of this character, the resistance will probably be so great as to require artificial dilatation with the knife. Generally speaking, however, the whole circle of the uterine opening is not involved, portions still remaining of natural structure, and, therefore, capable of dilatation. On examination, it feels irregular both in shape and hardness; a part being soft, cus.h.i.+ony, yielding, and forming the segment of a well-defined circle, the rest of it uneven, k.n.o.bby, and hard, being evidently puckered up by cicatrisation.

In many cases, these callous contractions give way more or less when the head begins to press powerfully against them; but even where this is not the case, the healthy portion of the os uteri is so dilatable as to yield sufficiently. It would be difficult to estimate how far an os uteri in this state, with perhaps, not more than half, or even a third, of its circle in a healthy condition is capable of dilating. But from cases which have come under our own observation, and others which have been recorded by authors in whom we place the greatest reliance, we are quite confident that with proper treatment a sufficient degree of dilatation can be effected without resorting to artificial means.

Bleeding to fainting, the warm bath, laxatives, and enemata, will a.s.sist greatly in promoting our object. Where, however, the contracted portion shows no disposition to yield to this treatment, or to the pressure of powerful pains, but forms a hard resisting bridle or band, which effectually impedes the farther advance of the head, it must be divided by the knife in order to prevent dangerous laceration of the part on the one hand, or protraction of labour on the other. The mode of doing this will be described when these conditions as effecting the v.a.g.i.n.a are considered.

Artificial dilatation of the os uteri by incision has been practised very rarely, the chief of these operations having had reference to the v.a.g.i.n.a.

F. Ould considered that mere contraction of the os uteri from former lacerations did not require this operation; but that where it was in a state of schirrus, there would be ”no chance for saving either mother or child but by making an incision through the affected part.”

We have quoted, on a former occasion, a case of cicatrised os uteri recorded by Moscati, and where, in consequence of injury in a former labour, the opening was nearly closed; fearing the laceration which had occurred in a similar case under his father's care, in consequence of making merely one incision, he made a number of small incisions round the whole of the orifice until a sufficient dilatation was produced.

_Agglutination of the os uteri._ Another condition of the os uteri which may produce very considerable impediment to the pa.s.sage of the child, is that which has been called _agglutination_, where by some adhesive process, apparently that of inflammation, the lips of the opening adhere and completely close it. These species of imperforate os uteri may occur in primiparae as well as in those who have borne children: the agglutination of its edges takes place during pregnancy, probably shortly after conception. Upon examination we find no traces of hardness, rigidity, or any other morbid condition, either in the os uteri itself, or the parts immediately surrounding it; the os uteri is closed by a superficial cohesion of its edges, and which in some cases seem to adhere by means of an interst.i.tial fibrous substance; this when of a firmer consistence forms a species of false membrane, which in some cases is capable of resisting the most powerful uterine contractions, and in others it appears to cover the os uteri so completely as to conceal it most effectually, and give rise to the erroneous conclusion that the os uteri is altogether wanting. Baudelocque describes this condition (_Op. cit._ -- 1961;) but from the brief mention which he makes of it, as also from the treatment recommended, it is plain that he had no very distinct notions about it, for he advises that ”in all cases the orifice must be restored to its original state, and be opened with a cutting instrument as soon as the labour shall be certainly begun.”

In by far the majority of cases which have been recorded, the pains have after a time been sufficient to dilate the os uteri. Dr. Campbell has described two of these cases, where no os uteri could be traced for some time after the commencement of labour: both were first pregnancies: in the former, uterine action continued about twelve hours before the os uteri could be distinguished, when it felt like a minute cicatrix; the other patient had regular pains for two nights and a day before the os uteri could be perceived, and she suffered so much as to require three persons to keep her in bed; both these patients were largely bled, gave birth to living children, and had a good recovery.

We may suspect that the protraction of labour arises from agglutinated os uteri, when at an early period of it we can discover no vestige of the opening in the globular ma.s.s formed by the inferior segment of the uterus, which is forced down deeply into the pelvis, or at any rate, where we can only detect a small fold or fossa, or merely a concavity, at the bottom of which, is a slight indentation, and which is usually a considerable distance from the median line of the pelvis. The pains come on regularly and powerfully; the lower segment of the uterus is pushed deeper into the cavity of the pelvis, even to its outlet, and becomes so tense as to threaten rupture; at the same time it becomes so thin, that a pract.i.tioner who sees such a case for the first time would be induced to suppose the head was presenting merely covered by the membranes. After a time, by the increasing severity of the pains, the os uteri at length opens, or it becomes necessary that this should be effected by art: when once this is attained, the os uteri goes on to dilate, and the labour proceeds naturally, unless the patient is too much exhausted by the severity of her labour. Although the obstacle in some cases is capable of resisting the most powerful efforts of the uterus, a moderate degree of pressure against it whilst in a state of strong distention, either by the tip of the finger, or a female catheter, is quite sufficient to overcome it; little or no pain is produced, and the appearance of a slight discharge of blood will show that the structure has given way. Two interesting cases of this kind have been described by the late W. J. Schmitt, of Vienna, under the t.i.tle of two cases of closed os uteri which had resisted the efforts of labour, and where it was easily dilated by means of the finger.[127]

_Contracted v.a.g.i.n.a._ The v.a.g.i.n.a may be naturally very small, or unusually rigid and unyielding: in the first case serious obstruction to the progress of labour is rarely produced, the expelling powers being generally sufficient ultimately to effect the necessary degree of dilatation; the proper precautions must be taken to avoid every species of irritation and excitement of the circulation; the bowels must be duly evacuated; the circulation controlled either by sedatives, or, if necessary, bleeding, and where it is at hand, a warm bath; if this latter cannot be easily procured, a common hip bath, or sitting over the steam of warm water will be of great service; the great object will be to ensure a soft and cool state of the pa.s.sage with a plentiful supply of that mucous secretion which is so essential to the favourable dilatation of the soft pa.s.sages.

Nauseating remedies, and even tobacco injections, have been tried to a considerable extent for the purpose of relaxing the mouth of the uterus; but they produce little or no good effects, and cause much suffering to the patient. In Dr. Dewees' second case of obstructed labour from the above causes, a sufficient trial of this remedy was used to satisfy all doubts as to its effects. ”It produced great sickness, vomiting, and fainting, but the desired relaxation did not take place: we waited some time longer and with no better success. In the course of an hour, or an hour and a half, the more distressing effects of the infusion wore off; and resolving to give the remedy every chance in our power, we prevailed on our patient with some difficulty to consent to another trial of it: its effects were the same as before,--great distress without the smallest benefit, the soft parts remaining as rigid as before its exhibition.”

Bleeding was now proposed; the patient became faint after losing ten ounces, and the most complete relaxation followed: the forceps were applied, and a living child delivered.

_Rigidity from age._ In women pregnant for the first time at an advanced period of life, the v.a.g.i.n.a and os externum are said to oppose considerable resistance to the pa.s.sage of the child from their rigid condition, the parts having lost the suppleness and elasticity of youth; the vessels also convey less blood to the mucous membrane and adjacent tissues: hence the secretion of mucus is more sparing; the cellular tissue is more condensed and firm; still nevertheless, although it is constantly mentioned by authors as a cause of this species of dystocia, we cannot help declaring that it exists to a much less degree than has been generally supposed, and that primiparae at a very early age are much more liable to have tedious and difficult labours than those at an advanced age. Still, however, the circ.u.mstance is well worthy of notice; and in such cases we may produce much relief by the warm bath, or hip bath, by sitting over the steam of hot water, by warm water enemata, and great attention to the state of the intestinal ca.n.a.l and of the circulation. Mucilaginous or oleaginous injections into the v.a.g.i.n.a have been recommended; but we have no experience of their effects: we have frequently used lard, &c. to the edges of the os externum when the head was beginning to distend it, and we think with relief; at any rate it produces a feeling of comfort to the patient, being soft and cooling.

_Cicatrices in the v.a.g.i.n.a._ The most serious impediments to the progress of labour connected with the v.a.g.i.n.a are the contractions of this ca.n.a.l from callous cicatrices, the results of sloughing and other injuries in former labours. The v.a.g.i.n.a may be contracted throughout its whole length, its parietes hard, gristly, and uneven, and so small as not to admit even the tip of the little finger; the course of the ca.n.a.l from the irregularity of the contractions and adhesions is frequently much distorted; in other cases it is obstructed in different places by bands or septa, which have been produced by similar causes.

Where the condition of the v.a.g.i.n.a has been ascertained before labour, much may be done to ameliorate the condition of the parts, not only by the treatment already mentioned for rigidity of the v.a.g.i.n.a under other circ.u.mstances, but also by the judicious application of tents, bougies, and other means for dilating the pa.s.sage. A case of this kind came under our notice some years ago; the patient had been married many years without being pregnant, and was considerably beyond the age of forty. The deranged health and enlargement of the abdomen which took place excited no suspicions of pregnancy either in her mind or that of her medical attendant: the case was suspected to be ovarian dropsy, and a variety of medicines under this supposition were administered, both internally and externally: the commencement of actual labour appears to have been equally mistaken; nor was it until labour had advanced considerably that the real nature of the case was discovered; from its length and severity, violent inflammation and sloughing of the v.a.g.i.n.a was the result, the ca.n.a.l became much contracted, and was rendered still farther impervious by the formation of strong bands or septa which were stretched across it, and which effectually prevented the os uteri from being reached; sponge tents, and oval gum elastic pessaries of different sizes were introduced, and by degrees such a state of dilatation was produced as not only permitted the os uteri to be reached, but restored the v.a.g.i.n.a in great measure to its natural size.

The action of labour forcing the head of the child against these contractions and adhesions is frequently sufficient ultimately, to effect the necessary degree of dilatation; where, however, this is not the case, they require to be divided by the knife. The proper moment for doing this is during a pain, when the parts are put strongly on the stretch: we can now feel exactly where there is the greatest resistance, and where an incision will produce the most effect. In this state also the incision can be effected with most ease, for the stricture being firmly distended, the knife will more readily divide it than where it is relaxed; the patient also at this moment is not sensible to the cutting of the knife. The lower part of the blade well armed with lint or tow should be cautiously introduced along the side of the finger during an interval of the pains: in this way the necessary number of incisions may be made: this is usually followed by a good deal of bleeding, which tends still farther to relax the parts; and when the head has advanced low enough, a cautious attempt may be made with the forceps to deliver it.

In recommending dilatation by means of the knife, it must be distinctly understood, that a sufficient time should be allowed in order to see how much can be effected by the uterine efforts, for in many of these cases the stricture has at length yielded after severe and protracted suffering.[128] In cases of this kind, also, the effects of bleeding are by no means inconsiderable, and must not be neglected.

The _unruptured hymen_ has been said to be capable of impeding the progress of the head, but this can only be where the membrane is of unnatural strength and thickness. It has more than once occurred to us at the commencement of labour, to find the hymen uninjured; but it has broken down under the finger, even during examination, and we are convinced would have produced no obstacle whatever to the child. Where its structure is abnormal, and the advance of the labour is evidently r.e.t.a.r.ded by it, division is the simplest and easiest remedy.