Part 27 (2/2)
_Treatment._ Left to itself prolapsus of the cord is almost certain destruction to the child, for unless the labour comes on very briskly, and the head pa.s.ses rapidly through the pelvis, the cord is pressed upon so long as to render it impossible for the child to be born alive. Still, however, where the pa.s.sages are yielding, and the pains active; where the head is of a moderate size, the pelvis s.p.a.cious, and the cord in a favourable part of it, viz. towards one of the sacro-iliac synchondroses; where also the membranes remain unruptured until the last moment, there will be a very fair chance of the child being born alive. Under no circ.u.mstances is it of such paramount importance to avoid rupturing the membranes as in these cases, for the bag of fluid which they form dilates the soft pa.s.sages and protects the cord from pressure.
”Many methods of relief have been recommended, such as turning, delivering with the forceps, pus.h.i.+ng up the funis through the os uteri with the hand, and endeavouring to suspend it on some limb of the child, collecting the prolapsed cord into a bag, and then pus.h.i.+ng it up beyond the head, pus.h.i.+ng up, the funis with instruments of various kinds, endeavouring to keep it secured above the head by means of a piece of sponge introduced; these and many other similar expedients have been resorted to.” (Collins, _op. cit._ p. 344.)
The first two of these means have been chiefly used in cases of prolapsed funis, the others having, for the most part, been found entirely inefficient. Thus Mauriceau, in the 33 cases which he has recorded, turned 19 times: the children were all born alive, except one, which was dead, but required turning as it presented with the arm. In later times, turning or the forceps have been preferred, according to the period of labour at which the prolapsus was discovered or occurred. Thus Madame Boivin has recorded 38 cases, 25 of which occurred at the commencement of, and 13 during labour, the former were all turned; in the latter the forceps was used; 29 children were saved, seven were lost, and the two others were putrid.
Our practice must be in great measure guided by the circ.u.mstances of the case: where the os uteri is not fully dilated, where the head is still high and not much engaged in the pelvis, the liquor drained away, and the cord beginning to suffer pressure during the pains, we dare not wait until the case be sufficiently advanced to admit the application of the forceps, but must proceed as soon as possible to turn the child. The operation should be performed with the greatest possible caution; the cord should be guided to one of the sacro-iliac symphyses; the expulsion of the trunk must be very gradual; a dose of secale should be given to ensure the requisite activity of the uterus when the head enters the pelvis, and the forceps kept in readiness to apply the instant that its advance is not sufficiently rapid. On the other hand, where the labour has made considerable progress before the membranes give way, and the head has fairly engaged in the cavity of the pelvis, if the os uteri is fully dilated, it will be no longer advisable to attempt turning; the head is within reach of the forceps, which should be immediately applied, taking care that the cord does not get squeezed between the blades and the head.
Where the arm or shoulder presents, this will of itself require that the child should be turned.
_Reposition of the cord._ Although the reposition of the cord has been recommended from the time of Mauriceau, and by the majority of authors since, it has nevertheless met with so little success as to have fallen into complete disuse until the last few years; one of its strongest opposers was the celebrated La Motte. ”The delivery ought to be attempted as soon as we find that the string presents before the head, it being to no purpose to try to reduce it behind the head, which at that time fills up the whole pa.s.sage, and can only admit you to push it back into the v.a.g.i.n.a, and it will fall down again at every pain; and if you have done so much as to reduce it into the uterus, what hinders you from finis.h.i.+ng the delivery at once, by seeking for the feet? the chief difficulty is then over.” (_La Motte_, English translation, p. 304.) This mode of delivery (turning) has been more adopted by pract.i.tioners in such cases than any other, especially in former times, when the forceps was either not at all or imperfectly known; by none has it been so with more success than by Mauriceau himself, having saved every living child in which he attempted the operation. Still, however, he recommended that the attempt should be made to return the cord wherever it was possible, and has recorded four cases of this mode of treatment, all of which proved successful, although one of the children was born so feeble as to die shortly afterwards.
Giffard seems to have attempted the reposition of the cord only once, and failed, apparently from the unusual size of the child. In later years Sir R. Croft, ”has related two cases in which he succeeded, by carrying the prolapsed funis through the os uteri, and suspending it over one of the legs of the child. In both these cases the children were born alive.”
(Merriman's _Synopsis_, p. 99.) It is to Dr. Michaelis of Kiel that we are indebted for much recent and valuable information on the subject of replacing the prolapsed cord. Having pointed out the fact that it is the uterus alone which prevents the cord from prolapsing, he shows that, in order to replace the cord, we must carry it ”above that circular portion of the uterus which is contracted over the presenting part.” The reposition of the cord may be effected by the hand, or by means of an elastic catheter and ligature. In replacing the cord by means of the hand alone, Dr. Michaelis remarks that we shall effect this more readily by merely insinuating the hand between the head and the uterus, and gradually pa.s.sing it farther round the head, pus.h.i.+ng the cord before it. In this manner we do not require to rupture the membranes when we have felt the cord before the liquor amnii has escaped; a point of considerable importance.
The reposition, by means of the catheter, is effected by pa.s.sing a silk ligature, doubled, along a stout thick elastic catheter, from twelve to sixteen inches in length, so that the loop comes out at the upper extremity; the catheter is introduced into the v.a.g.i.n.a, and the ligature is pa.s.sed through the coil of the umbilical cord, and again brought down to the os externum. A stilet with a wooden handle is introduced into the catheter, the point pa.s.sed out at its upper orifice, and the loop of the ligature hung upon it; it is then drawn back into the catheter and pushed up to the end. The operator has now only to pull the ends of the ligature, so as to tighten it slightly, pa.s.sing the catheter up to the cord, which now becomes securely fixed to its extremity. When the reposition has been effected, he has merely to withdraw the stilet; the cord is instantly disengaged.[139] To prevent any injury, the ligature should be brought away first, and then the catheter.
”Dr. Michaelis has recorded eleven cases of prolapsus of the cord, where it has been returned by the above means, in nine of which the child was born alive. In three cases the arm presented also, which was replaced, and the head brought down; in two of these the child was born alive.”
(_British and Foreign Med. Review_, vol. i. p. 588.) A similar plan of replacing the cord by means of an elastic catheter has been tried by Dr.
Collins, but he had not tried it sufficiently often at the time of publis.h.i.+ng his _Practical Treatise_ to be able to give a decided opinion about it.
The plan of introducing a piece of sponge after replacing the cord, in order to prevent its coming down again, is of no use whatever. Dr. Collins tried it in several instances, and considers that ”it is quite impossible, however, in the great majority of cases, to succeed in this way in protecting the funis from pressure, as it is no sooner returned, than we find it forced down in another direction.” The plan has been recommended by several modern authors, but it is by no means a new invention, having been proposed by Mauriceau; it does not appear, however, that he ever put it in practice.
Where no pulsation can be felt in the prolapsed funis, which is flabby and evidently empty, no interference will be required; the child is dead, and therefore the labour may be permitted to take its course. We should, however, be cautious in examining the cord where it is without pulsation, and yet feels tolerably full and turgid, for a slight degree of circulation may go on nevertheless, sufficient to keep life enough in the foetus, even for it to recover if the labour be hastened. We should especially examine the cord during the intervals of the pains, and after we have guided it into a more favourable part of the pelvis, where it will not be exposed to so much pressure, for then the pulsation will become more sensible to our touch, and prove that the child is still alive.
The following case by Dr. Evory Kennedy is an excellent ill.u.s.tration of what we have now stated:--”The midwife informed me that there was no pulsation in the funis, which had been protruding for an hour; on examination made during a pain, a fold of the funis was found protruding from the v.a.g.i.n.a, at its lateral part, and devoid of pulsation. As the pain subsided, I drew the funis backwards towards the sacro-iliac symphysis, and thought I could observe a very indistinct and irregular pulsation; I now applied the stethoscope, and distinguished a slight foetal pulsation over the p.u.b.es. Fortunately on learning the nature of the case, I had brought the forceps, which were now instantly applied, and the patient delivered of a still-born child, which, with perseverance, was brought to breathe, and is now a living and healthy boy, four years of age. Had I not in this case ascertained by the means mentioned, that the child still lived, I should not have felt justified in interfering; but, supposing the child dead, would have left the case to nature, and five minutes, in all likelihood, would have decided the child's fate.” (Dr. Evory Kennedy, _on Pregnancy and Auscultation_, p. 241.)
CHAPTER XI.
PUERPERAL CONVULSIONS.
_Epileptic convulsions with cerebral congestion.--Causes.--Symptoms.-- Tetanic species.--Diagnosis of labour during convulsions.-- Prophylactic treatment.--Treatment.--Bleeding.--Purgatives.-- Apoplectic species.--Anaemic convulsions.--Symptoms.--Treatment.-- Hysterical convulsions.--Symptoms._
Women are liable, both before, during, and after labour to attacks of convulsions, not only of variable intensity, but differing considerably in point of character. We shall consider them under three separate heads, viz. epileptic convulsions with cerebral congestion; epileptic convulsions from collapse or anaemia; and hysterical convulsions. Other species have been enumerated by authors, but they are either varieties of, or intimately connected with, those of the first species.
No author has more distinctly pointed out the fact that epilepsy may arise from diametrically opposite causes than Dr. Cullen; a circ.u.mstance which, in a practical point of view, is of the greatest importance. ”The occasional causes,” says he, ”may, I think, be properly referred to two general heads; the first, being those which seem to act by directly stimulating and exciting the energies of the brain, and the second, of those which seem to act by weakening the same.” ”A certain fulness and tension of the vessels of the brain is necessary to the support of its ordinary and constant energy in the distribution of the nervous power”
(_Practice of Physic_;) and hence it may be inferred that, on the one hand, an over-distention, and, on the other, a collapsed state of these vessels, will be liable to be attended with so much cerebral disturbance as to produce epilepsy.
_Epileptic convulsions with cerebral congestion._ Epileptic convulsions connected with pregnancy or parturition, and which are preceded and attended with cerebral congestion, alone deserve, strictly speaking, the name of _Eclampsia parturientium_ (which, in fact, signifies nothing more than the epilepsy of parturient females,) being peculiar to this condition; whereas, the anaemic and hysterical convulsions may occur at any other time quite independent of the pregnant or parturient state.
The term ”puerperal convulsions” is employed in a much more vague and extended sense, and applies generally to every sort of convulsive affection which may occur at this period, and as such, it therefore, forms the t.i.tle of the present chapter.
_Causes._ The exciting cause of eclampsia parturientium is the irritation arising from the presence of the child in the uterus or pa.s.sages, or from a state of irritation thus produced, continuing to exist after labour. The predisposing causes are, general plethora, the pressure of the gravid uterus upon the abdominal aorta, the contractions of that organ during labour, by which a large quant.i.ty of the blood circulating in its spongy parietes is driven into the rest of the system, constipation, deranged bowels, retention of urine, previous injuries of the head or cerebral disease, and much mental excitement, early youth: also ”in persons of hereditary predisposition, spare habit, irritable temperament, high mental refinement, and in whom the excitability of the nervous, and subsequently the sanguiferous system is called forth by causes apparently trivial.”
(_Facts and cases in Obstetric Medicine_, by I. T. Ingleby, p. 5.)
_Symptoms._ From the above-mentioned list of causes it will be evident, that these convulsions will be invariably attended and preceded by symptoms of strong determination of blood to the head. Previous to the attack the patient has ”drowsiness, a sense of weight in the head, especially in stooping; beating and pain in the head; redness of the conjunctiva; numbness of the hands; flus.h.i.+ng of the face, and twitching of its muscles; irregular and slow pulse; ringing in the ears, heat in the scalp, transient but frequent attacks of vertigo, with muscae volitantes, or temporary blindness; derangement of the auditory nerve; embarra.s.sment of mind and speech; an unsteady gait; constipation and oedematous swellings.” (Ingleby, _op. cit._ p. 12.)
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