cavity.
135
LECTUEE IX.
LABORIOUS LABOURS.
Symptoms of Inflammation — Of Exhaustion — Treatment — Different Degrees of
Disproportion in the Pelvic Cavity — Case in which the Head moves very slowly
through the Pelvis — Opposite Opinions as to its Management — Discussion of the
Question — Attempt to determine it by Statistical Results.
In tlie preceding lecture we pointed out to you the manner in
whicla tire head may be impeded in the pelvic cavity, and
explained the terms used to designate the different degrees of
disproportion. We shall now bring before you the effects that
result therefrom, those symptoms that indicate danger in labours
of this class, and the general treatment required to secure the
patient from injury. We shall then endeavour to determine,
as far as is possible, the circumstances that justify artificial
assistance, and the nature of the aid that is called for. You will
recollect, that, in speaking of the second stage of natural labour,
we directed your attention to the striking change in the action of
the uterus when the waters were discharged and the os uteri
fully dilated.* The action then becomes much more powerful,
and the effort to force the child forward is assisted by every
muscular aid that can be called into action by the patient. Hence
the danger that may arise if the advance of the child be opposed
by any unusual resistance from the pelvis. If the head be
arrested, but still more if it become impacted, the most serious
consequences might follow, if not prevented by a judicious
treatment. It is therefore necessary, in all such cases, that you
watch very closely any alteration in the symptoms that accompany
the struggle, in order to foresee the approach of danger, and to
* Page 60.
136 LECTURES ON PARTURITION.
enable you to act with that promptitude and decision which the
circumstances require.
The unfavourable results that follow these labours, and, indeed,
the majority of all difficult labours, depend generally upon one
of two causes — inflammation or exhaustion. Inflammation of
the passages may arise, and, if it proceed to any extent, may
terminate either in slough of some part of the vagina (more
especially the vesico-vaginal septum, because most exposed to
pressure), or in slough of the whole vagina, if the inflammation
assume an erysipelatous character, or perhaps in slough and
laceration of the portion of the vagina connected with the neck
of the uterus, thus leading to rupture of the uterus itself. Each
of these consequences, although diflering in degree, is equally to
be avoided. It is therefore important to observe the earliest
symptoms of inflammation.
Another cause of danger is exhaustion of the uterus. When
the uterus becomes powerless, artificial assistance is absolutely
required to deliver the child. The danger, however, does not
consist in this necessity, but rather in the cause that led to it.
Atony of the uterus is not easily produced ; and when it occurs,
the shock of the constitution is very great. Sudden death has
been the consequence of it; and the patient is always placed in
imminent danger, because of the symptoms of constitutional
disturbance which present themselves. Beside this, the uterus
having lost to a certain extent its power of contraction, haemor-
rhage may be the result; and this increases the exhaustion of the
patient, and, consequently, the danger of the case.
Hence, one of the most serious effects that can follow prolonged
labour is, that the patient becomes, in the true meaning of the
term, exhausted. It is one which should be guarded against by
every precaution, and one which justifies the most prompt
interference the moment any indication is given of such an
unlooked-for alteration in the constitution of the patient. But
do not confound exliaustion with mere fatigue. Fatigue is the
ordinary effect of long-continued exertion, and, therefore, of long
and severe labour ; exhaustion, a very rare result of it ; never-
theless, the term exhaustion is applied indifferently to express
both effects. The patient will tell you that " she is quite
exhausted." Her friends will exclaim, that " she will sink from
exhaustion if not relieved." This language is well tuiderstood
SLOW PROGRESS OF THE HEAD. 137
and appreciated by the intelligent practitioner in cases where
there is no exhaustion whatever ; but we fear we must add that
it is an appeal very readily listened to by some who are not quite
so prudent, and who feel quite as much inconvenience from
fetigue as the patient. You must not be betrayed into impatience
from such a cause, but rather steadily observe the character of
the labour, and be prepared to recognise the earliest symptom of
exhaustion the moment it presents itself Thus you will be able
to interfere with promptitude when your assistance is required,
and, on the other hand, will not be hurried by these urgent
solicitations into an unnecessary, and perhaps an injudicious,
attempt to terminate the labour.
When the head of the child moves very slowly, or ceases to
advance through the pelvic cavity, the second stage of labour is
often greatly lengthened. In such instances, the uterus continues
to act for a certain time with the same power as before ; but if
no effect be produced, its action is suspended in the same manner
as in the first stage, only for a shorter time. When the pains
are renewed, they are not so strong as before ; the uterus seems,
as it were, conscious of the difficulty ; the pains are shorter,
although very often severe. At this time the woman is disposed
to use every effort to force the child forward, and, impatient of
the delay, will strain with all her strength : failing in her object,
she becomes alarmed and dispirited, and her mental anxiety still
further interrupts the action of the uterus. She should therefore
be dissuaded from fruitless attempts of this kind, because nothing-
is so well calculated to excite inflammation, if not to produce
exhaustion. It is the more necessary to point out this to you,
because the patient is too frequently recommended to adopt this
very practice. She is often desired " to bear down with her
pains," and " to assist herself" at a time when she can give herself
no assistance whatever.
After this comparatively feeble action of the uterus has con-
tinued for some time, the pains return in their former strength,
especially if the patient has had even momentary sleep. If the
difficulty be still insuperable, they may either again cease, or
continuing, may produce inflammation of the passages. When
this is in the least degree indicated, the pains are very short,
extremely severe, and in their intervals the patient still complains
of pain, and a feeling of soreness. If the uterus be examined
138 LECTURES ON PARTURITION.
tlirougli the abdomen, you will observe a very perceptible difference
in the sensation it communicates. It feels almost as hard and
contracted in the interval as during the pain ; the patient cannot
bear to have the abdomen touched. Beside this alteration in
the character of the pains, we have other symptoms, both local
and general, to guide us. Febrile irritation, which had been
j)reviously absent, shows itself; the pulse becomes quick, frequent,
and not easily compressed ; the tongue is dry, and the patient
has great thirst ; the countenance is anxious, and the features
slightly collapsed ; there may be a distinct rigor, but more
usually there is but a slight chill. Locally, the vagina becomes
hot and tender, the mucous secretion ceases ; it is therefore dry,
or, if the inflammation increase, a serous discharge may be
substituted. Wlien inflammation thus commencing is neglected,
and it extends to the uterus, there are further local changes
depending tipon the effect produced on the contents of the uterus.
The membranes undergo decomposition, and then a thick, yellow,
oily, and very offensive discharge flows from the vagina. This
is increased if, the death of the child having taken place, its
tissues undergo a similar change. You should bear in mind,
however, that there are cases where the death of the child may
have taken place either in the beginning of labour, or before it
has commenced. In such instances, putrescency may take place
rapidly, and similar appearances to those just mentioned might
present themselves without any inflammation having existed ; you
must not, therefore, confound the dark and foetid discharges from
the vagina, that depend upon such a cause, with those that occur
in connexion with inflammation of the vagina and uterus.
Wlienthe head remainsinthecavity of the pelvis, and the least ten-
dency to inflammation is manifested, the most prompt and decided
measures are necessary. In strong and plethoric habits, free
general depletion, followed by nauseating doses of tartar emetic,
emollient enemata, and local fomentations, will check the advance
of inflammatory symptoms, and give time to determine the
important question as to the delivery of the child. In those
feeble constitutions where you have reason to dread lest exhaus-
tion should ultimately take place, you cannot employ general
depletion, nor any means that would reduce the strength of the
patient to any extent. It is preferable to deplete locally, to use
fomentations, enemata, and, after the bowels are evacuated, to
SYMPTOMS OF EXHAUSTION. 139
give a moderate dose of liquor opii sed., combined with some
diaplioretic. Inflammation does not so readily arise in tliese
cases, and wlien it occurs it is more easily arrested; but ex-
haustion would be much more likely to follow prolonged labour
than in those more robust constitutions we have alluded to. Both
cases demand from you an equal attention ; but you perceive it
must be directed to a different object. We shall therefore briefly
detail to you those premonitory symptoms that indicate the ap-
proach of exhaustion. When the uterus is becoming weak, and
its strength is, in the strictest sense of the term, almost exhausted,
the pains become short and inefiicient, the intervals between them
longer, and sometimes they are quite suspended; but the nervous
system being excited, the patient derives no advantage from such
suspension. She does not sleep, but continues watchful, anxious,
and restless; the pulse is increased in frequency, is very easily
compressed, and its pulsations are disturbed and rendered irregular
by the most trifling causes. The countenance of the patient is
peculiar. To say that it is collapsed would not convey its exact
expression. Watchfulness and anxiety are portrayed on features
that equally indicate languor and listlessness. An observable
change takes place, but to explain how is not easy. If these
monitors be neglected, further symptoms of constitutional dis-
turbance will soon present themselves. Constant watching, in-
creased restlessness, hurried respiration, irregular chills, and slight
delirium, all rapidly succeed each other, and hasten to the most
unfavourable conclusion. When there is the least reason to ap-
prehend exhaustion, promptitude in delivery is imperative; but
before interference is thus called for, much may be done to pre-
vent its necessity. Rest is very important in these cases, because
it is an evidence that the over-excited nervous system is tran-
quilhzed; therefore, when the pains are becoming weak, or re-
turn only at long intervals, a moderate dose of opium is often of
great service: if the patient sleep, even for a short time, the
uterine action is renewed with much more power. I have ex-
pressly stated a moderate dose of opium, because the case now
under our consideration is that in which the same medicine has
produced the most opposite efiects, according to the dose admi-
nistered, and, consequently, it has sometimes been discarded, be-
cause it has been misapplied. The object which it is intended to
accomplish by opium, is to subdue the nervous irritation which
140 LECTURES ON PARTURITION.
precedes exhaustion, and to restore, by rest, the energy of the
uterus. The eiFect produced by too large a dose may be to
paralyze all nervous power, and thus at once to cause uterine ex-
haustion. You must therefore exercise proper caution in the use
of it; twenty to twenty-five minims is generally sufficient for the
purpose. After a temporary rest has been thus produced, if the
uterus still continues to act feebly, ergot of rye may be given in
an equally cautious manner, carefully attending to its influence
on the pulse, and especially on the circulation of the foetus. If in
either case, after giving this medicine, the rate of the pulsations
be diminished, you must not persevere in its employment, other-
wise the death of the child may be the result.* It is also necessary
* Ergot of rye should be given with great caution. Its effect has been closely
observed by Dr. Beatty, and he is led to the following conclusions: —
" That the administration of ergot to a woman in labour is attended with
danger to the child, whenever a time sufficient for the absorption and transmission
of its noxious properties elapses before the child is born. The degree of eifect
produced, differs with the time that elapses between the exhibition of the dose
and the birth of the child. Hence, the ergot should never be given in any case
where there is a likeliliood of the labour lasting more than two homs after its
administration; except when it may be employed to save the mother's life ; and
secondly, if delivery is delayed to two hours, we should resort to artificial assistance
to save the life of the child." — Dublin Journal.
Dr. Hardy has since made its effects the subject of his observation, and has
drawn up a series of Tables to determine —
1st. The period after administration that its action commences.
2d. Its effects on the maternal pulse (when any), and how soon evident.
3d. Its effects upon the foetal heart (when any), and how soon produced.
4th. The state of the uterus and lochial discharge during convalescence, in cases
in which it has been exhibited.
1. It appears that, in some (^ases, ergot of rye acts on the uterus so soon as seven
minutes after its exhibition, whilst in others a much longer period of time is re-
quired; from about ten to fifteen minutes may be stated as the average. In those
cases where the children have been expelled alive, I have always observed the
action of the uterus to commence within twenty-five minutes. On the otlier hand,
when a longer period than this elapses before the uterus takes on action, the use
of instruments has been necessary to perfect the delivery, or the children have been
dead-born.
2. In nineteen cases there was a marked diminution in the frequency of the
mother's pulse, following the administration of ergot. This efl'cct generally began
to take place from about fifteen minutes to half an horn-. In all these instances,
when the depression of the pulse occurred, the foetal heart underwent a similar
change. In several cases where the circulation of the patient underwent this de-
pression from the action of the ergot, the effect continued several days.
3. In the majority of cases, a diminution in the foetal heart's pulsations fol-
lowed the exhibition of ergot. The period at which this effect begins to be pro-
ERGOT OF RYE. 141
to be careful to avoid the use of secede cornutum, if tlie delay
in this stage arises from great disproportion between the head
and the pelvis. It must be obvious to you, that in a case like
this it would be very dangerous to use a means of exciting
the action of the uterus, over which you can have no control. A
preparation which exerts a specific influence on the uterus,
which often causes the most violent action, and that not return-
ing at intervals, as ordinary pains do, but which excites a con-
tinuous effort of the uterus to expel the child, is not the safest to
employ when there is much resistance opposed to this action.
The remedy, when cautiously administered, is useful, however,
in those cases where the delay chiefly arises from want of power
in the uterus, which may be exhausted if not thus artificially
stimulated to action.
duced, varies from fifteen minutes to half an hour. The most common eflfect is
a diminution in the frequency of the pulsations, this is succeeded after some
time by an irregularity in its beats, which irregularity continues, more or less,
until the sounds intermit, and at length after a variable period become quite in-
audible. In those cases where the number of pulsations have been steadily
reduced below 110, and at the same time with intermissions, the child will rarely
if ever be saved, although its delivery should be effected with the greatest possible
speed.
4. The volume of the uterus is often found much greater than after ordinary
labours. In addition to this enlarged state of the uterus, it has sometimes a
firmly contracted feel, which generally continues for several days. In a few
instances the lochial was rather pale and scanty, although nothing unfavorable
occurred during convalescence to account for this circumstance. With some few
exceptions, the women had generally good recoveries. The children that were
born alive, all, with one exception, did well. In this case, delivery was effected by
the forceps, as the foetal heart had fallen so low as 100 fi-om the exhil)ition of the
ergot. It died in three hours after delivery.
General Results of Dr. Hardy's Tables.
Cases in which the uterus expelled the child alive 7
Cases in which the children were born alive by the application of the
forceps or vectis (after ergot was given) 7
—14
Cases where the uterus expelled the child dead-born (after ergot) . .1.5
Cases in which the forceps or vectis were applied (after ergot), but the
children dead -born 6
The children dead (from ergot), delivery effected by the crotchet . .13
—34
Dublin Journal, vol. xxvii. p. 224. 48
From the above summary of cases given by Dr. Hardy, it appears that in
forty-eight cases where ergot of rye had been given, thirty-four children were
still-born,— nearly three-fijurtlis !
142 LECTURES ON PARTURITION.
Having given you tliis brief outline of tlie general treatment ne-
cessary in tliese protracted cases, we sliall now enter upon tlie more
difficult question of tlieir management, to secure the delivery of
the child, assuming that instrumental aid is not rendered impera-
tive by the presence of inflammation or exhaustion. It is hardly
necessary to state to you that there is every variety in the degree
of disproportion between the head and the pelvis. In some
instances it is so slight that the child may be safely delivered
without any assistance; only it will occupy a longer time in
passing through the pelvis. In others, the amount of difficulty
may be so much increased as to render it doubtful whether the
head can pass without assistance ; and it is in these cases that the
rules which are given for your guidance are the most contra-
dictory. Again : you may have a still greater disproportion, in
which there is no doubt about the improbability that the head
can be expelled by the natural effi^rts of the uterus, although
there is very great doubt, and no little dispute, as to the means by
which the head must be extracted. Lastly : you have occasional
instances in which the narrowness of the pelvis is such, or the
magnitude of its distortion is so great, that the safe delivery of
the child is hopeless: the head must be lessened; it must be
destroyed before it can be brought into the world. In extreme
cases of this kind, even this cannot be done ; but recourse must be
had to the difficult and dangerous operation of removing the
child from the uterus by laying it open, in order to save the
mother from the dreadful alternative of dying undelivered.
In those cases of slight deviation from the standard pelvis,
where there is every evidence of space sufficient for the head
ultimately to pass through the pelvis, if nature be allowed time
for the purpose, you would not, of course, interfere with her;
although I believe instances might be quoted where very adroit
operators have, even in such cases, relieved the tedium of a long
attendance by a ready application of the forceps. It is sufficient
to say, that the united testimony of the profession, given in every
standard work of midwifery, is opposed to such a practice; and
if any accident should arise from this mischievous meddling, the
operator is fully responsible for all the consequences that follow
from it. But in those more doubtful cases, in which there seems
hardly sufficient space for the head to pass safely through the
pelvis, the practice is not so clear, nor is the evidence of the pro-
MANAGEMENT WHEN THE HEAD ADVANCES SLOWLY. 143
fession so unanimous on the subject. Wlien, in such instances,
the head is actually arrested, and so remains for some hoiirs in
the same position — a sufficient length of time to satisfy you that
the uterus cannot advance it — if the ear can be felt, or the finger
be passed easily between the head and the pubis, you may use
the forceps to deliver the child, and I think the weight of autho-
rity will support your practice. But when the head is not so
arrested, but, at the same time, advances so extremely slowly
that it seems to be arrested, you have here the discordance of
authorities at once confounding you. Burns devotes the greater
part of a chapter* to prove the impropriety of delay under such
circumstances, and advocates the application of the forceps in cases
of arrest, or rather of slow progress of the head, because " in such
cases then we may experience much evil from trusting too long to
nature, but add little to the sufferings of the patient, and nothing
to her hazard, by instrumental aid."t He applies the same prin-
ciple to cases of impaction, which we shall presently consider.
The evil he dreads is uterine exhaustion, if this second stao-e be
much prolonged. In this view he has the support of the late
Professor Hamilton, who equally dreaded delay. Dr. Campbell
also gives a similar opinion, but more guardedly expressed. " It
may, however, be repeated, that while the delivery is advancing,
and the patient continues free from unfavourable symptoms, the
use of the forceps is to be abstained from altogether. But when-
ever the progress is slow and imperceptible, and the subordinate
means already recommended have failed to accelerate the transit
of the foetus, the case should be watched, and this instrument
applied with very little delay after the passages are prepared.'' % Other
names might be added to this list of advocates for interference in
the case supposed. But let us turn to the other side, and you
will find the eminent names of Wilham Hunter, Osborne, and
Denman, opposed to this practice. Dr. Osborne would wait until
exhaustion had actually taken place — a maxim for which he has
been very severely, and I admit very justly, criticized. Dr.
Denman's fifth aphorism states, " It is meant, when the forceps are
used, to supply with them the insufficiency or want of labour
pains; but so long as the pains continue, we have reason to hope
they will produce their e&ect, and shall be justified in waiting."^
* Burns, chap.vi. p. 428. t ^'>^'~U P- 434.
J Campbell's Midwifery, p. 281. § Denman's Aphorisms, p. 12.
144
LECTURES ON PARTURITION.
Wlien tlie pains cause the head to advance, although very slowly,
they are producing their effect; and the case therefore comes
vdthin the limits of the aphorism. Dr. Collins observes, " Let it
be carefully recollected at the same time, that so long as the
head advances ever SO slowly, the patient's pulse continues
good, the abdomen free from pain on pressure, and no obstruction
to the removal of urine, interference should not be attempted,
unless the child be deadr* Dr. F. Ramsbotham's third rule on
this point is, " If the head advance at all, and be not impacted,
provided the strength and spirits are good, there is seldom need to
interfere."! Dr. R. Lee's name might also, I think, be added, as
being favourable to this rule of practice.
I shall not, gentlemen, so far trespass on your patience as to
ask you to unravel with me this tangled web of contradictory
experience. It is suflB.cient if I convince you of the difficulty of
the subject, and if it induce you to give a patient attention to the
only mode that I can adopt to draw a legitimate conclusion —
that is, to derive it as nearly as possible from facts, without
reference to opinions. I think this may be done. Bearing in
mind that the great and leading principle to be observed in these