During this period the structure of the perinasum becomes more
and more unfolded, so that the delay which usually takes place
in the labour at this point seems to arise much more from the
feeble character of the pains than the resistance of the perinasum.
At length, when tbe bead is enabled to pass down so far that the
* Collins' Report, p. 83.
72 LECTURES ON PARTURITION.
occipital portion can emerge from tlie outlet, the perinseum suffers
its greatest degree of distension. Tlie occiput tlien first rests
against tlie iscliio-pubic ramus, and as it is expelled, rises upwards
towards the pubic arch. It becomes a fixed centre, round which
the remaining portion of the head moves: the whole force of
every pain is, therefore, spent upon the perineum ; and, if these
return with much rapidity or violence, there is a danger that this
part may be lacerated. In the majority of cases, however, the
head retreats in the intervals of the pains, even where it seems to
be almost expelled. At this time, also, the pains become much
stronger, and are the severest and most trying to the patient
of any that she has experienced. At the conclusion of this stage
one or two very strong pains take place, by which the head is
first protruded so far that it does not retreat, and it is then
delivered. As soon as the head is born, you are given a favour-
able opportunity of confirming your diagnosis as to the position.
In this, the first position, the face is directed obliquely upwards
towards the right thigh of the mother, because when the shoulders
and body of the child pass into the pelvic cavity, they enter the
brim of the pelvis in the oblique measurement, opposite to that
in which the head has passed, and therefore as the child goes
through the cavity of the pelvis, the thorax and abdomen corre-
spond to the right or superior side of the pelvis, and the face looks
in the same direction.
When the shoulders are being expelled, the perineum is again
put upon the stretch, and is sometimes unequally protruded by
the arms of the child, by which, if care be not taken, it might be
lacerated, but as soon as they escape there is no further danger.
The uterus also ceases to act with the same force, the remaining
pains are weaker, so that the body and limbs of the child are very
slowly expelled. Such is the manner in which the child, in its
most usual position, is delivered, and this stage completed; but
before entering upon the consideration of the third stage, we would
direct your attention to the mode in which other positions of the
head are expelled, and their influence on the perineum. When
the head passes out in the second position, the back of the child is
to the right side of the pelvis, in the same relation as the thorax
and abdomen are in the first position; the face therefore looks
downwards to the left thigh. When the shoulders are passing the
perineum in this position, great caution is necessary, because you
THIRD STAGE OP LABOUR. 73
do not feel the hands and arms coming out, as in the first position ;
they might therefore press on tlie perinseum unequally, and
lacerate it without your knowledge. When the face is towards the
pubis, the perineum is very much endangered, in consequence of
the greater distance to which the head must descend before it can
pass under the pubic arch ; and in order to do so, the direction of
its motion is downwards and backwards, the reverse of what
usually occurs: consequently, the perineum suifers a much
greater degree of tension than in ordinary cases, and there is
a proportionate risk that it will give way. In face-positions,
from a similar cause, the perinasum also suffers, but not to the
same extent, because the tension upon it is only continued until
the chin passes under the arch, when the pressure is at once
relieved.
As soon as the expulsion of the child is accomplished, the uterus
ceases to contract for some time, the interval varying from five to
fifteen minutes; then the contractions are renewed, for the ex-
pulsion of the placenta. This constitutes the third stage of labour-.
These can scarcely be called pains ; they bear no resemblance to
those which preceded them, and are but little noticed by the
JDatient. The manner in which the placenta is separated depends
very much upon the mode in which the uterus contracts while
expelling the body and limbs of the child. If the fundus receive
due support from the abdominal muscles, so as to ensure a uniform
and efficient contraction from above downwards, it often hap-
pens that the same pain which extruded the limbs of the child
from the vulva, expels the placenta from the uterus into the vagina,
where it may remain for some time. The same will occur if arti-
ficial support be given by pressure with the hand on the fundus : in
either case, the uterine contractions have no further effect upon it.
It would continue for some time in this situation if left to itself,
and either be gradually removed from it by the slow action of
the fibres of the vagina, or suddenly, by some shock from above
driving the uterus down upon it; as, for instance, coughing
retching, or mvich forcing with the slight pains which occur at
this time. It is seldom, however, suffered to remain, but is gene-
rally drawn away by the funis. Retention of the placenta may
arise from different causes. Sometimes the sphincter of the
vagina closes upon it, and the placenta is thus retained until
removed by the hand, or by firm pressure on the fundus of the
74 LECTURES ON PAKTURITION.
uterus. In other instances, the placenta remains in the uterus after
the delivery of the child, until it is expelled by its subsequent
contractions, rendered efficient by similar contractions of the
diaphragm and abdominal mviscles. This additional aid is re-
quired, inasmuch as the action of the uterus alone is not sufficient
for the purpose. Hence, when the abdominal muscles are feeble,
so that the uterus can derive no support from them, the placenta
is retained in this cavity. This cause of retention has been gene-
rally mistaken for inertia of the uterus ; and under this impression
the placenta has been, very unnecessarily, v^ith drawn from the
uterine cavity; it is therefore necessary for me to direct your
attention especially to this point, in order that you may under-
stand the principle upon which the management of this stage
depends. When the child leaves the uterus, a very powerful
stimulus to its action is removed; and this stimulus the placenta
is quite inadequate to supply. The uterus, therefore, first ceases
to act for a certain time, and when the action is renewed, it is
weak, and continues only for a short time. If the uterus fail
in discharging the placenta by a few of these effiarts, it becomes
accustomed, as it were, to its presence, and it no longer acts as
a stimulus, but remains with the uterus imperfectly contracted
around it. A very efficient means of supplying this want of
irritation to the uterus, is the pressure of the abdominal viscera
which surround it. When the abdominal muscles are strong,
they contract upon the retiring uterus, compressing the in-
testines, and consequently the uterus, on all sides. These weak
pains, therefore, are greatly assisted and rendered effectual by the
straining efforts of the patient acting as a stimulus to the uterus
from without. But the abdominal muscles are not always strong:
on the contrary, in most instances, they are extremely weak, in
consequence of our civilized habits. They are too often reduced
almost to a state of atony from the constant pressure of the corset ;
hence it follows that the uterus derives little or no support from
them, and the placenta is retained, not from any want of power
in the uterus to expel it, but from a want of sufficient stimiilus to
cause the uterus to contract. There is no inertia of the uterus,
but only a suspension of its action. It is for this reason, and to
supply this deficiency, that the pressure of the hand on the fundus
of the uterus, during the expidsion of the child, is found so
useful; and on the same principle, as we shall have again to ex-
EETENTION OF THE PLACENTA. 75
plain to you, the application of a bandage round the abdomen is
always necessary, m order to give it proper support. This sus-
pended action of the uterus, as a cause of retained placenta, must
be carefully distinguished from time uteiine inertia, which we shall
allude to under the subject of hasmorrhage.
The placenta may also be retained from irregular contraction of
the uterus, either during the expulsion of the child or subsequently.
One of the fundal muscles may contract and not the other ; or the
fibres of the body may draw the uterus into a cylindrical shape,
leaving the fundus relaxed; or lastly, there may be a spasmodic
contraction of the fibres at the cervix, forming a kind of stricture.
These irregular contractions may arise, either from the too
rapid delivery of the child not allowing the uterus time to follow
its usual order of contraction, or from that order being inverted,
in consequence of too great relaxation of the fundus, the result
of deficient irritation. The efiect may be, that the cervix or body
contracts first, and therefore retains the placenta. Sometimes an
irregular contraction of the fundus may exist and not be per-
ceived, especially if frictions be used over the abdomen for the
purpose of exciting uterine action. The anterior wall of the
uterus remains firm and contracted, and the fundus seems to be
so too ; but if the hand be passed down towards the sacrum,
and along the posterior wall of the uterus (where the placenta
is often situated), it will generally be found relaxed, and, when
excited to contract, often expels the placenta, which had been
perhaps for a long time retained. All these irregular contrac-
tions must be corrected by endeavouring to restore the order of
uterine contraction from the fundus to the os uteri. The stricture
at the cervix is, however, an exception; it must be overcome, in
the same manner as strictures in other places, by direct dilatation.
Another cause of retained placenta is adhesion, either partial or
general ; but this, Hke uterine inertia, is so constantly accompanied
with haemorrhage, that we must defer its consideration to that part
of our subject.
When none of these causes operate, and the placenta is ex-
pelled in the usual time, the uterus does not altogether cease its
contraction for some time afterwards. If left altogether to itself,
without being properly supported, there is a danger that there
may be too great relaxation of the uterus; consequently, ha3mor-
rhage and severe after-pains, from the attempts made by . the
76 LECTURES ON PARTURITION.
uterus to discharge the coagula formed in its cavity. This is one
of the most frequent causes of after-pains. You have abundant
evidence that it arises from the circumstance stated, because these
after-pains occur far more frequently with women who have had
many children, than with those who are only pregnant for the
first time. In the latter case, the abdominal parieties being only
once distended, retain a certain degree of tonic contractile power,
which is altogether destroyed by frequent pregnancies.
If we have succeeded in placing before you in a clear manner
the phenomena which take place in parturition, the contrivance
employed by nature for the safe delivery of the child, and the
principle which she seems to follow for the accomplishment of
her purpose, we shall be enabled to enter upon the considera-
tion of the management of labour, and you will have but little
difficulty in determining the value of those rules which are laid
down for your guidance. The management of labours, therefore,
shall form the next subject for our attention.
77
LECTURE V.
MANAGEMENT OF NATUKAL LABOUR.
Fremonitory Symptoms of Labour — Evidence of the Commencement of the first
Stage — Character of the grinding Pains. Obstetric Duties of the Practitioner
— When summoned to attend — Caution respecting his Patient — Objects of the
Vaginal Examination in the first Stage, before the Membranes are ruptured — Signs
of the first Stage being completed — Mode of preparing the Bed, and supporting
the Patient.
Hitherto we have considered tlie process of parturition as an
interesting subject of observation, one of a thousand illustra-
tions of the perfect adaptation of means to the end proposed,
by which nature accomplishes her purpose. We have now to
enter upon the more practical inquiry ; the symptoms that attend
the phenomena we have described to you, and the treatment re-
quired to secure the safety of the patient. We would therefore
direct your attention to the symptoms of labour, and to what are
popularly called " the duties of the obstetrician."
During the period that the uterus is descending towards the
pelvis, the size of the abdomen diminishes, and the patient feels
much less inconvenience and distress than she did previously.
Her respiration is less impeded, and she has less anxiety. In
some instances, the woman seems almost to forget what has been
the constant object of her thoughts for many previous months. As
the time of labour approaches, some monitors present themselves
to remind her of the event; sometimes the nerves are very much
pressed upon, so as to cause sensations of numbness or tingling,
down one or other of the limbs : both are seldom affected. Occa-
sionally they are slightly paralyzed, and cause lameness. As
the uterus begins to press more on the pelvis, the patient becomes
78 LECTURES ON PARTURITION.
awkward in her carriage, and unable to walk even a short dis-
tance without fatigue. The neighbouring organs soon show the
influence of the change going forward in the uterus; the bladder
becomes irritable, so that constant micturition is the result. We
may, however, find it in the opposite state, and the urine re-
tained: the rectum is also affected in a similar manner, and a
fasculent diarrhoea frequently precedes labour. This is always
salutary, because it secures the important object of having the
intestines unloaded; so also constipation sometimes takes place,
especially in hysterical habits. The length of time that the
rectum may remain without an evacuation, and the woman feel
no inconvenience from it, is often far beyond what you might
suppose; a fortnight, and even three weeks, is not unusual. In
these instances, the patient is sometimes deceived, and imagines
that her bowels are quite regular, because there is a daily inclin-
ation to go to stool; there is then a scanty discharge of loose
fteculent matter, leaving the mass of scybalse undisturbed. You
cannot, therefore, pay too much attention to this point of practice,
because when the rectum is in this state, the whole of the large
intestines become distended with flatus, which causes spasmodic
pains that are often mistaken for labour-pains. Should the
patient escape this, and labour actually commence, the action of
the uterus goes on imperfectly: the same influence which is
exerted by the uterus on the rectum in suspending its ordinary
action is, as it were, reflected on itself, producing a similar sus-
pension of the uterine contractions. For some time previous to
labour, the mucous secretion from the vagina begins to increase
in quantity, and often amounts to an abundant viscid discharge.
This change may appear even for three weeks before labour, and
consequently is occasionally mistaken by the yoimg and inexpe-
rienced mother for the well-known symptom of labour called
" the show."
When this latter evidence presents itself, the discharge is
tinged with more or less blood, arising from the ruptured vessels
of the OS uteri when it first dilates. As soon as this takes place,
labour properly begins; the patient has now entered upon the first
stage. The pains which accompany the first contraction of the
uterus are slight, short in their duration, and return at long in-
tervals. The French describe them by the expressive term,
" les mouchettes." They generally also (like the mosquitos)
FIRST PAINS OF PARTURITION. 79
attack tlie patient at night, and are sufficient to prevent her
obtaining her usual sleep, although not so severe as to call for
assistance. Towards morning, however, they increase in fre-
quency and severity ; all inclination to sleep is dissipated ; the
woman is anxious to rise in order to change her posture, and will
move from place to place, and try every alteration of position that
may seem to allay her suifering.
Unless the patient has more than usual fortitude, and has great
command of her feelings, she cannot help giving loud and almost
agonizing expression to the pain she endures. She generally
avoids to take a deep inspiration, or to use any straining effort.
A short inspiration is followed by a shrill cry, which she cannot
suppress. ^Vlien you are accustomed to obstetric practice, you
will learn to distinguish these grinding pains (as they are popu-
larly called) from the hearing pains that follow them, by the
peculiar cry that accompanies each. During the first stage, the
irritability of the bladder and rectum generally continues, so
that the patient has a frequent desire to evacuate them. A slight
rigor may be observed in the commencement, or she may be
seized Avith sudden vomiting. The latter is often very serviceable
in those who are of a plethoric habit, because the nausea and
sense of exhaustion that follow are often a means of controlling
excitement, either in the mind or in the circulation. When any
of these evidences prove that labour has commenced, the prac-
titioner is generally hastily sent for. Sometimes, however, it is
avoided until the pains seem to say, " He can no longer be dis-
pensed with." If labour be preceded by false pains, he is often
summoned unnecessarily, these spasms being mistaken for labour.
The medical attendant, knowing that such a mistake is possible,
and that even if labour have actually commenced, it will occupy
some time before he can be of use, might procrastinate : he
might be disposed to think that he has quite sufficient time
before him, and give but a dilatory attention to the message he
receives. A greater mistake cannot he committed. Any summons
from one who has placed entirely in your hands her own safety
and that of her offspring, equally dear to her, should receive
instant attention; neither are you to consider the urgency as
measured by your own, but by her impressions of the case. You
may be called upon without there being the least necessity for
haste; but by your promptitude you will gain a considerable
80 LECTURES ON PARTURITION.
advantage in strengthening tlie confidence she lias already given
you. The necessity, however, may ' be real, and not fictitious.
Cases have occurred in which the patient has been delivered
before the practitioner arrived; and if such an accident arose
from any negligence on his part, he must have a much greater
influence over his patient than is usual, if he can recover from the
eflfects of it.
If it be a first pregnancy that you are summoned to, it is
advisable that your introduction be not too abrupt: caution in
this respect is of still greater importance if called to a patient to
whom you had not been previously introduced ; the mere circum-
stance of a stranger entering the apartment of a parturient woman
has caused a total suspension of her labour. Some preparation,
in the way of announcement, is therefore necessary. For the
same reason it would be prudent, when introduced, to direct your
patient's attention as much as possible from contemplating the
character in which you appear before her, to draw her away from
the subject that brought you there, and to lead her to forget the
office that you have to fulfil. You would not therefore catechise
her too strictly about herself, or remind her of what is going to
happen by too busy a display of preparation. A few minutes'
conversation with the nurse is generally sufficient to learn every
particular of importance; but your patient should only receive
from you the words of comfort and encouragement. The nurse,
however, does not require the same forbearance. It will be your
duty to ascertain from her every point upon which you desire to
be satisfied. When the pains commenced? Their character? If
accompanied by much, or by little excitement? The state of the
bowels, and whether the bladder has been relieved? If your
patient has any constitutional peculiarity? You should also ex-
amine the bandage, pins, ligature, and every trifling matter which
might inconvenience you, if not prepared according to your views.
Having satisfied yourself, you can then return and engage
your patient, if possible, in general conversation. You may thus
form your own opinion of the character of her labour. If it be
in the commencement, when the pains are short and the interval
between them long, you can engage her attention with facility;
but if the pains are severe, these attempts at conversation had
better be dispensed with. The patient should be left in charge
of the nurse, because your presence may become unpleasant to
VAGINAL EXAMINATION. 81
her as a witness of her suffering, and would be embarrassing, if
it interfered with the necessary evacuations: jou may therefore
retire to the neighbouring apartment, until you have determined
upon the time for taking the first important step in your profes-
sional capacity.
Making a Vaginal Examination. — Some have considered it as a
matter of the first importance, that this should be done as early
as possible in the labour, in order that any correction which mio-ht
be required in the presentation should be effected before it was
too late ; as, for instance, the funis or hand coming down with the
head, the head descending in a wrong position, or perhaps the
shoulder presenting. In order to interfere with any of these
complications, the labour must be more than in its commencement;
the OS uteri must be dilated, although the dilatation may be far
from being complete. It would be precipitate, therefore, to
require an examination before the steady frequency of the pains
gives evidence that this was likely to have taken place; and there-
fore a vaginal examination very early in the labour, when the
pains only return slowly, would be unnecessary. Neither is the
object for which such an examination is stated to be made, of that
importance which seems to be attached to it. The funis cannot
be interfered with, or suffer any very dangerous pressure, so long
as the membranes are entire. We shall presently point out to
you the danger of meddling too much with supposed wrong posi-
tions of the head, as well as when the hand comes down with it.
The only position that should be ascertained before the waters
are discharged, is the shoulder presentation; but if you examine
for this too soon, when the os uteri is only slightly dilated, and
the presenting part above the brim, you might fail to detect any
presentation, and even if you did, may, after all, be mistaken in
the result; the hand and arm might be felt, and yet the head
afterwards descend. It is certainly very satisfactory to find out
that the head presents, as early as you can; but if you cannot do
so in the beginning of labour, it is no proof that the position is
preternatural. If you cannot, therefore, gain a decided advantage
by making a very early examination, there is one strong reason
for a little delay. Wlien the patient is only enduring the first
short pains that attend this stage, she has always a great reluct-
ance to be examined; all her natural feelings and prejudices are
in full play against you : she submits very unwillingly, and
G
82 LECTURES ON PARTURITION.
complains loudly of the least pain or inconvenience you may
cause her. You will not, therefore, find it easy to make a satis-
factory examination; and if you fail, you may not so readily
obtain her consent to its repetition. ^Vhen there is no absolute
necessity, therefore, it is better to wait until these grinding pains
increase in strength and frequency; her mind is then absorbed
in her present suffering; she is willing to submit to anything
which may be of use to her, and is often very anxious to know
whether the labour will be safe: you have also the great ad-
vantage of being able to make the examination perfectly, because
the dilatation of the uterus has made some advance. Having
determined upon the proper time for making a vaginal examina-
tion, the nurse should communicate your wishes, which are now
readily acceded to : she may then place her in the most favourable