Henry J. (Henry Jacques) Garrigues.

A text-book of the science and art of obstetrics online

. (page 38 of 80)
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however, be careful not to enter more deeply than necessary, as other-
wise he might injure the foBtus. For cleanliness it is well to place a
bedpan under the patient, into which the expelled hc^uor amnii will flow.

If the child is born in the ovum, this should be torn in order to
admit air to the lungs.

Adherent Membranes. — In normal labor separation between the
uterus and the ovum takes place in the ampullar layer of the decidua.
But if there has been endometritis before or during pregnancy, the
decidua is too thick and resistant, and the chorion adheres more or
less to it. Then the separation takes place between the chorion and
the amnion, and the chorion and decidua are retained, which may
give rise to hemorrhage. If this occurs the accoucheur should intro-
duce his whole hand into the uterus and scrape off the retained mem-
branes with his finger-nails, and then give an intra-uterine douche,
preferably with creolin on account of its combined antiseptic and
haemostatic properties.

If there is no hemorrhage, but a large piece of the membranes is
retained, then it is well to tie a silk thread to it, and leave it until the
following day, when by pulling on the string the shred is easily
removed. The smaller shreds are discharged with the lochia.

§ 2. Abnorraalities of the Umbilical Cord. — Coiling. — We have
seen that during pregnancy the cord may be wound around the body
of the foetus. It may also lie coiled up in front of the presenting
part, and during labor the child may be pushed through one or more
circumvolutions. In this way a cord that really is too long may be-
come relatively too short and prevent the proper movements of the
foetus during labor. It is quite frequently twisted once or twice
around the neck, which exposes the child to strangulation. When
this is the case, the accoucheur tries to loosen the string and to pull
it over the head or let the child glide out through the loop. In breech
presentation it may descend between the legs and extend over the
back. Then the loosened loop should be pushed over one of the but-
tocks. But if the cord does not yield so as to allow these displace-
ments, it should be cut and both ends tied.


Shortness of Cord. — If the cord is so short that it interferes with
the free movement necessary in labor, it may be torn off near the
body of the foetus, which may bleed to death while still in the uterus.
Or if the cord holds it may pull off the placenta from the uterus and
cause hemorrhage and asphyxiation in that way. Or if also the
placenta resists, the uterus may become inverted or the birth of the
child may be prevented.

The diagnosis during pregnancy is impossible and during labor
difficult. We maybe brought to think of this condition if the meco-
nium is expelled or the heart-beat becomes slow. If the cord can be
reached, it may be felt tense, and should then be cut at once, and the
foetus extracted.

Prolapse of the Cord. — The umbilical cord may present at the
brim below or with the other presenting part before the membranes
rupture, and it may, after the waters have broken, sink down into the
vagina or even outside of the vulva, while in other cases only a small
loop is found outside the os.

The frequency with which this unfortunate accident occurs, seems,
like that of face presentations, to vary much in different countries.
In France it was only observed in 1 case of each 446, in England in 1
out of 207, and in Germany in 1 out of 156. Maybe the usual posture
used in delivering women has some influence : in France they place
the woman on her back with somewhat elevated pelvis, in England
they use the lateral posture, and in Germany they prefer the dorsal
position with elevated shoulders, which would certainly promote pro-
lapse of the cord. But perhaps the relative frequency of contracted
pelves accounts for a corresponding frequency of prolapse cases.

Etiology. — The chief factor that causes presentation and prolapse
of the cord is a deficient adaptation between the presenting part and
the brim of the pelvis. They occur, therefore, in contracted, espec-
ially flat, pelves. They are much more frequent with abnormal pre-
sentations, especially transverse, face, and foot presentations, than
with vertex presentation. Flaccidity of the lower uterine segment
will give rise to a less perfect adaptation between the uterus and the
presenting part, and we find also that the accident is much more com-
mon in pluriparae than in primiparge. The longer the cord is, the
greater is cceteris paribus the chance of its prolapsing. A large amount
of liquor amnii and its sudden discharge will be apt to wash the cord
down. A premature rupture of the membranes and a prolonged
partial opening of the os naturally increase the danger of a prolapse
occurring. A low insertion of the placenta M'ill also favor it. With
a vertex presentation it can only happen at the time of rupture or
shortly after. When first the head is well engaged, there is no space
left for the prolapse to take place in.


Diagnosis. — Before the waters break it is not always easy to recog-
nize a presenting cord. Still, in an interval between pains, when the
bag relaxes, we may feel the movable, soft, finger-thick string and its
pulsation. When the membranes have ruptured, a small loop high up
in the vagina may be overlooked, but if the fetal heart-sounds grow
weak and slow, the accoucheur should bear in mind the possibility
of its presence and feel for it. When a larger loop descends into
the vagina, it obtrudes itself on the examining fmger and cannot be
taken for anything else.

Prognosis.- — The prognosis for the mother is good, but that for
the child is so much the worse. For it prolapse of the cord is one
of the most dangerous complications of childbirth. According to
statistics over one-half of the children die. The mortality is greater
in primiparae than in pluriparae, which can easily be accounted for
by the more tedious labor and the greater firmness of the soft parts
of the parturient canal. If prolapse of the cord is comparatively rare
with vertex presentation, on the other hand it is much more dangerous
than with other presentations, the cord being more apt to be squeezed
between the hard skull and the pelvis. The breech is softer, and with
a transverse presentation or a foot presentation there is hardly any
danger. With vertex presentation the infantile mortality reaches the
terrible number of 64 per cent.

The great danger in prolapse of the cord arises mainly from com-
pression, which, as we have seen in speaking of delivery in pelvic
presentations, leads, in a very short time, to asphyxia and death of
the child.

Treatment. — The diagnosis once made, the patient cannot be left
a moment alone. She and her child have to be watched constantly,
since, when the time for action has come, delay means the death of the
latter. We must distinguish three different conditions, each calling
for different assistance, — the time before the rupture of the membranes,
the time after rupture of the membranes with a not fully dilated os,
and the time after full dilatation has been accomplished.

As long as the membranes are unruptured, there is little or no
danger, and, on the other hand, it is of the greatest importance to
preserve them till full dilatation is established. To try to push the cord
aside is of little avail, since in all likelihood it will fall down again, and
we run the risk of rupturing the membranes by our manipulations,
which would make the situation worse. We may place the patient in
the elevated-pelvis position on her back, and whether the cord slides
away or not, we may then place the patient on the side where the pro-
lapse was, the effect of which is to tip the fundus down on this side
and the lower uterine segment over to the other side, so that there is
less pressure on this side in case the cord falls down again. The position


on the back with the head low cannot be sustained very long, unless
the patient is ansesthetized, which is not desirable, since we want
labor-pains to dilate the os. If the cord slides up into the cavity of
the uterus, we may by pressure from above try to press the head into
the brim and thus prevent the prolapse from being reproduced. In
order to further dilatation a colneurynter maybe placed in the vagina,
which protects the membranes, but if stethoscopy shows that the cord
is being compressed, the colpeurynter should be removed.

If the OS is not sufficiently dilated to end labor with forceps or
version, but the waters have broken, the patient should be placed in
the elevated-pelvis position and the cord replaced with a suitable
instrument, such as represented in Fig. 329.

Fig. 329.

Repositor for prolapsed umbilical cord.

I found it in an instrument-maker's store, but could not ascertain
the inventor's name. All the people remembered was that it had
originated with a California doctor.

The instrument consists of a rather stiff flexible tube through
which runs a whalebone stylet with handle. At the other end is a
bit of ribbon with a button that fits into the end of the tube. The
ribbon is carried around the prolapsed cord, the button pushed into
the tube, and this together with the cord brought all the way up to
the fundus, where it may be kept till after the birth of the child, but
if it is sure that the cord cannot again prolapse, it may also be
withdrawn after releasing the ribbon by pushing the button out by
means of the whalebone staff.

The position with elevated pelvis facilitates the replacement very

Where no operating-table with facilities for elevating the pelvis
is available, we may improvise one by using a chair as we did to raise
the shoulders (Fig. 222, p. 191), but now the chair is placed under the
pelvis and the feet are bent over the round (Fig. 330).

Or else the patient may be placed on a padded ironing-board, the
lower end of which is raised and fastened to the foot of the bed or a
chair.^ The elevated-pelvis position has the advantage over the knee-
chest position, which generally is recommended, that the patient can

1 The elevated-pelvis position is mostly known in this country as Trendelen-
burg's position, from the name of the surgeon who has contributed most to popularize
it, but it was used and described years before by Bardenheuer, of Cologne, in his
work, "Drainage der Peritoneal Hohle," Stuttgart, 1881. In Germany it is called


be kept longer in it without being anaesthetized, that an anaesthetic can
easily be administered, and that it is more favorable for performing
version and extraction. By pulling the patient so far out as to have
the lower extremities fall down at full length we obtain even Walcher's
Hangelage, which facilitates extraction, as will be described later. (See'
Operations, Fig. 424.)

Having replaced the cord, the accoucheur should anaesthetize the
patient, and try if he can dilate the cervix manually according to the
method of Dr. Philander A. Harris. (See Operations, Fig. 422.)

The third eventuality, and that most frequently met with in con-
sultation practice, is that the os is fully dilated when the patient is
seen. Then the patient should rapidly be put in the elevated-pelvis
position, and the accoucheur seize the prolapsed cord with his whole
hand and, if possible, carry it up into the abdomen, turn and extract.
If there is any compression of the cord, this should be done without
anaesthesia in order to save time. If there is no room to pass the
hand, he should apply the forceps and extract as rapidly as possible.

In pelvic presentations one foot should be brought down, as
thereby the breech is diminished, and the leg serves as protection for
the cord against pressure.

In prolapse with face presentation, and when an arm is prolapsed
together with the cord, version and extraction are indicated. In foot
presentation it would be useless to try reposition, since the prolapse
is immediately reproduced, and there is not much danger of com-

With cross presentation reposition would also be useless, and with
this presentation there is no danger of compression. The case is
treated with podalic version and extraction as soon as the os is suffi-
ciently dilated. If there is no pulsation in the prolapsed cord, there
is no call for any special treatment, and the case should be managed
as we would deal with it were there no prolapse ; only the accou-
cheur should, in order to avert blame, foretell to the friends that the
child is lifeless.

§ 3. Retained and Adherent Placenta. — Normally the placenta
can be expressed within twenty minutes, but sometimes our efforts at
expression remain fruitless. The after-birth does not come out. This
may be due to one of two conditions vastly different in importance.
The placenta may simply be retained or it may be adherent.

The retained placenta may lie in the vagina or in the uterus. If it
is in the vagina, the uterus is well contracted and small, and by insert-
ing two fingers into the vagina we not only feel the placenta, but can
easily pull it out by following the cord and pressing on the placenta at
both sides of the cord or by hooking the two fingers over the top of
the placenta.




The placenta may have been cast loose, but is retained in the
uterine cavity by muscular contraction, especially at the seat of the
contraction ring. Authors attribute this frequently to so-called hour-
glass contraction^ but in reality the upper part of the uterus is, as a
rule, more or less contracted, and the lower part is decidedly flaccid
(Fig. 331). Only the contraction is irregular and strongest at the
narrowest part of the uterus. Retention of the placenta used to be
much more common when the mode of delivery was to puil on the
cord or press directly on the placenta inside the uterus. With the

Fig. 331.

Retained placenta.

introduction of Crede's expression method retention has become a
rare accident. This indicates the prophylactic treatment. The cura-
tive treatment, if there is a serious obstruction, consists in administer-
ing chloroform and pressing on the contracted ring with the fingers
united into a cone around the thumb. But often all that is needed is
to follow the cord up to its insertion, wind it around the fingers of
the left hand, and press on the placenta with the index and middle
finger of the right hand, when the placenta readily yields.

As it is always preferable not to enter the uterus, and the placenta
may come, out spontaneously or by expression, the accoucheur should
be in no hurry about removing the placenta if there is no hem-
orrhage. It is the writer's rule to wait an hour before having re-
course to any other measures than repeated compression of the

If the uterus has been entered, it ought also to be washed out with
some antiseptic solution, especially lysol or creolin.


Adhesion of the placenta is a much more serious matter than mere
retention. It may be total or partial ; in the latter case it is mostly
found at the periphery, while in the centre the connection with the
uterus may be normal. The decidua serotina in the adherent parts
has been replaced by tough connective tissue, which extends deep
into the muscular coat. This condition is usually due to chronic
endometritis. Some women have an adherent placenta in several
successive pregnancies. It follows sometimes partial detachment of
the placenta during pregnancy. The cause may also be an abnormal
structure of the placenta, especially a membranous placenta. The
adhesion is most frequently found in the cornua of the uterus, the
original site of implantation of the ovum, where the connection may
have become more sohd, or where villi of the chorion may have grown
into the tubes. It is also apt to be found with placenta prsevia,
where the insertion takes place over the os internum.

Prognosis. — Both retention and especially adhesion of the placenta
often give rise to hemorrhage, which may prove disastrous to both
mother and child.

Treatment. — The patient is placed on a table and anaesthetized, the
legs drawn up and the knees bent. The particularly well-disinfected
hand is carried between the membranes and the uterine wall up to
the upper margin of the placenta ; the fmgers are bent and the nails
are used as knives to sever the connection between the placenta and
the uterus, while this is steadied from without with the other hand.
If we cannot obtain a line of cleavage here, we try the sides of the
placenta and enter where best we can. It is a great advantage if the
placenta can be peeled off in one piece and from above downward.
But where the connection with the uterus is very dense this is impos-
sible, and we must be satisfied by removing it piecemeal, which is
apt to be accompanied by much more hemorrhage.

Besides the fingers, the large dull wire curette (Fig. 411) and a
placenta-forceps with good grip and broad dull ends (Figs. 412, 413)
may be needed. If necessary, it is better to leave a little of the pla-
cental tissue than to perforate the uterus. When as much as possible
has been removed, the uterus is irrigated.

§ 4. Placenta Praevia. — The fertilized ovum may become embedded
so low down on the wall of the cavity of the uterus that the placenta
covers the internal os, or at least that portion of the uterus which must
change its position in order to allow the dilatation of the os necessary
for the passage of the foetus. When this dilatation takes place, more
or less of the placenta is separated from its connection with the uterus,
which process is accompanied by hemorrhage, and will be described
together with hemorrhage from other sources.




§ 1. Displacements of the Uterus. — Pendulous Abdomen. — We
have seen that, as a rule, anteversion during pregnancy is of httle im-
portance when there is an abdominal wall offering normal resistance,
which makes the uterus rise to the proper position. But if the ab-
dominal wall is weak, the heavy pregnant uterus falls forward, and it
may even tip so much downward that the fundus is in the neighbor-
hood of the knees.

Sometimes there is only an unusual flaccidity of the abdominal
wall, but in other cases there is such a diastasis between the recti
muscles that the uterus protrudes between them and lies directly
under the skin.

Through the altered inclination of the uterus to the pelvis, the
OS is carried too far up and the presenting part is prevented from

This condition is due to distention of the abdomen by previous
pregnancies or tumors, to laparotomies, or umbilical or ventral hernias.
It is also found in primiparte in consequence of a narrow pelvis which
prevents the normal descent of the presenting part into the pelvic
cavity during the latter part of pregnancy.

The treatment is similar to that mentioned in speaking of deficient
abdominal pressure during labor. The fundus of the uterus is to be
raised and kept in place with a tightly adjusted binder.

Ventral Fixation and Vaginal Fixation of the Uterus. — A peculiar
artificial antedisplacement of the pregnant uterus has been brought
about by the different operations by which the anterior surface and
the fundus of the uterus are fastened to the abdominal wall or the
vagina.^ The anterior wall being fastened, the uterus must chiefly
grow by expansion of the posterior wall, and the os is carried high up.
This unnatural position of the uterus gives rise during the progress
of pregnancy to much discomfort, such as a dragging pain at the
seat where the uterus has been moored, and excessive nausea and
vomiting, and it leads often to abortion. During labor it has prevented
engagement, causing inertia and rupture of the uterus, and made
delivery impossible by the natural way, so that in several cases Csesarean
section became necessary to bring labor to an end.

Any kind of fixation of the uterus itself should, therefore, be dep-
recated, and such operations be substituted which shorten or attach
the round ligaments, and among these again the preference should be

1 Garrigues, Diseases of "Women, third ed., p. 473.



given to those in which the uterus is not unnaturally anteverted or

Latero VERSION. — The uterus, in most cases, is tilted more or less
to the right side of the abdomen, more rarely to the left. This rarely
interferes with labor. If it does, the malposition is easily corrected
by placing the patient on the opposite side, when the fundus will sink
down towards the couch, and the os move in the opposite direction.

Sacculation. — If the presenting part, generally the head, presses
somewhat unevenly on the lower uterine segment, this will be dis-
tended and form a deep pouch, fitting like a hood over the foetus,
while the os remains high up in the vault of the vagina. Most
frequently it is the anterior part of the lower uterine segment that
undergoes this distention, and the os is, therefore, drawn high up

Fig. 332.

Anterior sacculation of the uteras. (Tarnier and Budin, 1. c.)

behind the presenting part (Fig. 332) in the neighborhood of the

Much more rarely it is the posterior part of the lower uterine
segment that forms the sac, while the os is found above the sym-
physis pubis (Fig. 333). A similar condition has been found with a
bicornute uterus, one horn developing in the pelvic cavity and the
other in the abdomen.

We have seen that retroflexion, as a rule, corrects itself or is arti-
ficially corrected. It happens, however, in rare cases that the replace-
ment is not total, and that a part of the posterior wall of the uterus



is retained, while the larger part of it and the whole anterior wall are
distended by the growing foetus. In this kind of cases the labor-pains
have not much effect on the os, most of the impetus being spent in
distending that part of the lower uterine segment which forms the'

The prognosis is better in anterior sacculation than in posterior.
As a rule, the os will open and come lower down. But if the ab-
normal distention continues, the uterus will rupture.

The diagnosis may be quite difficult. Sacculation has been taken
for closure of the os, and an incision has been made in the uterus. It

Fig. 333.

Posterior sacculation of the uterus. (Taruier and Budin, 1. c.)

has also been mistaken for a fully dilated os, the distended lower
uterine segment being so thin that it was overlooked and the forceps
applied outside of it. The pelvic cavity is full, although there is no
dilatation. The os is placed at the bottom of a deep pouch formed
by the vagina. If it is not within reach of a finger, the whole hand
must be introduced during anaesthesia. If the os is in front, some-
thing may be gained by placing the patient in the knee-chest position
and having her supported by assistants (Fig. 260). In this position
the patient rests on her knees, the upper part of the chest, the right
side of the face, and the right forearm. The thighs are kept perpen-
dicular, and the back is hollowed. It makes the fundus of the gravid
uterus gravitate strongly forward and downward, and consequently
brings the os downward and backward.



By hooking one or two fingers over the lower border of the os,
it is gently pulled down during a uterine contraction, which may be
repeated several times, until the os is brought to its normal position.
It has been found necessary to make numerous small incisions in
the circumference of the os. In another case the foetus was turned
and extracted by the feet, and in one even Csesarean section was
resorted to.

Partial Prolapse. — The whole uterus is never found prolapsed at
full term. There may be a prolapse of the lower part of the uterus
and the cervix become hypertrophied and oedematous, but the bulk
of the uterus is in or above the pelvis. Fig. 334 shows such a

prolapse with a protruding foot.
Fig. 334. In Fig. 335 is represented a case

of head presentation with prolapse
and hypertrophy of the cervix.

In delivering these cases the
uterus should be kept back, while

Fig. 33-t

Partial prolapse of uterus with protruding
foot. (Wagner.)

Prolapse and hypertrophy oi the cervix with
head presentation. (Faivre. i

the extraction of the child is made with forceps or hand. That is

Online LibraryHenry J. (Henry Jacques) GarriguesA text-book of the science and art of obstetrics → online text (page 38 of 80)