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considerable, and the same rules apply- to the conduct of the obstetri-
cian as in osteomalacic pelvis.

§ 4. Spondylolisthetic Pelvis. — The word spondylolisthesis means
sliding of a vertebra. A spondylolisthetic pelvis (Fig. 376) is one in



Fig. 376.




Si>ondylolisthetic pelvis. ( Olshausen-Veit.



which the body of tlie fifth lumbar vertebra has slid forward into the
upper strait and the cavity of the pelvis, where it leans against the
anterior surface of the first or even the two uppermost sacral vertebrae.
The spinous process stays in its place and so does the inferior articu-
lar process, while the superior goes with the body. This is only pos-
sible by an elongation or a fracture taking place in the arch of the



DEFORMITIES OF THE PELVIS. 491

vertebra (Figs. 377, 378). As a rule, this is a slow process, due to
imperfect ossification and the carrying of heavy weights, but a similar
condition results if through injury the vertebra is broken suddenly,
as on the woman whose pelvis is seen in Fig. 78, p. 108.

When the vertebral body slides down in front of the sacrum, the
intervertebral cartilage atrophies and disappears, the bones become
smoothed off through pressure against each other, and sometimes
they grow together, when further sliding, of course,, is rendered im-
possible. Although this is one of the rarer deformities, a considera-
ble number of spondylolisthetic pelves have of late years been observed
and descrilDed.

The displacement of the vertebra has very serious consequences,
both in regard to the spinal column and the shape of the pelvis. By

Fig. 378.





Normal lumbar vertebra. Lumbar vertebra with elongated interartieular

portion. (Xeugebauer. )

the sliding the centre of gravity is brought farther forward. In order
to compensate this disturbance the trunk bends backward and the
lumbar portion of the vertebral column forms a strong convexity for-
Avard. This lordosis obstructs the entrance of the pelvis, so that' the
nearest point to the symphysis pubis may be found on the fourth, the
third, and even the second lumbar vertebra, and this distance measures
only between 2 and 3 inches (5 and 8 centimetres).

In the pelvis great changes of form are inaugurated. By the press-
ure exercised by the vertebral column the sacrum is tilted around
a transverse axis so that the upper end is pushed back and the apex
forward. The base is driven backward, and must as a wedge sep-
arate the posterior spines of the ilia from each other. The apex is
driven in the direction of the pubic arch aud shortens the antero-
posterior diameter of the outlet. The upper ends of the hip-bones
being driven farther apart, the lower ends must be brought nearer
together. Consequently the distance between the tuberosities of the
ischia is diminished. The outlet is then diminished l3oth in the
anteroposterior and in the transverse diameter.

At the brim, the filth lumbar vertebra lying in front of the sacrum,
the conjugate becomes shortened, while through tlie spreading apart
of the hip-bones t lie transverse diameter becomes somewhat elongated.



492



ABNORMAL LABOR.



When the Aveight of the trunk is brought forward, a compensatory
movement takes place in the pelvis. It is lifted in front and tilted
backward around a transverse axis. In this way the inclination of
the pelvis becomes much diminished. But thereby the iliofemoral
ligament becomes stretched, and that again pushes the femora against
the acetabula and contributes to the approximation to each other of
the tuberosities of the ischia.

Etiology. — As a rule, there is a congenital predisposition. But
perhaps even the carrying of great weights can force a normal ver-
tebra out of its connection with the adjacent bones. In many cases
the displacement is due to injury, especially in youth.



Fig. 379.



Fig. 380.



Fig. 381.







Aspect of a patient with a spondylolisthetic pelvis. (Ahlfeld.)



Diagnosis. — The diagnosis is not difficult. Often the mere aspect
of the patient suffices to make it (Figs. 379, 380, 381). The thorax
and legs are normal, but there is a remarkable shortening of the
abdomen, the upper part of the wall sinking into the pelvis and the
lower hanging forward over the symphysis. On account of the slight
inclination of the pelvis the mons Veneris and the vulva are brought
more upward and forward. The skin being too large, two wide folds
form over the crests of the ilia. The hips are far apart. The loins
are deeply pressed forward, and the sacrum is felt protruding back-
ward.



DEFORMITIES OF THE PELVIS.



49r



By vaginal examination the obstetrician feels the displaced vertebra
in front of the sacrum. On account of the small inclination of the pel-
vis the common iliac arteries or even the end of the abdominal aorta
may be felt, but that may also be the case in lumbosacral kyphosis.

A low degree of pelvic inclination, which constitutes such a
prominent feature of the spondylolisthetic pelvis, is also found in
lumbosacral kyphosis, in osteomalacia, and in rhachitis, but there are
distinctive features of each of these conditions. None of them pro-
duces the peculiar shape of the abdomen just described.

In kyphosis there is the external gibbosity. There is no hollow
back. The false pelvis is large ; the promontory is little marked, or
cannot be reached at all. The alae of the sacrum cannot be reached.

The osteomalacic pelvis has the protruding symphysis, the narrow
pubic arch, and the Y-shaped brim. The sacrum is strongly curved
longitudinally. The ilia are curved inward in their anterior portion.

As to rhachitis, it may be difficult to decide whether the hollow
felt under the promontory is due to the curvature of the sacrum itself,
as in rhachitis, or to the displacement of the lumbar vertebrae in re-
gard to the sacrum, which characterizes spondylolisthesis. But first
of all, we have the history of rhachitis in childhood. Next, we observe
characteristic pathological changes in the skeleton, — curved legs, thick
wrists, chicken-breast, etc. Finally, by following the linea terminalis
from the promontory, we feel the alae of the sacrum form a direct
continuation of it, while in spondylolisthesis we feel only the dis-
placed vertebra, and beyond it the alae of the sacrum, but not as a
continuation.

Prognosis. — The prognosis of spondylolisthesis is bad. The nar-
rowness extends over a large area, and may be very considerable.
Coarctation may begin high up in the abdomen. Great resistance is
met at the brim, and the outlet is
considerably contracted in both di-
rections.

Treatment. — Artifi cial ab or tio n ,
induction of premature labor, or
Caesarean section will be indicated
in most cases. The obstetrician
must calculate the length of the
substituted true conjugate, and, on
account of the extension of the nar-
row portion, demand half an inch
(one centimetre) more than he would in a flat pelvis before allowing
labor to be established.

§ 5. Pelvis Contracted by Tumors springing from the Pelvic
Bones. — Large tumors attached to the interior walls of the pelvis



Fig. 382.




Osteoma of sacrum. (Olslmusoii-Veit.)



494



ABNORMAL LABOR.



may practically obliterate it from an obstetric stand-point. In Fig.
382 is represented an osteoma of tlie sacrum, in Fig. 383 an en-
chondroma of the same. In other cases the tumor was fibrous,
sarcomatous, or carcinomatous.

These occurrences are exceedingly rare, and each such case must
be judged on its own merits, but, as a rule, Cesarean section is the
only available method of delivery.

Fig. 383.



''"''^an..^!




Enchondroma of sacrum. (Stadfeldt.)



§ 6. Split Pelvis. — The pelvic ring may be open at the site of the
symphysis pubis or at that of the sacrum.

1. Pelvis Split at Symphysis Pubis. — In early fetal life the pedicle
of the allantois, which forms the bladder, may be over-distended with
fluid and rupture. In consequence of this the bladder remains open
in front — so-called exstrophy of the bladder — and the symphysis is only
formed by strong ligaments, which admit movements of the ends of
the pubic bones.

Most of such children are stillborn or die early in life. Those
who survive have a constant dripping of urine from the exposed ends
of the ureters, and are not very likely to become impregnated.



DEFORMITIES OF THE PELVIS.



49;



The pelvis with split symphysis (Fig-. 384) makes the impression
of being somewhat flat, which must be due to the resistance offered
by the strong ligaments uniting the bones in front.



Fm. 384.




Pelvis without symphysis pubis. (Ahlfeld.)

In the few cases of labor in a pelvis with split symphysis that
have been reported, artificial help was needed on account of inability
of using the abdominal pressure or a faulty presentation of the foetus.

Fig. 385.

4M^




Pelvis without sacrum. (Litzmanu.)



In several a very narrow vaginal entrance necessitated deep incisions.
In one case symphyseotomy was performed by cutting the ligaments
replacing the symphysis. One woman was delivered with the forceps.



496 ABNORMAL LABOR.

2. Pelvis Split at Sacrum. — The posterior breach in the pelvic
ring is produced by deficient development of the sacrum (Fig. 385) or
by surgical removal of the bone.

The few specimens known in which the sacrum was rudimentary
were of the infantile type. One case occurred after extirpation of the
sacrum. The mechanism of labor w^as normal, and a large child was
born without difficulty.

§ 7. Too "Wide Pelvis. — After having dwelt so long on pelves
that are too small, it is quite a relief to come to one that is too wide.
But the old rule, ne quid nimis, holds good. Too great dimensions of
the pelvis may as well become a source of dystocia as too small ones.
In the first place, too wide a pelvis favors precipitate labor, with all
its dangers to mother and child, — hemorrhage, laceration, or syncope,
avulsion of the umbilical cord, injury to the child's head, etc. (see
pp. 359, 360). Secondly, too much space interferes with the normal
mechanism of labor, and may become the cause of faulty positions
that demand operative interference. Thus, occipitoposterior and
occipitolateral positions (p. 362 et seq.) are frequent accompaniments
of the too wide pelvis.



CHAPTER X.
HEMORRHAGE.



Some loss of blood is normal in childbirth, but if it passes certain
limits, it is one of the most serious complications, and so much more
terrific as the hemorrhage may be so profuse that the patient succumbs
almost without warning. The obstetrician should therefore give this
subject his undivided attention and prepare himself to meet this
dangerous and insidious foe.

Hemorrhage may occur during pregnancy, during labor, or after
labor. We have spoken of it in connection with abortion (p. 263).

Towards the end of pregnancy it is called ante-partum hemorrhage,
and after the birth of the child it is known as post-partum hemorrhage.
It may be due to a faulty implantation of the placenta, — placenta prcevia,
— to detachment of a placenta normally inserted, to rupture of the
circular vein of the placenta, to atony of the uterus or inversion of
this organ, or to laceration of the soft parts of the genital canal.

§ 1. Placenta Praevia. — Placenta prseviais the implantation of the
placenta at the internal os. It may be divided into complete, or central,
placenta prsevia and incomplete, of partial, which again is subdivided
into marginal placenta praevia and lateral placenta prsevia. It is called
central when it covers the whole internal os (Fig. 386) ; marginal if it
only touches a part of the margin of the os, and lateral if it does not



HEMORRHAGE.



497



reach the internal os at all, the lowest limit of it being somewhere on
the lower uterine segment.

Pathological Anatomy. — Frequently the placenta praevia, besides
being abnormally inserted, is abnormal in shape and construction.
Often it is membranous, horseshoe-shaped, or accompanied by pla-
centae succenturiatae. On the atrophic portions of the placenta the villi

Fig. 386.




Central placenta praevia. Half actual size. From a patient under the author's care. End of
sixth month of pregnancy. Entire unruptured ovum expelled after tamponade continued for three
days. No loss of blood. The placenta covers the whole back of the .specimen and a little of the
upper end, beside the whole lower end and nearly half of the front. Most of the phicenta was
inserted on the anterior surface of the uterus. The shortest distance from the os internum to the
circumference of the placenta was two inches.



of the chorion are covered only with connective tissue and not with
decidua. Their interior is full of granules and fat drops and often it
is the seat of thrombosis. This imperfect development of the placenta
is probably due to the thinness of the decidua near the os internum
compared with that higher up on the walls and the fundus.

Etiology. — Much ingenuity has been expended, and in the writer's
opinion wasted, in explaining the occurrence of placenta praevia. A

32



498 ABNORMAL LABOR.

chief theory is that the faulty insertion is due to an arrested abortion.
The advocates of this theory think that the ovum originally is embedded
higher up in the uterus and becomes detached and re-embedded over
or near the os internum. But if we take into consideration that the
whole unimpregnated uterine cavity is only 2^ inches (6.5 centimetres)
deep, of which fully one-half belongs to the cervix, it seems to me
easy to imagine that the ovum may not as usual become embedded
at a short distance below the uterine ostium of the Fallopian tube
and grow downward, chiefly spreading over the anterior or posterior
wall, but is carried down by the movement of the cilia of the uterine
epithelium and even by gravity, until it is so low that, when it grows,
it extends to or even beyond the internal os. This theory of the
primary low implantation of the ovum is corroborated by the clinical
facts that placenta prsevia becomes more and more common with
repeated pregnancies and that uterine catarrh predisposes to it. By
repeated pregnancies and endometritis the endometrium becomes
abnormal. There is not the same perfect nidation, prepared to catch
the ovum, retain it, and enclose it. It slides down on the hardened,
glazed surface of the uterus.

In many cases it is doubtless lost, being washed out with uterine
secretions. That is why women rarely have more than four or five chil-
dren, and why those who suffer from corporeal leucorrhoea rarely be-
come impregnated. In other cases the ovum is arrested and finds a
seat for development near the internal os. From this point it spreads
upward and around the internal os, forming the horseshoe-shaped
placenta ; or it may extend across to the other side, as shown in the
figure. In this case nidation probably had taken place on the pos-
terior wall, to which the larger and thicker part of the placenta was
found attached.

In exceptional cases the placenta may even extend into or through
the cervix by tongue-shaped prolongations, reaching as far as the
vaginal surface of the vaginal portion ; or the whole cervix may be
the seat of the placenta, as in Fig. 387. The cervix then becomes
unusually thick and succulent, and the decidua is formed all the
way down to the external os. In such cases I think the original im-
plantation of the ovum occurred just at the internal os, but the
growth extended only in the direction of the cervix (cervical placenta
prcevia).

Symptoms and Diagnosis. — The chief symptom of placenta praevia
is the hemorrhage. Any hemorrhage occurring in the latter half of
pregnancy must awaken the suspicion of placenta prtevia. Generally,
it is, however, only during the last three calendar months that bleed-
ing begins, most commonly between the twenty-eighth and the thirty-
sixth week, less frequently between the thirty-seventh and the fortieth



HEMORRHAGE.



499



week, and still less frequently at the normal end of pregnancy. Often
pregnancy ends in abortion or premature labor.

Placenta prsevia is met with once in about 573 labor cases. The
hemorrhage comes on suddenly, often without known cause. In gen-
eral the causes of it are the same as those which lead to hemorrhage
from a normally implanted placenta, such as the rupture of a uteropla-
cental vessel at the internal os, rupture of the marginal sinus of the
placenta, partial separation of the placenta from the uterine wall in con-
sequence of jerks and falls or uterine contractions which, as we know,
begin early in uterogestation (pp. 99 and 102). In many cases hemor-

FiG. 387.









Cervical placenta prsevia. (Von Weiss.)



rhage occurs only during labor or after the birth of the child. In rare
cases nature itself conquers the dangers. The bag of waters is rup-
tured, the presenting part compresses the bleeding surface, acting like
a tampon. Good labor-pains, causing a rapid delivery, favor this for-
tunate termination. But this event is so rare that it would be folly
to expect it and await it. As a rule, the hemorrhage is so great that
the patient deprived of the help of obstetric art loses her life. The
hemorrhage that occurs during pregnancy may be quite moderate, but
there is no telling when it will be repeated and with what strength it
will reappear. A patient with placenta pmevia is in constant danger
of death. Often the hemorrhages occur at the time when menstru-



500 ABNORMAL LABOR.

ation would be due, doubtless on account of an active congestion
taking place at those periods. The central form causes the worst
hemorrhage. As a rule, the cervix and lower uterine segment are
soft and yielding. The uterine expansion that occurs during the end
of pregnancy may therefore take place without causing any hemor-
rhage, but when the internal os begins to open up, the lower pole of
the ovum must of necessity separate from the uterine wall, and this
cannot be done without tearing villi of the chorion, opening uterine
sinuses, and sometimes tearing uterine arteries. If the hemorrhage
begins after delivery, it is particularly dangerous. It is then due to
atony of the placental site ; and the best natural means of arresting
uterine hemorrhage, muscular contraction, is deficient or absent.

The blood appears externally at the os uteri during contractions,
and the contractions may, of course, sever vessels, and thus cause
bleeding ; but, on the other hand, contraction compresses torn vessels
and prevents them from bleeding, and pushes the presenting part
against the bleeding surface of the uterus, which it compresses like a
tampon.

It has been noticed that if the placenta is expelled before the child,
all bleeding ceases, which is due to this same mechanism of uterine
contraction and pressure against the bleeding surface of the uterus.

By vaginal examination the upper part of the vagina or one side
of it presents a peculiar boggy sensation, due to the presence of the
placenta in that locality.

If the cervical canal is open, a spongy, soft mass is felt, which can
be distinguished from a mere blood-clot by not breaking down under
pressure with the examining fmger. The wall of the uterine cavity
may be divided by two horizontal lines into three zones, the fundal
zone, the middle zone, and the lower zone, composed of the cervical
canal and the lower uterine segment. The fundal zone is the portion of
the cavity situated above the uterine apertures of the Fallopian tubes.
This is often, but erroneously, described as the normal seat of the
placenta. It is true, the placenta may extend more or less over the fun-
dus, but the bulk of it is inserted on the anterior or the posterior wall.
The middle zone corresponds to most of the corpus of the uterus and
extends down towards the line that marks the degree of dilatation of
the external os necessary to let the head pass. To this extent the
uterus must retract from the lower pole of the ovum, and if any
part of the placenta is implanted here it must become detached from
the uterine wall as far as this line. By marking the largest circum-
ference of the fetal head and measuring the distance of this ring from
the lowest point of the presenting head, we find that the distance from
the external os to the ring of greatest dilatation is about 3 inches (8
centimetres). On the fundus and in the middle zone the placenta is



HEMORRHAGE.



501



entirely safe, biit in the lower uterine segment it must be detached
when labor opens up the internal os, and hemorrhage will follow.

The uterine contractions are often weak, and not infrequently the
placenta is adherent and must be removed artificially.

Prognosis. — Placenta prpevia is one of the gravest complications
of labor. It is fraught with danger both for mother and child. For
the mother the danger consists partly in loss of blood and partly
in the exposure to infection by the
manipulations necessary for the proper
treatment of the case. The child's life
is also endangered by loss of blood
through the detached part of the pla-
centa, but especially by interference
with oxygenation of the blood, if a
large portion of the placenta is de-
tached. If the whole placenta is de-
tached and expelled before the foetus,
it must of necessity die, unless it can
be delivered from its prison in a very
short time. Many children die on
account of their lack of maturity.
Formerly about half of the children
succumbed. As to the mothers, the
mortality used to be twenty-five or
even thirty-three per cent., but by
improved methods of treatment this
has been brought down to a small
percentage. Hofmeier lost only 1 in
46 mothers, and in Pinard's clinic
infantile mortality has been reduced
to 6.8 per cent.

Treatment — The dangers threatening the mother and the foetus
are so great that, as a general rule, we may say that the latter's life
should not be considered, but everything done to save the former,
unless, of course, we can save both. Still, if the foetus has not reached
the age of viability, we may try to continue pregnancy until this term
is reached. If hemorrhage occurs before the end of the seventh month,
the accoucheur should try the effect of absolute rest in bed, rectal sup-
positories containing pulvis opii gr. i (6 centigrammes), one every three
hours, fluid extract of viburnum prunifolium, si, internally every three
hours, adrenalin, stypticin, and vaginal suppositories with tannic acid :

R Acid, tannici, ^i ;

01. theobromae, ,^ii.
M. et ft. suppositoria No. xii.




Placenta descending to boundary-line
of largest expansion of the external os.
(R. Barnes.) The placenta is above the
line and therefore safe. The space between
A A and B B is the range of orificial expan-
sion necessary to permit the passage of the
head.



502 ABNORMAL LABOR.

The diet should be cool and bland, and the bowels should be kept
open with a sahne aperient.

If the child is dead, it is also best to follow a similar course, as
the placenta will atrophy, and the danger of bleeding during and after
labor will be much lessened.

If the hemorrhage occurs after the child is viable, no attempt
should be made to prolong pregnancy. The accoucheur should be
guided by two purposes, — to stop the hemorrhage and to avoid injur-
ing the mother. In most cases the cervix is soft and dilatable, but in
others it is friable and tears easily. The mother's condition may be
so low in consequence of loss of blood sustained before the arrival
of the obstetrician that the first indication is to gain a little time and
allow her to recuperate before beginning any operative manipulations.
Under such circumstances, and if at the same time the os and the
cervical canal are closed, the proper thing to do is to pack the vagina
and vulva very tightly with creolin cotton (see Operations) and cover
the genitals with two towels rolled so as to form hard cylinders and
retained in place by a T-bandage with two tails crossed in front of
the towels. For safety's sake the patient should, however, be watched
all the time with regard to internal hemorrhage or blood soaking
through the tampon. Concealed hemorrhage would betray itself by
weakening of the pulse, pallor, yawning, and clamminess of the skin.
If the tampon works well, it may be left in two or three hours, and,
if necessary, renewed.

But if the patient's condition warrants it, and the cervix is
dilatable, it is much better to abstain from the tamponade and begin
artificial dilatation at once either by Harris's or Bonnaire's method.
(See Operations.) If by this means the os externum can be dilated



Online LibraryHenry J. (Henry Jacques) GarriguesA text-book of the science and art of obstetrics → online text (page 45 of 80)