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PRACTICAL

OBSTETRICS



BY



THOMAS WATTS EDEN

M. D., C. M. Edin., F. R. C. P. Lond., F. R. C. S. Edin.

OBSTETRIC PHYSICIAN AND LECTURER ON MIDWIFERY AND GYNECOLOGY,
CHARING CROSS HOSPITAL
CONSULTING PHYSICIAN TO QUEEN CHARLOTTE'S LYING-IN HOSPITAL
SURGEON TO IN-PATIENTS, CHELSEA HOSPITAL FOR WOMEN



FOURTH EDITION



WITH 5 PLATES AND 354 ILLUSTRATIONS IN THE TEXT



ST. LOUIS

C. V. MOSBY COMPANY

1915



PREFACE TO THE FOURTH
EDITION



N preparing the present edition of this Manual a further
increase in size has been found necessary in order to
include the advances in various subjects which have been
made during the last three years.

The introduction of Abderhalden's Test, and the progress
which has been made in our knowledge of the pregnancy-
changes in the endocrinous glands, has altered the aspect of
the General Physiology of Pregnancy so much that this
section has been entirely re- written. The description of
the Toxaemias of Pregnancy, and of the obstetric treatment
of Eclampsia, has also been completely revised.

The valuable work of British obstetricians in recognising
and explaining the Local Contraction Ring as a cause of
obstruction in labour has been taken advantage of, and an
attempt made to classify the different varieties of over-
action of the parturient uterus. The treatment of Placenta
Prsevia has also been completely revised.

Four coloured plates are included in this edition, which
it is hoped will be of service to students making their first



vi PREFACE TO THE FOURTH EDITION

acquaintance with the conditions illustrated. I hare to
express my thanks to my coUeague, Dr. Cuthbert Lockyer,
for permission to make use of two interesting specimens in
his collection, and to Dr. Hubert M. Turnbull, of the London
Hospital; for the microscopic preparations represented in
Plate III.

Thos. Watts Edex.

26, QuEEx AxxE Street, W.
1915.



CONTENTS



PAET I
NORMAL PREGNANCY

PAGE

Ovulation 1

Menstruation . 6

Fertilisation and Implantation of the Ovum ... 9

Chorion and Placenta 27

Amnion, Umbilical Cord, and Foetus 47

The Gravid Uterus 62

The General Physiology of Pregnancy . . . .71

The Diagnosis of Pregnancy . . . . . . . 83

Multiple Pregnancy 97

Management of Normal Pregnancy 104



PAET II

ABNORMAL PREGNANCY

Classification 106

Albuminuria and Eclampsia 113

Hyperemesis Gravidarum 126

Reflex Disorders of Pregnancy 131

Displacements of the Gravid Uterus . . . .132
Malformations of tpie Uterus and Pregnancy . . . 141

Pressure Symptoms 142

Uterine Moles 143

Decidual Endometritis . . . . . . .157

Hydramnios ' 159



viii CONTENTS

Page

Diseases of the Placenta . . . . . . .181

extka-ttteeixe gestation 168

Mateexax Disoedeks associated WITH Peegxaxct . . 199

Ovarian Tumoues and Pregnancy 214

Tumours of the Gravid Uterus 215

Abortion 218

Death and Retention of Fcetus in Uteeo . . . 236



PAET III

A^0i?3/J.i L ABOVE

Clinicajl Phenomena 241

Anatomy and Physiology of the First and Second Stages 254

Anatomy and Physiology of the Thied Stage . . . 279

Mechanism 284

Management 308

Occipito-posteeior Positions of the Vertex . . . 337



PART IV

ABJOEJIAL L ABOVE

Classification 343

Face Presentations ......... 344

Brow Presentations 356

Breech or Pelvic Presentations . . . . , . 358

Transverse or Shoulder Presentations .... 377

Twin Laboue 386

Prolapse of the Umbilical Cord ..... 389

Pelvic Contraction . 394

Eare Forms of Contracted Pelvis 423

Abnormal Conditions of the Soft Parts . . . . 433

Abnormalities in the Action of the Uterus . . . 442

Obstructed Labour . 455



CONTENTS ix

PAGE

Rupture of the Uterus ....... 462



Inversion of the Uterus
Ante-partum Haemorrhage .
Non-expulsion of the Placenta
post-partum haemorrhage .
Labour complicated by Eclampsia



480
483
510
518

527



PAET V

THE PUEBPEBIUM

General Physiology 542

Process of Involution 548

Management of the Puerperium ..... 556

Puerperal Infection 563

Clinical Varieties of Puerperal Infection . . .575

Local Pelvic Inflammation 594

Phlegmasia Alba Dolens . . . . . . . 598

Inflammation of the Mammary Glands . . . . 603

Puerperal Hemorrhage . . . . . . . 606

Chorionepithelioma . . . . . . . . . 607

Reproductive Insanity 611

Sudden Death in the Puerperium 613



PAET VI
THE NEW-BOBN CHILD



General Management . . . .. . . .615

Infant Feeding . . . 617

Management of Premature Infants 628

Digestive Disturbances . , 631

Asphyxia Neonatorum . 633

Injuries to the Head ........ 641

Ophthalmia Neonatorum . . . . 646

E.M. h



X CONTENTS

4

PAET YII
OBSTETRIC OPERATIONS

VACJE

Artificial iNTERRUPXioisr of Pkegxanct . . . . 651

Version 671

Obstetric Forceps 689

CESAREAN Section 719

Craniotomy ; Decapitation ; Evisceration . . . . 737

Symphysiotomy ; Pubtotomy 749

Primary Repair of the Perineum 754

INDEX 759



Part I.
NOEMAL PREGNANCY.

Ovulation

The ovary is the storehouse in which egg-cells (oocytes)
are preserved, and from which they are periodically liberated
during the years comprised between puberty and the
menopause. Ovulation is the process by which oocytes are
discharged from their protecting chambers — the Graafian
follicles — ^into the peritoneal cavity ; this process includes
the two stages of maturation (ripening) and dehiscence
(rupture) of the folhcles. A follicle in the resting phase
{i.e. before ripening has commenced) lies deeply in the cortical
layer of the ovary, separated from the surface by a stratum
of ovarian tissue of variable thickness. In the ripening
process two changes occur : (1) it first approaches the surface,
and finally becomes partly extruded, forming a protuberance
on the ovary, the germ -epithelial covering at that spot being
lost ; (2) it increases greatly in size. The structure of a
ripening foUicle is shown in Fig. 1. The process of extrusion
has not been fully studied, but there occurs an undoubted
displacement of the enlarging follicle towards the surface.
The causes of rupture are also obscure and probably complex,
and many different views concerning them have been
advanced. A great increase in the amount of liquor foUiculi
occurs during maturation, partly by transudation from the
congested ovarian vessels, and partly perhaps by secretion
from the proliferating cells of the granulosa ; towards the
end of the process haemorrhage may also occur into the
follicle, causing a sudden increase in tension which would
easily determine rupture. Clark has pointed out that there
is great proliferation of the granulosa cells during ovulation,
which he beheves also increases the intra-foUicular tension.
In addition, degenerative processes of the nature of necrosis
occur in that part of the wall of the follicle which lies exposed

/ E.M. 1



2 NORMAL PREGNANCY

upon the surface, and is unsupported by the ovarian stroma,
which so weaken it that it is unable to resist the high ten-
sion within, and rupture results. Rupture is therefore due
to weakening from degeneration of the wall of the follicle,
combined with increased intra-foUicular tension.

When the follicle ruptures, the contained fluid escapes and



Discus proligerus



Tu.mca albuginea
of ovary




Tunica fibrosa
fmiter coat of folLtcLe.)



Tunica vasculosa
(irtrver cooU of foLLicL^)



Fig.



1. — Ripening Graafian Follicle protruding upon the Surface of tlie
Ovary. (Bumm.J



as a rule carries the oocyte with it into the peritoneal cavity.
The discus proligerus is usually, 'but not always, attached to
the deepest part of the wall of the follicle. Nagel has shown
that fatty degeneration of the granulosa cells occurs during
maturation, and this, by weakening the attachments of the
oocyte, no doubt assists its liberation and escape from the
follicle. Occasionally two and sometimes three oocytes are
found in a Graafian follicle. Sometimes Graafian follicles



OVULATION 3

may rupture without detachment of the oocyte occurring ;
this gives the opportunity for ovarian pregnancy to arise if
spermatozoa should chance to enter the ruptured folhcle
(see p. 169) ; otherwise the oocyte would perish in situ and
non-detachment thus become a possible cause of sterility,
but we have no definite information upon this point. The
human oocyte is a large cell, 20()jji in diameter, consisting of
the zona pellucida or striata (cell-envelope), the vitellus or
yelk consisting of coarsely granular protoplasm (cell-body,



^4^




3



Fig. 2.— Human Oocyte showing the Corona Eadiata, Zona Eadiala,
G-ranular Protoplasm, Germinal Vesicle, and Germinal Spot.
("Van der Stricht, from Galabin and Blacker.)

cytoplasm), the germinal vesicle (nucleus), and the germinal
spot (nucleolus). An oocyte sometimes contains two nuclei,
and the nucleolus is not infrequently double. The human
oocyte, after its escape from the follicle, is shown in Fig. 2 ;
it retains a covering of several layers of cells derived from
the discus proligerus, which serve to protect it during its
transit to the Fallopian tube ; in the tube this protective
covering disappears. The cells forming the corona radiata
are merely somewhat speciahsed cells of the same origin as
those of the discus proligerus.

After its discharge from the ovary the oocyte migrates into

i— 2



4 NORMAL PREGNANCY

the Fallopian tube. It was at one time thought that during
ovulation the fimbrise of the abdominal ostium became turgid
like erectile tissue and spread over the ovary like the fingers
of the hand, so that the ovum was discharged directly into
the mouth of the tube itself. This view appears to rest
upon fancy, and is opposed to established clinical facts. We
know now that the oocyte does not always enter the Fallopian
tube of the same side, but may pass across the pelvic
peritoneal cavity and enter the opposite tube. This
phenomenon, known as ' external wandering,' has been
demonstrated by cases in which a woman has become
pregnant after losing the ovary of one side and the tube of
the other ; the discharged oocyte must, in such cases, pass
across the pouch of Douglas. The distance between the ovary
and the mouth of the opposite Fallopian tube is not great,
and may be reduced by the pelvic congestion accompanying
ovulation. The oocyte has no locomotive power of its
own, and must be carried by peritoneal currents from the
ovary to the tube. There is no difficulty in believing that
such currents exist in the neighbourhood of the abdominal
ostia, for the cilia covering the mucous surfaces of the
fimbrise work towards the uterus and naturally set up
currents travelling in that direction in the thin layer of
fluid which covers the peritoneum. Their existence in
lower animals has been actually demonstrated by injecting
insoluble particles into the peritoneal cavity ; some of
these have afterwards been found in the tubes, having been
carried thither by peritoneal currents. When once the
oocyte has reached one of the tubal fimbrise, it is probable
that peristaltic contractions of the tubal muscle play a part
even more important than ciliary action in passing it on to
the uterus.

After the Graafian follicle has ruptured and discharged its
contents, it undergoes important changes and is henceforth
termed the corpus luteum. A great deal of attention has
recently been paid to both the structure and the fiuictions of
this body, and there is some evidence accumulating that it
may normally exert a certain controlling influence upon
pregnancy, and that morbid conditions of the developing
ovum within the uterus, and of the corpus luteum in the
ovary, frequently co-exist.



CORPUS LUTEUM 5

The cavity of the ruptured follicle is at first filled up with
blood effused from the site of rupture ; the degenerated
granulosa cells are mostly cast off, their place being taken by
many layers of actively proliferating polygonal cells of
epitheloid character in which a yellow pigment called lutein
has appeared. These cells are therefore now called lutein
cells. So well marked are their characters that their presence
in a structure of indeterminate nature is sufficient to prove
it to be active ovarian tissue. They arise either from the



lAitein
Layer




Vessels of
tunica
propria



Fig. 3. — Corpus luteura three weeks after Menstruation, showing the
Central Blood- clot, the Convoluted Lutein Layer, and the Vascular
Tunica Propria. (Bumm.)



connective-tissue cells of the tunica vasculosa or from the
membrana granulosa. Each of these views has its advocates,
but the more recent observations have been unanimously
in favour of their origin from the follicular epithelium.
Owing to the collapse of the follicle after evacuation of its
contents the wall becomes convoluted along its entire length
from the formation of folds, and the lutein layer thus comes
to acquire its characteristic sinuous outline (Fig. 3). Subse-
quent changes consist in the absorption of the central blood-
clot, the complete occlusion of the cavity by proliferating
lutein cells, and gradual shrinkage of the entire body. It has



6 NORMAL PREGNANCY

been recently shown that masses of lutein cells can often be
found scattered through the ovarian stroma during preg-
nancy, so that their function is probably not limited to the
repair of the ruptured Graafian follicle. Soon the lutein cells
undergo a kind of hyaline degeneration, losing their nuclei
and cell outlines, and becoming transformed into structure-
less masses. These masses in turn are replaced by connective
tissue which invades them from the surrounding ovarian
stroma ; at this stage it is usually called the corpus fihrosum
or corpus albicans. Frequently the corpus albicans becomes
divided into portions by ingrowing strands of stroma, so
that a considerable number of white bodies, isolated from
one another, may be found in an adult ovary. Finally all
trace of lutein cells disappears, and only a small depressed
cicatrix remains upon the surface of the ovary to indicate
the previous existence of the corpus luteum. The length of
time occupied by these changes is variable, becoming longer
as age advances ; many weeks or months are probably
always required for their completion.

During pregnancy the corpus luteimi attains a greater size
than when pregnancy does not occur ; it may continue to
increase in size, probably from progressive haemorrhage, for
three or four months, and may come to occupy about one-
third of the whole ovarian area. It then gradually undergoes
the retrograde changes just described, which are not com-
pleted until after the termination of gestation. The large
corpus luteum met mth in pregnancy was formerly called
the ' true corpus luteum,' and that formed when pregnancy
does not occur the ' false corpus luteum.' Since there is
no essential difference between them, either in structure or
in the changes they undergo, these names are meaningless ;
the one is no more ' false ' nor ' true ' than the other.

Menstruation

It is undoubtedly true that the processes of ovulation and
menstruation are closely related to one another ; but whether
they are coincident or consecutive, and, if consecutive, which
precedes the other, we do not know with certainty. That
menstruation is not essential to the occurrence of pregnancy,
and that a fertilised ovum may be successfully implanted



MENSTRUATION 7

upon a quiescent endometrium, is well known ; for preg-
nancy may occur either before the establishment of the
menstrual function at puberty, after the menopause, or
during a temporary suspension of menstruation such as that



Disintegrat ed- Vy. •^' ; f' jj. .
svirface -.tvyr-v-j" •sij!-'.'.-^!^

Blood- r-^^f \^W?
vessels •■■''■■'^^^'•'''''''



Superficial






epithelium



■•!^/:y'Vl D isintegrated
auj-foLce






. •• G land-

; !:'*-';V''- tubule









.<)



_Blood-

vessel










Fig. 4. — Vertical Section of Endometrium during the First Day of
Menstruation. (Schafer.)

which usually accompanies lactation. There is, however,
much to be said for the time-honoured view that the uterus
is in some way prepared by the menstrual changes for the
reception of the fertilised ovum ; for regularity of the
menstrual function is the rule in fertile women, and clinical



8 NOEMAL PREGNANCY

observations indicate that conception, although it may occur
at any point in the menstrual cycle, is most likely to occur
during the days which immediately follow a menstrual
period. From careful chnical observations upon cases in
which the ovaries were examined in the course of opera-
tions, Fraenkel has expressed the opinion that ovulation
ordinarily occurs soon after the close of a menstrual period.
This view also receives support from the fact that the changes
which the uterine mucous membrane undergoes diu-ing
menstruation present certain well-marked resemblances to
those which immediately follow upon conception and result
in the formation of the decidua. So marked is the resem-
blance that many writers now speak of the endometrium
during menstruation as the menstrual decidua.

The anatomy of menstruation has been recently studied
by Gebhard, Sellheim, and others in human uteri removed
during a menstrual period. The earhest changes appear to
be hypersemia and swelling of the mucosa, associated mth
engorgement of blood-vessels, which is most marked in the
superficial capillaries (Fig. 4). The glands become elongated
and irregularly dilated, presenting a somewhat corkscrew
outline ; when seen in longitudinal section the dilated lumen
is irregularly divided by transverse septa upon which
prohferating epithelium is seen ; the inter-glandular con-
nective tissue increases in amount, becomes looser in texture,
and sometimes shows traces of infiltration with leucocytes
(pre-menstrual phase). A little later small interstitial
haemorrhages appear, situated chiefly beneath the superficial
columnar epithelium, and as a result patches of these cells
become thro"^Ti off ; but the amount of tissue lost in this
way is very small. It is uncertain whether the haemorrhages
are due to diapedesis, or to degeneration and rupture of the
walls of the capillaries. The menstrual flow comes in part
from the denuded patches, but probably the whole of the
greatly congested mucosa bleeds more or less. In addition a
large amomit of mucus is produced by the active glands, and
this substance forms a considerable part of the bulk of the
menstrual fluid. There is no formation of large ceUs in the
connective tissue, such as occurs in pregnancy. The mucous
membrane of the cervix takes little or no part in these
changes. If an ovum becomes fertihsed, further important



FERTILISATION 9

developments occur in the endometrium, resulting in tlie
formation of the decidua of pregnancy ; if not, the congestion
subsides, the damaged surface is repaired, the glands become
inactive, and the mucous membrane passes again into the
phase of quiescence.

The most important difference between the mucosa during
menstruation and the decidua of pregnancy is the formation
in the latter of the characteristic decidual cells ; in most
other respects the resemblance between them is striking.

Fertilisation and Implantation

The process of fertihsation consists in the union of the
male element (spermatozoon or male gamete) with the
female element (oocyte or female gamete). From what we
know of the process in lower mammals there is reason to
believe that the spermatozoon and oocyte usually meet in
the Fallopian tube. We have seen that the oocyte may be
carried into the tube by peritoneal currents and then passed
on by the action of the ciliated epithelium and tubal muscle.
The spermatozoon makes its way upwards from the vagina
by means of the propelling apparatus with which it is
provided, consisting of a long tail which acts like a paddle
in driving it forward through the thin layer of fluid which
covers the mucous membranes. The activity of the sperma-
tozoa is very great in certain animals, for they can travel
from the vagina into the peritoneal cavity in a few hours.
It is somewhat doubtful whether their progress is opposed
by the action of the ciliated epithelium, for the existence
of ascending currents in the secretions of the genital tract
has been demonstrated by Bond, who placed insoluble
particles of colouring-matter in the vagina, and recovered
them in the Fallopian tube on operation a few days later.
The time occupied by the transit through the tube in the
human species is unknown, but from comparative observa-
tions, it is believed not to exceed twenty-four hours (Teacher).
It is possible for spermatozoa to lie in wait for the oocyte in
the Fallopian tube for considerable periods ; thus they have
been found alive in a human Fallopian tube removed three
and a half weeks after the last act of sexual intercourse.
Only one spermatozoon is required for the fertilisation of an



10



NORMAL PREGNANCY



oocyte, and of the enormous numbers found in the seminal
fluid nearly all must perish without achieving their physio-
logical destiny. The fertilised egg-cell is termed morpho-
logically the zygote ; clinically it is convenient to call it
the ovum, a term which may be applied at all stages of its
development.

The details of the process of fertilisation naturally cannot
be studied in the human species ; most of what we know









Pig. 5. — The Process of Pertilisation in the Mouse, after Sobotta. (Von

Winckel.)

a. Penetration "by a spermatozoon, h. Formation of polar body, and first division of
segmentation nucleus, c. Binary division of the ovum.

comes from observations upon certain of the echinoderms
and ascarides which possess transparent oocytes, but Sobotta
has recently succeeded in studying fertilisation in the mouse.
The matter can only be very briefly referred to here.

Immediately before the union of the spermatozoon and
oocyte, certain changes occur in the nucleus (germinal vesicle)
of the latter, resulting in the extrusion of one or two minute
portions of its substance, with a covering of protoplasm,
beneath the zona radiata ; the extruded portions are termed



FERTILISATION 11

the polar globules, but their significance is quite unknown,
and they soon disappear. The polar globules carry with
them one half of the chromatin loops (or chromosomes)
which the germinal vesicle originally contained ; conse-
quently the latter when fertilised contains only one half of
its proper number. It is possible that this process deter-
mines the occurrence of variations in hereditary characters.
As the human oocyte possesses no micropyle, such as exists
in the invertebrates, the spermatozoon penetrates (Fig. 5, a)
the zona radiata (z. pellucida), and when the head has
entered, the tail separates and disappears. The human
egg-cell is a large cell 200^ in diameter, and visible to the
naked eye ; the head of the spermatozoon measures about
5fjL in length. Attention has recently been paid to the
behaviour of the nuclei during fertilisation, and observa-
tions on lower animals have established the following facts.
The included head of the spermatozoon {male pronucleus)
and the germinal vesicle of the ovum {female pronucleus)
each divides into two, and active karyokinetic changes occur.
After an interval the four nuclei fuse to form a single nuclear
spindle to which an equal number of chromatin loops
{chromosomes) is contributed by the male and female pro-
nuclei. Every cell formed from the fertilised ovum therefore
contains chromosomes derived originally from each parent
(Adami).

The cell resulting from fusion of the two pronuclei is
the fertilised ovum or zygote. The fertilised ovum now starts
immediately upon a career of extraordinary activity by
which all the organs and tissues of an individual human
body are formed from it by cell-division and differentiation.
The process of cell-multiplication in its earliest stages is
known as the segmentation of the ovum. The segmentation



Online LibraryThomas Watts EdenPractical obstetrics → online text (page 1 of 59)