CHAPTER III.

PARTURITION.

FALSE PAINS occur most frequently in a first pregnancy, but most pregnant women have occasional pains, and these become more violent within three weeks of the full time. They may be owing to a disordered stomach, as well as to the action of the uterus; but they usually come on at night, and are liable to be mistaken for labor pains. They are, however, unattended with show; they often change from place to place, perhaps going successively to the hips, loins, lower extremities and abdomen; they come on at irregular intervals, and are at one time violent, at another feeble, and they occasion no dilation of the os uteri; but true pains come on with some regularity, and usually increase in severity. False pains are from various causes, such as fatigue of any kind, especially too long standing, sudden and violent motions of the body, costiveness or diarrhœa, general feverishness, agitation of the mind, or a spasmodic action of the abdominal muscles. It is necessary to adopt the means used for the relief of the pains to the apparent cause, and generally to give an opiate proportioned to the degree of pain, or to repeat in small quantities at proper intervals till the patient shall be composed.

PERIOD OF GESTATION.

The duration of pregnancy is not always absolutely a certain number of days. The usual term is ten lunar months, or nine calendar months and one week. If we could have correct records of all cases we should probably find that half the cases of pregnancy terminated in labor in the fortieth week, but that in a few instances the term was prolonged to the forty-fifth week and that in as many cases women were delivered of fully developed children as early as the thirty-seventh week.

A woman may make her count pretty correctly as follows: She should first note the last day of her being unwell. Let forty weeks from that day be marked in an almanac, and she may expect her labor to come on near that time.

It may happen that a woman who never has her menses while she is suckling, may become pregnant and not have a date to count from; but she ought in that case to reckon from the time that she quickens. Although quickening takes place at various periods, she may then consider herself nearly half gone in her pregnancy, and calculate that in four and a half months she will be delivered.

A woman may have a show for one or two monthly periods after her gestation commences, but the discharge may be distinguished from the regular menstrual fluid by its being either small in quantity, or by its clotting, and generally by its lasting but a few hours. The woman should reckon from the time when she had her last regular menstruation.

PARTURITION.

NATURAL LABOR. The uterine functions are characterized by periodicity. If an abortion occurs that is not the result of an accident, it is generally at what would have been, but for conception, a monthly period, and even injuries are more likely to produce their bad effects at that particular time. So the normal period for parturition corresponds to a menstrual period, and generally labor may be looked for at about the tenth period after the last appearance of the catamenia. We can hardly tell why it so uniformly happens at that particular time; the process is analagous to the falling of ripe fruit—it drops because the fruit is fully matured.

It is not in accordance with the plan of this work to dwell at all upon any other than what is called natural labor, but I shall include in this class all such as are terminated by the natural powers, whether they be head, face, breach, or foot presentations.

By PRESENTATION, I mean that part that presents itself at the brim of the pelvis, so that the accoucheur’s finger impinges upon it as the end is passed into the center of the os uteri.

The DIAGNOSIS of the different presentations is made by the touch. The head may be known by the hardness and roundness, and more certainly by the fontanelles and sutures; the breach by its general softness, and by the tuberosity of the haunch bone; by the cleft between the buttocks, the scrotum or the vulva, and the anus; the knee by the hardness and roundness of the bone; the foot by its form, its being at right angles with the leg, the nearly equal length of the toes, the narrow heel, etc.; and the face by the inequalities of the presenting part. (These inequalities cannot at first be felt; upon touching it we first perhaps detect the brow, then, as labor progresses, we may feel the nose, mouth, etc.) The head presents in about 98 cases out of 100.

PHYSIOLOGICAL PHENOMENA OF LABOR.

According to the division made by standard authors on parturition, its first stage extends from the beginning of labor to the complete dilatation of the os uteri; the second terminates by the birth of the child, and the third by the expulsion of the placenta.

During the last two or three weeks of the term, the uterus sinks lower in the pelvis, and seems to spread out laterally; the lungs and stomach are not so much compressed, and respiration and digestion, if difficult, become more easy, and often the patient becomes more cheerful and active. The precursory symptoms of labor vary in intensity in different women; but it may be observed pretty generally that there is more activity and disposition to movement for one day preceding the real labor.

But during the last few days of the gestation there are contractions of the uterus, which, though short and distant, and not attended with much pain, are effective in dilating the cervix, and preparing for the subsequent labors.

The subsidence of the lower end of the uterus into the pelvis, however, causes many unpleasant symptoms. The pressure upon the bladder renders a frequent evacuation of its contents necessary; there is often an ineffectual desire to urinate, and sometimes strangury. There is often a sense of weight about the anus, an irritable state of the bowels, occasional griping pains, and a desire to go to stool when but little is passed, and sometimes diarrhœa. The œdema and varices of the lower extremities augment, the hemorrhoidal vessels swell up, and the piles are larger. These precursory symptoms are manifested more in primapara than in others. To some, walking becomes at this time impossible.

There are during the last month, and especially toward the close of it, painless uterine contractions; there may be at first a sort of squeezing sensation with it. But about twenty-four hours previous to the commencement of actual labor, these contractions are accompanied with some pain and are periodical, recurring perhaps every twenty or thirty minutes. If an examination be made of the os tincæ at the COMMENCEMENT OF LABOR it will be found that the rounded collar of the os is already effaced. The pains then suddenly become acute, and it can be observed that the uterus contracts if we notice its greater hardness and roundness during a pain. The os uteri if somewhat dilated closes partially with each contracting, and it can be observed that its margins are growing thinner though tense and resistant at the time of the pain.

The contractions distend the membranes; these are first pressed _on_ the neck, then _into_ it, then as soon as the dilatation is sufficiently advanced engage in it in the form of the segment of a sphere, whose dimensions progressively increase with the dilatations.

There is now and perhaps has been for several hours a glairy discharge from the vagina, which becomes streaked with blood, there are perhaps shiverings or rigors (not accompanied with a cold skin), the pains increase in force and frequency, the pulse is hard, full, and rather frequent, the countenance is flushed, often there is vomiting, and the patient is prone to despond and be discouraged.

She is less agitated after the pain subsides, though it does not cease entirely. During the interval the margins of the os again become supple, the membrane that was tense while the pain lasted becomes flaccid, and the child’s head can be more plainly felt. As the contractions are repeated the os uteri dilates more and more until it is completely opened and no part of its margin can be touched; though very frequently from some obliquity of the uterus, the margin on one side can be observed pushed down before the head of the child, while that on the other side cannot be reached. In ordinary cases the membranes are ruptured and the waters escape at the commencement of the second stage, and the time occupied by the first stage is nearly three-fourths that for the whole labor. But the duration of the stages as well as the time occupied by the parturition is exceedingly variable, and the same may be said in regard to the duration and character of the pain.

We may observe here that pain is nearly inseparable from the contractions of the uterus, so that in common language the two expressions are used indifferently; but using the word in its ordinary sense the pain in the first stage of labor is different from that in the second. What are called grinding pains characterize the first part of labor, and although they differ in different individuals, they are pretty generally so severe as to cause the patient to cry out. As soon as the labor advances to _the second stage_ there is a change in the character of the pains. They are more frequent and longer and the intervals shorter; but though the suffering may be greater the cry is more suppressed, the bearing down is carried to a greater degree, and each pain is succeeded by a calm more perfect than that in the first stage. Should the interval be rather long some patients get a little sleep between the pains, but if there has not been a bursting of the waters previously there is generally now a pain sufficiently hard to break the membrane.

Either in the first or last part, or during the whole of the labor, the woman says that the pain is in her back, it being in the lumber and dorsal region; the grinding pain she speaks of as being forward, they seem however to go through from the umbilicus to the sacrum. In cases where there is rigidity of the uterine orifice, there is I believe pain especially in the back; and when the os becomes fully dilated, the pains are bearing down; the patient at the accession of a pain holds her breath, and seizing hold of something with her hands, brings the muscles of the back and abdomen and extremities to aid the expulsive efforts of the uterus. I do not doubt that this straining of the mother at this time is advantageous; these efforts of the mother should not be encouraged, however, at the first part of the labor, because then they do no good, nor at the very last, as combined efforts then may rupture the perineum.

As the head advances through the pelvic cavity the pressure upon the nerves which pass through it gives rise to cramps in the thighs and legs.

As the head passes into the vagina the walls become flabby and the canal seems to enlarge and elongate and to be prepared to yield to the pressure of the head. If an internal examination be made the head will be perceived filling the cavity, descending with each pain and receding at its conclusion—the advance ordinarily exceeding the recession, though sometimes the gain is not perceptible. When the head rests on the perineum, that offers some resistance, which seems to stimulate the uterus and abdominal muscles to greater efforts and more forcible contractions.

If it be a first labor there may be at this point a little delay in its progress. But the fœtal head being forced down by the rapidly recurring pains so presses against the floor of the pelvis that it yields and becomes bulging in front, and distended, though there still is recession as the pain intermits. But adequate force is called into action; each pain gains upon the advance made by its predecessor; the vulva partially opens, and at each pain they open more and more; the resistance of the parts is finally overcome. After the perineum has given the head its proper direction in its transit, there usually comes a hard pain—forcing a loud cry from the woman—another pain succeeds immediately, which expels the head altogether from the parts; then after a short rest the uterine power is again exerted to expel the body of the child.

There may be an interval of a few minutes before the pains return with sufficient force to expel the shoulders, but the child is in no particular danger; it is best to wait awhile, the nurse in the meantime making pressure with her hand over the uterus, before any traction is made on the head or shoulders. If the body is very large, however, it may be well soon to draw a little on the head or to reach with one finger into the axilla and to bring down the lower shoulders; then the rest will be delivered without any difficulty.

The intense suffering of the mother is now exchanged for perfect joy or ease; there is at once a transition from extreme misery to total freedom from pain, though the labor is not yet completed. Ordinarily a few pains return before many minutes, and complete the last stage of labor—the expulsion of the placenta. Sometimes the contractions that expel the child, expel also the membranes and placenta; but more generally they are only partially detached or they may be adherent and not easily removed.

After the birth of the child, and the tying of the naval string, it is proper to apply the hand upon the abdomen of the mother to ascertain whether there be another child, and whether the uterus be contracting properly. I advise that an effort should be made immediately to remove the afterbirth and secundines, making firm pressure over the womb; this will generally stimulate the uterus to make good contractions, and may assist in pressing out the placenta. I do not advise that a midwife should pull upon the cord, but it is my practice to press the fingers of my right hand well into the vagina, and as soon as possible grasp a little of the placenta; my left hand at the same time pulling slightly on the cord, and thus by combined effort removing the afterbirth pretty quickly.

I have never had much trouble about retained or adherent placenta in cases where I myself officiated in the delivery, and I attribute my good fortune in this respect to the fact that I do not tie the placental portion of the cord, preferring to let some blood discharge from the afterbirth, thus diminishing its size, and then if necessary I direct that considerable effort be made in the way of squeezing and pressure and friction over the uterus.

It is true that if nothing is done a pain will usually come on within twenty minutes that will expel the afterbirth very effectually including all the membranes, and considerable clots of blood; but I apprehend that in many cases during this delay there is an hour-glass contraction of the womb comes on, which retains the placenta and prevents its proper separation.

But before attending to the placenta, the necessary attention should be paid to the child. A little cold water sprinkled on it will usually make the child cry, if it does not breath immediately after it is born, and this makes the change in it from uterine to breathing life. The child may then be separated from the mother by cutting the cord. After the removal of the child it is proper to endeavor to deliver the afterbirth, though it may not be necessary at first to do anything more than to use friction over the uterus with moderate pressure, which may be gradually increased.