CHAPTER V.
DIAGNOSIS OF ARTIFICIAL LABOR.
When the expulsion of the fœtus takes place from the efforts of nature alone, the labor is called by some authors spontaneous or natural, but when art is obliged to interfere it is called artificial. It would be very useful to us if we could always decide in the commencement of labor whether the assistance of art would be required, and I will group together in a few pages such instructions as I am able to give on this important subject.
The nurse or midwife will not very generally be able to decide any point by auscultation, but she as well as the physician may judge from the appearance of the woman, from her past history, from palpation of the abdomen, and from vaginal touch. She should accustom herself to judging by all these means, that she may be able to decide early whether the help of an accoucheur will be _imperatively_ needed.
No one can decide certainly from simply seeing a patient in the beginning of labor, whether her labor will be natural and spontaneous, or artificial; but I have many times when first looking at a lady, if her complexion was fair, and her form good, but rather tall, predicted that her accouchement would proceed regularly and favorably. But in forming our opinion we need to know something of the previous health and present ailments of the patient, and, if a multipara, the character of former labors. If nausea and vomiting or any other ailment has reduced her strength so that she is exceedingly weak, this may give rise to some reasonable apprehension; but I have known a woman that could scarcely retain a morsel of food on her stomach for seven or eight months, that had become very weak indeed and exceedingly emaciated, who yet endured her labor well and soon recovered. The general rule is, that the more perfect the woman’s health is, the better she is fitted for child bearing, but if her general health and strength is reduced below its proper standard by some previous or accompanying disease, such for example as consumption, she may endure the labor very well, and succumb to the disease afterwards.
Pregnant women are liable to be attacked with epidemic, endemic, and sporadic diseases. Eruptive fevers, etc., may attack parturient women, and if they do, the disease and labor in every case will have a reciprocal influence on each other—the disease will complicate the case. Influenza or intermittent fever may attack a woman at any period of gestation, and there may be no serious results. Cholera, small pox, typhoid fever, scarlet fever, measles, pneumonia, and jaundice are liable to cause abortion, and there is danger of fatal results, or either of them would be a dangerous complication at the time of labor. Syphilis would be a cause of abortion or premature labor, and any disease which allows the mother to carry the child the full term may reduce and weaken her. Glandular engorgements and scrofulous ulcers improve during gestation, but if the woman is suffering from a fracture, the bones will not unite very well. Tumors in the abdomen and pelvis may be an obstacle to delivery, and ulcerations of the cervix may also be harmful and protract the labor, as also may constipation, dropsy, and albuminuria.
The latter may not be detected without an analysis of the urine, but dropsy will be obvious as soon as it exists. The evidences of tumors and ulcerations are found by palpation and the touch—sometimes by the use of the speculum.
After learning the present appearance and the former history of the patient it may be necessary to examine further perhaps by palpation.
By PALPATION we may sometimes (but not always) distinguish the head of the child, and perhaps tell to which side its back is turned. When making the examination let the patient lie on her back, make gentle pressure when the pains are off and the abdomen is relaxed; press the ends of your fingers above the body of the pubis; by pressing downwards you may perhaps feel the head if it has descended into the pelvis. You will need to press the abdomen carefully all over to ascertain if there are tumors, and also to ascertain if the body or some other part presents at the cervix uteri.
If _auscultation_ is used we may determine positively the position of the fœtus by observing just where the sounds of the fœtal heart may be most plainly heard.
The VAGINAL TOUCH is the usual mode of determining whether there is an unfavorable presentation of the child, as well as whether there is deformity of the pelvis, tumors in the vagina, ulcerations, &c.
When the head presents in the commencement of labor, if the fundus of the uterus is not too much inclined forwards, and there is no deformity of the pelvis, the os may easily be reached, and the hard round head of the child be felt without difficulty. Should a hard presenting part not be felt either through the dilated os or the walls of the uterus, it may be because there is a breech or body presentation, or there may be twins, or there may be an unusual amount of water in the uterus, or the child may have hydrocephalus—in either of these cases it might not be possible to decide immediately about the presentation and position.
FACE PRESENTATIONS cannot be detected very early in the labor. Before the membranes are ruptured the head is high and difficult of access. When it is reached the forehead is first encountered, afterwards we may feel the nose and mouth. It is unfortunate for us that we cannot usually distinguish a face presentation in the early stage of labor. It is not so important that we make an early diagnosis of presentation of the breech, as there is no danger to the mother involved in the latter.
PRESENTATION OF THE BODY should always be detected early, at least as soon as the membranes are ruptured. The abdomen of the mother is much longer in the transverse diameter than is usual, and the head of the child may sometimes be felt in the iliac fossa. The form of the mother’s abdomen is irregular as the fœtus lies curved on itself. When we are able to touch the fœtus, if the shoulder presents, we first feel a small bony projection, the acromion point of the shoulder; then other points, including the acute angle of the shoulder blade. We should ascertain as soon as possible on which side the head lies, and also the posterior plane of the child.
Sometimes the hand comes down in the vagina or even appears at the vulva; if it does we may know by that (and by slipping the finger of our hand up into the axillary space) just how the child lies. If the back of the child’s hand is turned towards the mother’s right thigh the head is to the right, and if to the left thigh, to the left. The little finger being towards the coccyx indicates that the child’s back is towards the mother’s loins, and the same finger being towards the pubis is evidence that this is in front. It is quite important that these points should be noted.
There are various causes of tedious, difficult and obstructed labor, and in each case we are obliged to depend principally upon the touch for diagnosis. In some instances the difficulty will be obvious as soon as we attempt to make an examination. A NARROW and UNDILATABLE VAGINA will be easily recognized, but this will rarely be found a serious obstacle to the passage of the child; as the labor proceeds the vagina seems naturally to dilate and to be more softened and relaxed.
Cases have been reported where there was a _scirrhus tumor_ or cancer connected with the neck of the uterus, even during labor; happily such cases are rare. The scirrhus would be felt hard and unyielding. A tumor of any kind connected with the os uteri, the vagina or the rectum may obstruct the descent of the child’s head more or less according to its size and mobility. Of course they can be detected.
A VAGINAL CYSTOCELE ought always to be rectified. It sometimes happens that the bladder is caught by the head of the child in its descent into the cavity of the pelvis and pushed before it, and it can be seen as a soft red tumor between the vulva. The finger can be passed posterior to it, but not anterior, and the catheter cannot be passed in the usual direction.
A few cases are on record where a _stone_ (calculus) in the bladder was pushed down before the fœtal head. A careful examination will show that the tumor is covered by the bladder; its hardness will indicate its nature.
A COLLECTION OF HARDENED FECES IN THE RECTUM is detected without difficulty. It will be of an irregular form, hard and inelastic.
SWELLING OF THE SOFT PARTS may cause obstruction. If the child’s head is detained for a long time pressing upon the brim of the pelvis, it may obstruct the circulation and diminish the capacity of the passage. In such cases there is unusual heat and dryness in the parts.
When a nurse or midwife makes an examination by touching, she needs to continue it through several pains, and to repeat it again soon to know if there is any progress to the labor. If the progress is very slow this may be from various causes, some of which I will now simply name. It may be because the uterus is very much distended, and this renders the pains inefficient; there may be partial and irregular contractions of the uterus, weakness of constitution, fever or local inflammation, a want of irritability in the constitution, a deformity of the pelvis and spine, or doubts and fears on the part of the patient may diminish the action of the uterus. The labor may be slow because it is the first one, or because the membranes were ruptured too early, or because the woman is advanced in years at the time of having her first confinement. The uterus may be pitched over obliquely, there may be extreme rigidity of the os uteri, extreme rigidity of the soft parts of the mother, a contracted or small pelvis, the head of the child may be large and ossified so as to be unyielding. One or both arms may come down by the side of the head of the child; on the part of the mother there may be a distended bladder from inability to void the urine, there may be cicatrices (scars) or adhesions of the vagina, and in some cases it has happened that an enlarged ovary has dropped down into the pelvis, or a portion of intestine containing scybala or hardened feces obstructs the passage, or the os uteri is very minute, or imperforate, or totally absent.
Some of these cases may demand the interference of art in the first stage of labor, but delay at that time involves very little danger; as a rule neither the mother nor child is in danger (except when there is hemorrhage or convulsions) on account of labor before the membranes are broken. If the nurse can ascertain the cause of the delay and finds that time is what is especially needed, she must exercise patience herself and encourage her patient to do so.
It is hardly possible to predict beforehand in what cases convulsions will occur, but if there is much headache in the commencement of labor and if there has been considerable albumen in the urine of the patient, we have especial reason to apprehend trouble of that kind.
The history of the case is important in forming an opinion as to whether there may be severe hemorrhage. Some women are naturally predisposed to flowing.