Many are the causes which tend to obstruct the process of parturition, but they may be referred to two general heads; viz. to increased powers of resistance, or to decreased powers of expulsion.
Of THE FIRST VARIETY. Rigidity of the parts of generation, either of the os uteri or of the external parts, or both, is one of the most common causes which produce increased resistance, (more particularly in a first labour.) There is generally a deficient vaginal secretion, the parts feel hot, and the female is feverish.
Treatment. The patient is to be confined to the horizontal posture; a quantity of blood (proportioned, of course, to her strength and constitution,) to be taken from the arm; the rectum emptied by means of an enema, and afterwards a full dose of opium administered. The repeated application of warm wet cloths to the perineum is also useful, by encouraging the mucous secretion, and thus giving the parts a greater disposition to dilate. Frequent examinations per vaginam ought to be avoided, and great care taken not to rupture the membranes.
Disproportion between the size of the head and the bony structure of the pelvis, is also another cause. Thus, the pelvis may be distorted, or the head may be larger than usual, or its sutures may be closely ossified, so that it cannot be squeezed into the proper shape for its passage through the cavity. Again, the head may be greatly enlarged by the accumulation of water within it.
Treatment. The slighter degrees of disproportion will be overcome by nature's unassisted efforts, though a considerable time may be required. The patient's strength may be supported by unstimulating nourishment, her spirits kept up by cheerful conversation, and great attention paid to the bladder and rectum. In the greater degrees of disproportion, recourse must be bad to instrumental interference. Where the difficulty arises from an accumulation of water, the scalp may be punctured with a pair of scissors or a trocar; the fluid escaping, the bones of the cranium will collapse, and the child will then readily pass.
Unusual toughness of the membranes containing the liquor amnii occasionally, though not very frequently, produces increased resistance, This is known by their not giving way at the usual period; the patient at the same time experiencing hearing-down pains.
Treatment. When the parts are thoroughly dilated, the end of the finger, or a blunt-pointed probe, should be passed through the bag during a pain.
A very large quantity of liquor amnii is sometimes the cause of protracted labour. When it is contained in that part of the bag which protrudes before the head of the child, it is easily distinguished; when behind it, we shall find, if we press with a finger upon the presenting part, in the absence of pains, that it will suddenly recede and get out of reach.
Treatment. Precisely the same as in the preceding case.
Too early rupture of the membranes, by destroying the natural wedge by which the os uteri is dilated, is not an uncommon cause of protracted labour; the process not only being delayed, but rendered much more painful.
Treatment. These labours are generally slow in their progress, and are rather retarded than hastened by manual interference.
A distended state of the urinary bladder, or of the rectum from an accumulation of hardened faeces will prove a serious obstacle to delivery, not only from the encroachment which is necessarily made upon the pelvic cavity, but also from the uterine paroxysms being sensibly diminished till the causes are removed. There is, therefore, a double disadvantage; the powers of resistance being increased, whilst those of expulsion are diminished.
Treatment. The catheter, and large emollient enemata, are the obvious remedies.
Descent of the hand along with or before the head will sometimes retard the progress of a labour, especially if it be a first labour, and the parts rigid, or should there be a large head or a small pelvis. This is easily detected, as the fingers can be felt without difficulty.
Treatment. It has been recommended by some, that the hand should be pushed back over the head; but experience has amply proved that, in a large proportion of instances, this mode of proceeding is not necessary, these cases merely requiring a longer time for their completion than ordinary ones.
Of THE SECOND VARIETY. An unfavorable state of the patient's constitution will greatly interfere with and impede the parturient actions, whether it be in consequence of a state of plethora, or of the opposite state, viz. that of inanition. These two conditions are easily recognized by the general appearance of the patient. In the former there is a flushed state of countenance, headache, a pulse either full and round, or contracted and hard, a coated tongue, thirst, and generally a deficiency of the mucous secretion from the vaginal surface, the parts of generation ho and tender: this tenderness sometimes extending over the uterine region, in which case internal inflammation may be suspected.
In the latter the pulse is feeble, though perhaps quick; the skin cool, moist, and flabby; there is sometimes a feeling of great oppression over the eyebrows: the parts of generation dilatable, and bathed with a copious secretion*
Treatment must, of course, be regulated by the cause which produced the symptoms. Where there is a plethoric state of system, abstraction of blood is at first to be had recourse to; the bowels are then to be freely opened, the room to be kept cool, and perfect quietude and the recumbent posture strictly enjoined; unnecessary examination per vaginam to be avoided.
An opposite mode of treatment is required where the patient is debilitated and exhausted. Nourishment may be administered, and a little stimulus allowed, such as mulled wine, or weak and hot brandy and water.
When the female has somewhat rallied, it become a question whether it will be more to her advantage to expedite or to retard delivery, If the pains have altogether subsided, and there be a disposition for sleep, a full dose of opium may be given, and quietness strictly observed, in order that rest may be procured: but, if nature appear to be on the alert, if the pains regularly continue, though defective in power, twenty-five grains of pulv. secalis cornuti may be exhibited in warm tea, and repeated in the course of twenty minutes, if necessary. The effect of the ergot is in these cases frequently very decided; the pains, after a short period, in-creasing both in frequency and in force, and continuing till the delivery is completed.
Imperfect action of the uterus. For the purposes of labour it is necessary that there should be a perfect contraction of the whole muscular structure of the womb; but this action is sometimes partial only, which produces considerable distress to the patient, without advancing the labour. In these cases there is no freedom from pain, although it may be aggravated at intervals. If the hand be placed upon the uterine region, and pressure applied, the uterus will sometimes be found to have an irregular (eel, one part being much firmer and harder than another.
Treatment. If the patient be plethoric, blood must be removed from the arm, the bowels attended to, and opium, both by the mouth and by enemata, administered in large quantities. If, on the contrary, the female be weakly and irritable, the bloodletting is inadmissible.
A shortened state of the funis umbilicalis is now and then, though very unfrequently, a cause of protracting labour: under these circumstances the head remains a considerable time at the outlet, though the pains continue severe; but it is not till after the expulsion of the child that the cause can be ascertained.
Treatment. Care should be taken to put the cord as much as possible oil" the stretch, by bending the body of the infant towards that of the mother. The funis ought to be divided as soon as within reach.
Previous Next
From Charles Waller
Elements of Practical Midwifery: Or, Companion to the Lying-in Room, 1829
