PRETERNATURAL LABOUR includes every variety of presentation and situation of the child, excepting that described as occurring in natural labour; cases of monstrosity; and also those in which the uterus contains a plurality of children.
Malposition of the head. The head of the foetus may present in various ways: thus, it may be a vertex presentation, with the occiput directed towards the sacroiliac synchondrosis, instead of the acetabulum. It may be a presentation of the forehead, of the side of the head, (in which case the ear is easily recognized) or of the face: in none of which, with the exception of the ear, need manual interference, for the purpose of rectifying such position, be had recourse to, as nature very generally completes the task herself, without injury either to the mother or the child, though these labours are tedious and severe. If the patient's strength seems to be giving way, assistance may be given with the forceps after the head has descended. The propriety of using much exertion in order to bring down the vertex, may be fairly questioned when the parts are rigid[and indisposed to dilate; and, if they are lax and yielding, the mucous secretion copious, and the pelvis well formed, there will be no occasion for such interference.
In presentations of the ear, (which are exceedingly rare,) the child should be turned, and brought down by the feet.
Presentation of the feet is known by the lengthened form of the membranes which protrude through the os uteri, by the shape of the toes, the projection of the os calcis, and of the malleoli. This presentation can only be confounded with that of the hand, from which it may readily be distinguished by the signs just enumerated, and by attending to the difference in the relative situation of the parts with which they are articulated. If it be the hand, it will be in a state of pronation, and consequently will be in a direct line with the forearm; whilst, in a presentation of the foot, this part, from the nature of the articulation, will always be found at right angles with the leg.
Treatment. The most favorable position of the child in these cases is with its toes directed to the mother's back, as the head will, under such circumstances, pass through the pelvis with much greater facility than when they are placed in the opposite direction : if, therefore, upon examination, they are found to be thus situated, no interference is required till the scapula; arc about to pass through the outlet; it then becomes of great importance to prevent the arms from being pressed between the occiput and symphysis pubis; for, if they become thus wedged in, the delivery of the head will be rendered extremely difficult. In order to prevent this occurrence, the fingers are to be introduced into the vagina, and the arms gradually and cautiously (for fear of fracture) thrown backwards into the hollow of the sacrum, from whence they may be easily extricated, by sweeping them, as it were, over the perineum. If this operation be performed rudely and violently, not only will there be danger of fracturing the bones, but also of lacerating the perineum. Sometimes difficulty is experienced in the delivery of the head, especially if there be any disproportion existing between its size and that of the pelvis: now, as the cord must necessarily suffer from compression when the head has descended into the cavity of the pelvis, it becomes of great importance that it be born as speedily as possible. The finger being passed into the child's month, and a little pressure made upon the lower jaw, in a direction downwards and forwards in the axis of the outlet, will assist greatly in bringing out the head from under the arch of the pubis. When the breech and the head are passing the external parts, the perineum must be carefully guarded.
Where the child is coming down in a different situation, viz. with the toes towards the mother's abdomen, then, as soon as the buttocks have passed the os externum, it is proper to grasp them with both hands, and gently to turn the body of the child, so as to place it in a more favorable position, viz. with the face to the mother's back; after which, the delivery is to be conducted according to the rules just laid down.
Presentation of the breech. This presentation is known by the prominences of the buttocks, the cleft between them, and frequently by the organs of generation being distinctly to be felt; occasionally there is also a discharge of the meconium. The most favorable position is where one of the buttocks is directed to the acetabulum, the other to the sacro-iliac junction.
Treatment. No interference is required until the breech has passed the outlet, when the same plan is to be pursued as in presentation of the feet.
Presentation of the knees is to be treated in the same manner.
Presentation of the arm or hand is known by the length of the fingers, the situation of the thumb, and the shape of the articulation! (Vide Presentation of the Feet.) Sometimes the scapula is the presenting part, the arm lying across the pelvis; in which case care ft required, or it may be confounded with the crista of the ilium. This mistake may readily be corrected by bearing in mind that the scapula is moveable, whilst the ilium is fixed.
Treatment. These presentations can only be rectified by the operation of turning the child in utero, and converting it into a footling case, by bringing down the feet; a proceeding which requires the utmost caution, or the soft parts of the mother are likely to be injured. This ought not to be commenced until the os uteri and external parts are sufficiently dilatable to allow the hand to be introduced without violence. The bladder and rectum should also be emptied; and, if the uterus be in a comparatively quiescent state, the difficulty will be greatly diminished; and hence the necessity of bloodletting and the administration of opium in cases where the female plethoric, and the womb is acting forcibly. If violence were used under such circumstances, the probability is that laceration or contusion would be the result. In women of irritable and delicate habits, the bloodletting must be dispensed with, and the opium alone trusted to.
When about to turn, the situation of the presenting hand is to be carefully noticed, whether the palm be directed forwards towards the pubis, or backwards towards the sacrum, as it will always be found pointing to that part of the uterus in which the feet are to be found. The right or left hand may then be used at the operator's convenience; the right reaching more readily the anterior, and the left the posterior part of the organ.
Before the operation be commenced, the back part of the hand and arm ought to be well smeared over with oil, lard, or pomatum, in order to facilitate its introduction. The patient is to be placed on her left side, with her buttocks close to the edge of the bed. It is but seldom, if ever, necessary to push back the presenting part into the uterus, as it generally revolves very readily when the feet are brought down. The fingers and thumb of the accoucheur should be so adjusted as to enter the vagina in a conical form, and, in the progress of the hand, the peculiar curvature, and the axes of the different parts of the pelvis through which it is passing, carefully remembered. The introduction is greatly facilitated by carrying the hand forward in a sort of zigzag manner, and not by sudden jerks. When the os uteri is reached, the membranes ought to be broken, (and this should be done in the absence of pain,) the hand at once being passed into the uterine cavity, and directed to that part in which the feet are situated; cautiously however resting, and laying the palm flatly upon the body of the child, at each renewal of the uterine efforts, If both feet can be readily found, it is better to bring them down together: but, if much difficulty be experienced in reaching the second, the child may easily be turned by laying hold of one having grasped one or both feet, they are gently to be drawn down, taking care to bring them over the child's abdomen, and not over the back; when they have passed the external orifice, the position of the child must be attended to, that the head may be brought into the pelvis in the most favorable situation for its passage through that cavity, (see Presentation of the Feet,) when there will be no further difficulty in the completion of the delivery.
The operation of turning a child in utero is much more easily performed if attempted early, before the rupture of the membranes containing the liquor amnii; for, when this escapes, the uterus contracts forcibly around the body of the child, and affords great, and in some few instances irresistible difficulties to the introduction of the hand; the child descends, and becomes so completely jammed into the cavity of the pelvis, that the operation would be attended with infinite danger to tin mother. Under such circumstances the case must be strictly watched, and, if the strength of the patient keeps up, the uterine action powerful, and, above all, if, with each returning pain, the presenting part is evidently descending, or (to use the words of the justly celebrated Dr. Haighton,) "if we find that nature shews a disposition to be upon the move," then, at any rate for a time, she may be safely trusted to; it being, under such circumstances, reasonable to presume that she will be able to complete the delivery by expelling the child in a doubled state; and, as in these severe cases the foetus is generally dead no anxiety need be entertained on its account. The death of the child is, indeed, to be re garded as favorable in these cases, for, when putrefaction has taken place, this doubling process is the more readily effected.
But, on the other hand, should the strength of the mother begin to fail, or, notwithstanding the continuance of the pains, the child remain fixed in the pelvic cavity, or untoward symptoms arise, such as marks of incipient inflammation, &c.; then it will become necessary for the delivery to be instantly accomplished by the evisceration and subsequent extraction of the foetus. Dr. Denman appears to have had great reliance upon the powers of : nature in such instances; but it is now a point of practice agreed upon by all, never to trust to her where turning can be safely performed at the full term of utero-gestation. It is well known that, at the sixth month, this process (of doubling) very readily takes place.
In presentations of the abdomen, the back, the nape of the neck, or the throat, delivery must be effected by the operation of turning.
Presentation of the funis. Although the descent of the umbilical cord into the cavity of the pelvis does not interfere with the parturient process, still, from the pressure to which it must of necessity be subjected, the circulation through it becomes interrupted, and the infant frequently perishes if nothing be done for its rectification.
Treatment. A piece of soft sponge is to be introduced into the vagina, and passed up into the uterus, the funis being carried beyond the head by pressure being thus made against it. The sponge is then to be left, which, by imbibing moisture, will so fur increase in size that it will not again descend till after the birth of the head. Where, however, there is much rigidity or irritability in the parts of generation, this plan must not be attempted, or it will be productive of great pain. The best plan in these cases is merely to place the cord in that part of the pelvis in which it will be exposed to the least pressure during the descent of the head.
It may be observed, that monstrous births are generally premature; but, should the female proceed to the full period of utero-gestation, no difference in the management of the labour will be required. The accoucheur will, in some instances, be greatly puzzled to discover the presentation.
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From Charles Waller
Elements of Practical Midwifery: Or, Companion to the Lying-in Room, 1829
