SIGNS OF THE DEATH OF THE FŒTUS.

Well has the celebrated Mauriceau observed, “S’il y a occasion oÙ le chirurgien doive faire plus grande reflexion, et apporter plus de prÉcaution aux choses qui concernent son art, c’est en celle oÙ il s’agit de juger si l’enfant qui est dans la matrice est vivant, ou bien s’il est mort.” There are few circumstances more painful to the feelings of an accoucheur, than the uncertainty as to whether the child be alive or dead, in a labour where the passage of the head is rendered unusually difficult or dangerous for the mother, even with the aid of the forceps; whether the difficulty be produced by want of proportion between the head and pelvis, unusual rigidity of the os uteri, &c. Could he assure himself that it was alive, he would feel justified in either trusting still longer to the efforts of nature, or in applying the forceps, even although he knows that the delivery cannot be effected without considerable difficulty and suffering: whereas, if he could once feel satisfied that the child had ceased to exist, he would have recourse to perforation, for the purpose of diminishing the size of the head, and thus releasing the mother from the dangers of her situation.

The increasing success which has attended the CÆsarean operation of late years, adds still more to the importance of having the signs of the child’s life or death in utero carefully investigated and understood; for, under such circumstances, it becomes a most serious question whether we are always justified in destroying the life of the foetus by perforation, when we might in all probability have saved it by resorting to another means of delivery, which, formidable as it is, is now infinitely less so than it was in former times. It becomes a question whether we ought not, in certain cases to adopt the same indications for performing the CÆsarian operation, as are used upon the Continent, and apply it not only to those cases where the child cannot be delivered par vias naturales, but also in those cases of minor pelvic obstruction, where, if we could feel sure of the child’s death, we should have recourse to perforation. Under circumstances of this nature, the question becomes one of fearful responsibility, the painfulness of which is not a little increased by the uncertainty as to whether the child be alive or not. Mauriceau was the first author who devoted a chapter expressly to the consideration of this subject, and those few who have done the same since his time, have borrowed largely from his observations.

A great number of symptoms have been enumerated as indicating the child’s death in utero, but for the most part they are deserving of very little confidence, frequently occurring where the result of labour has shown the child to be alive and strong, or vice versÂ. The most practical arrangement of these symptoms will, we think, be under the two following heads: those which occur before labour, and those which occur during labour.

The symptoms of the child’s death, which are usually enumerated as occurring before labour, are, cessation of the child’s movements; the abdomen undergoes no farther increase of size, but rather diminishes; the uterus has no longer the tense elastic feel of pregnancy, but becomes flaccid and moveable; the patient has a sensation of coldness and weight in the abdomen, so that when she turns from one side to the other, she feels as if a heavy weight rolled over to that part of the abdomen which is lowest; the breasts are flabby, and sometimes there is a fetid slimy discharge from the vagina. These changes are accompanied by some or all of the following symptoms: the patient is seized with a sudden shivering, languor, and debility; she loses her appetite and spirits; the stomach and bowels become disordered; the breath is fetid, and the face pale, sallow, and of a dark leaden colour under the eyes. All these symptoms taken collectively will enable us to decide, with a tolerable degree of certainty, that the child is dead: but scarcely any of them alone can be trusted to. The most trust-worthy is the sensation of a heavy weight rolling about the abdomen: when the female turns in bed, rises from her chair, or in any way alters her position, this weight is felt as it were tumbling down to that side which is lowest. A woman who is pregnant with a living child, feels nothing of the sort; she may even dance or jump, and yet she feels no more of a living foetus than she does of her own liver or spleen. The living foetus obeys the laws of organic life; the dead foetus those of gravity. When once the child has ceased to exist, it acts like any other mass of inanimate matter, and pushes the uterus down to that side which is lowest.

In most instances this symptom will be sufficient to make us suspect that the child is dead, but it now and then occurs where the result of labour proves the child to be alive; this must rather be looked upon as an exception to the rule, for it is not of frequent occurrence. We have observed it in two or three cases: it has been also noticed by Dr. E. Kennedy, (op. cit.;) and, therefore, cannot invariably be looked upon as a certain sign of the child’s death. We have observed it frequently in cases threatening abortion at an early period: in many it has been followed by premature expulsion, but in others the symptom has gradually disappeared as the health improves, and the patient has eventually been delivered of a living child at the full period.

In these cases, we should rather attribute the source of this symptom to a loss of the firmness and tone peculiar to the uterine parietes during pregnancy, and which depends upon the increased activity of the circulation in them at this period: when this is considerably diminished, the uterine parietes will necessarily become more flaccid, and, therefore, less able to withstand the influence of gravity, or sustain the uterus in its proper situation. The embryo itself during the first two or three months is too small and too light to produce this symptom itself.

The sensation (to the mother) of the child’s movements is as fallacious an indication of the child’s life as it is of pregnancy; nor can the absence of this sensation be looked upon as a proof of its death. Women are very liable to be misled in this respect; so much so, that it will be much safer for the practitioner never to allow his diagnosis to be at all influenced by their statements; the more so, as it applies equally to mothers of large families as to primiparÆ. Thus cases every now and then occur where the patient declares her conviction that the child is dead; that she has not felt it move for several days before labour; that she feels altogether differently to what she did in any of her former pregnancies, and yet she is delivered of a healthy living child. On the other hand, we as frequently meet with cases where, up to the very commencement of labour, the patient asserts that she has distinctly felt the motion of the child, and yet she brings forth a child in such a state of decomposition as proves beyond all doubt that it must have been dead some eight, ten, or more days.

As the sound of the foetal heart is the surest sign of pregnancy, so it is an equally certain proof of the child’s life: but is the absence of this sound, a certain symptom of its death? at the best it is a negative evidence, and the value of it must entirely depend upon the skill of the ausculator and the care with which he makes his examination. If, after repeated and careful auscultation of the abdomen, the well-practised ear can no where detect a trace of the foetal pulsations, it may be asserted on very safe grounds that the foetus has ceased to live. This is more particularly the case during the last weeks of pregnancy, when the pulsations are stronger, and the bulk of the child, in proportion to that of the liquor amnii being absolutely, as well as relatively, greater. The distance between the heart and surface of the abdomen is less during the last weeks of pregnancy also; the child’s movements are not so free as at an earlier period; and hence, if the foetal heart is beating, it will be more easily discovered.

The uterine souffle affords us little aid in the diagnosis of the child’s death: it is frequently very distinct when the child is evidently alive; and where it has been heard previous to its death, it will continue for some hours afterwards, although with diminished strength and over a smaller space.

During labour there are a variety of symptoms, by the aid of which we can pronounce, with a very tolerable degree of certainty, whether the child is alive or not; if alive, the foetal heart can invariably be detected; and, for the reasons above stated, will be heard more distinctly than in the earlier months of pregnancy. If, from the violence or duration of the labour, or any other cause, the child is becoming exhausted, the pulsations become weaker and slower until they stop; so that by the aid of auscultation we possess distinct evidence of the child’s life being endangered, and of its complete extinction.

If the head presents during labour, a firm elastic swelling (caput succedaneum) will rise on that portion of it which first enters the vagina: this is produced by the circulation in the presenting part of the scalp being obstructed by the pressure which the os uteri and vagina exert upon it, an effect which can only be produced upon the head of a living child: where, on the other hand, the child is dead, the scalp will be felt to be soft, flabby, and without swelling. This may be looked upon as a very certain proof of the child’s death in primiparÆ, where the head is advancing slowly, and where it is tightly encircled by the distended vagina. But in multiparÆ, where the soft passages have been dilated by repeated labours, the pressure upon the head is so slight, and its passage through them so rapid, that little or no swelling is produced: even in these cases the finger of the accoucheur will easily distinguish the head of a dead child by the loose yielding flabby feel of its integuments; the cranial bones are more moveable, and overlap each other at the sutures more than usual; their edges feel sharp, as if no longer covered by the scalp; and frequently communicate a grating sensation when they rub against each other. The great fontanelle is flaccid and loose; the bones, which form it, appear falling together, from a want of sufficient contents to keep them asunder, a circumstance which probably arises from the circulation in the brain having ceased; and in those cases where the child has already been dead some time, a crackling or crepitous sensation is communicated to the finger from emphysema, the result of decomposition.

The only case in which the swelling of the head is capable of misleading us, is in lingering difficult labours, where the child has been alive at the beginning, the swelling has formed, but from the duration and severity of the labour the child has died: wider such circumstances, a dead child may be born with the usual swelling of the cranial integuments which is observed in a living child. This can only happen where it has been expelled almost immediately after its death, for in two or three hours the swelling loses its former firm tense feel, and becomes so soft and flaccid, as not to be easily mistaken.

If the face presents during labour, the flabby state of the lips will instantly lead us to suspect that the child is dead: the tongue is also flaccid and motionless. Whereas, in a living child the lips are firm and full; if the face be approaching the os externum, a considerable swelling will be felt on that side which presents; the tongue is firm, and frequently moves upon the finger.

If the nates present, the state of the sphincter ani will be a sure guide in ascertaining whether the child be alive or not. If it be alive, it will be found closed, and will contract distinctly upon the finger; whereas, if dead, it will be relaxed, and insensible to the stimulus of the finger.

In an arm presentation, where the child is alive, the arm will swell, and grow livid or nearly black; but if it be dead, no swelling will be observed, the arm will be very flabby, and where it has been dead some time, the epidermis will peel off. In this case, as in head presentations, the date of the child’s death will more or less modify these appearances; if it has not taken place until some time after the commencement of labour, a dead child may be born exhibiting the swelling and discolouration above-mentioned. The pulse in the wrist of the prolapsed arm is no guide, as the very degree of pressure, which produces these changes in its appearance, will be generally sufficient to render it imperceptible.

In cases where the cord has prolapsed, we have certain evidence with respect to the child’s life: if alive the cord is firm, turgid, and distinctly pulsating; if dead, it is flaccid, empty, and without pulsation.

Fetid liquor amnii, and the discharge of the meconium, have also been enumerated as signs of the child’s death, which occur during labour. The first affords no proof whatever, as cases not unfrequently occur in which the liquor amnii is excessively fetid, and of a thick slimy consistence, and yet the child is born alive and healthy.

The appearance of meconium during labour is a suspicious sign where the nates do not present, and will at any rate justify the supposition, that if the child be not actually dead, it is very weakly; in nates presentations, however, this will not hold good, for the meconium is constantly discharged during labour, where the child is in this position, and yet it will be born alive and well.