ARTIFICIAL PREMATURE LABOUR.

Perhaps the greatest improvement in operative midwifery since the invention and gradual improvement of the forceps is the induction of artificial premature labour for the purpose of delivering a woman of a living child, under circumstances of pelvic contraction, where either the one must have been exposed to the dangers and sufferings of the CÆsarean operation, or the other to the certainty of death by perforation, or at least where the labour must have been so severe and protracted as to have more or less endangered the lives of both. It consists in inducing labour artificially, at such a period of pregnancy that the child has attained a sufficient degree of development to support its existence after birth, and yet is still so small, and the bones of its head so soft, as to be capable of passing through the contracted pelvis of its mother.

History. Few improvements have met with more violent opposition, or have been more unjustly stigmatized or misrepresented, than artificial premature labour, and it redounds, not a little, to the credit of the English practitioners that they have not only had the merit of its first invention, but with very trifling exceptions, have been the great means of bringing it into general practice and repute.

To the late Dr. Denman we are under especial obligations in this respect; for, although himself not the inventor of this operation, he, nevertheless, was one of the first who widely recommended it to the profession, and actively promoted it by the powerful support of his name and writings. “A great number of instances,” says he, “have occurred to my own observation of women so formed that it was not possible for them to bring forth a living child at the termination of nine months, who have been blessed with living children, by the accidental coming on of labour when they were only seven months advanced in their pregnancy. But the first account of any artificial method of bringing on premature labour was given me by Dr. C. Kelly. He informed me that about the year 1756 there was a consultation of the most eminent men in London, at that time, to consider of the moral rectitude and advantages which might be expected from this practice, which met with their general approbation. The first case in which it was deemed necessary and proper, fell under the care of the late Dr. Macauley, and it terminated successfully.[102] Dr. Kelly informed me he himself had practised it, and among other instances mentioned that the operation had been performed three times on the same woman, and twice the children had been born living.” (Denman’s Introduction to the Practice of Midwifery, 2d ed. vol. ii. p. 174.) Since this the observations of Mr. Barlow, Dr. Merriman, Mr. Marshall, Drs. J. Clarke, Ramsbotham, &c. &c., have afforded an ample body of evidence in its favour, and have, we trust, tended not a little to diminish the frequency of perforation. On the Continent it experienced a very different reception, being regarded as immoral, barbarous, and unjustifiably endangering the life of the mother and her child. In France, although at first successfully adopted by a few practitioners, (Sue,) its farther progress was completely stopped by the powerful opposition of Baudelocque, and by the plausible though erroneous objections which he made against it. A similar course was pursued by Gardien and Capuron, and even by the celebrated Madame la Chapelle, all of whom have taken a singularly incorrect view of it and assign it a totally different object to that which is intended: the very name which they have given to it of Avortement artificiel, plainly shows how little they have understood of its real character.

Among his objections, Baudelocque states, that “the neck of the uterus at seven months has seldom begun to open; it is still very thick and firm. The pains, or the contractions of that viscus, cannot then be procured but by a mechanical irritation pretty strong and long continued; but those pains, being contrary to the intentions of nature, often cease the instant we leave off exciting them in that manner. If we break the membranes before the orifice of the uterus be sufficiently open for the passage of the child, and the action of that viscus strong enough to expel it, the pains will go off in the same manner for a time, and the labour afterwards will be very long and fatiguing; the child deprived of the waters which protected it from the action of the uterus, being then immediately pressed upon by that organ, will be a victim to its action before things be favourably disposed for its exit, and the fruit of so much labour and anxiety will be lost. Premature delivery obtained in this manner is always so unfavourable to the child, that I think it ought never to be permitted except in those cases of violent hÆmorrhage which leave no chance for the woman’s life without delivery; the nature of the accident also disposes the parts properly for it.” (Baudelocque, transl. by Heath, § 1986, 1987.) All this plainly shows that Baudelocque did not rightly understand the real objects and nature of artificial premature labour, to which, in fact, his objections do not apply, but to the accouchement forcÉ of the French practitioners, where, on account of the sudden accession of dangerous symptoms, such as hÆmorrhage, convulsions, &c. &c., the os uteri was rapidly and violently dilated by the hand, which was then passed into the uterus, the feet seized, and the child forcibly delivered, an operation which is now rarely performed in Germany and never in this country.

The celebrated Carl Wenzel, of Frankfort, was the first in Germany who declared himself in favour of the operation. Kraus and Weidemann followed, the former two having performed it with complete success. The favourable results also in the hands of English practitioners and its increasing reputation quickly silenced the virulent abuse which was levelled at it by Stein, jun., and some other German authorities; the celebrated Elias von Siebold, of Berlin, who had first opposed it, candidly confessed his error and became one of its earliest supporters. Increasing experience showed that it could scarcely be looked upon as a dangerous operation for the mother, and that in by far the majority of instances it was also successful as regarded the child. Professor Kilian, in his work on operative midwifery, has collected the results of no less than 161 cases of artificial premature labour. (Operative GeburtshÜlfe, erster band, p. 298.) Of these, 72 occurred in England, 79 in Germany, 7 in Italy, and 3 in Holland: of these cases, 115 children were born alive and 46 dead; of the 115 living children, 73 continued alive and healthy; 8 of the mothers died after the operation, but of these, 5 were evidently from diseases which had nothing to do with the operation.

The most unfavourable circumstances under which the operation can be undertaken are, where the child presents with the arm or shoulder: here it will require turning, which, in many cases, owing to the faulty form and inclination of the pelvis, cannot be effected without considerable difficulty, and greatly diminishing the chances of the child being born alive. With this exception we cannot see why it should not be as favourable as labour at the full term of pregnancy; it is far less dangerous than other species of premature labour, for the hÆmorrhages, which are so apt to attend them, are never known to occur here.

This mode of delivery has not only been proposed in cases of contracted pelvis: “There is another situation,” says Dr. Denman, “in which I have proposed and tried with success the method of bringing on premature labour. Some women who readily conceive, proceed regularly in their pregnancy till they approach the full period, when, without any apparently adequate cause, they have been repeatedly seized with rigour and the child has instantly died, though it may not have been expelled for some weeks afterwards. In two cases of this kind, I have proposed to bring on premature labour, when I was certain the child was living, and have succeeded in preserving the children without hazard to the mothers.” (Introduction to the Practice of Midwifery, 2d ed. vol. ii. p. 180.)

Period for performing the operation. Although under the head of Premature Expulsion we have stated that a foetus is capable of maintaining its existence if born after the twenty-eighth week of pregnancy, we must not be supposed to recommend the artificial induction of premature labour at so early a period as this. “Experience has shown that it was not necessary to induce labour at so early a period as was first imagined, on account of the very great difference which even one or two weeks are found to make in the hardness of the foetal skull. Thus, for instance, in cases where the antero-posterior diameter was only three inches, six weeks before the full term of utero-gestation were found sufficient, and where it was three inches and a half, fourteen days made sufficient difference.” (NaegelÉ, MS. Lectures.) Still, however, as it is so difficult to be quite sure of the data upon which we have made our reckoning, it will be safer to fix the operation a week or two earlier; and if we lose a little time by failing in our first endeavours to induce uterine action, it will be of so much the less consequence: hence, therefore, as a general rule, the most eligible time will be between the thirty-fourth and thirty-sixth week; and if the deformity be very considerable, we may commence operations as early as the thirty-second week or two months before the full term, short of which it will seldom either be justifiable or necessary. On the other hand, where the state of the cervix and the history of her pregnancy combine to make our reckoning nearly a matter of certainty, the later we can safely delay the operation the better, for by so doing the process resembles more a natural labour, and the chances in favour of the child are much increased.

Operation. The original mode of artificially inducing premature labour was merely by puncturing the membranes and allowing the liquor amnii to escape; the more gradually this is done the better, for by this means the uterus is not entirely drained of its fluid contents, and is, therefore, prevented contracting immediately upon the child; the value of this precaution was pointed out by the late Dr. Hugh Ley, and also by Wenzel. A considerable interval may elapse between puncturing the membranes and the first contractions of the uterus, generally varying from forty to eighty hours: it should be performed while the patient is in the horizontal posture, in order to prevent the escape of too much liquor amnii. A moderately curved male catheter, open at its point and carrying a strong stilet sharpened at the end, is the best and simplest instrument for the purpose: on passing it up to the membranes, the stilet should be protruded, but to a short extent, to avoid injuring the child; and as soon as the liquor amnii runs from the other end, the instrument should be withdrawn, and the patient desired to remain quiet. A dose of opium has been usually given after the operation by the English practitioners, but its utility appears rather questionable: a brisk purge of calomel and jalap, some hours previously, is much more important; uterine action comes on much more regularly and effectively, and there will be much less chance of those rigours occurring which some practitioners, although erroneously, have supposed, were connected with the death of the child.

The practice of dilating the os uteri first, as recommended by BrÜninghausen, Kluge, and others, has, as far as we know, never been attempted in this country, and resembles much too closely the accouchement forcÉ of the French authors ever to be permitted.

The simplicity of the operation of tapping the membranes has rather led practitioners to overlook a still greater improvement, viz. the inducing uterine action first: this was proposed by Dr. Hamilton to be effected by passing up a catheter, and separating the membranes from the uterus to a considerable distance above the os uteri. The operation certainly succeeds in some cases; but our own experience goes to prove, that in the majority it is not sufficient by itself to provoke uterine contraction, and in order to ensure success we must combine with it other means.

The plan of treatment which we have found most certain is first to clear out the bowels by a full dose of calomel and colocynth, then to give the patient a warm bath, in which she may remain twenty or more minutes, after which the abdomen should be well rubbed with stimulating liniment as she lies in bed, and the secale cornutum given in doses of a scruple of the powder in cold water, repeated every half hour for five or six times. Contractions of the uterus rarely fail to follow, and although they generally require the secale to be renewed after a few hours, they will be found to have effected several very important changes preparatory to actual labour;—the abdomen has sunk, the fundus is lower, the cervix is shorter or has disappeared, and not unfrequently we feel the head has already passed the brim and is now in the cavity of the pelvis; the vagina and os uteri are lubricated with a copious secretion of remarkably pure and albuminous mucus; and in these cases especially, we frequently meet with those little lumps of inspissated mucus which were formerly called the ovula Nabothi. All these precursory changes are so many preparations of nature for a natural labour, and contribute not a little to the successful termination of the case, advantages which cannot be enjoyed where the membranes have been previously ruptured. If, however, we do not succeed in producing more than a slight dilatation of the os uteri, if the repeated exhibition of the ergot only produce vomiting, or constant pains which have no other effect beyond preventing rest and inducing exhaustion, the separation of the membranes from the uterus, as proposed by Dr. Hamilton, will now have the best effects: even if this fail and we are compelled to puncture the membranes, it will now be performed under so much more favourable circumstances, from labour having already commenced to a certain extent.

A warm bath and the other usual means for recovering the child should be in readiness. In most cases the secretion of milk follows as after labour at the full term, which is a great advantage; for the thin watery secretion of this early period is much better adapted to the weak digestive organs of the premature child. It is frequently a matter of some difficulty under these circumstances to make a child take the breast at first, and this is the chief reason why their digestive organs so soon become deranged. “In case no milk be present, a good substitute may be made by beating up fresh eggs and milk, boiling them over a gentle fire and straining off the thin fluid.” (Reisinger, die kÜnstliche FrÜhgeburt.)

One great encouragement in cases requiring this operation is the fact that in every successive pregnancy the uterus is more easily excited to premature action; and in some cases where it has been induced several times, it has at length, as it were, got so completely into the habit of retaining its contents only up to a certain period, that labour has come on spontaneously exactly at the time at which in the former pregnancies it had been artificially induced.[103] We have already alluded to this circumstance in the chapter on Premature Expulsion of the Foetus.[104]