PRECIPITATE LABOUR.

The second division of Dystocia comprises those species of labour where it becomes dangerous for the mother or child, without obstruction to its progress. Of these we shall first consider precipitate or too rapid labour, not only because it is liable to be followed by a great variety of injurious results, but also because it has received little or no notice by the obstetric authors of this country.

Precipitate labour depends on one of two conditions; either the expelling powers exceed their ordinary degree of activity, or the resistance to the passage of the child is less than usual. “Every normal labour has a certain course, which is neither too slow nor too quick. The passages are thus dilated gradually and without excessive suffering; the uterus is felt alternately hard and soft; and the pains have certain and regular intervals, which become very gradually shorter, during which both mother and child are enabled to recover themselves.” (Wigand, Geburt des Menschen, vol. i. p. 68.)

Violent uterine action. In the present case the pains are extremely violent from the very commencement of the labour; they produce great suffering; each pain lasts a considerable time, and the intervals between them are very short. During their presence, the patient is irresistibly compelled to bear down and strain with all her force; the whole body partakes of the general excitement: the patient is more restless and less manageable than usual, her manner is altered and becomes strange; the head is hot, the face flushed, and the pulse quick and full.

In some cases the intervals between the pains are scarcely perceptible, for one pain has scarcely left off before the next has already commenced; or the uterus falls into a state of continued violent contraction, which does not cease until the child is driven into the world. The abdomen is very hard during the pain, the whole body stiff and rigid; the patient expresses her sufferings very loudly, or actually raves with pain. From the constant and irresistible effort to strain, it seems as if she has scarcely time to get her breath, for she continues to hold it so long that respiration might be almost supposed to have stopped altogether. “As long as consciousness remains, the impulse to lay hold of any object within reach and pull by it is extraordinarily strong, until at length, in the midst of a violent scream, or grinding of the teeth, covered with sweat and with simultaneous evacuation of the rectum and bladder, she is suddenly delivered.” (Wigand, op. cit. vol. i. p. 71.)

Causes. This storm of uncontrollable uterine action “appears to depend upon an unusually powerful influence of the nervous system upon the contractile fibres of the uterus or upon a morbid degree of irritability.” (Ibid.) In some cases it appears as an individual peculiarity, every successive labour of the patient being remarkable for its violence and rapidity. Precipitate labours of this kind are frequently observed to be hereditary, and like an opposite and equally faulty condition of the expelling powers, viz. slow and lingering uterine action, are sometimes peculiar to certain families, the mother and the sisters of the patient having had all their labours peculiarly rapid and violent.

The character of the catamenial periods before pregnancy is frequently observed to bear a considerable relation to that of the labours in the same individual; thus, if she has always suffered much pain and other symptoms of uterine excitement just before or during these times, so much so as even to require slight medical treatment to allay the periodical suffering, the uterus almost invariably manifests a similar degree of energy and irritability during labour. On the other hand, where the menstrual periods produce so little suffering or derangement that, but for the appearance of the discharge itself, the patient has scarcely any means of determining their recurrence, the uterus betrays a similar want of activity when labour comes on, which may therefore, cÆteris paribus, be expected to be slow and lingering.

Mental affections, which we have already shown to be capable of retarding labour, occasionally have the opposite effect, and rouse the uterus to violent action. It is well known that the dread of the forceps, which the practitioner has declared would be required, has frequently been followed by so much activity of the uterus as to render its application unnecessary.

Where the patient is stout, robust, and plethoric, or of a nervous hysterical habit, this state of unruly uterine action is frequently attended with great cerebral excitement; during the pains she raves wildly, and for some time becomes quite unmanageable, or in other cases this state passes into actual convulsions.

In febrile diseases, especially of the eruptive kind, the labour is usually of this character; the exertions of the uterus in such cases, especially in scarlet fever, are sometimes quite extraordinary, so that the child seems to be born without any effort on the part of the mother. This is of great importance in inflammation of the lungs, &c. where the patient would be unable to inflate the lungs to that extent which is necessary for any violent efforts.

Deficient resistance. Where the rapidity of the labour arises from want of that degree of resistance to the expelling powers which is natural, it may depend on circumstances connected with the mother or the child; thus, it may arise from too large a pelvis; the head, covered by the inferior portion of the uterus, is forced down deeper into the pelvis than usual, especially if, as is not unfrequently the case, this state be accompanied with violent and powerful pains; the head may thus be actually forced through the os externum before it has passed the os uteri: cases have been recorded where nearly the whole uterus, has been thus protruded. In an “extraordinary case,” as Deventer justly terms it, “the head of the child had passed the os externum as far as the shoulders, and only the summit of it was visible, three-quarters at least of the head being still enclosed in the uterus, although the head and neck had already passed.” (Novum Lumen, part. ii. chap. 3.)

In other cases the sudden expulsion of the child appears to depend merely upon the great dilatability of the soft parts, and may occur quite independently of any disease. We recollect a case of this sort where the patient, a healthy woman, had only two pains—the first awoke her out of a sound sleep and ruptured the membranes, the next drove the child with great violence into the bed. Where the patient is weakened by previous disease, and the soft parts are very relaxed and flaccid, they produce no resistance to the advance of the head: this condition is very unfavourable, “as it implies a greater state of relaxation, or want of tone, than is compatible with the welfare of the patient: hence it is seldom found to take place except when the unfortunate subject is sinking under the last stage of debility, as in phthisis,” &c. (Power’s Midwifery, p. 138.)

The want of due resistance to the expelling powers may depend upon the size and hardness of the head; it is either smaller than usual, from the child being premature, or, if of the full size, the cranial bones are imperfectly ossified, the sutures are wide, the fontanelles large, and the whole head very yielding and soft; or it may depend on some congenital defect, in which the brain and cranial coverings are more or less imperfect.

In the ordinary cases of precipitate labour the case depends generally on a complication of violent pains, wide pelvis, and small child.

Effects of precipitate labour. Besides the mischief which may result from the rapid expulsion of the child causing prolapsus uteri, laceration of the vagina, perineum, and hÆmorrhage from inertia coming on in consequence of the uterus being so suddenly emptied, dangerous syncope, or even asphyxia, may follow from the shock which the nervous system has sustained, or in consequence of the sudden removal of that degree of pressure which the gravid uterus had exerted upon the abdominal circulation during pregnancy. Where the patient has been very unruly, and has exerted herself with great violence, “emphysema of the face and neck (says Dr. Reid) may suddenly occur during labour, and cause great alarm to a young practitioner, as it alters and disfigures the countenance in an extraordinary manner. Great straining or screaming may produce it, and it probably depends on some partial rupture of the lining membrane of the larynx. I have seen two or three cases of this description, and one which occurred to a great extent in the case of an out-patient of the General Lying-in Hospital, in whom this tumefaction spread to the shoulders and chest.” (Manual of Pract. Midwifery, by James Reid, M. D. p. 231.)

The child also may suffer from a precipitate labour, where the pains are excessively violent and run into each other, so that the whole labour is effected during one continued storm of uterine action. If the membranes have given way at an early period, so that the body of the child is exposed to the immediate pressure of the pains, the abdominal circulation suffers, and the child is destroyed in the same way as by pressure on the cord itself; or it may be suddenly dashed upon the floor before the mother has had time to reach her bed, or even put herself in a recumbent posture upon the floor: in this way it may receive a severe injury upon the head, or the cord may be lacerated, and the child die from hÆmorrhage before assistance can arrive: such accidents, however, are not so dangerous to the child as have been supposed, a fact which has been proved by medico-legal investigations. The direction of the pelvic outlet and vagina is such as to expel the child obliquely downwards and forwards when the mother is in the upright posture, so that the force of the blow is in a great measure broken by this circumstance; the head also, as well as the other parts of the body, are soft and yielding, and nearly preclude the chances of injury taking place; the violence of the fall is generally diminished in some measure by the patient being almost always compelled to drop upon her knees at the moment of great suffering, whilst the child is passing; her clothes also surround it more or less, and thus shield it from any severe injury.

Rupture of the cord. The cord is liable to be torn in these cases, showing that a considerable jerk had been applied to it, but neither the child nor its mother have suffered from it. Ten or twelve cases of ruptured cord have come to our own immediate knowledge, and in none of them were any unfavourable effects produced. It can scarcely be imagined possible that so much force could be applied to the cord, at the moment when the uterus is so suddenly evacuated, without inversion or prolapsus being the almost unavoidable result, the more so when we recollect that the cord at the moment of birth requires considerable force to break it. This circumstance may be partly attributed to the firmness with which the uterus contracts at the moment that the child is expelled, but chiefly to the fact that the axis of the brim is nearly at right angles with that of the outlet, more especially if the fundus, as is usually the case, is inclined somewhat forwards; the cord passes round the posterior part of the symphysis pubis as upon a pulley, so that a considerable portion of the force which is applied to it, is spent here before reaching the fundus uteri. It is however remarkable, that the umbilicus of the child should receive no injury from a jerk which breaks the cord, when, if we try afterwards to break the remaining pieces of the cord, we find that it will resist very powerful efforts: this fact, and the circumstance that the cord usually ruptures at about two or three inches from the umbilicus, as in some animals, seems to imply that this part is weaker than elsewhere, as if intended by nature to give way with a moderate degree of force.

Wigand considers that patients are particularly disposed to have quick labours, who are of a scrofulous, rheumatic, or arthritic diathesis; that such patients are very liable to have adhesion of the placenta after the birth of the child, with hour-glass contraction: the observation, however, has not been confirmed by the experience of others, and certainly not by the cases which have come under our own notice.

Treatment. Where, from the smallness of the child or unusual size of the pelvis, the pains are forcing the lower portion of the uterus down to, or through, the os externum, it will be necessary to support it carefully, until the os uteri is sufficiently dilated to let the head pass. A case of this kind occurred to Professor NaegelÉ, of Heidelberg, where, during the patient’s former labour, the pains had been so violent, and the uterus had been detruded to such an extent, that actually the lower half of it appeared between the labia: to prevent a similar accident occurring this time, (as the pains were beginning to show the same disposition to violent action as before,) he applied a broad T bandage very firmly upon her, coming over the os externum, so as to prevent the uterus being prolapsed beyond the labia; he cut a hole in it corresponding to the vagina, and the child was born through this with perfect safety to the mother.

Where we have sufficient warning, opium in effective doses will probably assist in lulling the irritability of the uterus: if the bowels have been previously well opened, an opiate enema will be desirable; if not, a large emollient enema should be premised.

The patient should be made to lie upon her side, and not only strictly forbidden to resist to her very utmost, the urgent impulse which she feels to strain and bear down, but must carefully avoid even holding by or pushing against any fixed body with her hands or feet. Still farther, to quiet the turbulence of the abdominal muscles, a broad bandage should be fastened firmly round the abdomen; it not only gives the patient a comfortable feeling of support, but tends greatly to calm the spasmodic irritability of these muscles. These precautions will be of so much more service if they can be used early, as in cases where we have been already warned by the character of her previous labours: we can thus avoid the premature rupture of the membranes, which is a thing by all means to be avoided; the uterus acts with increased power where its bulk has been diminished by the escape of the liquor amnii, and at the same time becomes still more irritable and unruly from contracting immediately upon the child; and not only is there imminent danger of its giving way in some part, but the child is almost inevitably destroyed by the violence of the pressure to which it is exposed.

In cases where the vehemence of the expelling powers appears to be quite beyond our control, Wigand has recommended a copious bleeding to complete syncope as the only means; in which suggestion, he has been followed by Froreip: neither of these authors, however, appear to have had any experience of this mode of treatment, and knowing how much more active the uterus becomes after a smart bleeding in ordinary cases, and how powerfully the state of syncope promotes the dilatability of the soft parts, we should hesitate exceedingly to employ so doubtful a remedy. Wigand also proposes, in cases of this desperate nature, to use effusion with ice-cold water to the abdomen and lower extremities, and by this powerful species of counter-irritation, produce a temporary calm for a few minutes—a measure we should fear of as doubtful a character as bleeding.

Connexion of precipitate labour with mania. Lastly, we may observe, that the subject of precipitate labour involves a medico-legal question of great importance and interest, which has as yet excited little or no notice in this country, viz. as regards acts of child-murder after labours of this character. The state of mental excitement and frenzy into which a patient is brought, by a labour of such violence and suffering, in many cases falls little short of actual mania. We now and then meet with instances, where, for the first half hour or so after a severe and rapid labour, the patient takes a most insurmountable antipathy to her child, and expresses herself towards it in so unnatural a manner, as to contrast strangely with the tender and affectionate feelings which she had a short time previously expressed for it. Cases have occurred where the patient has been without assistance, during labour, and where, in a state of temporary madness from mental excitement and pain at the moment of the child’s birth, she has committed an act of violence upon it, which has proved fatal; a circumstance, which, from obvious reasons, would be more liable to occur with single than with married women. These cases have been very carefully investigated in Germany of late, and in many of them the patient has been, we think, very properly acquitted, on the grounds of temporary insanity, having herself voluntarily confessed the act with the deepest remorse, at the same time declaring her utter incapacity to account for the wild and savage fury which seized her at the moment of delivery.