CHAPTER I.
DIAGNOSIS OF PREGNANCY.

A few of the early signs of pregnancy are not made available to the physician ordinarily when his opinion is demanded. A woman is naturally unwilling that her physician, if he be a man, should make even a digital examination, and this makes it more necessary that the nurse should know all the rational signs.

One of these signs is the changed color of the mucous membrane of the vagina and labia. This membrane is of a pale red color, but it becomes of a violet hue during the time of menstruation, and if a woman becomes pregnant, the violet or deep red color becomes continuous.

There is also, even in the commencement of pregnancy, a peculiar odor to the secretion from the vagina and os uteri, which has been compared to that of the vernix caseosa.

There is no sign of pregnancy by which we can always distinguish it in its early stages; in some instances nearly all the rational signs are absent. The general condition of a pregnant woman is changed in a greater or less degree, but all are not changed alike.

Generally she is plethoric, the pulse is fuller and quicker; the quantity of circulating fluid is augmented, the quality altered by the increase of fibrine; but these changes are not always obvious. Well marked sympathies are excited in various organs; the nervous system may suffer especially; the woman’s temper and disposition may change; she may become capricious, may have likes and dislikes in eating, especially if her digestion is weak; there may be loss of appetite, heartburn, increased flow of saliva, toothache, excitability of mind, sleepiness, etc.; but even when many of these symptoms are present, even when the liver and kidneys are affected, so that the skin is sallow or discolored in patches, and irritability of the bladder causes much pain and distress, these various signs may only furnish a sum of probabilities amounting almost to certainty.

In some cases of pregnancy the skin, instead of becoming sallow, is more florid, with occasional eruptions on the face.

Some women become fat during pregnancy; others lose flesh; their faces, in the early months, are pinched and pointed, and their features altered.

Milk in the breasts, especially in the first pregnancy, is a sign which is said to be reliable; but it is true of some women that, during their period of menstruation, their breasts enlarge; there is a sensation of fullness, with throbbing and tingling pain in them, and that a milk fluid may be secreted; the same symptoms that are present with others at the second month of pregnancy.

Another change is a more marked sign in the breasts. There is at first a soft and moist state of the skin, and the little glandular follicles around the nipples are bedewed with a secretion. This may often be seen at the second month, and it may also be noticed that the veins of the breast look more blue, and that the breasts themselves are firmer and more knotty to the touch.

There are, however, other signs which are more to be depended on than these that have been mentioned.

Females cease to be regular during pregnancy. A healthy married woman, during the period of child-bearing, bases her prediction upon this sign, and is seldom disappointed. But women are not all healthy; disease and disorder of the womb, or other organs of the body, especially of the lungs, may cause suppression of the catamenia; and, on the other hand, the discharge may recur for several months after conception, or even monthly during the period of utero gestation; and, in anomalous cases, some young married women, who had hitherto been quite regular, ceased to menstruate for several months without any known cause.

Morning sickness is one of the earliest signs of pregnancy, as it often occurs within two weeks. The nausea may be slight or it may be very distressing; it may happen to be soon relieved, but it usually continues for three or four months or longer. It varies also as regards the time of day during which it continues to be bad; but if it recurs at the regular time and in the regular manner, it is of great value as an evidence of pregnancy, when combined with other symptoms.

A dark brown areola around the nipple may usually be noticed at the end of the second month; this is a distinguishing sign, especially if it be a first pregnancy. A month or two later, the dark color is more obvious, and it is darker in persons with dark hair, etc. It may be described as being a dark circle, somewhat swollen, or with a puffy turgescence, both of the nipple and the surrounding disk; the surface of the areola studded over and rendered unequal by the prominence of the glandular follicles, the integument covering the part soft and moist; sometimes small mottled patches, of a whitish color, scattered over the outer surface of the areola, and for about an inch all around it.

These marks are quite plain at the fifth month, and at six months a number of silvery streaks may be observed.

Quickening is one of the most important signs of pregnancy, and occurs about the fourth or fifth month; not because the child is then first alive, but because the womb then rises higher in the abdomen, and because the child has reached a further state of development. Quickening is a proof that the woman is near half her time gone; though it may happen that the sensation is observed as early as the third or fourth month, instead of at four and a half months. In some cases women do not know the time when they quicken, as only a slight sensation is felt; this some compare to the fluttering of a bird. But a lady may at that time be faint, or giddy, or sick, though there seemed to be nothing more than a mere pulsation. Subsequently, however, the movements become stronger and more frequent. The motions of the child may be felt by a third person on placing the hand on the woman’s abdomen, especially if the person’s hand be cold. I have known one case in which, by placing my hand on the woman’s abdomen, I caused motions which simulated active movements of the child, although there was no foetus present.

Increased size and hardness of the abdomen is characteristic of pregnancy. Enlargement of the abdomen may be from flatulence, but such enlargement is not persistent; the belly is large one hour and small the next, and on pressing the bowels firmly, a rumbling of wind may be heard, which perhaps may move about, and on percussing (tapping) the part, a hollow sound may be elicited, as from a drum. A large abdomen may be due to fat, but there is a soft and doughy feeling that is characteristic of fat. On the contrary, in pregnancy, hardness, solidity and resistance to pressure characterize the gravid uterus, and the enlargement is not only persistent, but gradually increasing. It is true that when a very fat woman is pregnant, percussion or palpation of the abdomen may be fruitless, and any certain diagnosis cannot be made, but in most cases, if we are careful to observe these conditions, and also whether there is a distended bladder and rectum, the diagnosis can be made after the fourth or fifth month.

To make an examination by percussion and palpation, let the female lie down, with the head raised and the thighs flexed on the abdomen; then examine with both hands, especially near the pubis. Pressure with the ends of all the fingers, gradually moving them upward, will enable us to detect the womb, if it rise above the symphasis, and also the size and height of the fundus.

Ballottement, or repercussion, is used as a means of deciding upon the presence of a foetus; a means that is most available about the fifth and sixth month. The female examined should be in an upright position, or if she be in bed, her shoulders should be raised. We are directed to introduce the forefinger into the vagina and touch the cervix uteri, or, rather, in front of the neck upon the walls of the uterus; then slightly jerking upward by slightly flexing the first joint of the finger; observe if something recede from it and fall again in a moment. The ballottement is said to be a sensation “analagous to that produced by placing a ball of marble in a bladder full of water and then striking the bladder with the finger just under where the ball rests, when the latter is thrown up and falls from its own weight upon the finger that displaced it.”

When the vaginal touch is practiced, while one finger remains in the vagina, palpation of the uterus with the other hand may assist in the diagnosis by depressing the uterus, or by holding it firmly in place. Then the jerk of the finger upon the head of the foetus causes it to float upwards a little in the liquor amnii and descend.

Auscultation is used to decide many cases of doubtful pregnancy. The pulsations of the foetal heart are generally perceptible by the fifth month. The examination may be made by applying the naked ear to the abdomen of the mother, she being placed on her back in the bed with her head raised.

The foetal pulsations are frequent, generally from 120 to 140 a minute. The uterine souffle or bellows murmur may often be heard as early as the fourth month; it is synchronous with the mother’s pulse; its seat is said to be the uterus, and some believe that it indicates the position of the placenta. This sound and the pulsation of the umbilical cord are not very important diagnostic signs, and the same may be said of the presence of kiestiene in the urine, which may, however, be detected as early as the third month.

Some of the ailments that attend pregnancy I will now merely mention: There may be irritability and a disposition to inflammation; violent and obstinate vomiting; indigestion and depraved appetite, heartburn, costiveness, hemorrhoids, liver spots or blotches, especially about the face; diarrhoea or dysentery; strangury, with a frequent inclination to void the urine; leucorrhoea; varicose veins in the legs, thigh and abdomen; inquietude, and sleeplessness; dropsy, or an oedematous condition of the lower extremities; prurigo vulva; either of these may be more or less troublesome, but can hardly be regarded as diagnostic signs. Some remedies for these will be mentioned hereafter. (F. 69, 72, 75, 81, 131, 173, 206, 220).

The abdominal walls are often distended beyond what the woman is able to bear without inconvenience, as the skin may become inflamed and crack. It is much more common that the true skin beneath the epidermis cracks, and, although the outside is not altered, there often remains upon the abdomen of women who have had children a number of small marks, or little whitish streaks.

CHAPTER II.
ABORTION.

If a premature expulsion of the foetus occur before the end of the seventh month, it is called an abortion, or miscarriage; subsequent to this period, premature labor.

The cause of abortion may be in the ovum or in the mother, and it is more liable to occur at the beginning of each month corresponding to the menstrual period. The maternal causes may arise from the condition of the mother or may be accidental; may be anything that injuriously affects the mind or body. Debility of constitution, consumption, leucorrhoea, uterine irritation, febrile complaints, and obstinate constipation may be causes, but some women who are weak or sick retain the ovum with wonderful tenacity. Blows, falls, violent concussions, excessive or sudden exertions, straining, severe coughing, taking long walks, riding on horseback, or over rough roads in a carriage, a long railway journey, fright, sudden shocks, anger, joy, sorrow, good or bad news suddenly told, taking a wrong step in ascending or descending stairs, lifting heavy weights, violent drastic purgatives, calomel, dancing, and tight lacing may excite the uterus to action and effect the expulsion of its contents.

It is an unfortunate thing for a woman if she miscarry with her first and second child, for it often becomes a habit. Having once miscarried, she is more likely to miscarry again, and by repeated miscarriages her constitution is broken, and the chances of her ever having a living child become very small.

A woman may experience some threatening or warning symptoms of miscarriage for one or two days before those of labor supervene. There is usually a feeling of languor or weariness, of lassitude and depression of spirits, and a sense of uneasiness, and then, after these premonitory symptoms have lasted for some time, there may be a discharge of mucus or blood from the vagina. The show may increase to flooding, and soon there may be pain, at first slight and irregular, afterwards of a grinding character, and subsequently severe, irregular, and bearing down. At this stage we may be quite certain that the pains will continue to recur until the foetus at least, if not the afterbirth, have passed into the vagina.

The progress in different cases is, however, quite dissimilar. In the beginning of pregnancy the expulsion of the ovum might closely follow the accident that caused it. For example, a woman might slip in descending a staircase and fall violently on her seat, causing immediate expulsion of the ovum, with a large quantity of fluid blood. There are some women who have acquired the habit of aborting, and the ovum passes out of the womb with scarcely any pain, little or no hemorrhage, and the woman speedily recovers. But it will very seldom happen, after the first six weeks, that there is not some interval between the accident and the consequent abortion, and that there is not considerable and protracted pain.

If the cause of the abortion affects the mother instead of the ovum, she generally experiences, at the time of the accident, a sharp pain about the loins or abdomen, which may continue slightly for several days, and then be renewed, with violent uterine contractions, and some serous and then bloody discharges from the vagina.

The progress of a miscarriage is not as regular as a labor at full term. In many cases there are shiverings succeeded by fever for a day or more preceding the hemorrhage. Severe indisposition may continue for several days. There may be not only considerable uterine pain, but much pain in the bladder and loins; a sense of sinking in the epigastrium, of weight near the vulva and anus, and an ineffectual desire to urinate.

Such symptoms continue a longer or shorter time, and then usually the foetus alone is expelled, the placenta being retained. The latter is generally detached after a time, or it may (if within the first three months) be discharged and pass out in a dissolved condition, with the lochia. Very alarming hemorrhage may precede and accompany abortion; this makes the case one of danger at the time, and may permanently affect the health of the woman afterwards. The flooding may continue after the expulsion of the ovum; but I have always found that in such cases there was a portion of the placenta that was detached, and that might be removed, though not perhaps without some difficulty. A good physician should always be called in cases of continued flooding.

The patient ought always to preserve any and every substance discharged, that it may be showed to the physician. He should make a digital examination, and he usually finds the os uteri to be partially dilated, and a portion of the placenta hanging in the orifice. It has always been my practice to see that all was removed before leaving my patient, and I have known very dangerous hemorrhage to occur where this rule was not observed. The placenta can generally be seized by two fingers and removed; but if persevering efforts are necessary, they should not be relinquished until the safety of the mother is assured, which cannot be while the ovum, or membranes, or placenta remain in the uterus separated from their connections.

But it should always be considered especially important to PREVENT THE ABORTION. If a woman is prone to miscarry, she ought, as soon as she is pregnant, to lie down a great part of the day; she must keep her mind calm and unruffled, and must live on plain diet; she should retire early to rest, and she must have a separate sleeping apartment. She should avoid taking active physic, but keep her bowels open by diet or by the mildest aperients, or, possibly, daily enemata. Gentle exercise may be taken, alternated with frequent rest. Cold ablutions are proper every morning, but the body should be rubbed afterwards with a coarse towel.

The most usual time for a woman to miscarry is from the eighth to the thirteenth week, but if a woman have a particular time, which to her is the usual period, whenever that time approaches she should be unusually careful. Let her lie down more than she usually does; let her avoid exciting amusements. She might try to keep her bowels open by the external application of castor oil, or by the mildest aperients, or by hot water enemata.

If slight hemorrhage and trifling pains come on, we should seek to arrest the abortion by giving perhaps grain doses of opium every four or five hours. If the hemorrhage is severe, a drachm dose of fluid extract of ergot may be given, and a large draught of cinnamon tea; perhaps a quarter of a grated nutmeg, and, in extreme cases, a spoonful of brandy with it.

But let it be understood that in all such cases a physician should be called as soon as possible; and while waiting for him the patient ought to lie on a hair mattress; a vaginal injection of hot water may be given; she should have but scant clothing upon the bed; her room should be well ventilated, and if she is faint from the loss of blood, a little aromatic ammonia may be given.

CHAPTER III.
PARTURITION.

False pains occur most frequently in a first pregnancy, but most pregnant women have occasional pains, and these become more violent within three weeks of the full time. They may be owing to a disordered stomach, as well as to the action of the uterus; but they usually come on at night, and are liable to be mistaken for labor pains. They are, however, unattended with show; they often change from place to place, perhaps going successively to the hips, loins, lower extremities and abdomen; they come on at irregular intervals, and are at one time violent, at another feeble, and they occasion no dilation of the os uteri; but true pains come on with some regularity, and usually increase in severity. False pains are from various causes, such as fatigue of any kind, especially too long standing, sudden and violent motions of the body, costiveness or diarrhoea, general feverishness, agitation of the mind, or a spasmodic action of the abdominal muscles. It is necessary to adopt the means used for the relief of the pains to the apparent cause, and generally to give an opiate proportioned to the degree of pain, or to repeat in small quantities at proper intervals till the patient shall be composed.

PERIOD OF GESTATION.

The duration of pregnancy is not always absolutely a certain number of days. The usual term is ten lunar months, or nine calendar months and one week. If we could have correct records of all cases we should probably find that half the cases of pregnancy terminated in labor in the fortieth week, but that in a few instances the term was prolonged to the forty-fifth week and that in as many cases women were delivered of fully developed children as early as the thirty-seventh week.

A woman may make her count pretty correctly as follows: She should first note the last day of her being unwell. Let forty weeks from that day be marked in an almanac, and she may expect her labor to come on near that time.

It may happen that a woman who never has her menses while she is suckling, may become pregnant and not have a date to count from; but she ought in that case to reckon from the time that she quickens. Although quickening takes place at various periods, she may then consider herself nearly half gone in her pregnancy, and calculate that in four and a half months she will be delivered.

A woman may have a show for one or two monthly periods after her gestation commences, but the discharge may be distinguished from the regular menstrual fluid by its being either small in quantity, or by its clotting, and generally by its lasting but a few hours. The woman should reckon from the time when she had her last regular menstruation.

PARTURITION.

Natural labor. The uterine functions are characterized by periodicity. If an abortion occurs that is not the result of an accident, it is generally at what would have been, but for conception, a monthly period, and even injuries are more likely to produce their bad effects at that particular time. So the normal period for parturition corresponds to a menstrual period, and generally labor may be looked for at about the tenth period after the last appearance of the catamenia. We can hardly tell why it so uniformly happens at that particular time; the process is analagous to the falling of ripe fruit—it drops because the fruit is fully matured.

It is not in accordance with the plan of this work to dwell at all upon any other than what is called natural labor, but I shall include in this class all such as are terminated by the natural powers, whether they be head, face, breach, or foot presentations.

By PRESENTATION, I mean that part that presents itself at the brim of the pelvis, so that the accoucheur’s finger impinges upon it as the end is passed into the center of the os uteri.

The DIAGNOSIS of the different presentations is made by the touch. The head may be known by the hardness and roundness, and more certainly by the fontanelles and sutures; the breach by its general softness, and by the tuberosity of the haunch bone; by the cleft between the buttocks, the scrotum or the vulva, and the anus; the knee by the hardness and roundness of the bone; the foot by its form, its being at right angles with the leg, the nearly equal length of the toes, the narrow heel, etc.; and the face by the inequalities of the presenting part. (These inequalities cannot at first be felt; upon touching it we first perhaps detect the brow, then, as labor progresses, we may feel the nose, mouth, etc.) The head presents in about 98 cases out of 100.

PHYSIOLOGICAL PHENOMENA OF LABOR.

According to the division made by standard authors on parturition, its first stage extends from the beginning of labor to the complete dilatation of the os uteri; the second terminates by the birth of the child, and the third by the expulsion of the placenta.

During the last two or three weeks of the term, the uterus sinks lower in the pelvis, and seems to spread out laterally; the lungs and stomach are not so much compressed, and respiration and digestion, if difficult, become more easy, and often the patient becomes more cheerful and active. The precursory symptoms of labor vary in intensity in different women; but it may be observed pretty generally that there is more activity and disposition to movement for one day preceding the real labor.

But during the last few days of the gestation there are contractions of the uterus, which, though short and distant, and not attended with much pain, are effective in dilating the cervix, and preparing for the subsequent labors.

The subsidence of the lower end of the uterus into the pelvis, however, causes many unpleasant symptoms. The pressure upon the bladder renders a frequent evacuation of its contents necessary; there is often an ineffectual desire to urinate, and sometimes strangury. There is often a sense of weight about the anus, an irritable state of the bowels, occasional griping pains, and a desire to go to stool when but little is passed, and sometimes diarrhoea. The oedema and varices of the lower extremities augment, the hemorrhoidal vessels swell up, and the piles are larger. These precursory symptoms are manifested more in primapara than in others. To some, walking becomes at this time impossible.

There are during the last month, and especially toward the close of it, painless uterine contractions; there may be at first a sort of squeezing sensation with it. But about twenty-four hours previous to the commencement of actual labor, these contractions are accompanied with some pain and are periodical, recurring perhaps every twenty or thirty minutes. If an examination be made of the os tincÆ at the COMMENCEMENT OF LABOR it will be found that the rounded collar of the os is already effaced. The pains then suddenly become acute, and it can be observed that the uterus contracts if we notice its greater hardness and roundness during a pain. The os uteri if somewhat dilated closes partially with each contracting, and it can be observed that its margins are growing thinner though tense and resistant at the time of the pain.

The contractions distend the membranes; these are first pressed on the neck, then into it, then as soon as the dilatation is sufficiently advanced engage in it in the form of the segment of a sphere, whose dimensions progressively increase with the dilatations.

There is now and perhaps has been for several hours a glairy discharge from the vagina, which becomes streaked with blood, there are perhaps shiverings or rigors (not accompanied with a cold skin), the pains increase in force and frequency, the pulse is hard, full, and rather frequent, the countenance is flushed, often there is vomiting, and the patient is prone to despond and be discouraged.

She is less agitated after the pain subsides, though it does not cease entirely. During the interval the margins of the os again become supple, the membrane that was tense while the pain lasted becomes flaccid, and the child’s head can be more plainly felt. As the contractions are repeated the os uteri dilates more and more until it is completely opened and no part of its margin can be touched; though very frequently from some obliquity of the uterus, the margin on one side can be observed pushed down before the head of the child, while that on the other side cannot be reached. In ordinary cases the membranes are ruptured and the waters escape at the commencement of the second stage, and the time occupied by the first stage is nearly three-fourths that for the whole labor. But the duration of the stages as well as the time occupied by the parturition is exceedingly variable, and the same may be said in regard to the duration and character of the pain.

We may observe here that pain is nearly inseparable from the contractions of the uterus, so that in common language the two expressions are used indifferently; but using the word in its ordinary sense the pain in the first stage of labor is different from that in the second. What are called grinding pains characterize the first part of labor, and although they differ in different individuals, they are pretty generally so severe as to cause the patient to cry out. As soon as the labor advances to the second stage there is a change in the character of the pains. They are more frequent and longer and the intervals shorter; but though the suffering may be greater the cry is more suppressed, the bearing down is carried to a greater degree, and each pain is succeeded by a calm more perfect than that in the first stage. Should the interval be rather long some patients get a little sleep between the pains, but if there has not been a bursting of the waters previously there is generally now a pain sufficiently hard to break the membrane.

Either in the first or last part, or during the whole of the labor, the woman says that the pain is in her back, it being in the lumber and dorsal region; the grinding pain she speaks of as being forward, they seem however to go through from the umbilicus to the sacrum. In cases where there is rigidity of the uterine orifice, there is I believe pain especially in the back; and when the os becomes fully dilated, the pains are bearing down; the patient at the accession of a pain holds her breath, and seizing hold of something with her hands, brings the muscles of the back and abdomen and extremities to aid the expulsive efforts of the uterus. I do not doubt that this straining of the mother at this time is advantageous; these efforts of the mother should not be encouraged, however, at the first part of the labor, because then they do no good, nor at the very last, as combined efforts then may rupture the perineum.

As the head advances through the pelvic cavity the pressure upon the nerves which pass through it gives rise to cramps in the thighs and legs.

As the head passes into the vagina the walls become flabby and the canal seems to enlarge and elongate and to be prepared to yield to the pressure of the head. If an internal examination be made the head will be perceived filling the cavity, descending with each pain and receding at its conclusion—the advance ordinarily exceeding the recession, though sometimes the gain is not perceptible. When the head rests on the perineum, that offers some resistance, which seems to stimulate the uterus and abdominal muscles to greater efforts and more forcible contractions.

If it be a first labor there may be at this point a little delay in its progress. But the foetal head being forced down by the rapidly recurring pains so presses against the floor of the pelvis that it yields and becomes bulging in front, and distended, though there still is recession as the pain intermits. But adequate force is called into action; each pain gains upon the advance made by its predecessor; the vulva partially opens, and at each pain they open more and more; the resistance of the parts is finally overcome. After the perineum has given the head its proper direction in its transit, there usually comes a hard pain—forcing a loud cry from the woman—another pain succeeds immediately, which expels the head altogether from the parts; then after a short rest the uterine power is again exerted to expel the body of the child.

There may be an interval of a few minutes before the pains return with sufficient force to expel the shoulders, but the child is in no particular danger; it is best to wait awhile, the nurse in the meantime making pressure with her hand over the uterus, before any traction is made on the head or shoulders. If the body is very large, however, it may be well soon to draw a little on the head or to reach with one finger into the axilla and to bring down the lower shoulders; then the rest will be delivered without any difficulty.

The intense suffering of the mother is now exchanged for perfect joy or ease; there is at once a transition from extreme misery to total freedom from pain, though the labor is not yet completed. Ordinarily a few pains return before many minutes, and complete the last stage of labor—the expulsion of the placenta. Sometimes the contractions that expel the child, expel also the membranes and placenta; but more generally they are only partially detached or they may be adherent and not easily removed.

After the birth of the child, and the tying of the naval string, it is proper to apply the hand upon the abdomen of the mother to ascertain whether there be another child, and whether the uterus be contracting properly. I advise that an effort should be made immediately to remove the afterbirth and secundines, making firm pressure over the womb; this will generally stimulate the uterus to make good contractions, and may assist in pressing out the placenta. I do not advise that a midwife should pull upon the cord, but it is my practice to press the fingers of my right hand well into the vagina, and as soon as possible grasp a little of the placenta; my left hand at the same time pulling slightly on the cord, and thus by combined effort removing the afterbirth pretty quickly.

I have never had much trouble about retained or adherent placenta in cases where I myself officiated in the delivery, and I attribute my good fortune in this respect to the fact that I do not tie the placental portion of the cord, preferring to let some blood discharge from the afterbirth, thus diminishing its size, and then if necessary I direct that considerable effort be made in the way of squeezing and pressure and friction over the uterus.

It is true that if nothing is done a pain will usually come on within twenty minutes that will expel the afterbirth very effectually including all the membranes, and considerable clots of blood; but I apprehend that in many cases during this delay there is an hour-glass contraction of the womb comes on, which retains the placenta and prevents its proper separation.

But before attending to the placenta, the necessary attention should be paid to the child. A little cold water sprinkled on it will usually make the child cry, if it does not breath immediately after it is born, and this makes the change in it from uterine to breathing life. The child may then be separated from the mother by cutting the cord. After the removal of the child it is proper to endeavor to deliver the afterbirth, though it may not be necessary at first to do anything more than to use friction over the uterus with moderate pressure, which may be gradually increased.

CHAPTER IV.
MECHANICAL PHENOMENA OF LABOR.

The cavity of the uterus and that of the pelvis form a continuous PASSAGE through which the child must be forced in its exit from the womb at birth. The uterus possesses the character of muscularity and is the main agent in the expulsion of the child. By its own muscular action the cavity of the uterus is diminished and pressure made on the foetus, forcing it down towards the orifice, distending the cervix, and dilating the passage. During the second stage of labor the power of the uterus is aided by the voluntary muscles of the abdomen and by the depression of the diaphragm.

The character of the passage will be brought to mind by recalling what was heretofore said of the diameter of the pelvis. It will be remembered that the usual antero-posterior diameter of the brim does not exceed 4½ inches while the transverse is 5¼ inches, and that at the lower outlet the antero-posterior diameter is about 5 inches and the transverse about 4 inches.

The FIRST OBSTACLE which the child meets in its progress is the cervex uteri. This being composed partly of muscular fibre which acts somewhat as a sphincter, and partly of elastic celular tissue, holds the sphincter in the tissue with a tenacity which is not easily overcome. But repeated muscular contractions of the womb force down the bag of waters, which forms a sort of wedge, and this is forced down and into the os uteri, compelling it to open.

There are also muscular fibres in the uterus which have a longitudinal as well as some that have a circular course, and the action of the former tend after a time to retract the os, over the foetal head.

The second obstacle is the bony brim of the pelvis into which the head of the foetus cannot pass until its long diameter is adapted to certain diameters of the pelvis. The diameter of the bony pelvis is diminished over one-fourth of an inch by the soft parts upon it, but the oblique diameter of the pelvis will admit the long diameter of the head of the child, which does not often exceed 4½ inches. The head usually presents in this way, and passes in a somewhat spiral manner until it arrives at the outlet where the diameters are adjusted to each other. The head is, however, too large to pass, even in this way, were it not that it admits of a degree of compression to facilitate the entrance and progress through; this moulding is effected by the continued pains. The head of the child which presents at the brim with the occiput towards the left acetabulum rotates during the passage, so that the occiput at its exit is directly under the symphasis pubis; the cause of the rotation is found in the form and direction of the passage and in the shape and size of the foetal head.

This presentation and position is the most common one, though either of the following is liable to occur. By naming the position we indicate just how a presenting part lies, or is turned. We adopt the following classification, which accords with several good authors:

PRESENTATIONS AND POSITIONS.

The right occipito-iliac posterior (A 4) position is not a very uncommon one, but that variety which is described and named as the left occipito-iliac anterior (A 1), in which the occiput is directed in front and to the left, is most frequent. These and other vertex presentations may be recognized even in the commencement of labor through the vaginal walls, the head being known by its rounded spheroidal surface.

Supposing that we have a case of the kind that is most common (A 1), and that labor has begun, we may introduce the finger through the os uteri and we encounter a rounded, smooth and resistant surface, which is the anterior part of the head, and then by directing the finger upwards and backwards it will come in contact with the sagittal suture.

If the direction of the suture is oblique, and if it runs from before backwards and from the left towards the right, the position must be either the left anterior or the right posterior occipito-iliac one. (A 1 or A 4).

To complete the diagnosis we follow with the finger the sagittal suture until it reaches the fontanelle, and this determines the position. If the posterior fontanelle is found to the left and in front, and the anterior one is to the right and behind, the position is A 1, or the left antero-occipito-iliac one. The back of the foetus is turned forwards and towards the left side, while its face and anterior plane is turned backwards and towards the right, and the occipito-frontal diameter of the child’s head corresponds to the oblique diameter of the pelvic brim.

As the labor progresses and the head is forced down in the pelvis, it is also more strongly flexed on the chest and the occiput is pressed down in the excavation. With the occiput thus presenting, it traverses all the space between the superior and inferior straits until it reaches the floor of the pelvis; there it makes what is sometimes called the pivot turn—it executes a movement of rotation, which carries the occiput behind the symphasis pubis and the forehead towards the hollow of the sacrum; then the head being pressed forwards and stretching the perineum, the forehead and face being disengaged from it, emerge; then after the perfect expulsion of the head it again rotates, the occiput turns somewhat to the left thigh and the face towards the right thigh.

In the beginning of labor the shoulders are turned so as to correspond to the oblique diameter of the pelvic cavity, but they pass through the pelvis in a transverse position. After they reach the inferior strait, the body rotates so that the right shoulder of the child turns towards the left side of the mother and the wide diameter of the shoulders is accommodated to the wide diameter of the strait, and the rotation of the head, which is free externally, is secondary to the rotation of the shoulders.

In the EXPULSION OF THE BODY the right shoulder, or subpubic one, is the first one to appear in the vulvar fissure, but the left or posterior one may be disengaged at the commissure of the perineum before the right one is delivered; the remainder of the trunk is expelled very soon, describing a prolonged spiral course in its passage.

A child originally in the RIGHT POSTERIOR-ILIAC position becomes converted towards the last of the labor into an occipito pubic or anterior one, and the labor terminates as it does in A 1, when the occiput was originally in front. It is the left shoulder, however, which gets behind the arch of the pubis, and the occiput is directed towards the right thigh after the head emerges.

In some instances, though rarely, the child originally in A 4 position remains with the occiput behind to the termination of the labor. In such cases the forehead comes under the pubis and remains there for a time, while the occiput traverses the whole circle of the perineum; then the whole head and face is immediately delivered.

It is not deemed necessary to describe here the mechanism of labor in the more unusual varieties which are so very numerous.

As regards PROGNOSIS, head presentations are the most favorable of all, and those in which the occiput looks anteriorly in the beginning of labor are more favorable than those in which it is turned posteriorly. In occipito-posterior positions the labor is more tedious than when the occiput is in front, and the expulsion becomes particularly difficult when the head maintains its original position and does not rotate or take the pivot turn.

Upon the foetal head after it is delivered there is almost always a protuberance to be found—a tumefaction, more or less considerable upon some point of the vertex; its greater size indicating a longer continuance of the labor, and its seat indicating in what position the child was born. This tumor is almost always located on one of the posterior superior angles of the parietal bones, and shows that the occiput escaped under the pubic arch. During the labor the whole head is strongly compressed except at one point on the vertex, which therefore becomes the seat of a sero-sanguinolent infiltration. This tumor disappears usually within forty-eight hours; if it does not, it may properly be punctured. It may contain either serum, or serum and blood, or grumous blood.

When the expulsion of the foetus takes place from the efforts of nature alone, the labor is called by some authors spontaneous or natural, but when art is obliged to interfere it is called artificial. It would be very useful to us if we could always decide in the commencement of labor whether the assistance of art would be required, and I will group together in a few pages such instructions as I am able to give on this important subject.

The nurse or midwife will not very generally be able to decide any point by auscultation, but she as well as the physician may judge from the appearance of the woman, from her past history, from palpation of the abdomen, and from vaginal touch. She should accustom herself to judging by all these means, that she may be able to decide early whether the help of an accoucheur will be imperatively needed.

No one can decide certainly from simply seeing a patient in the beginning of labor, whether her labor will be natural and spontaneous, or artificial; but I have many times when first looking at a lady, if her complexion was fair, and her form good, but rather tall, predicted that her accouchement would proceed regularly and favorably. But in forming our opinion we need to know something of the previous health and present ailments of the patient, and, if a multipara, the character of former labors. If nausea and vomiting or any other ailment has reduced her strength so that she is exceedingly weak, this may give rise to some reasonable apprehension; but I have known a woman that could scarcely retain a morsel of food on her stomach for seven or eight months, that had become very weak indeed and exceedingly emaciated, who yet endured her labor well and soon recovered. The general rule is, that the more perfect the woman’s health is, the better she is fitted for child bearing, but if her general health and strength is reduced below its proper standard by some previous or accompanying disease, such for example as consumption, she may endure the labor very well, and succumb to the disease afterwards.

Pregnant women are liable to be attacked with epidemic, endemic, and sporadic diseases. Eruptive fevers, etc., may attack parturient women, and if they do, the disease and labor in every case will have a reciprocal influence on each other—the disease will complicate the case. Influenza or intermittent fever may attack a woman at any period of gestation, and there may be no serious results. Cholera, small pox, typhoid fever, scarlet fever, measles, pneumonia, and jaundice are liable to cause abortion, and there is danger of fatal results, or either of them would be a dangerous complication at the time of labor. Syphilis would be a cause of abortion or premature labor, and any disease which allows the mother to carry the child the full term may reduce and weaken her. Glandular engorgements and scrofulous ulcers improve during gestation, but if the woman is suffering from a fracture, the bones will not unite very well. Tumors in the abdomen and pelvis may be an obstacle to delivery, and ulcerations of the cervix may also be harmful and protract the labor, as also may constipation, dropsy, and albuminuria.

The latter may not be detected without an analysis of the urine, but dropsy will be obvious as soon as it exists. The evidences of tumors and ulcerations are found by palpation and the touch—sometimes by the use of the speculum.

After learning the present appearance and the former history of the patient it may be necessary to examine further perhaps by palpation.

By PALPATION we may sometimes (but not always) distinguish the head of the child, and perhaps tell to which side its back is turned. When making the examination let the patient lie on her back, make gentle pressure when the pains are off and the abdomen is relaxed; press the ends of your fingers above the body of the pubis; by pressing downwards you may perhaps feel the head if it has descended into the pelvis. You will need to press the abdomen carefully all over to ascertain if there are tumors, and also to ascertain if the body or some other part presents at the cervix uteri.

If auscultation is used we may determine positively the position of the foetus by observing just where the sounds of the foetal heart may be most plainly heard.

The VAGINAL TOUCH is the usual mode of determining whether there is an unfavorable presentation of the child, as well as whether there is deformity of the pelvis, tumors in the vagina, ulcerations, &c.

When the head presents in the commencement of labor, if the fundus of the uterus is not too much inclined forwards, and there is no deformity of the pelvis, the os may easily be reached, and the hard round head of the child be felt without difficulty. Should a hard presenting part not be felt either through the dilated os or the walls of the uterus, it may be because there is a breech or body presentation, or there may be twins, or there may be an unusual amount of water in the uterus, or the child may have hydrocephalus—in either of these cases it might not be possible to decide immediately about the presentation and position.

Face presentations cannot be detected very early in the labor. Before the membranes are ruptured the head is high and difficult of access. When it is reached the forehead is first encountered, afterwards we may feel the nose and mouth. It is unfortunate for us that we cannot usually distinguish a face presentation in the early stage of labor. It is not so important that we make an early diagnosis of presentation of the breech, as there is no danger to the mother involved in the latter.

Presentation of the body should always be detected early, at least as soon as the membranes are ruptured. The abdomen of the mother is much longer in the transverse diameter than is usual, and the head of the child may sometimes be felt in the iliac fossa. The form of the mother’s abdomen is irregular as the foetus lies curved on itself. When we are able to touch the foetus, if the shoulder presents, we first feel a small bony projection, the acromion point of the shoulder; then other points, including the acute angle of the shoulder blade. We should ascertain as soon as possible on which side the head lies, and also the posterior plane of the child.

Sometimes the hand comes down in the vagina or even appears at the vulva; if it does we may know by that (and by slipping the finger of our hand up into the axillary space) just how the child lies. If the back of the child’s hand is turned towards the mother’s right thigh the head is to the right, and if to the left thigh, to the left. The little finger being towards the coccyx indicates that the child’s back is towards the mother’s loins, and the same finger being towards the pubis is evidence that this is in front. It is quite important that these points should be noted.

There are various causes of tedious, difficult and obstructed labor, and in each case we are obliged to depend principally upon the touch for diagnosis. In some instances the difficulty will be obvious as soon as we attempt to make an examination. A NARROW and UNDILATABLE VAGINA will be easily recognized, but this will rarely be found a serious obstacle to the passage of the child; as the labor proceeds the vagina seems naturally to dilate and to be more softened and relaxed.

Cases have been reported where there was a scirrhus tumor or cancer connected with the neck of the uterus, even during labor; happily such cases are rare. The scirrhus would be felt hard and unyielding. A tumor of any kind connected with the os uteri, the vagina or the rectum may obstruct the descent of the child’s head more or less according to its size and mobility. Of course they can be detected.

A VAGINAL CYSTOCELE ought always to be rectified. It sometimes happens that the bladder is caught by the head of the child in its descent into the cavity of the pelvis and pushed before it, and it can be seen as a soft red tumor between the vulva. The finger can be passed posterior to it, but not anterior, and the catheter cannot be passed in the usual direction.

A few cases are on record where a stone (calculus) in the bladder was pushed down before the foetal head. A careful examination will show that the tumor is covered by the bladder; its hardness will indicate its nature.

A collection of hardened feces in the rectum is detected without difficulty. It will be of an irregular form, hard and inelastic.

Swelling of the soft parts may cause obstruction. If the child’s head is detained for a long time pressing upon the brim of the pelvis, it may obstruct the circulation and diminish the capacity of the passage. In such cases there is unusual heat and dryness in the parts.

When a nurse or midwife makes an examination by touching, she needs to continue it through several pains, and to repeat it again soon to know if there is any progress to the labor. If the progress is very slow this may be from various causes, some of which I will now simply name. It may be because the uterus is very much distended, and this renders the pains inefficient; there may be partial and irregular contractions of the uterus, weakness of constitution, fever or local inflammation, a want of irritability in the constitution, a deformity of the pelvis and spine, or doubts and fears on the part of the patient may diminish the action of the uterus. The labor may be slow because it is the first one, or because the membranes were ruptured too early, or because the woman is advanced in years at the time of having her first confinement. The uterus may be pitched over obliquely, there may be extreme rigidity of the os uteri, extreme rigidity of the soft parts of the mother, a contracted or small pelvis, the head of the child may be large and ossified so as to be unyielding. One or both arms may come down by the side of the head of the child; on the part of the mother there may be a distended bladder from inability to void the urine, there may be cicatrices (scars) or adhesions of the vagina, and in some cases it has happened that an enlarged ovary has dropped down into the pelvis, or a portion of intestine containing scybala or hardened feces obstructs the passage, or the os uteri is very minute, or imperforate, or totally absent.

Some of these cases may demand the interference of art in the first stage of labor, but delay at that time involves very little danger; as a rule neither the mother nor child is in danger (except when there is hemorrhage or convulsions) on account of labor before the membranes are broken. If the nurse can ascertain the cause of the delay and finds that time is what is especially needed, she must exercise patience herself and encourage her patient to do so.

It is hardly possible to predict beforehand in what cases convulsions will occur, but if there is much headache in the commencement of labor and if there has been considerable albumen in the urine of the patient, we have especial reason to apprehend trouble of that kind.

The history of the case is important in forming an opinion as to whether there may be severe hemorrhage. Some women are naturally predisposed to flowing.