A System of Midwifery Part 11

In the treatment of such cases, where there is so much liability to abortion, we must first examine the precise condition of the circulation, and ascertain whether it be above or below the natural standard of strength; for as abortion may arise from very opposite conditions of the circulation, our treatment must consequently vary. If there be signs of arterial excitement, a small bleeding may be necessary; it unloads the congested vessels, diminishes the force of the circulation, and therefore also the chance of an extravasation of blood between the uterus and ovum; the bowels must be kept open by cooling saline laxatives, and the circulation may be still farther controlled, by the use of nitre two or three times a day. The diet must be spare; she must take regular exercise in the open air, wear light clothing, dress loosely, and sleep upon a hard mattress.

In these cases we are often warned that congestion of the uterine vessels is present, by pain and throbbing, and sense of fulness in the groins; leeches applied to these parts give much relief, and frequently render venesection unnecessary. Tight lacing ought to be strictly prohibited in all cases of pregnancy, particularly where there is a disposition to plethora: among other bad effects, it prevents the proper development of the b.r.e.a.s.t.s, the nipples are pressed so flat as to be nearly useless, the child being unable to get sufficient hold of them: this may in some degree be avoided, by putting thick ivory rings upon the b.r.e.a.s.t.s, and thus shielding the nipples from injurious pressure. It will, however, be much better to have the dress made loosely, to allow for the development of the b.r.e.a.s.t.s, which takes place during pregnancy; for there can be little doubt, that irritation of these glands is very liable to be followed by a corresponding state in the uterus.

The common but erroneous notion that it is necessary to take an extra quant.i.ty of nourishment for the support of the child as well as of the mother must be strenuously opposed. Nature contradicts it in the most striking manner; for, by the nausea and sickness which most women experience during the first half of their pregnancy, she raises an effectual obstacle to any error of this kind. "It certainly cannot be intended for any other purpose, since it is not only almost universal, but highly important when it occurs, as it would seem to add much to the security of the foetus; for it is a remark as familiar as it is well grounded, that _very sick women rarely miscarry_; while on the contrary, women of very full habits are disposed to abortion, if exempt from this severe, but as it would seem, important process." (Dewees, _on Children_, -- 45.)

Where the case has become one of habitual abortion, the patient's only chance will be by living separate from her husband for twelve or more months: the uterus, not being exposed to any s.e.xual excitement during this period, becomes less irritable, and it gradually loses the disposition which it has acquired of expelling its contents prematurely. In such a case, when pregnancy has again commenced, it requires to be watched most narrowly; every possible source of irritation must be removed by the strictest attention to diet and regimen, and the patient must make up her mind to be entirely subservient to the rules laid down by her medical attendant. Although the chances are against her escaping without premature expulsion, still we are not to despair, experience showing that cases every now and then occur where the patient has gone the full term of pregnancy in safety, in spite of repeated previous abortions. Dr. Young of Edinburgh, in his lectures on midwifery, describes a case where the patient actually miscarried thirteen times, and yet bore a living child the fourteenth time.

On the other hand, where the condition of the patient evinces a state of strength considerably below the natural standard, we find a very different set of symptoms to those which have been just described, requiring opposite treatment: the face is pale and even sallow; the pulse is soft, small, and irritable; the tongue pale and flabby; the digestion impaired; the bowels torpid; and the extremities cold: fatigue, or rather a sense of exhaustion, is induced by the slightest exertion, and this is attended with dull, heavy, dragging pain about the pelvis and loins, and a feeling as if the contents of the abdomen required more support, and were disposed to prolapse either by the r.e.c.t.u.m or v.a.g.i.n.a, on her maintaining an upright posture for any length of time.

Even at a very early period of pregnancy, there is the sensation of a weight in the lower part of the abdomen, falling over to that side which is lowest, as we described among the signs of the death of the foetus at a later period, resulting in all probability from a loss of tone and firmness in the uterus. In this state, if nothing be done to restore the mother's strength, the embryo will inevitably perish, and expulsion follow, sooner or later, as a necessary result.

In all cases where pregnancy occurs, in a weakly delicate woman, measures should be taken to increase the general tone of health, in order to fit her for going through this process safely, by removing her to the country, or to the sea-side, or to some watering place, where she will have the opportunity of drinking a mild chalybeate, and enjoying a purer air. Where it is even hazardous to move her, she should be put upon a course of mild chalybeates. The food should be light and nourishing, and a gla.s.s or two of wine or mild ale, may generally be taken with advantage. Where she can bear it, tepid salt-water bathing, or sponging, will have the best effects.

"For a number of years, (says Mr. White of Manchester,) I have been convinced of the good effects of cold bathing, not only in preventing miscarriages when every other method has been likely to fail, but other disorders which are incident to pregnant women, and generally attendant upon a weak lax fibre. I don't mean the cold bath in the greatest extreme, but such as that of Buxton or Matlock, or sea-bathing, or bathing in a tub in the patient's house, with the water a little warmed. I have frequently advised my patients to bathe every other day, at a time when the stomach is not overloaded, and not to stay at all in the water; to begin this process as early as possible, even before they have conceived, as there will be then no danger from the surprise, and continue it during the whole term of pregnancy; and several have bathed till within a few days of their delivery." (White, _on Lying-in Women_, p. 70.) Where exercise can be taken without fear, it should be done regularly but cautiously, so as not to induce fatigue or exhaustion, which is the very effect we must be so careful to avoid; in fact, every means and opportunity should be used of recruiting the powers and the vigour of the system. In proportion as the strength increases, so does the irritability diminish; the uterus becomes less sensitive to external impressions, and can, therefore, bear its gradual development without being excited to contraction; the foetus receives its due supply of nourishment; the feeling of relaxation and deficient support of weight, and bearing down, go off as health returns; and by thus keeping up the powers of the system to the proper standard, it will be enabled to continue the process of pregnancy to the full term.

Although some women recover very quickly after an abortion, and appear for the time to suffer but little from its effects, they seldom escape with impunity, more especially if it has been repeated more than once: anaemia, with its varied train of anomalous symptoms and concomitant gastric and cerebral disturbance, profuse leucorrhoea, menorrhagia, and dismenorrhoea, are some of the more direct results of repeated abortion; we may also enumerate prolapsus uteri, inflammation of the cervix, with induration and scirrhus, as the more remote effects.

In the treatment of a case where expulsion is threatened, our object will be either to stop that process in time to save the life of the foetus, or if this cannot be attained, to carry it through, in such a manner, as to expose the mother to as little danger and injury as possible.[63] In the first instance, we must be guided nearly by the same rules as in the prophylactic treatment: if there be considerable arterial excitement, and evidence of general plethora, a small bleeding will be useful in restoring a calm to the circulation; the most perfect quiet of body and mind must be insisted upon; the patient should lie upon a hard mattress, and be covered with as little clothing as is consistent with safety; she must refrain from all exertion, and strictly maintaining the horizontal posture for a considerable time. The indications for our treatment will be, 1. to remove every thing which may, in any degree excite the circulation, and, 2. to prevent the contraction of the uterus. Stimulants of every description, and animal food must be forbidden; the bowels must be opened by gentle saline laxatives; and if the pulse still betrays any sharp or resisting feel to the finger, small doses of nitre may be taken as already recommended. When the circulation has become perfectly calm, and every trace of excitement allayed, opiates will prove of inestimable value: they stop any disposition to uterine contraction, and remove the pain in the back and loins which this will cause. The form which we prefer is the Liquor Opii Sedativus, as being more sure in producing a sedative effect than common laudanum, while at the same time, it produces less irritation and derangement in the stomach and bowels.

A moderate discharge of blood from the v.a.g.i.n.a, although showing that a separation has taken place between the ovum and the uterus, cannot be looked upon as an unfavourable sign, for it relieves the pelvic vessels, diminishes the pain in the back, and makes the patient feel more light and comfortable; but if it be at all brisk, and continues so after the employment of the above remedies, if also there be heat and throbbing in the region of the uterus, it will be necessary to apply cloths wrung out of cold water to the lower part of the abdomen and v.u.l.v.a, and to the groins and sacrum; and this treatment must be continued in full force until the symptoms of congestion have abated, and the discharge lessened or stopped.

If the haemorrhage be really profuse, it shows that the separation of the ovum from the uterus must be of considerable extent; and as there will be no chance of preserving the life of the foetus under such circ.u.mstances, the expulsion of the ovum is no longer to be avoided, but rather to be promoted; our attention therefore must now be directed to a.s.sist the uterus in the evacuation of its contents, with as little injury and danger to the mother as possible. It is, however, no easy matter to decide with certainty when we must give up all hope of preserving the ovum, for a large quant.i.ty of blood may be lost without expulsion being a necessary consequence. Uterine contractions may have even taken place, and yet by careful management the mischief may be sometimes averted, and the patient be enabled to go her full time. Even where they have been of sufficient force and duration to dilate the os uteri, we are not justified in discontinuing remedial measures unless the flooding has seriously affected the patient's strength, and the ovum be actually projecting through the os uteri. "We might often prevent abortion (says Baudelocque) if we were perfectly acquainted with its cause, even when the labour is already begun. A very plethoric woman felt the pains of childbirth towards the seventh month of her pregnancy, and the labour was very far advanced when I was called to her a.s.sistance, since the os uteri was then larger than half a crown; two little bleedings restored a calm, so much that the next day the orifice in question was closed again, and the woman went the usual time. Food of easy digestion prudently administered quieted a labour not less advanced in another woman, where it was suspected to be the consequence of a total privation of every species of nourishment for several successive days. Delivery did not take place till two months and a half afterwards, and at the full time. Emollient glysters and a very gentle cathartic procured the same advantage to a third woman, in whom labour pains came on between the sixth and seventh months of pregnancy, after a colic of several days' continuance, accompanied with diarrhoea and tenesmus." (_Baudelocque_,) -- 2232. Nor is it always easy to decide whether it be the ovum or not which we feel protruding through the os uteri. "When the abortion is in the second or third month, the pract.i.tioner must bear in mind that it may have been retention of the menses, and, therefore, what he feels in the os uteri may either be an ovum or a coagulum of blood. To decide this point he must keep his finger in contact with the substance lying in the os uteri, and wait for the accession of a pain (for where clots come away, pains like those of labour are present,) and ascertain whether the presenting ma.s.s becomes tense, advances lower, and increases somewhat in size; this will be the case where it is the ovum pressing through the os uteri. On the other hand, if it be a coagulum, which it is well known a.s.sumes a fibrous structure, it will neither become tense nor descend lower, but be rather compressed.

Generally speaking, the ovum feels like a soft bladder, and at its lower end is rather round than pointed, whereas, a plug of coagulum feels harder, more solid, and less compressible, and is more or less pointed at its lower end, becoming broader higher up, so that we generally find that the coagulum has taken a complete cast of the uterine cavity. If we try to move the uterus by pressing against this part, it will instantly yield to the pressure of the finger, if it be the ovum; whereas, the extremity of a coagulum under these circ.u.mstances is so firmly fixed, that when pressed against by the finger the uterus will move also. When abortion happens at a later period of pregnancy, we shall be able to feel the different parts of the child as the os uteri generally dilates, viz. the feet, or perhaps the sharp edges of bones, although we cannot distinguish the form of the head from the cranial bones being so compressed and strongly overlapping each other." (Hohl, _on Obstetric Exploration_.)

Although expulsion must be looked upon as the only means of placing the patient in a state of safety, where the symptoms have advanced so far as to preclude all hopes of preserving the life of the foetus, there are so many steps of this process to be gone through before it can be entirely completed, that more or less time must necessarily be required for that purpose. The ovum must be completely separated from its attachments to the uterus, and the contractions of that organ must have been of sufficient strength and duration to produce such a degree of dilatation of its mouth and neck as to allow the ovum to pa.s.s; but before this can be effected, such a quant.i.ty of blood may have been lost as greatly to endanger the life of the patient. Hence we must use such means as shall enable us to control the haemorrhage, whilst we give the os uteri time to dilate sufficiently: this object will be gained most effectually by plugging the v.a.g.i.n.a. The best mode of performing this operation is that recommended by Dr. Dewees of Philadelphia: a piece of soft sponge, of sufficient size to fill the v.a.g.i.n.a without producing uneasiness, must be wrung out of pretty sharp vinegar, and introduced into the pa.s.sage up to the os uteri; the blood, in filling the cells of the sponge, coagulates rapidly, and forms a firm clot, which completely seals up the v.a.g.i.n.a without producing any of those unpleasant effects which are produced by the insertion of a napkin rolled up for the purpose. A hard unyielding ma.s.s of this nature frequently produces so much tension, pain of back, and irresistible efforts to bear down, as to render it incapable of being borne for any length of time. The sponge plug may be borne for hours without inconvenience; we may either leave it to be expelled with the ovum, or after awhile remove it for the purpose of ascertaining what progress has been made. If the os uteri be still undilated, and the haemorrhage going on, the plug must be returned. It is however by no means a remedy to be used in every case of haemorrhage, for in most instances the treatment already mentioned will be sufficient to keep it within safe bounds. Where, however, the flooding has become very alarming, and the os uteri still remains firm and but little dilated, the plug will prove an invaluable remedy; and so long as the os uteri remains in this condition, and the uterus itself shows no disposition to contract, we may safely trust to perfect rest, cold applications, and the plug. Opium, which in the early stages of the attack is so useful in keeping off contractions of the uterus, will now for this very reason be contra-indicated; it will diminish the power of the uterus, and interfere with the process of expulsion.

The acetate of lead has been extolled as a powerful remedy for stopping haemorrhage, more especially by Dr. Dewees, who states that "in many cases it seems to exert a control over the bleeding vessels as prompt as the ergot of rye does upon the uterine fibre." (_System of Midwifery_, -- 1045.) We have never tried this remedy in premature expulsion, having found the means of treatment above mentioned sufficient; the authority however of such an author demands respect, the more so as it is known to be a valuable remedy in certain forms of menorrhagia.

Where a considerable quant.i.ty of blood has been lost, and the patient is much reduced, we must endeavour not only to excite the contractile power of the uterus, but also to a.s.sist this organ in the expulsion of its contents: syncope in these cases is a dangerous symptom, because, as the patient is in the horizontal posture, it will seldom be induced except by a serious loss of blood; although we must not therefore allow her to flood until she faints, still, however, when the pulse has become considerably affected, the os uteri dilates more readily, and in this way facilitates the expulsion; we must no longer trust to the plug, for the whole system is beginning to sympathize and grow irritable, the pulse grows quicker and smaller, and the stomach rejects its contents. Although vomiting as well as syncope are symptoms which we cannot safely wait for, they are nevertheless means which nature adopts to relieve herself from the impending danger: by syncope she not only produces greater dilatability of the os uteri, but also, by causing a temporary cessation of the heart's action, she favours the coagulation of blood, and thus checks the discharge; whereas, by the involuntary effort of muscles which she excites by the action of vomiting, the ovum is more speedily separated and expelled.

Where it becomes evident that expulsion cannot be prevented, it is our duty to promote this process before nature has had recourse to the means just mentioned. The ergot of rye is here a valuable remedy, for by inducing or increasing the contractions of the uterus we shorten the process and diminish the danger: the powder given in cold water is decidedly the best form in which it can be given; in infusion its powers seem to be injured by the heat of the water, and in tincture by the action of the spirit: the addition of about half its quant.i.ty of borax renders its action more powerful and certain. Borax has been long considered in Germany to possess a specific power in exciting uterine contraction, but it was first recommended for that purpose in this country by Dr. Copland.

(_Dict. Pract. Med._ art ABORTION.) A scruple or half a drachm of ergot powder with ten grains of borax may be given in cinnamon water, and this repeated every hour for several times.

In all cases threatening premature expulsion, wherever there has been much pain and discharge, the napkins which come from the patient should be carefully examined by her medical attendant, for otherwise the ovum may escape among the coagula and not be perceived. Where the separation is nearly complete, a portion of it protrudes at the os uteri; and this we can sometimes hook down with one or two fingers, and bring away: a still better mode is recommended by Levret, viz. of throwing up a pretty powerful stream of warm water by means of a syringe. Dr. Dewees has recommended a wire crotchet, which he has used with very good effect.

(_Op. cit._ -- 1011.)[64] We ought not, however, to be in a hurry to bring away the ovum, for when the uterine contractions have been of sufficient strength to dilate the os uteri, it will generally come away of itself.

One objection to the wire crotchet is, that it tears the membranes, and lets out the liquor amnii, and perhaps the embryo.[65] This is by all means to be avoided; the larger the body which is to be expelled, the more powerfully and effectually does the uterus contract upon it: hence, therefore, if the membranes of a three or four months' ovum be imprudently pierced with a view of hastening the expulsion, the liquor amnii and embryo escape, but the secundines remain and require protracted efforts of the uterus to expel them, during which time the sufferings of the patient are prolonged, and the haemorrhage kept up; whereas, if the ovum had remained whole, it would have been expelled more easily and quickly. On the other hand, where the foetus has already attained a considerable size (fifth month,) the plan recommended by Puzos of rupturing the membranes is very desirable; by this means the size of the uterus is reduced by the escape of liquor amnii, and thus the haemorrhage checked; and the foetus remaining in the uterus is of sufficient weight and bulk to excite contractions to expel itself and the membranes.

The treatment after abortion varies considerably: in many cases it will be merely necessary for the patient to remain in bed for a few days afterwards; but where she has been much reduced, a mild course of tonics will be necessary, in order to prevent that disposition to leucorrhoea and menstrual derangement which is so common a result: this, where it is possible, should be combined with removal into the country, or to the sea-side, or, what is still better to a watering place, where there are mineral springs of chalybeate character. For the treatment of anaemia we must refer our readers to the chapter on HaeMORRHAGE.

PART III.

EUTOCIA, OR NATURAL PARTURITION.

CHAPTER I.

STAGES OF LABOUR.

_Preparatory stage.--Precursory symptoms.--First contractions.--Action of the pains.--Auscultation during the pains.--Effect of the pains upon the pulse.--Symptoms to be observed during and between the pains.--Character of a true pain.--Formation of the bag of liquor amnii.--Rigour at the end of the first stage.--Show.--Duration of the first stage.--Description of the second stage.--Straining pains.-- Dilatation of the perineum.--Expulsion of the child.--Third stage.-- Expulsion of the placenta.--Twins._

Parturition may be divided into two great orders, _Eutocia_ and _Dystocia_, the one signifying natural labour which follows a favourable course both for the mother and her child; the other signifying faulty or irregular labour, the course of which is unfavourable.

We may define eutocia to be the safe expulsion of the mature foetus and its secundines by the natural powers destined for that purpose. No function exhibits such infinite varieties, within the limits of health and safety to the mother and her offspring, as that of parturition; no two labours, even in the same individual are exactly alike; still, however, the great objects of the process will be the same, viz. 1st. the preparation of the pa.s.sages and the foetus for its expulsion; 2dly, the expulsion of the foetus; and 3dly, the expulsion of the placenta and membranes.

That we may form a clearer and more comprehensive view of this process, labour has usually been divided into stages or periods, marked by the changes just now alluded to: hence it is generally said to consist of three stages; the first, or preparatory stage, commencing with the first perceptible contractions of the uterus, and terminating in the full dilatation of the os uteri; the second, or stage of expulsion, terminating with the birth of the child; and the third, consisting of the expulsion of the placenta.

_Preparatory stage._--_Precursory symptoms._ For some time before the commencement of actual labour, a variety of changes are taking place which must be looked upon as the precursors of this process: during the last weeks of pregnancy, nature appears, as it were, to be preparing for the great change which is at hand, and to be making such arrangements as shall enable it to be completed with the least possible danger both for the mother and her child.

One of the earliest warnings which we have of approaching labour is an alteration in the form of the abdominal tumour; the cervix uteri has by this time (especially in primiparae) entirely disappeared; the presenting part of the child has therefore descended to the lowest part of the uterus; the fundus has sunk lower and more forwards; and from the diaphragm being enabled to act with greater freedom, the respiration is performed with more ease and comfort to the patient; she therefore feels more capable of moving about, and is in better health and spirits than for some time previously. Upon examination per v.a.g.i.n.am, the head will be found deep in the cavity of the pelvis, covered by the lower and anterior segment of the uterus; the os uteri is still closed, and situated in the upper part of the hollow of the sacrum, forming merely a small circular depression. In women who have already had children, a portion of the cervix uteri is still remaining; it is thick and bulky; and in some cases, where the uterus has been greatly distended in several successive pregnancies, it is nearly as long as in the unimpregnated state; the os tincae or os uteri externum is open, its edge irregular from former labours; the upper extremity of the ca.n.a.l of the cervix is contracted, and forms the os uteri internum; it has been closed during the greater part of pregnancy, but usually is now sufficiently open to admit the finger; the os uteri is neither so high up nor so far backwards in the pelvis as in primiparae, and is reached with greater ease; whereas, the head of the child, instead of being felt in the cavity of the pelvis, generally remains at the brim until labour is more advanced.

_First contractions._ The first contractions of the uterus (in a state of health) are so slight as scarcely to be noticed by the patient: they create a sensation of equable pressure and general tightness round the abdomen, and during the contraction the uterus feels somewhat firmer, but they are neither attended with pain, nor do they appear at first to have any effect upon the os uteri; these precursory contractions generally come on a day or two before actual labour commences, and sometimes are felt at intervals for one or two weeks. Where the uterus has been exposed to any source of irritation, and especially where there is a disposition to rheumatic affection of this organ, they may produce much suffering and give rise to one form of what are called _false pains_, hereafter to be described. "The first contractions, says M. Leroux (_Sur les Pertes de Sang_, -- 41.,) are feeble, and communicate no sensation to the patient; in order to discover them we must hold our hand upon the abdomen, and if we feel the globe of the uterus raise itself and become hard, this is a true contraction. These contractions gradually increase until they excite pain: but pain is not essential to a contraction; it depends on the distension and compression of the nerves produced by the resistance of the body upon which the uterus acts, and increases in severity in proportion to the degree of resistance and contraction."

In proportion as the lower part of the uterus descends into the cavity of the pelvis, so does it exert a degree of pressure on the neighbouring parts; the capacity of the bladder and r.e.c.t.u.m is diminished; and being therefore unable to contain the usual quant.i.ty of urine and faeces, and being probably rendered more irritable by the pressure above-mentioned, the patient experiences frequent calls to pa.s.s water and evacuate the bowels, which is sometimes effected with considerable difficulty: in some instances she is obliged to lean forward, or support the abdomen, in order to take the weight of the child off the neck of the bladder before she can empty it: the same cause occasionally requires the use of the catheter, and sometimes renders the introduction of it a matter of considerable difficulty.

As these various changes make their appearance, the patient becomes restless and anxious; she cannot remain long in the same posture; the slight precursory contractions which have been just described, are becoming stronger, and begin to produce a sensation of pain; the os uteri (in primiparae) opens somewhat, its edge at first is exceedingly thin, and feels almost membranous; by degrees however it swells, grows thick and cushiony, and is now more dilatable.

_Action of the pains._ The os uteri does not dilate merely by the mechanical stretching which the pressure of the membranes and presenting part exert upon it; it dilates in consequence of its circular fibres being no longer able to maintain that state of contraction which they had preserved during pregnancy; they are overpowered by the longitudinal fibres of the uterus, which, by their contractions, pull open the os uteri equally in every direction.

The v.a.g.i.n.a also swells and grows more cushiony, and this is followed by a copious secretion of colourless and nearly inodorous mucus. "The more alb.u.minous it is the better, and it is always a good sign when lumps of alb.u.minous matter come away from time to time; the thicker, softer, and more cushiony the os uteri is, the more mucus does it secrete." (Wigand, _Geburt des Menschen_, vol. ii. p. 292.) The thin hard os uteri does not dilate, its fibres are all in close contact, and like a well-twisted cord will not yield; whereas, when they are separated from each other by the swelling of the os uteri, they easily yield to the dilating force which is applied to them. Besides serving the purpose of lubricating the pa.s.sage, the secretion of mucus is of great importance as a topical depletion, for, by thus unloading the congested vessels, they diminish the vascularity and heat of the part, and render it more capable of dilatation. "If, on the other hand, the entrance of the v.a.g.i.n.a is small, the neighbouring parts cool, dry, inelastic, and as if tightly stretched over the bones; if the finger, in spite of being well oiled and carefully introduced, produces pain upon the gentlest attempt to examine, we may expect a tedious and difficult labour." (_Op. cit._ p. 190.)

The patient is now no longer able to conceal her pains when they come on.

If she be in the act of conversing she stops short, and remains silent until the severity of the pain is over; if she be walking about her room she is obliged to stand still for the time, and rest against or hold by something until the pain has gone off. The true labour pains are situated in the back and loins; they come on at regular intervals, rise gradually up to a certain pitch of intensity, and abate as gradually; it is a dull, heavy, deep sort of pain, producing occasionally a low moan from the patient: not sharp or twinging, which would elicit a very different expression of suffering from her.

_Auscultation during the pains._ "If we direct our attention to the changes of tone which the uterine pulsations present during auscultation, we shall find them generally stronger, more distinct and varied in tone during labour; and this is especially the case just before a pain comes on. Even if the patient wished to conceal her pains, this phenomenon, and more especially the rapidity of the beats, would enable us to ascertain the truth. The moment a pain begins, and even before the patient herself is aware of it, we hear a sudden short rushing sound, which appears to proceed from the liquor amnii, and to be partly produced by the movement of the child, which seems to antic.i.p.ate the coming on of the contraction: nearly at the same moment all the tones of the uterine pulsations become stronger; other tones, which have not been heard before, and which are of a piping resonant character, now become audible, and seem to vibrate through the stethoscope, like the sound of a string which has been struck and drawn tighter while in the act of vibrating. The whole tone of the uterine circulation rises in point of pitch. Shortly after this, viz. as the pain becomes stronger and more general, the uterine sound seems as it were to become more and more distant, until at length it becomes very dull, or altogether inaudible. But as soon as the pain has reached its height and gradually declines, the sound is again heard as full as at the beginning of the pain, and resumes its former tone, which in the intervals between the pains is as it was during pregnancy, except somewhat louder.

This is the course of things if the pain be a true one, and attain its full intensity: where the pains are false or irregular it is very different; the uterine sound either remains unaltered, or increases only for an instant, or its seeming increase of distance, as above mentioned, is not observed." (_Die Geburtshulfliche Exploration_, von Dr. A. T. Hohl, erster theil, s. 105.)

_Effect of the pains upon the pulse._ It is curious to observe the effect which a regular pain has upon the rapidity of the mother's pulse; as the former comes on and goes off, so does the other increase or diminish. "The increasing rapidity of the pulse announces the commencement of the pain; it rises and attains its _summum_ with it; and as the pain subsides so does the pulse gradually resume the rate which it had during the intervals; a similar ebb and flow may be heard in the uterine souffle. The more regular the pain is, and the more distinctly it rises to its full extent, the more marked, regular, and distinct, is this change in it. We may also invert the order of things, and say, the more distinctly the rapidity of the pulse comes on and announces the pain, the more regularly it rises and attains a certain height, which it maintains, and then gradually subsides; in like proportion will the pain be more perfect, attain its full extent more completely, and act more efficaciously upon the regular progress of the labour. Where however the rapidity of the beats subsides before it had scarcely begun to increase, the pain is too weak; or where the rapidity rises by sudden starts, the pain is a hurried one; and in either case its effect will be imperfect." (Hohl, _op. cit._ vol. i. p. 108.) In order that we may ascertain these changes correctly, we ought to note the rapidity of the pulse during each successive quarter of a minute as directed by M. Hohl; thus, in a pain which lasts two minutes, the increase and diminution in the rapidity of the pulse may be as follows, 18. 18. 20. 22.; 24. 24. 22. 18. As labour advances it increases, so that shortly before the birth of the child we shall find that what was the rate of the pulse during the height of the pains at the beginning is now the rate of it during the intervals.

_Symptoms to be observed during and between the pains._ When a pain comes on, the uterus grows hard and tense; if the fundus be somewhat to one side, as is not unfrequently the case, it now gradually moves, so that the median line of the uterus corresponds with that of the patient's body; the various prominences of the child are no longer to be felt, the whole is now firm and unyielding; the os uteri is put tightly upon the stretch, the membranes which were loose become tense and are firmly pressed against it, and the presenting part is rendered indistinct: as the pain gradually subsides, the uterus becomes softer, and yields to the pressure of the hand; the different parts of the child which project, as also its movements, can now be felt more distinctly; the patient is free from pain, and feels herself in an agreeable state of tranquillity, which is frequently attended by a short refreshing doze; the os uteri, which has become somewhat more dilated during the last pain, is now soft and loose, so that we can hook the finger into it and move it about; the tight bladder of membranes becomes relaxed and flaccid, and retracts more or less into the uterus, so that we shall now be able to introduce the finger into the os uteri and feel the presenting part through the membranes; while the presenting part of the child, which during the pain was fixed, can be moved somewhat by the finger.

_Characters of a true pain._ In examining the course of a true pain we shall find that the contractions of the uterus do not begin in the fundus, but in the os uteri, and pa.s.s from the one to the other. (Wigand, _op.

cit._ vol. ii. p. 197.) Every pain which commences in the fundus is abnormal, and either arises from some derangement in the uterine action, or is sympathetic with some irritation not immediately connected with the uterus, as from colic, constipation, &c. We very seldom find that a contraction of the uterus, which has commenced in the fundus, pa.s.ses into the cervix and os uteri, and becomes a genuine effective pain; usually speaking, the contraction is confined to the circ.u.mference of the fundus, without detruding the foetus at all. When a genuine pain comes on, so far from the head being pressed against the os uteri, it at first rises upwards, and sometimes gets even out of reach of the finger, whilst the os uteri itself is filled with the bladder of membranes: if it had commenced in the fundus instead of the inferior segment of the uterus, so far from the head being drawn up at the first coming on of the pain, it would have been forcibly pushed down against the os uteri. In the course of a few seconds the contraction gradually spreads over the whole uterus, and is felt especially in the fundus; the head which had been raised somewhat from the os uteri is now again pushed downwards to it, and seems to act as a wedge for the purpose of dilating it; it is not until the whole uterus is beginning to contract that the patient has a sensation of pain. We may, therefore, consider that a genuine uterine contraction consists of certain phenomena which occur in the following order: first, the os uteri grows tight, and the presenting part rises somewhat from it; then the rest of the uterus, especially the fundus, becoming hard, the patient has a sensation of pain, and the presenting part of the child advances. The period of time necessary for all these changes varies not only in different individuals, but in the same individual in different labours, and in different stages of the same labour.

"The more completely the os uteri is opposite the fundus, and the more the axis of the uterus corresponds with that of the pelvis, the sooner are the pains, _caeteris paribus_, capable of dilating the os uteri."

(_Wigand_, vol. ii. p. 273.) The cushiony state of the v.a.g.i.n.a and os uteri, and the free secretion of thick alb.u.minous mucus from these parts, as already mentioned, will be of great importance in ensuring their easy dilatation. Where this secretion is either absent, or very scanty, the pa.s.sages become dry, hot, and tender, from no relief being afforded to the congested vessels by its effusion; and _vice versa_, where there is a febrile state of the circulation and considerable topical excitement, the secretion is sparing, or, perhaps, stops entirely. This state may arise from a variety of causes, such as from general plethora, too warm clothing, bad ventilation, derangement and irritation of the primae viae, and abuse of spirituous and other stimulating liquors: it may arise from constipation, or may be induced by rough and too frequent examination. The patient becomes flushed, excited, and feverish, with a hot skin, dry tongue, thirst, and headach; the uterine contractions become irregular, they produce much suffering, and but very little advance in the progress of the labour; the pa.s.sages are in a state of inflammation, and more especially the os uteri, which is much swollen and excessively tender. The process of labour is completely interrupted, and can only be restored to a healthy condition by bleeding, warm bath, laxatives, and enemata.

_Formation of the bag of the liquor amnii._ When the os uteri has dilated more or less, a quant.i.ty of liquor amnii begins to collect between the head and the membranes, so that when a pain comes on they form a tense, elastic, and conical bag, which presses firmly against the os uteri, and protrudes through it into the v.a.g.i.n.a, and from its form and elastic nature greatly facilitates the speedy dilatation of it. If the edge of the os uteri be still thin, it will become so tense during the pain, and the bag of membranes will press so firmly against it, that we shall have some difficulty for the moment in distinguishing the one from the other. As the labour advances, the intervals between the pains become shorter, whereas the pains themselves are of longer duration and more effective. In this way pain succeeds pain until the os uteri, at length, attains its full degree of dilatation; if the membranes have not yet ruptured, we may now expect them to burst with every succeeding pain.

_Rigour at the end of the first stage._ At this moment the patient is occasionally seized with a sudden and violent fit of shivering, so much so as to make the teeth chatter, and even communicate a tremulous motion to the bed itself; this is not the result of cold, nor is it relieved by the application of external warmth; and, in many cases, the patient will express her surprise that she should shiver thus violently, and yet not feel cold. It appears to be a modification of convulsive action, excited by sympathy between the os uteri on its becoming fully dilated, and certain muscles in other parts of the body.

_Show._ On examination at this stage of the process, streaks of blood will be found in the mucus which soils the finger, and sometimes it amounts to a slight discharge of blood: this appearance is called by midwives "_a show_," as it usually indicates that the os uteri is nearly or fully dilated. It is produced by a separation of the membranes from the vicinity of the os uteri, and consequent rupture of any little vascular twigs which may have pa.s.sed from the uterus to them.

The full dilatation of the os uteri terminates the _first stage_ of labour. During this stage, the action of the pains does not appear to have been so much for the expulsion of the child, as for preparing it as well as the pa.s.sages for this purpose, viz. by so arranging and regulating the different forces of the uterus, and at the same time by giving the child such a position (_i. e._ with its long axis parallel to that of the uterus,) and the os uteri such a degree of dilatation, as shall ensure its expulsion with the greatest possible ease and safety.