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is pressed close against the anus, and where the pressure is very great, even protrudes somewhat through it; the hæmorrhoidal veins are frequently much distended, and form a roll of cushiony swelling around the anus. A small quantity of liquor amnii dribbles away from time to time, but it is neither during a pain, nor during the absence of a pain, for in the former case the pressure of the head acts as a plug and prevents its escape, and in the latter there is no uterine contraction present to expel it: the liquor amnii dribbles away only at the moment when a pain is coming on or going
Expulsion of the child. As the head descends farther it begins to press more powerfully on the perineum, and during each pain pushes it out like a large ball; and then, as a contraction goes off, and the resiliency of the soft parts regain their superiority, it retires again. The breadth of the perineum (viz. from the anus to the vulva) increases, whilst it diminishes considerably in thickness, especially towards its anterior margin. Whilst passing through the inferior aperture or outlet of the pelvis, the head advances more or less forwards under the pubic arch, and begins to distend the os externum; during a pain it separates the labia, and protrudes between them, and again retires as the pain goes off; a larger and larger portion of the head gradually forces itself through the os externum as this dilates; the perineum becomes still thinner, so that at length it is scarcely thicker than parchment. When more of the head has passed through, it does not now recede when the pain goes off; the os externum and perineum are at their greatest distention, for the largest diameter of the head which is presented to the os externum is now encircled by it; the next pain brings the head into the world.
This is the moment of greatest pain, and the patient is frequently quite wild and frantic with suffering; it approaches to a species of insanity, and shows itself in the most quiet and gentle dispositions. The laws in Germany have made great allowances for any act of violence committed during these moments of phrenzy, and wisely and mercifully consider that the patient at the time was labouring under a species of temporary insanity. Even the act of child-murder, when satisfactorily proved to have taken place at this moment, is treated with considerable leniency. This state of mind is sometimes manifested in a slighter degree by actions and words so contrary to the general habit and nature of the patient, as to prove that she could not have been under the proper control of her reason at the moment. It is a question how far this state of mind may arise from intense suffering, or how far the circulation of the brain may be affected by the pressure which is exerted upon the abdominal viscera.
A short cessation of pain succeeds the birth of the head. The violent distention of the os externum has ceased for a time, and the patient feels comparatively easy; but in the course of a few minutes the pains return as before, although not quite so severe: first, the shoulder, which is turned forwards, passes under the pubic arch, followed by the other, which sweeps over the perineum. The rest of the child is expelled with comparative ease, and as soon as its pelvis has passed through the os externum, a gush of the remaining liquor amnii, which had been retained in the upper portions of the uterus, follows; the whole abdomen instantly sinks and becomes flaccid, while the uterus contracts into a firm globe upon the pla
centa, which is shortly to be expelled. A most delightful and perfect calm succeeds, and the sense of freedom from suffering, and joy for the termination of her trial, are expressed in the liveliest terms of gratitude.
Third stage.-Expulsion of the placenta. The period between the birth of the child and expulsion of the placenta varies considerably. Sometimes it follows the child very rapidly, so that, apparently, they are both expelled by the same effort of uterine action; at others, the interval is more considerable. There is generally an interval of ten or fifteen minutes, and then pains of a totally different character make their appearance: these are supposed to denote the separation of the placenta from the uterus, and, from their being usually attended with discharge of more or less blood, have been termed dolores cruenti by many of the foreign writers. The expulsion of the placenta is attended with little or no suffering; it descends into the vagina inverted, i. e. with its fœtal or amniotic surface turned outwards: whether or not this is produced by pulling at the cord is perhaps a question.
Twins. If there be twins, the placenta of the first child is seldom expelled until after the birth of the second child. The membranes of the second ovum become distended with liquor amnii, project into the vagina and burst, as in a common single labour; the passages have been sufficiently dilated and prepared by the birth of the first child, so that, when the uterus begins to contract, the expulsion of the second will be readily and easily effected. The uterus may resume its efforts for this purpose in twenty minutes after the birth of the first child, or it may remain quiescent for several hours without at all disturbing the regular and natural course of the process, which will be precisely the same as in the previous
The placenta of twins are usually expelled together, forming one large placentary mass; their vessels, however, are distinct from each other, so that with care one placenta can be peeled away from the other. In other cases, they are separated from each other by an intervening space of membranes; and in one rare instance of triplet placentæ the umbilical arteries of two placenta anastomosed with each other, before dividing into smaller branches.
Upon the expulsion of the placenta, the uterus, being now emptied of its contents, contracts into a firm hard ball, which may be felt behind the symphysis pubes, or sometimes a little to one side, of about the size of a full-grown foetal head. This state of hard contraction gradually disappears, and a discharge of blood called lochia follows, which having continued for a few days becomes colourless, and at length ceases altogether. For a description of the changes which the uterus and passages undergo in returning to their former condition as in the unimpregnated state, we refer to the chapter on the FEMALE ORGANS OF GENERATION.
TREATMENT OF NATURAL LABOUR.
STATE OF THE BOWELS.-FORM AND SIZE OF THE UTERUS.-TRUE AND SPURIOUS PAINS. -TREATMENT OF SPURIOUS PAINS.-MANAGEMENT OF THE FIRST STAGE.-EXAMINATION. POSITION OF THE PATIENT DURING LABOUR.-PROGNOSIS AS TO THE DURATION OF LABOUR.-DIET DURING LABOUR.-SUPPORTING THE PERINEUM-TREATMENT OF PERINEAL LACERATION.-CORD ROUND THE CHILD'S NECK.-BIRTH OF THE CHILD, AND LIGATURE OF THE CORD.-IMPORTANCE OF ASCERTAINING THAT THE UTERUS IS CONTRACTED AFTER LABOUR.-MANAGEMENT OF THE PLACENTA.-TWINS.-TREATMENT AFTER LABOUR.-LACTATION.-MILK-FEVER AND ABSCESS.-EXCORIATED NIPPLES.-DIET DURING LACTATION.-MANAGEMENT OF LOCHIA.-AFTER-PAINS.
THIS is a subject of great extent as well as importance, because it comprehends the whole mass of rules for the management of a woman, not only just previous to and during, but also after, her confinement. On nothing does the course of a natural labour depend so much, as upon the careful removal of every source of irritation which may tend in any way to derange or interrupt the regular progress of that series of changes or phenomena which constitutes the great process of normal parturition. It will be necessary that the reader should have made himself thoroughly master of the subjects discussed in the last chapter, before commencing those of the present one. With each change there mentioned, the state of the system and its functions should be carefully watched, and every slight deviation from the natural course of things checked by appropriate dietetic or medical treatment. Hence, therefore, the more a woman can follow her usual avocations, and take that degree of exercise to which she has been accustomed at other times, the better; for by so doing the circulation is equalized, the digestion is kept in full activity, and the tone and general strength of the system maintained.
It would almost seem, by rendering a woman more capable of moving about during the last weeks of pregnancy (which has already been shown to be produced by the sinking of the fundus enabling the respiration to act more freely,) that Nature intended she should use exercise at this period, and thus prepare her, by increased health and strength, for a process which requires so much suffering and exertion.
Her hours should be regular and early, her meals light and moderate, and by agreeable and cheerful occupation she should fit herself, both in body and mind, to meet the coming trial.
State of the bowels. Attention to the state of the bowels is of first importance, and must never be neglected. It is a subject nevertheless upon which women are remarkably careless, and they will frequently, when not attended to, allow labour to come on with their bowels in a very loaded and highly improper condition.
There is, perhaps, no one circumstance which is found to exert such a prejudicial influence on the course of a natural labour, in so many different ways, as deranged and constipated bowels. Where the contents are of an unhealthy character, the irritation which they produce in the intestinal canal is quickly transmitted to the uterus, and tends not a little to pervert and derange the due and healthy action of this organ: hence arises one of the most fertile sources of spurious pains, a subject which will shortly come under our consideration. Where the bowels are loaded, in consequence of the pressure upon the ascending cava, considerable obstruction to the free return of blood from the pelvic viscera is produced, the vessels of which become considerably engorged. No organ feels these effects more than the uterus: from the immensely dilated condition of its veins, a state of local plethora is engendered, which, from the congested state of the uterine parietes, considerably interferes with the free and regular action of its fibres, and not unfrequently predisposes to hæmorrhage.
Moreover, the rectum being distended with fæces, diminishes proportionally the capacity of the pelvis, and prevents the ready descent of the head into it; occasionally it forms, at the beginning of labour, a solid cylinder of indurated fæces, so hard, as, at the first touch, almost to induce the suspicion of a projecting sacrum. As a measure of common cleanliness, the bowels ought always to be attended to before labour, for, besides the more serious effects now enumerated, the labour may be rendered exceedingly filthy for the patient, and not less disgusting for the practitioner; for, as the sphincter ani loses all power of contraction when the head advances deeper into the pelvis, it follows that whatever fæcal matter may have been lodging in the rectum will now be unconsciously pressed out.
Hence, therefore, for the last few days of pregnancy, the bowels should be regularly opened (unless they are so spontaneously, which is seldom the case) by castor oil or other mild laxatives: and if labour has already commenced before this measure has been taken, and if, therefore, there is not sufficient time for the operation of the medicine, an enema should be given.* In Germany it is a rule to throw up some chamomile infusion at the commencement of every labour, by which means the process is rendered more cleanly than is frequently the case in this country; and also, for the reasons already given, the early stage is less apt to be tedious from spurious and ineffective pains.
Form and size of the uterus. The more regular the first precursory pains are, the more symmetrical and uniform will be the shape of the uterus; and again, on the other hand, the more uniform its shape, the more regularly and effectively will it act.
It is these slight but early contractions, which, although they produce little or no effect upon the os uteri, exert a very important influence over the first half of labour; for it is by their action, in great measure, that the form of the uterus is determined, as also the correct position of the child. Hence, therefore, some practitioners lay considerable stress on ascertaining the precise form of the abdomen as a means of determining what sort of labour the patient will have.
"Clysteres injiciantur, quorum irritatione expultrix uteri facultas excitatur, et depleta intestina ampliorem locum utero relinquat." (Riverius, Prax. Med. de Partu difficili.)
In a woman pregnant for the first time, and in a state of perfect health, the uterus is of an oval or rather elliptical form at the beginning of labour: when seen in profile, the abdomen presents nearly a uniform degree of convexity. In this state the child lies with its long axis parallel to that of the uterus, that is, with its head or inferior extremity turned towards the brim of the pelvis; and if the fundus has already sunk in the manner above-mentioned, the practitioner may very confidently prognosticate that the head presents, even before making an examination per vaginam.
In a perfectly healthy primipara there is scarcely any inclination of the uterus either to one side or forwards, its median line corresponding with that of the abdomen: whereas, in the multipara, the axis of the uterus is seldom straight, inclining more or less to one side, or, from the greater relaxation of the abdominal parietes, being somewhat pendulous. The size of the uterus should also be taken into consideration, especially in first pregnancies; a large uterus shows that either its parietes are gorged with too much blood, or that its cavity is distended with an unusual quantity of liquor amnii, or that the child is very large, or that there are twins. Whatever may be the cause of the distention, it interferes with the regular and effective contractions of the uterus, and tends to make the labour (at least the first part of it) tedious. A moderate sized uterus is much more capable of active exertion, for its fibres not being put so much upon the stretch are enabled to contract better.
True and false pains. If the patient is already beginning to suffer pains, it is of great importance to ascertain whether they be genuine or spurious; upon the correct diagnosis of which, the favourable or unfavourable course of the labour not unfrequently in great measure depends.
A genuine labour pain comes on at tolerably regular intervals, rises gradually to a certain degree of intensity, remains at that point for a few seconds, and then subsides as gradually; the body and the fundus of the. uterus increases in hardness, and the os uteri in tenseness, in proportion as the pain rises, and vice versâ; the pain is seated in the back and loins, and is of a dull aching character: but with the spurious pains it is quite the reverse; they come on and go off suddenly and irregularly, the pain is in the abdomen, and produces a sharp twinging sensation, and the hardness of the uterus and tenseness of its mouth bear no proportion to the pain.
Spurious labour pains are the early contractions of the uterus perverted and rendered irregular, spasmodic, and painful by irritation, congestion, or inflammatory action; they sometimes come on several days before actual labour commences, and if not recognised and removed, may expose the patient to considerable suffering and exhaustion. Derangement of the stomach and bowels is one of the most frequent causes of spurious pains, for by the irritation which is thus produced, the uterus is almost sure to sympathize, and to have its action more or less disordered. This may arise from unhealthy irritating contents of the bowels producing spasmodic, griping, and colicky pains, or from diarrhoea with tenesmus, arising from exposure to cold, or from irritation caused by the pressure of the gravid womb. Spurious labour pains of this character also frequently occur in patients who are accustomed to indulge in the luxuries of the