2. Labours which are rendered faulty without obstruction to their progress.

The first division of dystocia may either arise from a faulty condition of the expelling powers, or, without any anormality in this respect, it may depend upon the faulty condition either of the child, or of the parts through which it has to pa.s.s.

As respects the child it may arise from,

1. Malposition.

2. Faulty form and size of the child.

3. Faulty condition of the parts which belong to the child.

On the part of the mother this division of dystocia may arise from a faulty condition.

4. Of the pelvis.

5. Of the soft pa.s.sages.

6. Of the expelling powers.

The second condition where labour is rendered dangerous for the mother or her child, without any obstruction to its progress, may arise from,

1. Following too rapid a course.

2. Prolapsus, &c. of the umbilical cord.

3. From accidental circ.u.mstances, which render the labour dangerous, viz.

convulsion, syncope, dyspnoea, severe and continued vomiting, haemorrhage, &c.

We propose to consider the different species of dystocia in the order above enumerated.

CHAPTER I.

FIRST SPECIES OF DYSTOCIA.

_Malposition of the child.--Arm or shoulder the only faulty position of a full-grown living foetus.--Causes of malposition.--Diagnosis before and during labour.--Results where no a.s.sistance is rendered.-- Spontaneous expulsion.--Malposition complicated with deformed pelvis or spasmodically contracted uterus.--Embryulcia.--The prolapsed arm not to be put back or amputated.--Presentation of the arm and head.-- Presentation of the hand and feet.--Presentation of the head and feet.--Rupture of the uterus.--Usual seat of laceration.--Causes.-- Premonitory symptoms.--Symptoms.--Treatment.--Gastrotomy.--Rupture in the early months of pregnancy._

We have already stated that the presentations of the full-grown living foetus may be brought under three cla.s.ses, viz. those of the head, of the nates or lower extremities, and of the arm or shoulder: the former two have already been considered under the head of eutocia or healthy parturition, and may be distinguished from the latter, by the great peculiarity that in them the long axis of the child's body is parallel with that of the uterus, whereas, in arm or shoulder presentations this cannot be the case, its body lying across the uterus.

Although malposition of the child, strictly speaking, refers to one species of presentation only, viz. to that of the arm or shoulder, yet it has been rendered a matter of great perplexity by the speculations and theoretical notions of authors. No one has propagated more serious errors upon this subject than the celebrated Baudelocque, the more so as the great authority of his name has tended to silence all doubts as to the accuracy of his views upon this subject. Almost every author since his time has contented himself with copying more or less from him, without ascertaining by personal observation how far they corresponded with the actual course of nature. By forcing a stuffed figure into a pelvis in every possible direction, he succeeded in making actually ninety-four presentations of the child, all of which he described as if they had really occurred in nature.

Few have taken so simple a view of this subject as the late Dr. Denman.

"The presentations of children at the time of birth," says this distinguished accoucheur, "may be of three kinds, viz. the head, the breech or inferior extremities, the shoulder or superior extremities; the back, belly, breast or sides, properly speaking, never const.i.tute the presenting part."

The two greatest Continental authorities of modern times, viz. Madame La Chapelle and Professor Naegele, confirm this opinion: the former points out one of the sources of error which has induced pract.i.tioners to suppose that they had met with other species of faulty presentation besides those of the arm or shoulder. "In the greater number of shoulder presentations,"

says this experienced auth.o.r.ess, "I have very distinctly touched the chest, in some positions of the nates I have been able to reach the loins, the hips, or lower part of the abdomen; but it would require no slight bias from prejudice and theoretical systems to find presentations of the chest, the back, the abdomen, or the loins, the neck or the ear."[108]

We would, therefore, limit the term malposition of the child merely to presentations of the arm or shoulder: other presentations, it is true, occur, but not of the full-grown living foetus; they are only where the child is premature, or has been dead in utero some time. Under such circ.u.mstances it will follow no rule whatever; for in the first case it is too small, and therefore the pa.s.sages can have no effect in directing its course through them; and, in the second, a child which has been dead some time becomes so softened by gradual decomposition, that it may be squeezed by the pressure of the uterus into almost any shape: it is by this cause that we occasionally see in still-born children parts in close contact, which in a living child could not have been brought together.

We do not deny that such presentations may be made by ignorant and awkward attempts to deliver, but it is to be hoped that such cases are daily becoming of rarer occurrence.

Malposition of the child is fortunately not of very frequent occurrence: as a general average we would say that it occurs once in 230 cases, as the following results will show:--At the Westminster General Dispensary (1781) it occurred to Dr. Bland once in 210 cases: at the Dublin Lying-in Hospital, to Dr. Joseph Clarke, once in 212: in private practice, to Dr.

Merriman, once in 155: "calculated from a great number of cases," to Professor Naegele, once in 180: at the Dublin Lying-in Hospital, to Dr.

Collins, once in 416: at the Maternite, of Paris, to Madame La Chapelle, once in 230.

In arm and shoulder presentations the back of the child is turned towards the anterior part of the uterus more than twice as frequently as it is in the contrary direction, from which circ.u.mstance Professor Naegele has called this the first position of the shoulder to distinguish it from the other, which, as being rarer, he calls the second.

In investigating the nature of the causes which produce malposition of the child, which, from the above observations, is evidently a circ.u.mstance of rare occurrence, the question naturally suggests itself, by what means is the long diameter of the child in so large a majority of cases kept parallel with that of the uterus? This depends in great measure on the form and size of the uterus. Where the uterus is not unduly distended with the liquor amnii, and where it preserves its natural oval figure, it is scarcely possible that the child should present in any other way than with its cephalic or pelvic extremity foremost. There can be no doubt that the first early contractions of the uterus in the commencement of labour have a great effect in regulating the position of the child; for, by the gentle and equable pressure which they exert upon it, they not only maintain it in the proper direction, but tend materially to correct any slight deviations from the right position. Hence, therefore, we find that where any cause has existed to impair or derange the action of these precursory contractions of the uterus, the child is apt to lie across, or, in other words, to present with the arm or shoulder. Thus, for instance, if the uterus be much distended with liquor amnii, the contractions of its parietes can have little influence upon the child's position; this will be particularly the case where the acc.u.mulation is very considerable, for here the uterus becomes more or less globular, and presents but little variation as to the length of its diameter in any direction.

The form of the uterus is no less worthy of attention as a cause of malposition, and is also in a great measure influenced by the character of its early contractions. Thus in a uterus for the first time pregnant, they generally act equally on all sides: hence it is why in primiparae the uterus is so exactly oval, and why we so rarely meet with faulty presentations. Sir Fielding Ould, of Dublin, was the first and almost the only pract.i.tioner in this country who noticed the influence which the early contractions of the uterus have in determining the position of the child. "The first labour pains, which are very short, continue their repet.i.tion for two or three hours, or perhaps for more, before there is the least effect produced upon the os tincae, which time must certainly be employed in turning the head towards the orifice." (_Treatise of Midwifery_, p. 14.)

Wigand, in reasoning upon the physical impossibility of a child presenting wrong, where the uterus is of the natural configuration, says that "the chief cause of faulty position of the child does not depend so much upon the child itself, as upon the deviation of the uterus from its natural elliptical or pyriform shape." (Wigand, vol. ii. p. 107.)

The theory at one time so universally entertained, that the obliquity of the uterus was the chief cause of malposition of the child, has long since been disproved, although it continues to find a few adherents to the present day: the uterus, in fact, towards the end of pregnancy, is scarcely ever quite straight; the upright posture of the human female rendering it almost necessary that the fundus should incline somewhat to one side or to the other, or forwards, and yet we find that it has no influence upon the position of the child when labour comes on. The moment a pain commences, the fundus moves towards the median line of the body, so that its axis corresponds nearly with that of the pelvic brim: as the pain goes off, so does it return towards its former oblique position. Even in those cases where it is strongly inclined forwards, and where the abdomen is quite pendulous, the position of the child is unaffected by it.

Where, however, the uterus has been altered in point of form, where from irregular contractions of its fibres it has been pulled down unequally to one side, while it is quite relaxed in the opposite direction, the position of the child may be seriously affected, for it will now present obliquely as regards its long axis, and become a case of malposition.

We may, therefore, state that the causes of arm or shoulder presentations are of two kinds, viz. where the uterus has been distended by an unusual quant.i.ty of liquor amnii; or where, from a faulty condition of the early pains of labour, its form has been altered, and with it the position of the child.

It is a well-known fact that cross births, as they have been called, are frequently preceded by severe spasmodic pains in the abdomen, from which the patient suffers for some days or even weeks before labour has commenced: the uterus is more or less the seat of these attacks, which usually come on towards night-time; and, in some instances, it is felt for the time hard and uneven from irregular contraction. It was the circ.u.mstance of this symptom having preceded five successive labours of a patient, in all of which the child had presented with the arm or shoulder, which induced Professor Naegele, when attending her in her sixth pregnancy, to endeavour to allay these cramp-like pains, which had begun to show themselves as severely as on former occasions. Having tried opium by itself, and also in combination with ipecacuanha or valerian without effect, he ordered her a starch injection with twelve drops of Tinct. Opii every night as long as she continued to suffer from these attacks: the spasms soon ceased, nor did they appear again during the remainder of her pregnancy, and he had the satisfaction of delivering her at the proper time of a living child, which presented in the natural manner.

Many other causes of malposition have been enumerated by authors, which evidently exist only in theory and not in reality: thus, shortness of the umbilical cord, or its being twisted round the child, insertion of the placenta to one side of the uterus, faulty form or inclination of the pelvis, obliquity of the uterus, as above-mentioned, violent exertions or concussions of the body, plurality of children; of all these, we do not believe that there is one which can exert the slightest influence in determining the position of the child. There is no doubt that several of them will render labour difficult or even dangerous, more especially deformed pelvis; but we constantly meet with it under every degree and variety without at all altering the child's position. Indeed, if malformation of the pelvis were to be a cause of malposition of the child during labour, what difficulties would it not add to the process of delivery under such circ.u.mstances? And yet we find, with very rare exceptions, that in every case requiring artificial a.s.sistance on account of contracted pelvis, the head is resting upon the brim which is too narrow to allow it to pa.s.s.

We may also mention another circ.u.mstance which has occasionally seemed to produce a faulty position of the child. It sometimes happens that the hand, which is frequently felt lying by the side of the face at the beginning of labour, instead of slipping up out of reach as the head descends, which is usually the case, advances more and more, until it not only prevents the head from engaging farther into the pelvis, but pushes it out, so that the head slips up to one side, and lodges in the cavitas iliaca, allowing the shoulder with the rest of the arm to descend.

Where, however, the pelvis is large or the head small, the arm will not always force it to one side, but the two will come down together and be born in this position. (See case in our _Midwifery Reports, Med. Gaz._ April 19, 1834.)

Sometimes the two hands present (_La Motte_, book iii. ch. 26.,) or a hand and foot: this, however, does not long continue so, for when the membranes have ruptured, the liquor amnii flowed away, and the uterus contracted upon the child, one shoulder and arm descend before the rest, and remain in this position.

The complication of two arms presenting with the head we disbelieve entirely, except where it has been made during some awkward and ignorant attempts at delivery.

Although the symptoms of malposition of the child during the last few days before, or at the commencement of labour, are far from being distinct, still, however, when taken collectively, they will be sufficient to excite our suspicion. The abdomen is irregularly distended, and marked with unequal prominences; anteriorly, it is more or less pointed. It is usually much increased in breadth, and this is generally in an oblique direction, forming a globular protuberance at the upper part on one side, and at the lower part on the other: the former is the pelvic extremity of the child; the other, from its size, form, and hardness, may easily be recognised as the head.

"The movements of the child feel differently to what they did before; they are no longer exclusively confined either to one side or the other.

Sometimes, as before-mentioned, cramp-like pains are felt in the abdomen, during which it is more or less distorted with violent movements, apparently of the child, as if it were trying to force its way through the abdominal parietes at this spot." (Naegele, _Lehrbuch_, p. 223.)

Upon examination _per v.a.g.i.n.am_, either no presentation is to be reached at all, or only small parts can be indistinctly felt, such as the hand, the arm, or the shoulder. The not being able to feel a presenting part in a primipara shortly before or at the commencement of labour, is an unfavourable symptom; for the head at this time ought to be deep in the cavity of the pelvis; still, however, it does not necessarily prove that the child is presenting wrong, for it may be a presentation of the nates, which, as we have before shown, do not descend so low into the pelvis just before labour, as the head does; or it may arise from the unusual size of the child's head, especially in cases of congenital hydrocephalus. It may arise from a large quant.i.ty of liquor amnii, and where the head is nevertheless presenting; it may be a case of twins, or lastly of dystocia pelvica, where the head is presenting, but unable to pa.s.s through the contracted brim.

In women who have had several children, it is frequently impossible to reach the presentation during the early part of the labour: this arises either from the abdomen in these cases being generally more or less pendulous, or from the circ.u.mstance of the uterus having been distended in so many previous pregnancies: its lower part does not become so fully developed as before, but continues more or less funnel-shaped, a considerable portion of the cervix still remaining. Where this is the case, the head will not descend so low as usual at first, but remains out of reach, or nearly so, until the os uteri is fully dilated and the membranes have given way.

"If, upon such an examination, it should be ascertained that the os uteri is considerably dilated, and the child cannot be felt, this affords reason to suspect that the presentation is preternatural. Should the liquor amnii be discharged and the child be out of reach of the finger, the probability of a preternatural position is greater. Should the membranes be found hanging down in the v.a.g.i.n.a not of the usual globular form, but rather conical and small in diameter, this likewise is a presumptive proof of a cross-birth; especially if there be any part presenting through the membranes which is smaller, feels lighter, or gives less resistance when touched than the bulky heavy head."[109]

The diagnosis of the shoulder is by no means easy: it offers no distinctive marks, and may readily be mistaken for the nates, or even for the head. It feels round, but is smaller and softer than the head. The scapula and clavicle, the neck, the armpit, the arm itself, and the ribs, a.s.sist us in our diagnosis. From the direction of these parts, we shall be able to ascertain the position of the rest of the body, and which shoulder presents. If the hand has prolapsed, the direction of the palm and of the thumb will soon show the position of the child.

Labours with malposition are always dangerous; when left without a.s.sistance, they are almost always fatal to the child, and generally so to the mother.