246 



MIDWIFERY. 



Of Parturi. or top of the thighs ; but there is in this respect a great 

 tion. diversity with different women, or the same woman at 

 'different times. Sometimes the pain is felt chiefly or 

 entirely in the abdomen, the back being not at all af- 

 fected during this stage ; and it is generally observed, 

 that such pains are not so effective as tlio.se which af- 

 fect the back. Or the pain produced by the contrac- 

 tion of the womb may be felt in the uterine region; 

 and when it goes off, may be succeeded by a distressing 

 aching in the back. In other cases, the pain is confin- 

 ed to the small of the back and upper part of the sa- 

 crum, and is either of a dull aching kind, or sharp and 

 acute, and, in some instances, is attended with a consi- 

 derable degree of sickness, or tendency to syncope. 

 The most regular manner of attack, is for pains to be 

 at first confined to the back, descending lower by de- 

 grees, and extending round to the belly, pubis, or top 

 and fore part of the thighs, and gradually stretching 

 down the back part of the thighs, the fore part becom- 

 ing easy : occasionally one thigh alone is affected. At 

 this time also, one of the legs is sometimes affected with 

 cramp. The duration of each pain is variable. At 

 first it is very short, not lasting above half a minute, 

 perhaps not go long ; but by degrees it remains longer, 

 and becomes more severe. The aggravation, however, 

 is not uniform ; for sometimes, in the middle of the 

 stage, the pains are shorter and more trifling than in 

 the former part of it. During the intermission of the 

 pains the woman is sometimes very drowsy, but at 

 other times is particularly irritable and watchful. The 

 pains are early attended with a desire to grasp or hold 

 by the nearest object, and at the same time the cheeks 

 become flushed, and the colour increases with the seve- 

 rity of the pain. The os uteri being considerably dila- 

 ted, the second stage begins. The pains become diffe- 

 rent, they are felt Tower down, they are more protract- 

 ed, and attended with a sense of bearing down, or an 

 involuntary desire to expel or strain with the muscles ; 

 and this desire is very often accompanied with a strong 

 inclination to go to stool. A perspiration breaks out, 

 and the pulse which, during the first stage, beat rather 

 more frequently than usual, becomes still quicker, the 

 woman complains of being hot, and generally the mouth 

 is parched. Soon after the commencement of this 

 stage, it is usual for the liquor amnii to be discharged. 

 This is often followed by a short respite from pain ; 

 but presently the efforts are redoubled. Sometimes 

 there is no cessation, but the pains immediately become 

 more severe, and sensibly effective. The perineum 

 now begins to be pressed outward, and the labia are 

 put upon the stretch. The protrusion of the perineum 

 gradually increases, but it is not constant ; for when 

 the pain goes off, the head generally recedes a little, 

 and the perineum is relaxed. Presently the head de- 

 scends so low, that the parts are kept permanently on 

 the stretch, and the anus is carried forward. Then the 

 vertex pressing forward, the labia are elongated, and 

 the orifice of the vagina dilated. The perineum is 

 very thin, much stretched, and spread over the head of 

 the child. As the head passes out, the perineum 

 goes back over the forehead, becoming narrower, but 

 still more distended laterally. If the perineum did 

 not move backward as the head moved forward, it 

 would run a greater risk of being torn ; and indeed, 

 even in the most regularly conducted labour, a part of 

 it is often rent. Delivery of the head is accomplished 

 with very severe suffering ; but immediately afterwards 

 the woman feels easy, and free from pain. In a very 

 little time, however, the uterus again acts, and the rest 



of the child is expelled, which completes the second OfPamm- 

 stage of labour. The expulsion of the body is gene- ''<>'> 

 rally accomplished very easily and quickly ; but some- v " "Y""""' 

 times the woman suffers several strong and forcing 

 pains before the shoulders are expelled. The birth of 

 the child is succeeded, after a short calm, by a very 

 slight degree of pain, which is consequent to that con- 

 traction which is necessary for the expulsion of the pla- 

 centa. This expulsion is accompanied and preceded 

 by a slight discharge of blood, which is continued, but 

 in decreasing quantity, for a few days, under the 

 name of the red lochia. 



The existence and progress of labour, and the man- 

 ner in which the child is placed, are ascertained by ex- 

 amination per vaginam. 



Before labour begins, the os uteri is generally closed, 

 and directed backwards towards the sacrum. When 

 we examine, in the commencement of labour, the os 

 uteri is to be sought for near the sacrum, at the back 

 part of the pelvis, whilst between that spot and the 

 pubis we can pass the finger along the fore part of the 

 cervex uteri. On this the presenting part of the child 

 rests, so that in natural labour it assumes somewhat the 

 shape of the head ; and, for the sake of distinction, we 

 shall call it the uterine tumour. 



In some, it is so firmly applied to the head, and so 

 tense, that a superficial observer would take it for the 

 head itself. In this case the labour often is lingering. 

 This tumour, or portion of the uterus, is broad in the 

 beginning of labour, but becomes narrower as the os 

 uteri dilates, until at last it is completely effaced, the 

 head either naked, or covered by the membranes oc- 

 cupying the vagina. The breadth of this portion of 

 the uterus, therefore, as well as the examination of the 

 os uteri, will serve to ascertain the state of the labour. 



The protrusion of the membranes, and discharge of 

 the liquor amnii, ought to bear a certain relation to 

 the advancement of labour. Whilst the os uteri is 

 beginning to dilate, the membranes have little tension; 

 they scarcely protrude through the os uteri, until it 

 be considerably opened. But in proportion as the di- 

 latation advances, and the pains become of the press- 

 ing kind, the membranes are rendered more tense, 

 protruding during a pain, and becoming slack and re- 

 ceding when it goes off. In the first stage of labour, 

 the head will be found placed obliquely along the 

 upper part of the pelvis, with the vertex directed to- 

 ward one of the acetabula. The finger can easily as- 

 certain the sagittal, and afterwards the lamboidal su- 

 ture ; the central portion of the sagittal suture is the 

 point from which we set out, and, if the finger be 

 readily led to the angle formed by the posterior edges 

 of the parietal bones, we may be sure that the presen- 

 tation is favourable. If, on the other hand, we can 

 feel the anterior fontanelle, the vertex is generally di- 

 rected to the sacro-iliac articulation. When the pel- 

 vis is well formed, and the cranium of due size, the 

 head may commonly be felt in every stage of la- 

 bour ; but there are cases in which, even although the 

 pelvis be ample, it is not easily touched for some 

 time. 



When the vertex comes to present at the orifice of 

 the vagina, or passes a line drawn from the under edge 

 of the symphysis pubis back to the sacrum, the peri- 

 neum and skin near the tuberosities of the ischia be- 

 come full, as if swelled, but not tense. This at first 

 proceeds from relaxation of the muscles, and some de- 

 gree of descent of the vagina and rectum. Whenever 

 this is felt, we may be sure that the head is descend- 





