250 



MIDWIFERY. 



Of Parturi- born, the pains become suspended, and the second is 



"_!""* \_- not k orn ^ or severa l hours. Now this is an unpleasant 

 ""Y"*^ s t a te both for the patient and practitioner. She must 

 discover that there is something unusual about her ; he 

 must be conscious that hemorrhage, or some other dan- 

 gerous symptom, may supervene. The first rule to be 

 observed is, that the accoucheur is on no account to 

 leave his patient till she be delivered. The second re- 

 gards the time for delivering. Some have advised that 

 the case be entirely left to the efforts of nature, whilst 

 others recommend a speedy delivery. The safest prac- 

 tice, if the head present, lies between the two opinions. 

 If effective pains do not come on in an hour, the child 

 ought to be delivered by turning. 



It remains to be observed, that we ought to be pecu- 

 liarly careful in conducting the expulsion of the placen- 

 ta of twins. Owing to the distentionof the uterus, and 

 its continued action in expelling two children, there is 

 a greater than usual risk of uterine hemorrhage taking 

 place. The patient must be kept very quiet and cool ; 

 gentle pressure should be made with the hand exter- 

 nally on the womb, and no forcible attempts are to be 

 permitted for the extraction of the placentae, by pull- 

 ing the cords. If hemorrhage comr 0:1, then the hand 

 is to be introduced to excite the uterine action, and the 

 two placentae are to be extracted together. The ap- 

 plication of the bandage, and other subsequent arrange- 

 ments, must be conducted with caution, lest hemor- 

 rhage be excited. 



CHAP. V. 



Of Tedious Labour. 



Order First. 



Of Tedious Tedious labour may occur under three different cir- 

 labour. cumstances: 



First, The pains may be from the beginning weak or 

 few, and the labour may be long of becoming brisk. 



Second, The pains during the first stage may be 

 sharp and frequent, but not effective ; in consequence 

 of which the power of the uterus is worn out before 

 the head of the child have fully entered into the pelvis, 

 or come into a situation to be expelled. 



Third, The pains during the whole course may be 

 strong and brisk, but, from some mechanical obstacle, 

 delivery may be long prevented, and it may even be 

 necessary to have recourse to artificial force. 



Different causes may produce tedious labour, which 

 cannot be minutely enumerated in this place. Amongst 

 these we may mention a slight disproportion between 

 the capacity of the pelvis and the size of the head of 

 the child, rigidity of the soft parts, unnatural strength 

 of the membranes, &c. One of the most frequent is, in- 

 efficient action of the uterus, during which the pains, 

 though productive perhaps of considerable sensation, 

 have little efficacy, or they may be deficient both in 

 point of sensation and effect. Various causes may pro- 

 duce this : as for instance, premature evacuation of the 

 liquor amnii, undue distension of the womb, torpor of 

 the uterine fibres, passions of the mind, &c. and it is a 

 fact, that the same exciting causes may, in different cases, 

 produce very different, and even opposite effects, in 

 consequence of concomitant circumstances. In gene- 

 ral, it is not necessary to interfere artificially, unless the 

 labour be unusually tedious, or complicated with some 

 urgent symptoms. Stimulants are neither safe nor al- 

 lowable, if we except the exhibition of a clyster, to ex- 

 cite the uterus sympathetically. An oppt ite plan is 

 more useful, namely, instead of endeavouring to increase 



the force, to diminish the resistance, which is most rea- Of Parturi- 

 dily done by venesection. Hippocrates was well ac- ion. 

 quainted with the good effect of detracting blood in fa- *~~Y~~'' 

 cilitnting labour. He advised it to be taken from the 

 foot, but the modus operand! is the same, whatever vein 

 be opened, and it is deeply to be regretted, that the opi- 

 nion of this great man was so long neglected. Blood- 

 letting is safe in every case, where a debilitated consti- 

 tution, or exhausted system, or previous fatigue, do not 

 forbid it. In many cases, more particularly when the 

 os uteri is rigid, or the soft parts do not relax, it is pro- 

 ductive of most speedy improvement. The diminution 

 of resistance, and augmentation of expulsive force, do 

 not bear an exadt proportion to each other, but the lat- 

 ter is in a high ratio to the former, and when the expul- 

 sive action is once much excited, it goes on increasing. 

 This principle is illustrated by the fact, that parturition 

 is greatly accelerated by rupturing the membranes, and 

 thereby allowing the water to run out, and the ute- 

 rus to contract ; a practice which ought not to be adopt- 

 ed unnecessarily, but which, in tedious labour, is often 

 attended with most marked benefit. A change of pos- 

 ture also is useful, so as to make the power of gravity 

 correspond with the uterine efforts. Hence standing 

 or kneeling is often of benefit ; an erect position is also 

 of service, by the stimulus given to the sensible os ute- 

 ri by the greater pressure of the presentation. Walking 

 gives an additional excitement to the action. Another 

 advice to be given is highly important, namely, that 

 when the pains are regular, but not effective, and the 

 labour proves to be tedious, the os uteri should be gen- 

 tly dilated, so as to be completely opened within from 

 ten to fourteen hours from the establishment of labour. 

 The exact time cannot be laid down to suit any case, 

 as a little latitude within these periods must be allow- 

 ed, according to the state of the pains and the condition 

 of the patient, and the effect already produced on the 

 os uteri. It is not meant to say that the rule is abso- 

 lute ; for pains may, after continuing a few hours, go 

 off for a day, and the os uteri may scarcely be affect. 

 ed. In such cases interference is improper. But if the 

 pains have regularly continued, and the os uteri have 

 yielded slowly, and to an imperfect extent, and the pre- 

 sentation is felt resting on it, a delay beyond 12 hours 

 will generally be productive of future exhaustion of the 

 uterus. This is a principle which has most ably been 

 explained by Dr. Hamilton, who has insisted on the 

 great danger of allowing the first stage of labour to be 

 unduly protracted. By pressing steadily but gently on 

 the anterior margin of the os uteri during a pain, with 

 two fingers resting on the head, it is safely and easily 

 dilated to its full extent, by persisting for several pains 

 in succession, or repeating our gentle endeavour at longer 

 intervals. This, especially if preceded by blood-letting, 

 never fails to dilate completely the os uteri ; and those 

 natural efforts of the womb, which would have other- 

 wise been requisite to open the mouth of the womb, are 

 spared, and the strength and force directed to the ex- 

 pulsion of the child. The pains generally become 

 stronger and bearing down, not so much from the gen- 

 tle stimulus applied to the os uteri, as on the princi- 

 ple already laid down. All resistance is taken away 

 from the lower part of the uterine cavity, and the mus- 

 cular action has only to force the head through the pel- 

 vis. Even when the necessity of instrumental aid is 

 anticipated, this practice ought to be adopted ; and in- 

 deed in such cases, above all others, is important. When 

 the os uteri is rigid or tumid, blood-letting ought ne- 

 ver to be omitted, unless the patient be debilitated, and 



