WE now commence the study of those obstacles to its ready expulsion, which depend on the foetus and its appendages, the passage being in a normal condition, and the expulsive force sufficient. Some disease of the foetus may develop a true hydrocephalic condition, in which the head becomes so large as to make it impossible for it to pass through the cavity. This state may be known from the cranial bones separated far from each other, and each other, and each seems to swim, as it were, in water, when pressing upon them; there is also a wide suture between every bone of the cranium.
In cases of this kind, it will be necessary to plunge a trocar through the head, and draw off the water, when the natural forces will cause an expulsion.
Hydrothorax may exist. This disease may be diagnosed after the expulsion of the head or breech, by the arrest of progress, by the intercostal spaces being extended, and by the fluctuation of water between the ribs.
Ascites may occur and arrest the further progress of the child. When this is the case, fluctuation and enormous distention solve the mystery. In the last two, or in similar cases, the trocar is the only remedy.
An emphysematous condition may occur in foetuses which have been long dead and become so distended with gas as to hinder their expulsion. The trocar is to be used also in this case. Upon applying this instrument, large quantities of offensive air escape.
Tumors of the foetus may also cause a delay, until the tumor is removed, if solid; or punctured, if containing fluid.
We must be on our guard against accidents, and be duly prepared for every exigency which may arise.
Anchylosis of the foetal articulation has been known to occur, causing great delay. On the application of the forceps, and making severe tractions, a great cracking has been heard, and the child delivered.
Excess of volume on the part of the child may be a cause of delay; the volume may be so much in excess, indeed, as to constitute the child a monster. The application of the forceps or blunt-hook is the remedy in cases of this kind, that is if the vital forces are in adequate to a delivery.
Multiple and adhesive foetuses constitute a very formidable cause of dystocia. We can often ascertain before the time of delivery the fact of the pressure of two or more foetuses in utero; but we cannot ascertain whether they are separate and independent, until the hour of delivery has actually come. If two bags of water are found to be present, it is necessary to rupture the membrane twice. The same must be done if we have evidence of their being two distinct gushes of liquor amnii. We may then be assured that two pouches have ruptured, and it is made certain that there are no adherent foetuses present: for adherent children are always enclosed in a single set of membranes, and perfect twins are seldom enclosed in a single amnion. If, moreover, the head and feet appear at the superior strait, and particularly if we can draw upon the feet without causing the head to ascend, we may be sure that there is no adhesion; no adherent foetuses being ever so united that the feet and head are in different directions. If three or four feet appear at the vulva at the same time, and on pulling at one, another moves simultaneously, but the others remain at rest, we may be sure of the foetuses being detached from each other. If all move simultaneously, we can only ascertain this fact to a certainty by carrying the hand up into the uterus.
In all cases, whether there is an adhesion or not, sufficient time should be allowed for nature to operate unaided, but efficient aid should be rendered the moment that there is reason to believe it to be called for. Whether the union takes place at the head or the breech, the expulsion takes place, the one after the other, without difficulty. But if the union be at the occiput and the full term has expired, craniotomy will probably have to be resorted to.
Where there are two heads to one head will engage after the other, and the body will descend subsequently.
Where each head has its body, and the union takes place at any point of the trunk, one head may be born first; the feet belonging to this head may be brought down, next, the feet of the other child may be brought down, and lastly the head of this same child.
When there is but one head to two bodies, the head may be born first, and the two bodies simultaneously with each other. If the breech of one body comes first, the hand may be introduced and the feet of the other child brought down.
But it is impossible to lay down positive rules for all the anomalies which may arise. In special cases, the accoucheur, in deciding on his course, must be led by general principles.
Multiple and independent foetuses are often delivered one after the other, promptly and with but little delay; but usually these cases are more tedious. The child first presenting cannot be acted on as efficiently as if there were but one, for the uterine contraction must force one by acting upon the other.
Moreover the over distention of the uterine walls serves to weaken the contractile powers for the first child. When the first child presents by the breech, there is likely to be more difficulty in the birth of its head on account of the remaining child’s hindering the direct application of the uterine contractions upon it. Hence we must not overlook the importance of introducing a finger into its mouth in order to flex the chin upon the chest, and make sufficient and prompt traction for a safe delivery. Soon after the birth of the first child, in the course of twenty minutes, the contractions return, feebly at first, but soon more efficaciously, and the next child, and the next is promptly expelled. The accoucheur, as soon as one child is born, should always place his hand on the abdomen of the mother, to ascertain whether others are present there, and so on, successively, until all the births are effected. If another remains, the abdomen will seem to be but a little smaller for the expulsion of one or two: the presence of more will be unmistakable to both sight and touch. Sometimes, after one child has been born, a rest of some hours seems necessary, before the exhausted fibres are sufficiently recovered to renew their contractions. All troublesome symptoms such as flooding, fainting, &c., may now be relieved by the proper Homoeopathic remedies, according to the principles already mentioned. If the pains are delayed very long, they may be reproduced by resorting to the remedies already referred to under the head of Labor Sometimes it may be necessary to rupture the membranes for the passage of the second child, in order to excite contractions, and some times to tickle the os with the finger in order to excite a reaction.
Sometimes both heads incline to present at the same time, in which case one must be pushed aside to allow the other to descend. The same course must be adopted in the case the breech presents. If either child presents by the shoulder, and a pelvic version is determined upon great care must be exercised to seize the feet of the child to be turned; this is an easy matter, by constantly keeping the hand on the child whose shoulder presents.
When two feet appear at the vulva, and it should seem advisable to interpose assistance, but one foot should be drawn upon, and that very gently at first, in order to ascertain whether the other moves simultaneously, as belonging to the same body, and if this is found not to be the case, every effort should be made to return those which do not. A good, and perhaps the only way to accomplish this is to suspend the patient by the feet, at the same time holding on to a leg of one of the children, the others would return into the uterus, to be extracted after the expulsion of the first.
Prolapsus, or the falling of the cord, is a serious complication for the child, whilst it brings no harm to the mother, the life of the child being alone endangered: Fig. 95 exemplifies a case of this kind. The first evidence which the accoucheur has of this accident, is its actual presence with the presenting part of the child. The fold of the cord hanging may be of different lengths, simply hanging below the superior strait, or it may be six inches long, or more. If the child is living the cord will be felt to pulsate, one hundred and twenty to one hundred and forty beats a minute, and the cord will be felt firm and like a living tissue. But if dead, there will be no pulsation, and the cord will feel shriveled, soft and lifeless.
The treatment of this complication needs to be very prompt, lest the presenting part descend and cause the strangulation and consequent death of the child. The only plan of safety possible is to take a piece of wet sponge, about twice the size of a hen’s egg, and cut entirely through its centre a hole large enough to receive the fold of cord. Now pass a string through the loop of cord, and next pass the same string through the sponge. Now by holding on to the string and slipping the sponge upwards, the fold of cord is drawn into the sponge. Slip the sponge well up so as to secure a full introduction of this fold into the sponge. Now with the fingers crowd the sponge and all well above the superior strait. The sponge will dilate and retain all above the presenting part safely. It may be well to be always prepared with a small piece of sponge ready for the occasion. If the presenting part of the child has become so firmly engaged in the superior strait as to render the return of the cord impracticable, the labor should be terminated either with the forceps or the blunt hook. Should the shoulder present, and pelvic version become necessary, the cord should be carried up with the hand used for this purpose. When the breech presents, it may become necessary to hold the sponge at the superior strait until the part becomes so engaged as to retain the sponge without further effort. A little thought and reasoning will enable the accoucheur to quickly adapt himself to any variation which may occur. He should always endeavor to adapt himself quickly to circumstances as they arise.
