Obliquity of the uterus would throw the orifice of the neck to one side of the axis of the pelvis, either too far posteriorly, anteriorly, or yet to the right or to the left lateral. In such cases, the position of the patient should be so changed as to rectify the obliquity. If the os is looking backwards too much, she must lie on her back; if too much forward, even on to the pubis, she must throw her chest and trunk forwards; if to the right, she must lie on her right; if to the left, she must lie on her left. In all these cases, the uterus will right itself very soon, and a speedy delivery will ensue.
Agglutination of the external uterine orifice sometimes occurs, even at the hour of labor. Such a state will be recognized by feeling the outlines of the lips apparently covered over by a thin membrane. At every contraction, the line of demarcation between the lips will become more and more apparent, and allow the thin membrane to sink a little between the lips. Now, during a pain, the thinnest and most yielding spot must be found out, and the finger forced with much violence through the membrane. If the finger is not sufficient, a more potent agent must be used, great care being taken not to wound the child or the mother needlessly.
The swelling and elongation of the anterior lip is a frequent cause of delay in labor. The anterior lip, from some causes, may not dilate. It may swell and become paralyzed, and hang down upon the head of the child; whilst the posterior lip kindly dilates, and the presenting part is ready to pass through, but for the stubbornness of the anterior lip. Great and often immediate relief is obtained by pushing up with the finger this anterior lip, and holding it firmly, and even crowding it up further during a pain. It then slips up, sooner or later, above the head, and the distress of the patient is relieved, and the labor progresses finely to its completion.
Induration and hypertrophy of both lips are found in some cases, when the distress of the patient during labor will furnish the symptoms necessary for the indication of the remedy which will effect the desired dilatation.
A cancerous neck is sometimes an obstacle to easy labor. When the cancerous affection occupies only one-half or so of the neck, dilatation will be effected, and the labor brought to a close. But if two thirds, or quite all of the neck be affected, it will be necessary, in order that dilatation be effected, that an incision be made through the schirrosity, in six or eight places, equidistant from each other.
Complete obliteration of the cervix uteri, it is admitted by all medical writers at the present day, does sometimes occur. Of course no os, in this case, can be found by exploring in any direction, far back towards the promontory of the sacrum, and in other directions; but much care is necessary here, for sometimes it is found at an incredibly distant point towards the promontory of the sacrum. When not the faintest line of demarcation of an os can be discovered, one must be made at the lowest or most pendant point of the uterus by a vaginal Caesarean section.
Hernia of the womb, it is admitted, sometimes takes place, by the inguinal or crural rings becoming so much dilated as to allow the escape of the uterus. Pregnancy may continue to the full term, when a reasonable time should be allowed for spontaneous delivery; but it is most likely that a Caesarean section will be found necessary.
A prolapsed womb may become pregnant; or the womb may prolapse suddenly after conception, and the full term be accomplished there: a slow and difficult labor will result; but it may take place fairly, and the uterus return to its place.
DYSTOCIA FROM RUPTURE OF THE UTERUS.
Rupture of the uterus is one of the most serious complications or accidents which can possibly occur during the puerperal state. It may occur at any time during gestation or labor, but is much more frequent in the latter stage than in the former. Primiparae are much less liable to the accident than multiparae. It may occur in the body or in the neck, when it occurs in the neck, it almost always involves a rupture of the vagina also.
The cause of so unfortunate an accident may be referred to many circumstances: great thinness, a softening, or a diseased condition of the walls; mechanical injuries, or too violent contractions may all be enumerated among the circumstances.
When this accident occurs, a sharp, tearing pain is felt, and that so suddenly and severely as to cause the patient to sacrum out with great force, then a sensation of numbness, paleness, swooning, sinking of the pulse, and finally syncope.
When this accident occurs at an early stage of gestation, before the uterus contains much to be discharged, through the rent, the product of conception may dam up the passage, and cause the contents of the uterus to be retained for some days; so that when a reaction ensues after the first shock, a calm or precedes a more violent set of symptoms after the final escape of the product of conception into the cavity of the abdomen. In the later months of conception, the diagnosis is easier to be made, from the fact that the uterine globe has evidently become dissipated; its contents having escaped and become generally diffused throughout the abdominal cavity. There follows a sense of heat and then a burning sensation, as in cases of peritoneal inflammation.
When it occurs during labor, we have added to the other symptoms, a collapse of the bag of waters, or the retrocession of the presenting part, and a terrible hemorrhage from the ruptured organ, a small portion of which will escape from the vagina, but the remainder passes into the abdominal cavity. Hemorrhage occurs in all cases, it is true, but not from the vagina in so marked a degree as in labor, and after the rupture of the membranes. If this occurs during labor, instruments should be applied as soon as possible, to prevent the escape of the child into the abdominal cavity. Should the child have already escaped, the hand should follow and deliver through the rent, care being taken not to drag out the intestines, or to leave any of them embraced in the rent after the extraction of the child. If the rupture occurs from a hydrocephalic head, apply the trocar at once, and then the forceps, or the crochet. Should this be impracticable from the retraction of the uterine walls, the Caesarean section will be the only remedy.
Should the rupture occur after the seventh month, and previous to labor, the Caesarean section should be resorted to at once, particularly if the child be alive. If it occurs in the earlier months of gestation, it is thought to be the better plan to leave the consequences to nature and to such medication as the symptoms of the case would seem to require.
If, after all, in either of the above cases, the patient, survive the loss of blood we may entertain a reasonable hope to save her life, by combating the symptoms as they occur, by means of the proper medication. Inflammation.
When it occurs during labor, we, have aided to the symptoms, a collapse of the bag of waters, or the retrocession of the presenting part, and a terrible hemorrhage from the ruptured organ, a small portion of which will escape from the vagina, but the remainder passes into the abdominal cavity. Hemorrhage occurs in all cases, it is true, but not from the vagina in so marked a degree as in labor, and after the rupture of the membranes. If this occurs during labor, instruments should be applied as soon as possible, to prevent the escape of the child into the abdominal cavity. Should the child have already escaped, the hand should follow and deliver through the rent, care being taken not to drag out the intestines, or to leave any of them embraced in the rent after the extraction of the child. If the rupture occurs from a hydrocephalic head, apply the trocar at once, and then the forceps, or the crotchet, Should this be impracticable from the retraction of the uterine walls, the Caesarean section will be only remedy.
Should the rupture occur after the seventh month, and previous to labor, the Caesarean section should be restored to at once, particularly if the child be alive, If it occurs in the earlier months of gestation, it is thought to be the better plan to leave the consequence to nature and to such medication as the symptoms of the case would seem to require.
If, after all, in either of the above cases, the patient survive the loss of blood, we may entertain a reasonable hope to save her life, by combating the symptoms as they occur, by means of the proper medication. Inflammation will probably be the first, and the worst symptom to contend with. See the remedies under Peritonitis, Hysteritis, &c.
All foreign substances that remain in the abdominal cavity after rupture in any stage of gestation, become encysted as the patient recovers, and may be carried in the cyst for years, or even during her life time, and she may enjoy, in the meanwhile, a tolerable degree of health.
