25. CALCULATION OF THE TIME OF LABOUR
THE following table will be especially valuable to the newly married lady, who, through delicacy, might hesitate to seek advice on this important and interesting subject. Much time may be saved, often great anxiety avoided, and timely medical nd other attendants secured, by ability to approximate in reckoning to the hour of solicitude and hope.
The period of pregnancy, from conception to confinement, is calculated at ten lunar months, or forty weeks, which amount to 280 days. 1A very clear case, confirming this statement, occurred at University College Hospital. A maternity patient recorded the day of intercourse, distinctly remembering that she ceased menstruating the the day before. She quickened on 7th March, 196 days from the time of intercourse, and was delivered on 30th August, after a labour of 40 hours. The period of gestation was just 280 days. Similarly clear ceases have been reported in the Lancet, showing the period to be 272 and 286 days. The period of gestation cannot therefore be stated with certainty. it is sometimes reckoned at nine calendar months, that is 273 to 275 days, or 39 week; probably, however, forty weeks is the safer reckoning. Gestation is occasionally protracted beyond 280 days. Cases are recorded in which labour has been delayed 10, 20, or even 30 days beyond the usual period, but such cases are very rare. When the date of conception is known, the reckoning begins from that day. If that be not known, then the calculation must commence from the last monthly period. If the time of the last monthly course cannot be remembered, then that of quickening, or when the movements of the child are first perceived must be made use of. Although sexual connection may not be confined to any period of the month, yet it is an old observation, confirmed by the experience of moder accoucheurs, that conception is more likely to occur within a few days before or after the menstrual flux than at other times.
Patients who make use of the annexed table should remember that the period of pregnancy is slightly altered by the age of the parties concerned; the fact being clearly proved, that the younger the husband and wife, the shorter the term of utero gestation; and vice versa, as are increases, the term of gestation is proportionally lengthened.
Dr. Clay states that he once witnessed a curious experiment bearing on this subject, on the eggs of domestic fowls. Poult eggs can be easily distinguished from those of hens of three or more years old. A certain number of them where placed under a young hen, and on equal number of eggs from older fowls under an old hen. The result was, that every chick and escaped its shell from under the young hen at least twenty-four hours, some even as much as thirty-six, sooner than those of the old hen. This difference is very remarkable in so short a period of incubation. He infers from this and other circumstances that the duration of the gestative period is far more definite than has hitherto been supposed, and that where the circumstances, that the duration of the gestative period is far more definite than has hitherto been supposed, and that where the circumstances are similar, the result as to the length of term is very nearly the same. In maintaining that utero-gestation is definite and regulated by age, the age is not to be calculated by that the mother alone, but by the combined of both parents.
53. DIFFICULT LABOUR
Influence of Artificial Habits. Many of the sufferings attendant upon parturition arise from those habits of life which is the object of this Manual to expose and to guard against, such as- diet of an improper quality or quantity; the use of stimulating beverages; want of sufficient pure air and healthy exercise; tight lacing; late hours; and other injurious habits. Amongst savage tribes childbearing is comparatively free from the sufferings which too frequently attend it in an artificial state of society. Catlin tells us that an Indian woman on the march will often deliver herself, and safely rejoin her companions with her newly-born child on her back before night has set in. What a contrast to the physical disabilities which follow in the train of civilization. 1 (In a note in the American Edition of this Manual, the Editor, Dr. Ludlam, remarks: “The popular idea that the wild lies of Indian women exempts them altogether from the dangers and sufferings contingent upon childbirth is fallacious. The truth is, they often die in labour for lack of proper treatment. Cases of preternatural to the hardships of frontier life than with those who belong to the better classes in our cities and towns.”
Oviparous animals have been known to lose their lives when in labour, striving to be delivered of the egg. This is true of the ostrich, tortoise, and other creatures.) Even in our country, healthy women, of regular habits, accustomed to out-of-door exercise, and whose general mode of life is natural, are freed from the long train of miseries which are the too frequent concomitants of child bearing.
Obstructive Causes.-At the same time, causes, of difficult labour may exist of a more remote nature, the patient. Such are- contraction and deformity of the bones of the pelvis, fro Rickets, or from a similar diseases in adult life; anchylosis of the coccygeal vertebrae to each other and to the sacrum, diminishing nearly an inch the antero-posterior diameter of the outlet of the pelvis; 1 (The condition (described in the text is most frequent in women bearing a first child in life, in women who have been accustomed to sit during the greater part of the day. Anchylosis is loss not infrequent in women who ride too much on horseback.) obstruction from tumours, dropsy, the large size of the child, or from a hydrocephalic head; wrong presentation, etc. The management of these cases requires professional knowledge and skill.
Simpler causes of difficult or tedious labours are a distended bladder; accumulation in the lower bowel; or in digestion from a too full meal, or from food that disagrees, taken just before labour sets in. Prompt treatment suffices at once to remove these obstacles of the progress of labour.
Powerless Labour. Powerless labour is generally due to constitutional feebleness, as from previous of course, preventive treatment is indicated. This includes nourishing diet, pure air, suitable exercise, and the administration of one or more of the remedies which our now rich Materia Medica offers.
Preventive Treatment. This seems a proper place to make a remark on treatment preparatory to labour in cases about which any difficulty is apprehended. Our pharmacopoeia contains remedies which, selected according to the requirements of each case, and administered once or twice a day for some time prior to parturition, tend to facilitate that process, and event correct conditions that would otherwise operate as causes of difficulty. Patients for whom we have prescribed during gestation have often told us of the comparative absence of pains and difficulty which they had experienced in previous labours; and these instances are now altogether too numerous to allow of their being regarded as mere coincidences. As far as our observations extend, the difficulties and dangers of parturition are far less under homoeopathic than under allopathic treatment; to say the least, they are then reduced to a minimum, and especially when preparatory treatment has been adopted.
54. PREPARATIONS FOR LABOUR
The Monthly Nurse. She should be a middle-aged married woman, or a widow; temperate, kind, and cleanly habits; and free from any defect of sight of hearing. In every respect she should be subordinate to the medical attendant, and faithfully carry out his directions, both as to the mother and the infant, as he alone is responsible. Under no pretext should she interfere with the medical treatment, or employ remedies or applications not prescribed by the doctor. If such an arrangement were convenient, the nurse should be selected by the medical man, be engaged early, and as the whole of her time and the best of her energies are to be devoted to the lady and the infant, she should be liberally remunerated.
The Lying-in Room. It practicable, a spacious, well-ventilated room, having a southern aspect, should be selected. Provision should exist both for the admission of fresh air is generally best secured by occasionally leaving the door ajar, having the fireplace open, and the
top sash of the window more or less down, according to the season. Fresh air wonderfully helps a lady to go through the process of parturition. In cold weather a fire may be kept in the room, but neither the mother nor infant should be exposed to its direct influence.
Who should be in the Lying-in Room. In addition to the medical man and the nurse, one female friend-not the mother of the patient-may likewise be present in the chamber; the should be a prudent, cheerful person, and in herself the mother of children, so much the better. Remarks calculated to depress the patient, especially any referring to unfavorable labours, are strictly improper. If convenient, the mother of the patient may be in the house, or within a short distance, the knowledge of such fact tending to comfort the patient. Bus she should not be in the lying-in chamber, as maternal anxiety is occasionally very embarrassing there. There are, however, occasional exceptions to this rule.
Minor Preparations. All articles of clothing necessary for the mother and the infant should be well aired ready for immediate use, and so arranged that they may be found in an instant. A little fresh, unsalted lard; about twelve inches length of nice twine, to four or five threads; a pair of blunt-edged scissors; a few patent pins; and the blinder or bandage. Also a piece of waterproof sheeting, or strong oiled silk, or even a common oilcloth table-cover, should be placed under the blanket and sheet over the right side of the bed, no protect it from being injured by the discharges.
Attention to the bowels. Attention to the action of the bowels is necessary. Generally the bowels are some-what relaxed a provision of nature for by thoroughly emptying the bowel more space is gained for the birth of the child. Should, however, the bowels be confined, an injection of from one to two pints of tepid water will sufficient to empty the intestine, and is far preferable to the common but reprehensible practice of taking castor-oil, or any other aperient drug. Ample experience leads us emphatically to denounce the practice of giving purgatives, as both unnecessary and hurtful. A good injection of water as soon as labour has set in, especially when the lady is costive, will not only facilitate the birth of the child, but obviate the unpleasant occurrence of an escape of faeces during parturition. If there is a considerable collection of hardened faeces, a warm soap-and-water enema may be necessary.
The Bladder. During labour, a woman should never neglect to pass water as often as necessary. The proximity of the bladder to the womb renders it most undesirable that the former should be distended with urine, as nature requires the utmost available space for the passage of the child. Besides, the powerful action of the womb at the commencement of labour may, if the bladder is distended with urine, press it down into the vagina, thus injuring the bladder, and retarding labour. The caution is especially necessary in first labours, when, from a refined sensibility necessary in first labours, when, from a refined sensibility, ladies are apt to suffer much inconvenience from inattention to this point. If the bladder is full, and there is inability to pass water, the measures suggested in the Section on “Retention of Urine” should be adopted, or, better, the doctor should be informed of the fact. The importance of attention to the state of the bladder during and immediately after labour can scarcely be overrated.
Position of the Patient. During the precursory stage of labour the patient should not confine herself to bed-not even to her own bedroom, unless she desires it,-but walk about a little; a certain amount of unrest leads her from place to place, and it would be most undesirable to confine her to her bed. A change of position is a good preventive or remedy for cramp of the legs and thighs, which occasionally comes on, more especially when she is restricted to one posture. If medicine be necessary to remove this symptom, Cocc., Pulsatilla, or Verbascum Vir. may be administered.
To Prevent Difficult Labour. If from experience of previous labours a difficult labour is anticipated, Arnica should be taken three times a day for four weeks before the calculated time.
55. FALSE LABOUR PAINS
Towards the close of gestation, women are apt to suffer from pains which may be mistaken for those of labour, but which are of a perfectly distinct character.
DIAGNOSIS. The following table exhibits the difference between true and false pains:
1. Come on and go off regularly, gradually increasing in frequency and severity.
2. Are situated in the back and loins.
3. Are grinding or bearing-down, according to the stage of labour.
4. Arise from the contraction of the uterus, and the resistance made to its efforts, and the mouth of the womb may be felt dilated at each pain.
5. Are usually attended with “show.”
FALSE PAINS 1. Are irregular in their recurrence, or, in some instances are unremitting. 2. Are chiefly confined to the abdomen. 3. Are of a colicky nature.
4. Are caused by cold, flatulence, indigestion, spasms, fatigue, etc., and have no effect upon the mouth of the womb, which is found closed.
5. Are unattended with a “show.”
MEDICINAL TREATMENT. Aconite, Bryonia, Caulophyllum, Chamomilla, Cim., Dulcamara, Nux V., Pulsatilla, Verbascum V., Vib.
INDICATIONS FOR THE PRINCIPAL REMEDIES.
Aconitum. Pains in young plethoric persons, with febrile symptoms.
Bryonia. Dragging pains in the loins, increased by movement, and attended with constipation and much irritability.
Caulophyllum. There is no remedy, says Dr. Hale, upon which we can rely with more confidence than this one. If is equally efficacious when the pains are spasmodically or continuously bearing-down.
Nux Vomica. Dragging pains in the abdomen and back, as if from a bruise, and attended with constipation, flatulence, and irritability, in persons of dark complexions and lively temperament.
Pulsatilla. Symptoms similar to the bones under Nux vomica, but in women of a mild, gentle disposition, and fair complexion.
ADMINISTRATION. In severe cases, a dose every twenty to forty minutes; in mild or tedious cases, every three or four hours.
56. SYMPTOMS AND STAGES OF LABOUR.
Symptoms of Labour. The earliest is a diminution of the waist, from sinking of the child lower down in the abdomen. This subsidence of the womb given the lady a feeling of lightness and comfort; pressure on the thoracic region being removed, she breathes more freely and is better able to take exercise. But occasionally this alternation in the position of the womb leads to irritability of the bladder by its pressure on that organ, giving rise to frequent desire to urinate. After this symptom has existed for a few days, or even in some cases only a few hours, the more immediate symptoms of labour occur; these are-agitation, dejection of spirits, flying pains, frequent inclination to relieve the bladder and the bowels, relaxation of the external parts, and a slight discharge of mucus tinged with red. technically called the “show.” This latter is the most certain indication that labour has really commenced.
At this stage, sometimes shivering and sickness come on; but as they are not unfavorable symptoms, they require no particular treatment, externally not brandy, for their removal.
Stages of Labour. Labour has been divided into three stages. The first, in which the uterus alone the pains being of a grinding character; the os uteri (mouth of the womb) gradually dilates until it is sufficiently capacious to admit the passages of the head of the child. In this stage it is not necessary for the lady to confine herself to bed; she is better walking about the room, occasionally lying down when a pain comes on. She should not on any account bear-down, as some ignorant nurses advice, for before the mouth of the womb is sufficiently dilated, the child could not be born, except by rupture of the womb.
The second stage of labour is indicated by the pains being of a forcing bearing-down nature; the abdominal muscles and the diaphragm assist the action of the uterus, acting in an involuntary and reflex manner; this stage terminates with the birth of the child. In this stage the lady should remain on the bed. Even now she should make on voluntary efforts to bear-down especially in the absence of pain; she should keep her eyes closed, to prevent injury to them during the irresistible straining which attends the expulsive pains.
The third stage includes the expulsion of the placenta, which generally takes place in about fifteen or twenty minutes, or it may be a little longer, after the birth of the child.
Length of Labour It has been laid down as a general rule that a first labour continues six hours, and a subsequent one three hours. This calculation dates from the commencement of actual labour if the premonitory flying pains are included, the time would probably be doubled. The first labour of a woman who marries beyond the age of thirty usually occupies a longer time than one who marries at about the age previously indicated (p. 104).
Tedious Labour. In previous editions we have remarked and by no means necessarily dangerous. But this tediousness must be within certain limits-from three to six hours. If greatly prolonged beyond this, labour may be attended with danger to both mother and child. When the labour is likely to be prolonged, the mother is more likely to do well if the vectis of forceps be used early. Sir James Simpson and other careful obstetricians affirm that the mortality of mother and child is greater in labours prolonged beyond thirty-six hours than in those which terminate within twenty-four. If the head be well placed and the os well dilated without mechanical obstruction, slow labour with weep pains may be terminated at once.
Convulsions call for immediate interposition, and if the os be not sufficiently dilated mechanical dilation may be adopted until the forceps can be introduced. If courage be failing, and the sufferer be impatient, the instrument should be used, in case the nervous system be unstrung by the strain. Although it is undesirable to interfere with the operations of nature, the practitioner is present to aid nature; and prompt assistance may avert much agony and save many lives. In the hands of a man of ordinary intelligence and skill the vectis and forceps are perfectly safe, and attended with no more danger of laceration than natural labour.
MEDICINAL TREATMENT. So long as labour is progressing naturally and satisfactorily, the less is interfered with in any way, so much the better will it be for the patient’s comfort and recovery; but now and again cases are met with which require one or other of the following remedies to modify the course of the labour, or to remove some annoying or painful symptom: Aconite, Belladonna, Caulophyllum, Cim., Gelsemium, puls., Secale.
LEADING INDICATIONS FOR THESE REMEDIES.
Aconitum. Feverishness, palpitation, etc.
Belladonna. Flushed face, throbbing headache, confusion of ideas; a tendency; to wander may occur; or there may be convulsive movements, sensitiveness to noise, light, etc.
Caulophyllum. As a uterine excitant.
Cimicifuga. Spasmodic, painful, too violent, intermitting pains, sometimes with cramp in the limbs, and a tendency to general convulsions; also nervous irritability and dejection.
Coffea. Excessively violent pains, with restlessness and great mental depression and nervous excitement.
Gelsemium. To produce relaxation of a rigid unyielding os uteri in labour, this remedy, in from one to five drops of the strong tincture, every half-hour, is probably superior to every other.
Pulsatilla. Irregularity, uncertain, and fitful pains, confined chiefly to the back.
ADMINISTRATION. A dose every fifteen, twenty, or thirty minutes, as required. If no relief follows the third dose, another medicine may be chosen.
ACCESSORY MEANS. When the pains are flagging friction, with moderate, well-directed pressure over the abdomen, often stimulates the womb to increased activity. The pressure should be exerted until the placenta is detached.
CHLOROFORM IN LABOUR. A natural labour is best, and its attendant pains should be patiently borne, especially when all is going on well. Chloroform is probably less frequently used now than it was a few years ago; still, with proper precautions, it is often a great blessing to those who are undergoing the “perils of childbirth.” It may slightly retard parturition by somewhat weakening, or rendering less frequent, uterine contraction; still a lady may be delivered naturally under its influence. It is unattended with danger to the child, or tend to the production of Puerperal Mania. The pulse and the respiration furnish reliable indications as to the extent to which it may be carried, and the length of time the inhalation may be continued. When requested by a patient to administer it, and no objection to its use exists, the author never hesitates to do so. It should not, however, be administered except by the sanction and under the care of a qualified medical man. It may be given by pouring a sufficient quantity into a tumbler, and letting the patient inhale it in small doses, well diluted with atmospheric air, when the stomach is empty. One or two minutes’ inhalation is generally necessary to effect a sensible diminution of the pain; its administration should be commenced when the dilation pains of the first stage of labour are past, and have been succeeded by the forcing, expulsive pains of the second stage. It should he inhaled just as a pain comes on, and he discontinued directly it goes off, or ceases to be felt. Unless during instrumental delivery, the patient need not be made entirely unconscious by it. Talking in the room should not be allowed while she is inhaling the chloroform. Her head should not be raised, and she should not be allowed to sit up in bed for some hours after its administration.