Part 49

=Ovum.=—As the ovum develops the decidua reflexa expands until it fills the decidua vera at the end of the second month, and by the end of the third month it has intimately united with the decidua vera to form one membrane. Until these two membranes have coalesced the ovum is not free in the uterine cavity, but is enclosed in the decidua reflexa.

=Pregnant Uterus.=—As pregnancy proceeds the uterus ceases to be a pelvic organ; it becomes rounded, and after the sixth month gradually assumes an ovoid shape. At the end of the third month it has reached to the brim of the pelvis. By the sixth month it is level with the umbilicus, and by the ninth it has reached to the tip of the sternum. During the last fortnight the organ sinks a little, and this relieves to some extent the shortness of breath which has been caused by the pressure on the diaphragm.

=Fetal Membranes.=—Inside of the decidual membranes we find the chorion and amnion. Whereas the deciduæ are maternal structures, the chorion and the amnion are derived from the ovum. The chorion is the more external of the two fetal membranes; it early surrounds the ovum and throws out processes (villi) toward the decidua reflexa and serotina. These processes are at first formed equally all over the chorion, but those which lie in connection with the decidua serotina grow more rapidly in size and complexity, and remain to form the main part of the placenta. The membrane in which the fetus lies is the amnion. Contained within the amnion is more or less fluid, the liquor amnii, in which the fetus rests as in a water-bed. It permits free movements on the part of the fetus and protects it from violence from the outside; it equalizes the pressure on the uterine walls, preventing pressure on the cord and placenta; and during labor it assists in the dilation of the os uteri and lubricates the maternal passages. From it also the fetus derives its supply of water. Occasionally water may form between the three membranes, and during labor the chorion may rupture and not the amnion, and the waters between them be discharged. In like manner, water which has formed between the decidua and the chorion may come away. These, then, are two sources of fluid which may be discharged from the vagina in labor when the amnion is intact.

=Umbilical Cord.=—The organ by which the fetus is attached to the uterus is a whitish, glistening structure which springs from the fetus at the center of the abdomen, and passes to the internal aspect of the placenta. It contains two arteries and one vein surrounded by a gelatinous material (Wharton’s jelly), the whole being covered with a layer derived from the amnion. The vessels usually run tortuously in the cord, thus lessening the danger of compression, which might otherwise occur. This arrangement also tends to regulate and equalize the circulation of the blood through its vessels.

=Placenta.=—The “after-birth” is a spongy cavernous organ and has a circumference of from 20 to 24 inches. It is made up of two elements, fetal and maternal, chiefly the former. The fetal surface, to which the umbilical cord is attached, is formed by the amnion. External to the latter is the chorionic tissue, consisting mainly of finger-like processes of villi, many of which extend to the decidua. These villi are mostly vascularized. The vascular villus is made of a capillary loop, lying embedded in a connective tissue, the blood-vessels being derived from the umbilical vessels. The villi are surrounded by maternal blood, which circulates in the intervillous spaces. The maternal part is represented by the decidua serotina. Its surface is rough and irregular, being broken up into segments or cotyledons. It is made of two layers: (a) The deep or spongy layer, and (b) the compact, or layer to which the villi are attached. The decidua serotina contains large cavities or sinuses, which are formed by a dilation of the blood-vessels in the wall of the uterus. They communicate with the intervillous spaces of the placenta, and it is through the maternal blood circulating in them that nutriment is conveyed to the fetus through the medium of the villi. An interchange takes place between the fetal and maternal bloodstreams, though, of course, there is no direct continuity between them. The placenta thus has a two-fold function in acting both as an organ of circulation and of respiration. It is through the walls of the villi that this interchange of gases and fluids takes place; nourishment and oxygen passing through them to the fetus, and carbonic-acid gas and waste materials passing through them to the mother. There is no direct communication between the fetal and the maternal blood. The placenta, normally, is attached to the contractile part of the uterus, and on its separation the blood-vessels are closed by the contractions of the uterine wall. The placenta may be divided into two or more portions, or one or more of its cotyledons may be detached from the rest of the organ and have their own vascular supply. The importance of this lies in the fact that after the placenta is expelled these isolated masses may be left and give rise to hemorrhage or blood-poisoning.

SYMPTOMS OF PREGNANCY.

=Suppression of the Menses.=—The cessation of the periods may be due to other causes, but it is usually the first indication of pregnancy. Conception may take place and menstruation yet continue. It usually occurs but once or twice, and then only where conception took place immediately before an expected period.

=Morning Sickness.=—Nausea and vomiting continued for any length of time is almost a certain sign of pregnancy. It may begin as soon as conception takes place and last for many months; sometimes it may occur toward the end of pregnancy, or occasionally not at all.

=Salivation.=—The excessive secretion of saliva often accompanies the morning sickness. The secretion is tenacious and difficult of expectoration. Heartburn, abnormal appetite, longing or loathing for particular articles of food, toothache and the like may be present.

=Quickening.=—The first feeling of fetal life felt by the mother is usually between the fourth and fifth months, but may be experienced occasionally as early as the third month, or be deferred until the sixth. Quickening occurs as soon as the uterus comes in contact with the abdominal wall. Improper elimination of the bowels, causing gastro-intestinal trouble, may produce movements not unlike this indication; therefore, this symptom is not reliable.

=Enlargement of the Breasts.=—The breasts grow larger toward the end of the second month. In some cases the enlargement is very marked, but in others there is scarcely any increase in size during the whole term of pregnancy.

=Pigmentation.=—Coloring of the skin takes place in different parts of the body. The face may show brownish spots. The skin darkens in the axilla and in the areola of the breasts. A dark line presents itself down the middle of the abdomen. The vagina takes on a violet tint, the cervix becomes purple, the various colors becoming more marked with the progress of pregnancy.

=Changes in the Abdomen.=—The abdomen grows larger gradually, and with it the gait and carriage of the woman change, to counterbalance the weight of the abdomen. It enlarges symmetrically unless the uterus is displaced by adhesions, or by a tumor in the uterus or external to it. The tearing of the under layer of the skin of the abdomen while distended produces streaks (stria), first pink and then white, which remain after the form resumes its natural shape; any other enlargement of the abdomen, especially when caused by a tumor, may produce the same result. The various conditions mistaken for pregnancy, due to changes in the abdomen, are fibroid in uterus; metritis; swelling of the tubes and ovaries, distended bladder, a pendulous belly; excessive fat; extra-uterine pregnancy; and inflammatory conditions, such as peritonitis. Pregnancy and any of the conditions named may coexist, and the former may be overlooked, while the latter is recognized.

=Fetal Heartbeat.=—The heart sounds are generally audible between the fourth and fifth months. The rate is from 120-140 a minute, being double that of the mother’s pulse. About midterm is heard the uterine souffle, a blowing sound, quite unlike the fetal heart, and its origin is the rushing of the blood through the enlarged and twisted arteries.

=Ballottement.=—In normal cases there is no pain on palpation. The uterine wall varies in consistence, being alternately soft and firm. The fetal parts may be felt through the abdominal wall in the late months.

=Lightening.=—In the last two weeks, especially in primiparæ, the child’s head sinks into the pelvis, and its body falls a little forward. The uterus sinks down and forward with the child. The waist-line lowers, the stomach region is flatter, the navel more prominent. The patient breathes easier, but does not walk as well.

=Duration of Pregnancy.=—Average time is 280 days; protracted, 314; a short term about 245 days. There is no positive period.

=Prediction of the Date of Labor.=—Count 9 calendar months from the beginning of the last menstruation and add 7 days. An error of 2 or 3 weeks, however, is possible. (See Table on page 178.)

=Premonitory Symptoms of Labor.=—(1) Lightening.—Dropping may be attended with slight pains similar to labor pains.

(2) False Pains.—These vary in nature and quality. They may be short and sharp, or long and continuous, or irregular. As a rule, they are marked by irregularity. They are mostly abdominal, rarely like true pains beginning in the sacral region and moving around to the region of the pubes. They may be caused by cramps in the abdominal wall, intestines, or in the distended bladder. They may be due to old inflammatory areas within the abdominal and pelvic cavities. They are frequent in cases in which there is marked bowel irregularity, and in conditions of over-fatigue. Some authors believe that they may be produced by irregular contractions of portions of the uterine wall. One important test is the condition of the uterine body during the pain. If there is no genuine contraction, the uterus will not become hard when pain is felt. This indication is not always reliable, however, since palpation may be unsatisfactory on account of the woman’s nervousness, her sensitiveness, or the thickness of the abdominal wall. If the cause be contractions of the uterus, partial hardening may be felt.

TABLE FOR CALCULATING THE PERIOD OF UTERO-GESTATION.

----------+--------------------------------------------------------------------------------------------+------- January | 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31| OCTOBER | 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 1 2 3 4 5 6 7|NOV. ----------+--------------------------------------------------------------------------------------------+------- February | 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 | NOVEMBER | 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 1 2 3 4 5 |DEC. ----------+--------------------------------------------------------------------------------------------+------- March | 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31| DECEMBER | 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 1 2 3 4 5|JAN. ----------+--------------------------------------------------------------------------------------------+------- April | 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 | JANUARY | 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 1 2 3 4 |FEB. ----------+--------------------------------------------------------------------------------------------+------- May | 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31| FEBRUARY | 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 1 2 3 4 5 6 7|MAR. ----------+--------------------------------------------------------------------------------------------+------- June | 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 | MARCH | 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 1 2 3 4 5 6 |APRIL. ----------+--------------------------------------------------------------------------------------------+------- July | 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31| APRIL | 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 1 2 3 4 5 6 7|MAY. ----------+--------------------------------------------------------------------------------------------+------- August | 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31| MAY | 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 1 2 3 4 5 6 7|JUNE. ----------+--------------------------------------------------------------------------------------------+------- September | 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 | JUNE | 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 1 2 3 4 5 6 7 |JULY. ----------+--------------------------------------------------------------------------------------------+------- October | 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31| JULY | 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 1 2 3 4 5 6 7|AUG. ----------+--------------------------------------------------------------------------------------------+------- November | 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 | AUGUST | 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 1 2 3 4 5 6 |SEPT. ----------+--------------------------------------------------------------------------------------------+------- December | 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31| SEPTEMBER | 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 1 2 3 4 5 6 7|OCT. ----------+--------------------------------------------------------------------------------------------+-------

EXPLANATION.—Find in top line the date of menstruation, the figure below will indicate the date when confinement may be expected, i.e., if date of menstruation is June 1st, confinement may be expected on March 8th, or one day earlier if leap year. (Dr. ELY.)

(3) True Pains.—The contractions of the uterus as they become stronger, in the great majority of cases, cause the woman pain. For this reason “true pains” is used synonymously with “uterine contractions.” With their appearance the woman becomes restless, likes to sit down, to bend forward and to press on the sacrum. “True pains” are felt in the sacral region, gradually moving around toward the pubes. They begin slowly, increase in intensity, and slowly pass away. The pains are involuntary, and the woman tries to complain or cry out. Differences in this largely depend upon the nervous temperament of the patient, though they are also related to variations in the physical factors. “True pains” must be distinguished from “false pains.”

(4) The Show.—Within twenty-four hours before labor really begins there is a discharge from the vagina of thick mucus, more or less stained with blood. This is called the “show,” and is the plug of mucus which fills the cervical canal during pregnancy. Sometimes the show is absent or appears after labor has been in progress for awhile. If there is much pure blood with the discharge it is unusual, and the physician should be notified.

LABOR.

=First Stage.=—The first stage extends from the time of the labor pains to the complete dilatation of the os uteri. It may come on very slowly or act quickly. Slow dilatation occurs normally in a woman over thirty years of age; and it may be due to inflammatory conditions or appear in cases where the membranes lining the uterus are adherent. On examining the vagina there is found a bulging (which is a main factor in dilatation of the cervix) and a discharge of mucus tinged with blood. The dilatation increases until it is 4 in. across, and the bag of membranes bulges like a saucer. In abnormal cases it comes down into the vagina in the shape of a tube. When the os is fully dilated the membranes rupture, a rush of water escapes down the vagina, and the first stage of labor is ended. Not all of the water comes away, for the head comes down and acts as a plug. It is very important for the nurse to recognize the true rupture and not mistake it for incontinence of urine.

=Second Stage.=—This comprises the period from the time of complete dilatation of the cervix to the end of the expulsion of the child. The patient has some relief after the first stage, and when the second stage comes on she holds her breath and contracts the abdominal muscles as much as she can in making expulsive efforts. The pains become of longer duration and more frequent; and upon examining the vagina the head is found down, the tissues bulge, the rectum becomes stretched, the majora and minora separate, and then, while the pain is on, there is some change in the position of the head as it recedes and advances again. Nature brings it slowly, for if the head plunged down it might produce complete laceration of the perineum. If the head is delayed too long there is swelling of the scalp. The most painful period is when the head passes the perineum. Then there comes a marked change in the position of the fetus, and it lies in that position for some time; following, comes a rotation to one side, the shoulders turn, and birth occurs. The cord is still in the vagina, and the third stage begins with a flushing of amnii fluid. The placenta is still in place in the uterus. The child may cry, and the pulsation may continue in the cord for as long as fifteen minutes, but ordinarily for about five minutes, while a new circulation is established in the infant and more blood is drawn from the placenta.