LETTER XXV.. Management of Labor.

MANAGEMENT OF LABOR.

Its Premonitory Signs—Progress of Labor—Its Different Stages—Age as Affecting it.

It is very common for women to experience a manifest improvement in all their symptoms some days before labor is about to come on.

Some days previous to its commencement, a remarkable subsidence of the abdomen and diminution in the size of the body takes place. This is occasioned by the sinking of the womb, and, of course, its contents with it move into the brim of the pelvis. It is possible, likewise, that the walls of the uterus begin at this time to bring themselves into closer contact with the child, thus rendering the abdomen somewhat smaller. At all events we know, that the fact does occur in most cases, and the circumstance is always to be looked upon as a favorable one.

Just before labor a sort of general distress arises in the patient’s mind, owing, no doubt, in part, to the state of the body, and in part to the natural apprehensions of pain and the danger which she is to pass through. “This,” as Dr. Denman observes, “does not seem to be confined to the human species, but to be common to all creatures, as they universally show signs of dejection and misery at this time, though they suffer in silence; and even those animals which are domesticated, strive to conceal themselves, and refuse all offers of assistance.”

STAGES OF LABOR.

Labor may be appropriately divided into three stages, which are the following:

1. That which includes “all the circumstances which occur, and all the changes made, from the commencement of the labor to the complete dilatation of the os uteri (mouth of the uterus), the rupture of the membranes, and the discharge of the waters.”

2. This stage includes those circumstances which occur between the first stage and the expulsion of the child.

3. The third stage includes all that relates to the separation and expulsion of the placenta or after-birth.

As labor is about to come on, and even for some days previously to it, an increased mucous discharge takes place from the vagina, which for a day or two at the last is apt to become streaked with blood, forming what is termed the show. This arises from a partial detachment of the placenta, at which time it might perhaps with propriety be considered that labor had actually commenced, although in a slight degree.

This show, however, does not always appear, for, as Dr. Denman observes, “in many cases there is no colored discharge in any period of the labor, and then the dilatation proceeds more slowly; for the discharge is not only a sign that the parts are in a state disposed to dilate, but it also improves that state.”

If the bladder is at all irritable, the woman at this time suffers from strangury, more or less. This is in consequence of the pressure of the womb upon the neck of the bladder, or upon the urethra. If the rectum is in a similar condition, there is apt to be tenesmus, or a bearing-down feeling at the lower bowel, as if something should be discharged, but which the woman is not able to accomplish. All these are common symptoms; but in some cases labor begins, as it were, suddenly, without any warning whatever.

Not unfrequently, in the beginning of a labor, the woman experiences one or several rigors, which may be in connection with or without a sense of cold. These are supposed to arise in consequence of the system rallying its energies to concentrate them upon one important object, namely, that of effecting the dilatation of the uterus and the expulsion of the fetus. They are evidently not attended with any danger, and should therefore give the patient no alarm.

State of the Bowels.—It is not uncommon for patients to have one or more loose discharges from the bowels at the beginning of or during labor. This symptom occurs in consequence of the sympathy that exists between the womb and the lower part of the alimentary tract. There appears to be in the minds of most women a great prejudice against bowel complaints through the different stages of pregnancy, and at the time of labor, and, as a consequence, there is a willingness, and often anxiety, on their part to use such means as are supposed to have an effect in suppressing them. But in most cases of diarrhea under these circumstances, the patient is relieved by it rather than made worse, and should therefore take no special means of counteracting it, unless, indeed, under the guidance of a medical attendant who should deem such a course necessary.

Nature of the Pains.—It is an object to know how you may distinguish between the true pains of labor and those which are false.

The true pains of labor usually begin in the back and loins, and shoot round to the upper part of the thighs; or they may commence first in the lower part of the abdomen, as if in the region of the bladder, passing backward toward the spine. Some women commence being sick, as if they had eaten something that disagreed with them; and I have repeatedly known them to attribute the pains of the commencement of labor to this cause. A little time in such cases is sufficient to convince them of their error.

Periodicity is, in most cases, a symptom showing that the pains are not false. The interval between them may vary in different cases from one minute to thirty, forty, or more, according to the action of the uterus, on which they depend. The more the pains are multiplied the better it is to be regarded for the patient, and for the reason, that if an effort of great importance to the constitution is to be produced, the more slowly and gradually it is done the better, if the slowness is not the effect of disease. A sudden and violent labor is never to be looked upon as being so safe as one which happens in a more gradual manner. “It is an old observation,” says Dr. Denman, “confirmed by daily experience, that after the completion of slow or lingering labors, patients usually recover better than after those which are quick; not to mention that they are less liable to the untoward accidents which precipitation may immediately produce.”

A considerable difference exists in the character of the pains, according to the stage of labor in which they occur. The earlier pains are termed cutting or grinding, from the fact that uterine fibers alone are principally concerned in them. Afterward the pains get to be lower down, and are of a more bearing-down nature. When these pains exist, the woman is instinctively led to bring her abdominal muscles into powerful action, causing her, at the same time, to hold in her breath, so that after the pain has ceased, or partially so, she utters a deep groan. In the earlier part of the labor, the cries are more shrill, so that an experienced observer will often be able to judge of the stage of the labor merely by hearing the manifestations made. In some cases, however, the patient does not exhibit any of the aforementioned signs of distress, until the moment when the child is about to pass into the world. She is then obliged to put forth an expression of agony, which proves but too well how much it is her lot to endure.

THE LIQUOR AMNII, OR WATERS.

In order that you may the better understand the first stage of labor, I will here make some remarks on the nature and office of the fluid above-named. By liquor amnii, or waters, is meant that fluid which is contained within the membranes surrounding the child.

The quantity of the waters, when compared with the size of the child, is greater in the earlier parts of pregnancy. At the time of labor it is found to vary a good deal in different cases, amounting in some to four or five pints, and in others to scarcely as many ounces. It is thought to be largest in case the child has been for some time dead, as also when it is very feeble.

In regard to the office of this fluid, some have imagined that the fetus is nourished by it, the liquor being swallowed into the stomach. But in answer to this doctrine, it is to be remarked, that there are many examples of children having been born without any passage to this organ. There have also been born children of a full size and well-formed shape, all except the head, which was wanting. These facts make it clear that the child must be nourished in some other way than by the waters surrounding it.

Some also have supposed this fluid to be an excrementitious substance; but this belief is not now generally adopted, or rather, no physiologist of any eminence regards it as such at the present day.

The liquor amnii “is generally transparent, often milky, and sometimes of a yellow or light-brown color, and very different in consistence; and these alterations seem to depend upon the state of the constitution of the parent. It does not coagulate with heat, like the serum of the blood; and chemically examined, it is found to be composed of phlegm, earthy matter, and sea-salt, in different proportions in different subjects, by which the varieties in its appearance and consistence are produced.”

It has been supposed that the liquor amnii may, all of it, be discharged as early as the sixth month of pregnancy, without producing injury to either mother or child; but this cannot be true, it would appear, since it is well known, that when the membranes are broken intentionally, so that all of the waters are discharged, the uterus never fails to contract itself until abortion or the birth comes on. A discharge from the vagina, somewhat resembling the waters, however, may appear for weeks, and even months, before the delivery takes place; but in such cases it has been observed, that no diminution in the size of the abdomen occurs, from which circumstance it is known that the real liquor amnii does not pass off.

The normal purposes of this fluid in the system appear to be to afford the fetus a safe and easy lodgment in the uterus. If it were not there to protect the embryo, it would constantly be in danger of being destroyed by mechanical violence; besides which, it would be almost certain of adhering to the inner surface of the womb in such a way that the birth could not possibly take place. At the time of labor, too, we see the advantages of the “bag of waters,” for as it is protruded in advance of the child, it forms a soft, yielding wedge, as it were, which gradually dilates the soft parts, without overstretching or tearing them, which would not be the case if the comparatively hard head of the child was the first to present itself.

The rupture of the membranes, which ends the first stage of labor, may take place a very short time before the expulsion of the child, or it may happen prematurely, as it were; that is, many hours, or even days or weeks before the child is born. In such cases the occurrence is to be considered as an accident or exception to the general rule. It does happen, however, every now and then, and in many cases it seems to make no difference whatever in regard to the future progress and safety of the delivery.

The greatest agony, as I have remarked, is experienced at the time the child is brought into the world; but if I could make plain to you the mechanism of labor, you would be struck with admiration, I am sure, at the wonderful marks of benevolence and design which are exhibited in the manner in which a child is expelled from the uterine cavity.

You may ask why it is that a woman should be made to suffer pain at all in bringing forth a child, and why did not the Creator form the system of woman in such a way that a child could be expelled without causing any of that agony which is well known to be a natural circumstance of childbirth. I answer, it was not possible for God to create woman in such a way. Suppose He had made her pelvis larger, and the soft parts more yielding; she would have been constantly subject to the misfortune of miscarriage; or rather, it would not have been possible for her to carry a child at all.

But see the beautiful, and at the same time wonderful operation of nature in the mechanism of parturition. At first, some days before labor is to come on, the abdomen begins to subside, showing that the uterus, with its contents, is gradually sinking downward in preparation for the greater struggle that is to take place at the birth. Probably, too, the womb at the same time begins to contract itself more firmly upon the child, and, as it were, begins to gather strength for the contest which it is about to engage in, namely, that of forcing the child into the world. After this there appears a greater discharge of mucous than ordinary from the womb and vagina, which serves to soften and lubricate the parts in preparation for the terrible distension which is to take place. Gradually, also, in the first stage of labor, the womb dilates, for too sudden a distention of this important part would be very apt to cause a fatal rupture of the organ. In the second stage, the head of the child is driven through the os uteri into the vagina. As the pains continue, the face of the child is turned into the hollow of the sacrum; that is, toward the back of the mother, the wider part of the head being in the wider part of the pelvis, just as a wise mechanician would naturally place it; but in the beginning of labor, when the child’s head is at the upper part of the pelvis, it lies more to the side of the mother, corresponding to the wider diameter of this upper strait.

Look at a skeleton, I repeat, that bugbear of our childhood, that grim yet beautiful remnant of our mortality; and when you see and understand how admirably adapted the form and shape of the pelvis is to the ends for which it was created, tell me if you do not recognize in this adaptation the most unmistakable evidences of the work of an Almighty hand.

In cases of first children, the first or dilating stage usually occupies from six to thirty or more hours. It is natural to expect that a woman must suffer greater pain, and bear a more tedious labor with her first child than with the subsequent ones. “I have heard a voice as of a woman in travail, and the anguish as of her that bringeth forth her first child,” saith the prophet Jeremiah. The difference in the length of the first and subsequent labors, however, is not usually in proportion to the number of children that have been borne. If a woman be twenty-four or thirty-six hours in labor with her first child, she may be only six or eight with her second, and in the subsequent labors only three or four hours. There will, of course, be many deviations from any calculation of this kind that can be made, but the practitioner will, however, often be able to form a tolerably accurate opinion of the probable duration of a labor, if the woman have had a number of children previously. But even here there will be a good deal of liability to error, since the fifth, sixth, or tenth labor may prove a very tedious and difficult one, because of some mal-position of the child. I had an example of this kind in my own practice some months ago, in which a lady suffered incomparably more with the birth of her third child than with both of the former together, and the labor was protracted to thirty hours, which was a much longer period than either of the former had been. This happened in consequence of the face of the child, that is, the wider part of the head, presenting forward in the narrower part of the outlet of the pelvis, whereas in almost all cases the reverse of this takes place, as I before remarked. Such cases are, however, fortunately very rare, the exception only to the general rule.

You will readily understand why the first labor is apt to be somewhat more difficult than subsequent ones, when you recollect that all the soft parts, such as the womb, vagina, the external organs, etc., are more rigid and unyielding in the first labor than they afterward are. The bones, recollect, are the same at all times; they do not give or separate, as many of you have supposed; they are bound so firmly together that it is not possible for them to be separated, in their natural and healthful state, by any such force as that which is exerted in the birth of a child, although this force is a great one. It is necessary that the bones of the pelvis should be thus strongly bound together, otherwise they would not be sufficiently firm to answer the purposes for which they are intended.

THE AGE AS AFFECTING LABOR.

If the patient be considerably advanced in years at the time of her first pregnancy, the labor is apt to be, or rather, must necessarily be, a more difficult one than would occur earlier in life.

In the life of any woman there is a period at which her system has become, as we say, matured, or, in other words, capable of child-bearing. After the system has become thus matured, it is evidently more natural, and consequently more healthful to bear children than not to do so. We are to suppose, then, that if a woman follows the order of nature, it will be better for her, in regard to the easiness of childbirth, than if she becomes old before this function is brought into action. Nature, however, is not so closely bound down to arbitrary rules as we might at first conclude. Indeed, we could not reasonably suppose that the Creator would form woman’s system in such a way that she could not safely bear children, even if the child-bearing function were not brought into action until some years after puberty. I knew a lady whose marriage took place quite late in life, and whose first child was born when she was forty-two; and although her labor was a severe one, lasting seventy-two hours and upward, yet she recovered remarkably well, as much so as almost any one I ever knew. Her child, too, was a fine, healthy one, and throve well. Another lady, whom I attended about one year since, who was thirty-eight years old at the time, it being her first labor, felt some pains for two days and nights previously to the one on which I was called to visit her. It could hardly be said, however, that labor had fully set in before ten o’clock of the day on which the child was born at four in the afternoon, making the real labor only about six hours. Thus we see that, although the age of the individual has generally more or less influence in regard to the painfulness and length of labor, yet a woman who is far advanced in the child-bearing part of her life, when she bears her first child, has apparently as good a chance for a speedy and favorable recovery as a younger one has. In this circumstance, too, we have still another among the many proofs of the benevolence of the Creator of all things. He, in His wisdom, foreknew that it would not be proper for every woman to marry precisely at that age in which it is most natural for her to become pregnant, and consequently her system was formed with a reference to that circumstance, although it is admitted that labor is somewhat more difficult and protracted if it occur for the first time late in the fruitful period.

It is an unwise procedure to tell a woman, as has been sometimes done, that because she is somewhat advanced in years, and must consequently expect to have a difficult labor, she should be bled frequently toward the close of her period, have purgative medicines given her, etc., with the view of helping nature, as it is said. But it were far better, more honest, as well as more truly philosophic, to tell her that, in order to get along the best that may be under the circumstances, she should do every thing in her power to improve her general health; for always the more strong and vigorous the patient at the time of labor, the better is her prospect in every respect. Suppose, too, it were deemed necessary to reduce her system somewhat toward the close of pregnancy, how much better are abstinence and fasting for that purpose than bleeding and cathartics? It is a foolish practice to bleed or drug the system when we have always at hand so much better means.