The accoucheur's vade mecum

Front matter

J . XxV( Hop

TIIE

ACCOUCHEUR’S

CHAP. V. Parturition

Opinions and Observations on 67

Conduct to maintain the Confidence of the Patient • • • • 80

Management of Labor 81

Easy Cases

Premature Delivery 83

Observations previous to Labor 88

Observations during Parturition 89

Classifications of Labors 90

CHAP. VI. Natural Labor

Definition and Stages of Natural Labor • 91

Application of the Ligatures and Division of the Funis

Umbiliealis

Dressing the Child 07

Expulsion of the Placenta 98

Inversion of the Placenta 100

CHAP. VII. Protracted Labor

Observations on KM

Various ^States of the Foetus K).j

Impediments to Delivery ids

Impediments from Mal-Position of the Head 10&

CONTENTS.

ix

P.iliE

On Instruments 108

Outline of Instruments 109

Rules for applying the Forceps Ill

Directions for using the Forceps 112

Lessening the Head 113

Directions for using the Perforator and Crotchet Ill

CHAP. VIII. Preternatural Labor

First Division 117

Management of Breech Cases 118

Second Division of Preternatural Labor - 120

The Art of Turning 121

Uterine Action 123

Spontaneous Evolution 124

Separation of the Head 125

Extraction of the placenta - 126

Retension of the Placenta by its adhesion to the Uterus 127 Retention of it from Inaction or Spasmodic Contraction

of its Muscular Fibres 129

Inversion of the Uterus 130

Chap. IX

f

Complex Labor.

First Division 132

Second Division 140

Caesarean Section 142

Third Division of Complex Labor il>

Fourth Division 144

Monsters 143

Moles 146

CONTENTS xi i

CHAP. X. Puerperal State

Diet of the Patient *•'* 14!!

first Visit to a Child-bed Patient 14‘.»

Lochia ib.

After-Pains 150

Laceration of the Perinaeum 151

Suckling 152

THE accoucheur’s

Wa*rt#tccum.

CHAP. I. Anatomical Description

To illustrate the science on which I am about to treat, it will be unnecessary to enter into a detail of the human structure; but it may not be irrespective to give an outline of the parts more immediately concerned in Midwifery; and therefore, I trust, with a general knowledge of anatomy, the following brief description will give a comprehensive view of the subject.

Is the foundation on which the other parts of the trunk are sustained ; the term pelvis means the bones composing it/which in adults are four Os Sacrum, the posterior part ; Os Coccygis, the inferior ; and Ossa Innominata , the lateral and anterior parts.

The Os Sacrum serves as a ba sis for the support of the spine, of which it is an imperfect continuation ; it is of a triangular figure, with the shortest side upwards ; the anterier surface is smooth, and has a curvature to

B enlarge the cavity of the pelvis, and accommodate the forehead of the foetus in its passage, called the hol/oxv of the sacrum; in infants it is composed of four or five bones, joined by intervening cartilages, termed false vertebra; these cartilages, in adults, become bone, leaving lines on the anterior surface showing their former separation. The bones diminish in size as they descend; — the lowest forms the point of the sacrum, life superior part of which joins the inferior lumbar vertebra; the latter inclining over the former, makes an obtuse angle, called great angle or getting-in of the sacrum. On the anterior surface are four or five pair of holes, according to the number of bones composing it, for the transmission of nerves. The lateral parts form a broad surface connected with intervening cartilage, to the posterior surface of the ossa innominata. The point joins the superior part of the coccyx ; the latter being broader than the former, makes the small angle of the sac nan.

The Os Coccygis is an appendage attached to the inferior part of the sacrum. In infants, it is cartilaginous; but in adults, composed of two or three bones^ connected by intermediate cartilages, between which a regressive motion is preserved. When pressed by the foetus it occasions an enlargement of the inferior aperture of the pelvis. The coccygcus, and other muscles inserted in its sides, prevents lateral motion.

The Ossa Innominata are two in the adult; but in children each is composed of three portions, viz — Iliac, Ischiatic and -Pubic , and are called Os Ilium, the haunch bone; Os Ischium, the hip bone; and Os Pubis, the

THE PELVIS.

share bone. This division of names is retained in adults; though, from ossification, they form but one, the os innominatum , the lines of distinction may be observed at the acetabulum.

The Os Ilium is the superior portion of the innominatum, of a complicated figure ; its superior concave space spreads outwards to give room for the expansion of the uterus in gestation; the inferior thick part forms a share of the acetabulum anteriorly, and of the circumference of the ischiatic notch posteriorly, which last is completed by the ischium and sacrosciatic ligaments. The inferior prominence of the internal side is a line continuous with that of the os pubis, and inclining to the jetting-in of the sacrum called Linea Ilio-Innojninata, defining the superior aperture of the pelvis.

The Os Ischium is the inferior portion of the innominatum, and forms the inferior part of the acetabulum ; its spinous process projects inwards, and backwards ; the obtuse process is thick, and turned downwards; the thin process ascends obliquely from the obtuse, and joins a similar one, which descends from the anterior inferior part of the os pubis, and forms a side of the foramen thyroideum .

The Os Pubis is the anterior and smallest portion of the innominatum, which forms a part of the acetabulum ; the junction of it with its fellow, is made by a strong cartilage, termed Symphysis pubis ; the superior edge lias a flexure outwards, to encourage the entrance of the head of the foetus into the cavity of the pelvis; and at the inferior part is a divergence which facilitates the passage of the former; it has a thin process, which descends obliquely, and unites with that of the ischium.

The Arch of the Pubes is formed by the ossa ischii and ossa pubes; the anterior parts of the ossa pubes form the top, the thin processes of the is chi (R and pubes the sides, and the tuberosity of each ischium the bottom ; the arch, being wider in women than in men, is favourable to the free passage of the foetus at the time of birth. The anterior superior vacant space in the pelvis above the pubes is to allow the contents of the uterus an easy bed.

The Connexion of the Sacrum with the innominata at the sacro-iliac junction, and of the innominata with each other at the symphysis , is covered with a ligamentous cartilage, adhering to the parts which it encloses ; the periosteum is internally thickened at those places ; the tendons are inserted into the projecting extremities of the bones, and all of them externally contribute to the strength of the pelvis. From the posterior surface of the innominata, which joins the sacrum, strong ligaments pass to bind them together, and the space between is filled with muscles, covered by a tendinous expansion, which forms a smooth surface. From the obtuse processes of the ischiee, the external sacro-sciatic ligaments pass to the posterior edge of the sacrum and coccyx; from the spinous processes of the ischiee the internal sacro-sciatic ligaments arise, which, crossing and adhering to the former, pass to the inferior inner edge of the sacrum and coccyx.

The Capacity of the Pelvis is the space be-

THE PELVIS.

tween the bones, divided into two cavities, superior and inferior. The axis of the superior cavity is in a line from the centre of the diameters at the brim to the extremity of the os coccygis, and that of the inferior cavity is in a line from the centre between the tuberosity of each ischium to the centre of the hollow of the sacrum. The avis of the inferior cavity and direction of the vagina are synonymous terms. An illustration of the direction . of the upper and lower cavities is conveyed by placing a catheter in the axis of the brim, with its extremity in that of the outlet. The line of motion of the head of the foetus corresponds to the axis of the part in which it is placed.

The Dimensions of a standard Pelvis. — Its cavity has two apertures ; the superior is the brim, the inferior the outlet; the superior aperture represents an oval figure ; the long diameter is from the inferior prominence of one ilium to that of the other, and measures five inches and a quarter ; the short is from the superior part of the os sacrum to that of the pubes , four inches and a quarter ; the dimensions of the inferior aperture are reversed. Allowing for the regression of the 05 coccygis, there are five inches from its apex to the inferior portion of the pubes ; and the inferior parts of the ischixe are four inches asunder.

The Depth of the Cavity from the superior part of the os sacrum in a straight line to the point of the os coccygis , when pressed back there is a space of six inches ; the depth of the sides to the inferior extremities of the ischicB is four inches. From the superior to the inferior parts of the ossa pubes, is a distance of two inches, admitting the ligaments to make a share of the outline of the inferior aperture. By recollecting — 1st, That the sides are twice, and the posterior three times the depth of the anterior part ; and — 2nd, The situation of the presentation at the commencement, we may judge how far the head of the foetus has proceeded through the cavity of the pelvis , at any subsequent period of labor.

The Form of the Cavity is posteriorly con*- cave; laterally and anteriorly perpendicular, with a convergence towards the inferior aperture, formed by the points of the spinous and obtuse processes of the ossa ischii, and termination of the coccyx. It is of importance in regulating the passage of the head, as it descends ; for, being perfected by the soft parts, it gives to the presentation the disposition to emerge under the arch of the pubes. The facility of the head passing through the cavity may depend on the hollow of the sacrum ; a similar curvature is continued by means of the ischiatic sinus, and by the disposition of the sacrosciatic ligaments to the obtuse processes of the ischice at the sides, where the cavity is perpendicular.

By a knowledge of the separation of the bones of the pelvis, relaxation of their connecting medium and of its relation to other parts, are we enabled to explain many sensations to which women are subject during pregnancy, at the time of labor, and after delivery. It was formerly an opinion that the bones separate in parturition ; frequently we may observe a considerable lameness during labor, and often an inability to walk, or even to put one foot before the other, without being supported between two persons, indicating relaxation of the connecting medium ; when either it or a separa-

THE PELVIS.

IP tion happens three causes may be assigned, — a spontaneous disposition of the connecting parts, their morbid affection, and the violence with which the head of the foetus may be protruded through the cavity. After delivery we may ascertain whether either of these effects has happened by complaints women make of pain in those places ; they are generally relieved of relaxation during their month of confinement ; but, should it remain longer, the continuance of rest and a recumbent posture favour# the restoration of the parts ; for by quietude their infirmity must be repaired. If we were to draw' a conclusion from many of the French writers, we should judge that a separation of the bones is by no means uncommon ; still, however, I must state that I never saw a case in which that occurrence was clearly defined.

A distorted Pelvis ; — The observations on the cavity relate to its natural state and shape ; but it is liable to deformity ; the most usual cause is the rickets, a disease incident to children; preventing the bones from acquiring their due strengh to support the weight of the body ; they bend in different directions, and fix the distortion for life. This disease seldom exists without communicating some effects to the pelvis: the distortion generally produced, is by the superior part of the sacrum and inferior lumbar vertebra projecting too far towards the pubes.

In a Pelvis that allows an ordinary sized head to pass through its cavity — 1st, The projection of the sacrum is touched with difficulty by a vaginal examination, and it is three inches from the ossa pubes ; — ‘2nd, The concavity of the sacrum is natural without convexity, or straightness, and its point with the oscoc - ci/gis does not press inwards ; — 3d, The arch of the pubes is in its ordinary state, and we can place two fingers nearly flat under the symphysis, with a distance of three inches from one tuberosity to the other.

THE HEAD OF THE FOETUS

Is of an oval figure, largest from the hind to the forepart; the diameter from one ear to the other is less by the same proportion as the antero posterior diameter of the brim of the pelvis is less than the lateral one.

The bones of the cranium are six in number ; the os front is, forming the anterior part ; the ossa parietalia, the superior; the os occipilis the posteriory and the ossa temporum the lateral parts.

The Sutures are many; but we shall enumerate such as connect the external convex division of the skull together, as they only require the Accoucheur’s attention. The sutur a frontalis unites the two pieces of the os frontis together. The coronalis joins the os Jrontis to the ossa parietalia. The sagittalis connects the ossa parietalia together; the lamdoidalis joins the os occipilis to the ossa parietalia.

In theFcETAL Cranium weobservetwo tangibleapertures formed by an imperfect coalescence of the bones, superiorly situated, these are denominated the fontanels, of which — 1st, The anterior is an unossified space between the coronal sagittal and frontal sutures, known to the touch by four angles ; — 2nd, The posterior is where the sagittal meets the lamdoidal suture, and

THE HEAD OF THE FCETUS.

which is known to the touch by three angles. We notice that at birth the bones of the head are but incompletely ossified, and this enables the cranial bones to overlap each other ; thus by diminishing the size of the head, facilitates its readier extrusion. In its passage it is subject to a considerable degree of pressure, which without the above arrangement would often prove fatal to the child. The largest part of the head naturally corresponds with the widest capacity of the pelvis, so that they maintain a relative proportion between each other, and thus the head assumes a variety of shapes, which spontaneously disappear after birth.

The Vertex or Crown, is that part of the scalp where the hair diverges in a radiated manner, which in regular labor presents first, but in irregular comes last ; hence the division Accoucheurs have adopted between natural and preternatural ; by the first is meant, when the head precedes the body in delivery ; by the last, when it follows the other parts.

In the Progress of the Head through the cavity of the pelvis, the long diameter is applied to that of the superior aperture with the vertex to the centre; and an car towards the pubes, being aided by the form of the internal surface, the lower the gravitation the more diagonal is the position of the ears; when the head has descended to the inferior portion of the ischium the posterior fontanel may be felt near it. By a convergence of the inferior part of the cavity, the vertex is forced to emerge under the arch, where it finds the least resistance, which, at the same time, guides tire forehead into the hollow' of the sacrum ; thus the long diameter is applied to that of the inferior aperture. If the head presents differently, there will be corresponding hut not the same changes ; or if small, it will not be influenced by the cavity, but pass in any direction. The changing position of the head through the cavity of the pelvis, is founded on the presumption that it presented naturally, and is guided by the form of the internal surface : no ill consequence would follow an erroneous opinion of it in natural labor, if assistance be not wanting; no principle of conduct is required.

COMPARATIVE PARTURITION.

Taking a view of parturition, we find it more tedious in women than in quadrupeds, owing, perhaps — 1st, From the perpendicular position of the body rendering a relative capacity of- the pelvis indispensable to prevent the impregnated uterus from descending by its own gravity ; — 2nd, Not being in a line with the spine, the direction of any body that passes into and through it must be changed whilst proceeding through the vagina ; it takes a different course to that which brought it into the upper cavity, — 3d, The head of a foetus being larger in proportion to the magnitude of its body than that of any other animal ; probably from the greater quantity of cerebral organs it contains, w hich appears necessary for the better exercise of the sensorial functions, it being acknowledged that the powers of rationality bear analogy to the size of the brain possessed by every thinking being. The above causes may augment the ardour or pain, but cannot be said to lessen the safety of human parturition.

the organs of generation.

THE ORGANS OF GENERATION

Are divided into external and internal : — the former are visible, the latter invisible. —

TheJ^TERNAL Parts are — 1st, The Mom veneris, a prominence upon the ossa pubes covered with hair, extending towards the groins and abdomen ; defined by an imaginary line drawn at right angles, with the superiorpart of the pudendum; — 2nd, Labia Pudendi, having, also, a similar covering anteriorly; they commence at the inferior part of the mons veneris, and unite posteriorly at an obtuse angle, called, — 3d, Frenum Labiorum , or fourehette, and forming a cavity denominated — 4th, The Fossa Navicular is — 5th, Os Externum, or vulva magna, the intermediate space between the labia, going inwards to the vagina, for direction of the penis in coitu, — 6th Perinceum, or that portion of common integuments from ihe fossa navicularis to the anus, which is sometimes, though rarely, lacerated in labor — 7th, Clitoris, a small oblong body situated below the anterior angle of the pudendum, in shape very similar to the male penis, having a glans, but no urethra ; its prepuce is denominated the preepuftwmclitoridis, and it arises by two crura which coalesce and form a spongy body, to which the nymphee or labia minora are attached — 3th Nymphee, which are two small fleshy appendices anterior to the labia magna , spreading outwards and downwards in direction of the orifice of the vagina ; they form the fossa magna between them, and serve to regulate the stream of urine — 9th, Urethra, a short cylindrical canal, about i>4 THE ACCOUCHEUR’S VADE MECUM.

an inch in length, leading to the vesica or bladdei, situated between the nymph a , just above the vaginal entrance, immediately under the pubic arch, and about two fingers breadth below the glans clitorides ; it is know n to the touch by a small rugous papilla, or protrusion, in the centre of which its orifice or meatus is to be found ; surrounding it are several minute glandular folliculcb ; it runs to the bladder aloDg the internal surface of the symphysis.

The Hymen, which is a semilunar membrane, extending across the entrance of the vagina at the lower part of the vulva towards t lie meatus, so as to torn) a barrier between the external and internal organs. The ancients considered it the test of virginity, and exhibited it in the form of a crescent as an emblem of chastity. The hymen is usually broken in the first act of coition; but it has been known to acquire a morbid thickness so as mechanically to impede the flow of the menstrual deposit, and to obstruct connubial intercourse. In case of imperforation, a small puncture will generally be sufficient ; but in some instances a more scientific operation is required.

The Internal Parts are — 1st, The Vagina, the passage from the os externum to the os internum, of a conical form, the narrowest extremity downwards, more contracted in virgins than in married women : the upper end is connected with the cervix uteri, and reflected over the mouth of the womb ; by this mode of union the os uteri is suspended with protuberant lips in the vagina — 2nd, The os tinea, os internum , and os uteri, are synonymous terms, and promiscuously used by Accoucheurs. They mean the entrance to the womb

*25

THE ORGANS OF GENERATION.

i

resembling the mouth of a tench or a young puppy, prior to labor , but after dilatation lias commenced for delivery, it loosing that resemblance, is more properly called os internum, or os uteri. — 3d, The uterus , matrix, or womb, is a hollow bag-like receptacle for containing the foetus after conception. It is divided into cervix, corpus, and fund?is, and is suspended at the superior termination of the vagina between the vesica and rectum. It is three inches long from the os internum to the fundus ; one inch thick from the anterior to the posterior part ; two inches broad at the fundus, and one at the cervix. Its substance is about the eighth of an inch thick, which increases during pregnancy, probably to near half an inch. The uterus serves as a nidus for the ovum to grow in, and increases in proportion as gestation advances, by enlargement of its vessels and parietes ; when increased in size it lies in the abdomen before the intestines ; it is composed of muscular fibres w hich, although not always cognizable to the eye, manifest their existence by uterine offices in parturition : during part of the second, and the whole of the third stage of that process, the commencement of the uterine cavity, and termination of the vaginal, form one continuous canal ; and thus, by dilatation, the os internum, in a manner, becomes obliterated till the expulsion of the foetus. — 4th, The fallopian tubes, each having a fimbria or morsus diaboli, originate from the angles of the uterus, and by cauals which pass through them preserve a communication between its cavity and the ovaria . — 5 th, The Ovariti are two spherical bodies,

c situated about an inch from the uterus, inferiorly to the fallopian tubes, and are enveloped in a duplicature oi the peritoneum.

Chap. II. Menstruation

The Time of Puberty varies in different climates; — in this country it appears from fourteen to sixteen years of age, sooner or later. The effects are — 1st, Ilair growing in the axilla , and on the mons veneris , which swells up— 2nd, The Uterus becoming more expanded, receives its adult form and is susceptible of impregnation — 3d, The Vagina is enlarged — 4th, The Pelvis and its cavity augmented, but do not acquire the adult size until women are eighteen years of age; therefore they ought not to marry before that period — 5th, The Breasts are expanded, and their glandular substance unfolded — 6th, An animated countenance and a graceful attitude are visible — 7th, An harmonious tone of voice is heard — 8th, New passions begin to operate with, — 9th, The regular appearance oi the menses.

The Menstrual Flux is a periodical secretion from the uterine vessels. Although red and similar in appearance to blood, its properties are different ; for it is never found to coagulate; and is discharged from the genetals of a healthy woman, about every lunar month, from puberty till late in life, unless interrupted

MENSTRUATION.

by pregnancy, lactation, or disease. When the time of menstruation approaches, women are liable to pains, in the inferior extremities, loins, breasts, head, &c. ; and to hysterical or nervous affections, more or less acute ; all of which are removed when they appear, but return with considerable violence in some women at every period.

The Efficient Cause of this discharge is not explained, but its final effects are — 1st, The Health of the female constitution — 2nd, The Salacity of her disposition, and — 3d, Tire Capability of her uterus for procreation. Girls are not liable to conceive prior to the appearance of the menses; but subsequent to it, they are most likely just before and direetly after. Lactation and menstruation have a similar effect in preserving the uterine functions; and pregnancy stops the secretion of the menstrual fluid in the uterus, and pure milk in the breasts. Though the former may flow in the latter, it loses its grateful taste and nutritive principle. Two similar processes in the system, are rarely witnessed at one time — if one child is at the breast and another in utero, the lirst will be neglected by nature.

Observations on Menstruation ; — 1st, The Menstruating period, which lasts about four days, is implied by the term unwell — 2nd, During that time, fresh fish, or milk, are apt to derange the stomach — 3d, The quantity secreted at each period is about four ounces; but it depends on constitution, manner of living, orcliinate; as warm countries increase and cold ones diminish it — 4th, As much is secreted in a middle dav, as in

28 THE ACCOUCHEUR’S VADE MECUlVf.

the first and last days together — 5th, It varies in diC ferent women in the same climate, and with the same persons at successive periods — 6th, The appearance of the menses in youth governs their disappearance in age; one year earlier or later in the former being equivalent to two or three in the latter ; — evident by one menstruating at fourteen and another at sixteen, the first, continuing at regular periods till forty and the last till forty-six — 7th, They customarily continue about thirty years — 8th, Women are more subject to spasmodic and hysterical complaints during the menstrual period than at other times— 9th, In some the secretion appears early without any morbid cause, induced by strength of constitution, vascular action or fullness of vessels, and usually characterized by a full pulse, florid complexion, enlarged breasts, and a warm imagination ; with such females it may commence by the thirteenth year, and, in many instances, before that time ; — here a spare diet, aperient medicines, and well-regulated exercise, are recommended — 10th, Whenever we attend females about the age of puberty, whatever their disease may be, the menses should form a part of our inquiry ; it shews attention, affords us information, and conveys an idea of our acquaintance with the peculiarities of the female constitution — 11th, When patients apply for the removal of an obstruction of the menses, if the\ have morning sickness, pain and swelling in the breasts, a dark areola round the nipples, with a natural colour on the cheeks, we suspect the existence of pregnancy — 12th, Obstructed Menses, with flushings in the face, slight cough, pain in the breasts, difficult

DISEASED MENSTRUATION.

‘29 respiration and fever, indicate a hectic disposition; in which it is advisable to bleed in small quantities ; give gentle aperients, antiphlogisties, and prescribe a vegetable diet ; pure air and a cautious attention to the nonnaturals. — 13th, When an attack of alarming peripneumony or any other inflammatory affection supervenes n a constitution labouring under obstructed menses; the urgent symptoms must be attended to without regarding the primary complaint.

DISEASED MENSTRUATION.

The disordered state of this secretion has two general divisions : —

Amenorrhcea is the first division ; a partial or total obstruction to the menstrual deposit, from other causes than pregnancy or old age. It is essential to health, that the catamenia should be regular in quantity, quality, and its monthly periods — If it is obstructed, nature essays to obtain it some outlet, and when her efforts fail, the consequence may be the accession of various other affections. Amenorrhcea has its subdivisions into — 1st, Chlorosis emansio mensium , that is, when the discharge does not appear so early as is usually expected. — 2nd, Suppressio mensium; when, after the menses appear and continuing established for some time, they cease, from various causes ; but it is generally owing to an unguarded exposure to cold or moisture, improper food, impure air, want of exercise, abstinence from sexual intercourse, &c. If the exciting cause to amenorrhcea be recent, the result may

c 2

JH> THE ACCOUCHEUR'S VADE MECUM.

be Acute Obstruction, attended with a full quick pulse, hot dry skin, thirst, pain in the head, back, loins, and limbs, with an increased action of the vessels. The treatment here recommended, is, early bleeding, emetics, cathartics, the warm bath, and diaphoretics. It the exciting cause to Amenorrheea be the failure of the monthly evacuations for several periods, it is termed Chronic Obstruction, which, although originally accompanied by an increase of action in the vascular system, is succeeded by debility, and the ill state ot the patient’s health becomes evident ; — 1st, By appearance, as manifested in a sallow skin, pale complexion, cold, flabby or feebleness, with edematous swelling of the feet and ancles towards the evening, and a turgid appearance around the eyes in the morning — 2nd, By constitutional affections, — as, a weariness and debility ; air inaptitude to exertion ; loss of appetite, or an inclination for improper food ; flatulence, difficult raspiration ; palpitation ; hysterical symptoms ; disturbed sleep; small quick pulse; pain in the head ; sense of weight over the eyes ; pain of the back, loins, Ac. The most successful treatment, is, the occasional exhibition of gentle emetics and aperients, to keep the priinae vise clear from fnccal accumulation : with this intention invariably had in view, other remedies should be resorted to, as the combination of symptoms renders their utility evident. Where the stomach and appelite are mended, small doses of steel may be given, or the chalybeate waters, with generous diet, pure air, and moderate exercise ; which last is to be increased with the strength of the patient. Although the discharge