This deficiency may appear at any stage in the labor, and may persist throughout the entire period, or, it may be confined to a single stage, that of dilatation, expulsion, or delivery; all degrees may exist, from simple irregularity to complete and prolonged suspension of the entire contract ing force of the uterus. Naegele and Grenser recognize three varieties of inefficient pains, viz.: 1. Uterine inertia, in which the pains are weak, and reappear after long intervals. 2. Atony of the uterus, where they grow more and more feeble, and finally disappear entirely. 3. Paralysis of the uterus, where the organ may be completely relaxed. Cazeaux divides them into: Pains that are feeble at the beginning of labor; those which begin strongly, but subsequently diminish, or disappear entirely; and pains which present marked irregularity in their duration, intensity and recurrence. Jacquemier defines inefficient pains as those which are " unable to overcome the normal resistance to the expulsion of the fcetus." The English expression " tedious labor" is peculiarly appropriate.
If feebleness of the contractions is present during the first stage, com plete dilatation may require from twelve hours to several days. The women may have regular pains, but these are separated by very long in tervals, or the pains recur frequently, but are brief and slightly marked; again, they may be irregular in their appearance, duration and intensity.
Two or three pains rapidly succeed one another, then comes an inter val of repose, a fresh pain occurs, and is succeeded by slight and short ones, dilatation being discouragingly slow. If dilatation is finally accom plished, it seems as if the uterus had exhausted all its energy, the pains cease, the membranes do not rupture, and labor is prolonged.
In another case the first stage proceeds regularly, but as soon as dilata tion has been completed, the pains become infrequent and feeble, the stage of expulsion being indefinitely delayed. If the membranes have ruptured, the presenting part of the fcetus becomes the seat of a con siderable swelling, which may lead the attendant to think that the child has descended, when in reality it remains stationary.
Although retarded labor is usually borne well during the first stage, it is not the case during the second. If the latter is prolonged, in addition to the fatigue produced by the length of the labor, there is often vomit ing, fever, a hot and dry skin, uneasiness, anxiety, tremor, a dry tongue, hot vagina, etc. The foetus is also affected, as shown by disturbance of the heart, and may perish purely from the prolongation of the labor. The long contact of the fcetal head with the same point in the pelvis may cause sloughing of the maternal tissues, with the subsequent formation of fistulae, not to speak of the favorable condition in which the exhausted woman is placed for the occurrence of future septic infection.
Causes.—These are often obscure, and feeble pains may be observed in robust, as well as in delicate females, in the young, as well as in those more advanced in years. They seem to be of more frequent occurrence
in primiparfe than in multiparre, however, and are often seen in women of marked adipose development. Sometimes, the uterine inertia results from a condition of general debility, caused by previous diseases, hemor rhages, or bad hygienic surroundings. The uterus may itself be inert, or the feebleness may be to a certain extent hereditary, or acquired in con sequence of severe labors, repeated abortions, or chronic leucorrhcea. Other causes are premature rupture of the- membranes, hyper-distension of the uterus (twin pregnancy, hydramnios, fibrous tumors, etc.), death of the foetus, prolongation of the first stage, and endometritis (Grenser). To these may be added uterine congestion and inflammation, biliousness, gastric irritation, distension of the bladder, and mental emotions (fright, anger). The arrival of the physician, or the presence of obnoxious per sons, may produce the same effect, although in this case the cessation of the pains is only temporary.
For the is usually without gravity during the first stage, when the effects are limited to the fatigue, agitation, and impatience experienced by the patient; but the prognosis may become more swims if the period is so extended that she is deprived of sleep, loses her appetite, and becomes thoroughly exhausted. During the second stage it becomes still more serious, because, aside from the exhaus tion of the mother, the pressure of the foetal head may cause sloughing, with resulting fistulae or other grave effects. All writers agree in regard ing retarded labor as one of the most potent causes of the serious puer peral sequelte, without mentioning primary accidents (hemorrhage, etc.), which may occur at the time of delivery.
2. For the long as the membranes remain intact, feeble pains seem to be innocuous no matter how prolonged the labor may be. Thus, among 133 cases collected by Tarnier and others, in which the first stage was prolonged from twenty-four to sixty hours, only eight children were dead-born. After the rupture of the membranes, however, and when dilatation is complete, the case is different. Although the foetus may not be affected for a long time, because of the relaxed condition of the uterus, if the stage of expulsion is prolonged beyond eight or ten hours the placental circulation is disturbed, the heart-beats become irregular, and the children perish in a considerable number of cases. This period, eight to ten hours, seems to us too long, although fixed by Jacquemier, and, in our opinion, we should apply the forceps when the head has been arrested for an hour or two after reaching the pelvic floor, and thus both snatch the child from the perils that threaten it, and relieve the woman of unnecessary suffering.