The best way to accelerate labor during the second stage is to termi nate it either by extraction or by the forceps, but we must not interfere too hastily. We wait from three to six hours after the rupture of the membranes, according to the condition of the mother and child, and the elevation of the presenting part. When the head has remained for two hours in the vagina, without making any progress, we do not wait longer, but deliver with the forceps, even wh9n the child is in no danger, in order to spare the mother from unnecessary prolongation of the labor. If the child is in peril, we of course interfere sooner. This problem becomes one of the most difficult of solution, when the life of the child is threat ened, before the os is dilated. In this case we should carefully try ex pression, but if the latter was not immediately successful, and the disturb ance of the fatal circulation increased, we should not hesitate to incise the cervix in one or two places, and to extract the child. But such cases are rare, because, as we have said, feebleness of the uterine contractions does not affect the fcetus during the first stage, while during the second stage extraction and completion of the labor are not, as a rule, attended with serious difficulties.
[For ineffective pains during the first stage of labor, we know of noth ing which will give better results than chloral. This drug regulates the pains, increases the interval between them, gives the mother rest, and thus restores her nervous force. We would administer the drug in fifteen grain doses every quarter of an hour, for four doses, or else give at once thirty grains per rectum, repeated in one half hour.
For ineffective pains during the second stage, twenty grains of qui nine have often increased the pains in our experience, and, in addition, we would strongly recommend the use of a mild faradic current, one elec trode held by the patient, the other moved over the abdomen.—Ed.] Abnormal Contractions.
The uterine contractions may be misdirected (perverted) or irregular in their course, or partial, only one portion of the uterus contracting, or the fundus alone may contract, the inferior segment being quiescent. Sometimes the entire organ remains in a state of tetany, sometimes the fundus, the inferior segment, or one horn contracts at irregular intervals, when the organ presents a nodular shape. No impulse is communicated to the foetus, and the membranes do not protrude during the pains, while the cervix remains hard, retracted and undilated, and is very sensitive.
If this condition persists, and the contraction is confined to the region of the isthmus, hour-glass stricture results; if it involves the entire uterus, it is called tetanus uteri. As a rule, such spasmodic contractions only appear towards the end of the period of dilatation; they sometimes occur after the passage of the head, and are confined to the region of the os internum, where the foetus is grasped like a stud in a button-hole. The stricture may be at the os externum. When very violent, spasmodic con tractions are attended with extreme pain, great agitation and fever; the genitals become hot and sensitive. The pain extends to the loins, thighs,
and entire abdomen, the patients complain of cramps and reflex pains, while in some cases delirium and convulsions may occur. In spite of the violence of the pains, labor makes no progress.
thuses.-- Although they may be due to some extent to the general condition of the patient, there are two agents that are particularly re sponsible, ergot and unskillful excitation of the uterus, and especially of the cervix. How often does the injudicious use of ergot give rise to this spasmodic retraction, not only of the cervix, but of the entire uterus? How often are frequent examinations, excessive friction of the uterus, and awkward attempts at version, applying the forceps, and hastening deliv ery, followed by consequences extremely serious to the mother.
for the cause of the spasmodic contraction, and apply one of the following remedies, as it may be suitable: Dover's powder, laxatives, ipecac, in hourly doses of from to 11 grains, enemata contain ing antispasmodics or laudanum, valerian, and camomile, warm injec tions or baths, and applications of belladonna ointment to the os. Lebert advises injections of morphine; Breslau injections of atropine; bleeding up to the point of syncope has been recommended. The best remedies are chloral (by the rectum) during the first stage, and chloroform in the second. Do not practise manual dilatation, but incise the cervix if it be comes necessary to interfere immmediately in the interest of the child.
[Instead of incising the cervix we should be in favor of chloroforming the patient, and gently dilating the cervix by means first of one finger and then another. This method is warmly commended by Sinclair, of Bos ton, Gillette, of New York, and others. It has answered us well.—Ed.] Irregular Contraction of the Abdominal Muscles.— Fracture of the Sternum. —Subcutaneous Emphysema.
The contractions of the abdominal muscles are partly subject to the patient's will, and it is common to see women making violent efforts, and exaggerating these contractions. Fracture of the sternum may rarely re sult from excessive straining; subcutaneous emphysema, following rupture of the pulmonary vesicles, is not so rare. It usually appears on the neck, face and chest. Haultcoeur reports 11 cases, and we have seen 2. This emphysema is usually of no significance when it extends to the medias tinum and neck, but when it is confined to the pulmonary parenchyma, the result may be fatal.
The abdominal contractions may be too feeble, either because of the severe pains, or because the women are weakened by pre-existing diseases (cardiac, pulmonary, etc.) Paraplegia sometimes plays an important part. Although feebleness of the abdominal contractions is insignificant in itself, when associated with ineffectual uterine contractions it may retard labor, and thus constitute an indication for artificial delivery.