PARTURITION, ABNORMAL.
The value of a careful examination, both general and local, of a pregnant woman cannot be overestimated. The mortality-rate of parturition has been diminished during the last ten years, but it still continues high mainly because a thorough examination of the patient months before the expected event is neg lected. As a result, the accoucheur is not prepared, until the labor sets in, to treat that which might have been avoided or checked by prophylactic measures. Again, a careful estimation of the size and conformation of the maternal pelvis, thus ascertaining whether or not there is a disproportion between the bony struct ures and foetal head, is the secret of suc cess in a large number of cases. The recognizable causes of abnormal parturi tion may be maternal or fetal.
Maternal Causes of Abnormal Par turition.
These may be subdivided into general and local predisposing factors. Any con stitutional vice, whether acute or chronic, predisposes to either primary or second ary uterine inertia, and thus causes dys tocia. Tuberculosis, organic heart dis ease, malaria, acute diseases,—such as pneumonia, nephritis,—with the possi bility of eclarnpsia, represent the general maternal causes most frequently encoun tered. The local maternal causes are of even greater importance, and consist of tumors, uterine or extra-uterine; pelvic deformities, including bony tumors, gen erally-contracted and flat rachitic pelvis, simple flat pelvis, and irregular pelvis; spasm or rigidity of cervix or abnormali ties or tumors; uterine malformations, either natural or acquired; hmmatoma of the genital tract; spasm, rigidity, or abnormality of the vulva or perineum; full bladder or rectum; and placenta prtevia.
TUMORS.—Fibroid of the uterus so frequently occurs as a complication of pregnancy that the condition is often considered as of no importance. So long as the growth does not obstruct the pel vie inlet it gives rise to no trouble ex cept possibly to predispose to haemor rhage in the third stage of labor. Fortu nately, fibroids are mostly situated at the fundus and are out of harm's way; or, being pedunculated, even though encroaching so as to materially inter fere with labor by occluding or narrow ing the pelvic inlet, in most cases they can be pushed up beyond the presenting part. The difficult cases are those in which large growths springing from the lower uterine wall or intraligamentous fibromata form an insurmountable bar rier to delivery.
The next most frequent obstructive tumor is the ovarian cystoma. Peculiar as it may seem, small growths are more apt to cause dystocia than the greater ones. While patients with enormous cystomata rarely become pregnant, if this obtains, the cyst is usually pushed out of harm's way. The smaller varieties —dermoids, for instance—are likely to become incarcerated and so wedged in the cul-de-sac as to make the possibility of terminating labor by the ordinary passage practically impossible. Again, the possibility of rupture of such a tumor is not remote probability.
In the treatment of ovarian tumor obstructing labor. the tumor should be pushed out of the pelvis if possible. Caesarean section will very rarely be necessary if the tumor he withdrawn from the pelvis. Abdominal ovariotomy is the safer operation, and should be pre ferred to vaginal ovariotomy. Spencer (Trans. of the Obstet. Soc. of London, vol. xl, pt. L 'OS).
In eases where a fibroid has obstructed labor and has been successfully "pushed up." if any dangerous symptoms super vene during the puerperium. emliotomy, followed by myomectomy (or hysterec tomy, if the need be). should be carried out without delay.
In a very large number of instances fibroids and pregnancy co-exist and no harm ensues, for, though the tumor oc cupies the pelvis in the early stages, it has become a part of the uterine tissues to such a degree that, as the enlarging organ rises out of the pelvis, it carries the fibroids with it. In the case of an incarcerated ovarian tumor it is differ ent, for, the more the fundus of the uterus ascends, the more the ovarian pedicle elongates and the more perfect the incarceration becomes.
From a very broad survey of this ques tion the following deduction has been reached: Ovarian tumors have given more trouble to pregnant and parturient women than fibroids: but fibroids have been far more lethal, as they so fre quently destroy puerperal women from sepsis. J. Bland Sutton (Lancet, Feb. 16, 1901).
Carcinoma is a somewhat rare condi tion. Early in the course of the affection the complication is not an alarming one, since the first stage of labor is rarely in fluenced. It is only during the ulcerative stage that the haemorrhages, sloughing, etc., make the complication a very trying one.