1853 The Lancet  
THE following case of rupture of the uterus possesses much practical value, inasmuch as it serves to illustrate some of the difficulties to be encountered in forming a correct diagnosis, where this accident occurs early in labour. There are no wellmarked symptoms or signs to guide us, and nothing which could lead us to infer that such an accident had occurred, until after many hours had elapsed. Mrs. H--, aged thirty-two, a well-made woman, the mother of six children, and has always got over
more » ... confinements well on former occasions. She was taken in labour with her seventh child on Tuesday afiternoon, December 14th, 1852, having gone to the full period of nine months. Labour began whilst she was cleaning up the room after washing, when she felt a slight pain. This I was at four P.M. She had pains at intervals from four to five I o'clock, when she sent for the midwife, who attended iinmediately. She was found leaning over the back of a chair, having just had a pain, and she said she was in the habit of being delivered on her knees. The midwife managed to get her into bed, and as soon as she was on the bed another pain came on. An examination was at once made,when itwas found that themembranes protruded externally, like a great bladder, to a considerable extent beyond the vulva; so much so as to induce the midwife to suppose that the head of the child had come down. In about five minutes after this, another pain of so violent a character came on, that the midwife expected delivery would be completed. When the membranes broke, the waters came away in a perfect torrent; the floor of the room as far as the fire-place was flooded, and the quantity of the liquor amnii was estimated by the midwife at about a gallon. On examination, the head of the child was found to be only at the brim of the pelvis, almost out of reach; the patient appeared very restless and anxious; no pains except what were called wringing pains" occurred, till about eight P.III., when two pains, which the midwife described as unsatisfactory and of a peculiar kind, came on, and the head descended somewhat into the pelvis. The pains after this ceased. The patient appeared to get into a low, anxious state, complaining of great tenderness when her abdomen was touched, and saying that she should never be delivered, if she went on like this till tomorrow. She said that she had never before been more than two or three hours in labour, and expressed a wish to have something done to take away the child. The midwife considered the case to be one of lingering labour depending on inertia of the uterus; and as there was no obstruction anywhere, at ten P.M. she gave her ten grains of the ergot of rye, and repeated this dose at half-past eleven P.M. It appeared to produce little or no pain, and the head of the child remained stationary; and, although the fingers could be passed without difficulty round the head, and no mechanical obstruction existed anywhere to its passage through the pelvis, still there was no expelling power in the uterus to make the head descend. The patient continued in nearly the same state till about three A.M. on the following morning, (Wednesday,) about eleven hours after the labour had commenced, and about seven hours after the last pain had been felt; when the midwife, not feeling satisfied with her condition, and observing that she was getting more anxious and lower, sent for a surgeon, who arrived at the house a little before four A.M., accompanied by a friend. They found the patient in a restless and exhausted state, with a weak, rapid pulse; she complained of great pain and tenderness when pressure was made over the abdomen, which was large, but not irregular. On examination per vaginam, the head was found presenting with the face directed backwards, towards the sacrum, and very slightly advanced into the pelvis. The soft parts were fully dilated, and no reason appeared why the head should not descend. As ergot of rye had been previously given by the midwife without effect, after some delay it was thought advisable to deliver the woman with forceps, which were accordingly had recourse to about six A.M.; the patient having had some wine given to her before using them. Owing to the high position of the head. the ear could not be felt, and the fontanelles, which could be easily distinguished, were the only guides to be taken in ascertaining what was the position of the head. The upper blade of the forceps was applied without difficulty, and having been placed in charge of the hands of a surgeon in attendance, the lower blade was then attempted to be passed; but here it was found that the mobility of the head interfered with the adjustment of the two, and they were withdrawn without any traction having been made. The greatest caution appears to have been shown in using them, The exhausted state of the patient now claimed particular attention, and made it necessary to give stimulants frequently. Subsequently two drachms of the æthereal tincture of ergot were given in divided doses, but without effect. As the case did not appear altogether clear, and was one which presented some unusual features, it was thought right to have another opinion on the subject. I was accordingly sent for to see the woman about half-past nine A.M., and found that she was in a state of great and immediate danger. She was quite conscious, and recognised me as having attended her family before. The pulse was small and tremulous; the countenance pinched and anxious, and the abdomen very tender on pressure. At no period of the labour does it appear that there had been any haemorrhage. Previous to proceeding to make an examination, I found it necessary to give her brandy, which restored some power to the pulse. The abdomen was very large, and the outline of the uterus not readily defined. 0 n examination per vaginam, I found the head just within the brim of the pelvis, and it could be easily pushed upwards by the fingers; there was no overlapping of the bones, nor any evidence of undue pressure having been exercised on any part of the head. The size of the head did not appear to be larger than the average, and the diameters of the pelvis were sufficient to allow of its passage. The exhausted condition of the patient rendered it necessary for me to give her stimulants at short intervals ; and after a careful consideration of the case, I thought it advisable that the woman should be delivered without further delay. The case was evidently one in which there was something far more serious than inertia of the uterus to contend with. The distress of the patient was not like that of nervous excitement or fatigue-it was collapse. The abdominal symptoms pointed to the seat of mischief. The inaction of the uterus, and the recession of the head, made me suspect rupture of the uterus; but although the supposition of rupture existing did cross my mind, I could not, on reviewing all the symptoms in this obscure case, ascertain that it had at that time taken place. Still I determined upon removing the child as quickly as possible, from a conviction that the structure of the uterus was so far implicated, as to give no hope of the child being expelled by the natural process of labour. Having come to this conclusion, I perforated the head, and proceeded to bring down the child. This was accordingly done, but not without considerable difficulty, owing to its mobility, its high position in the pelvis, and the total absence of uterine action. I succeeded in bringing down the head of the child with the blunt hook as low as the vulva; but I found that as soon as the traction was remitted, the head of the child showed a strong tendency to recede, and it required some force to prevent its doing so. After the head was born, the delivery of the body was soon accomplished.. Immediately the child was born, I introduced the hand into the uterus, and removed the placenta without difficulty, and in doing so, ascertained that there was an extensive rupture of the posterior part of the uterus. The uterus showed no disposition to contract, and the hand was therefore again introduced, previously dipped in cold water, at the same time that the cold douche was employed; by these means the uterus was very soon made to contract. The hemorrhage was slight. Some brandy was then given, and sub. sequently full doses of laudanum. There was a little return of & p o u n d ; haemorrhage about an hour after, which was readily checked. The pulse after delivery improved, and she rallied to a certain i extent from the shock, but the improvement did not continue. Although she did not suffer much from abdominal pains, and no vomiting occurred, yet she became lower and more exhausted, and died about ten P.M., eleven hours after the removal of the child. Remarks.—The two points to be considered are, the cause of the rupture, and the time at which it occurred. 1. Cause of' the Rupture. -Mechanical obstruction: The woman had had six children previously, with short deliveries ; the pelvis was well-formed, and there was no tumour or disease in the passage; the presentation was natural, and the head did not exceed the average size. The child in this case, as in the majority of those recorded, was of the male sex; but admitting increased development or greater size of the male sex to be of influence in these cases, the size of this child was not such as to be of importance as a cause.—Distention of the Uterus: There appears to have been a greater quantity than usual of the liquor amnii. The labour was not a protracted one; the uterus had not been exhausted by numerous pains, for there was no effective contraction of the uterus after eight o'clock, when the patienthad been only four hours in labour, and during more than two of those hours there does not seem to have been any effective pain. Ergot of rye caused no contraction. Had the uterus already given way? or could the ergot have produced any change in the structure of the fibres of the uterus ?-Use qf instruments: The careful manner in which it has been shown that the forceps were tried, precludes the supposition of injury. No other instrumental
doi:10.1016/s0140-6736(02)73065-1 fatcat:d5oduanp7fg7njwhvu3gvwehyu