OF UNNATURAL LABOUR.
<Illustration: process of delivery.>
IN showing the duty of a midwife, when the child-bearing woman's labour is unnatural, it will be requisite to show, in the first place, what I mean by unnatural labour; for that women do bring forth children in pain and sorrow is natural and common to all. Therefore that which I call unnatural labour is, when the child comes to the birth in a contrary posture to that which nature ordained and in which the generality of children come in to the world.
The right and natural birth is, when the child comes with its head first; and yet this is too short a definition of a natural birth: for if any part of the head but the crown come first, so that the body follows not in a straight line, it is a wrong and difficult birth, even though the head comes first. Therefore, if the child comes with its feet first, or with the side across, it is quite contrary to nature, or to speak more plainly, that which I call unnatural; now there are four general ways a child may come wrong: the first is, when any of the fore parts of the body first present themselves. Secondly, when by an unhappy transposition any of the hinder parts first present themselves. Thirdly, when either of the sides; or, fourthly, the feet present themselves first: to these four, all the particular and different wrong postures that a child can present itself in, for the birth may be reduced; and therefore I shall confine myself herein, to treat only of these four more generally wrong.
SECT. II. How to deliver a Woman of a Dead Child by Manual Operation.
THE last section of the last chapter was about the delivering of a woman of a dead child, wherein several things were directed to be applied in order to facilitate the delivery; but where all these fail, a manual operation is absolutely necessary. In order to which, let the operator acquaint the woman with the absolute necessity there is of such an operation; and that as the child has already lost its life, there is no other way left for the saving of hers; let him also tell her, for her encouragement, that he doubts not that with the divine blessing to deliver her safely, and that the pain arising thereby will not be so great as the fears; and then let him endeavour to stir up the woman's pains, by giving her some sharp clyster, to excite her throws to bear down and bring forth the child; and if this prevail not, let him proceed with his manual operation.
First, therefore, let her be placed across the bed that he may operate the easier, and let her lie on her back, with her hips a little higher than her head, or at least the body equally placed, when it is necessary to put back or turn the infant to give it a better posture: being thus situated, she must fold her legs so as her heels be toward her buttocks and her thighs spread, and held so by a couple of strong persons; there must be others also to support her under her arms, that the body may not slide down when the child is drawn forth, for which sometimes a great strength is required; let the sheets and blankets cover her thighs for decency's sake, and with respect to the assistance, and also to prevent her catching cold; the operator herein governing himself as well with respect to his convenience, and the facility and surety of the operation, as to the other things. Then let him anoint the entrance of the womb with oil or fresh butter, if it be necessary, that so he may with more ease introduce his hand which must also be anointed; and having by signs before mentioned received satisfaction that it is a dead child, he must do his endeavour to fetch it away as soon as possibly he can, and if the child offers the head first, be must gently put it back until he hath liberty to introduce his hand quite into the womb; then sliding it along under the belly to find the feet, let him draw it forth by them, being very careful to keep the head from being locked in the passage, and that it be not separated from the body which may be effected the more easily, because the child being very rotten and putrefied, the operator is not so mindful to keep the breast and face downwards as he is in living births. But if notwithstanding all these precautions, by reason of the child's putrefaction, the head should be separated, and left behind in the womb, it must be drawn forth according to the directions which shall be given in section 3 of this chapter for that purpose. But when the head coming first, is so far advanced that it cannot be well put back, it is better to draw it forth so, than to torment the woman too much by putting it back to turn it, and bring it by the feet: but the head being a part round and slippery, it may so happen that the operator cannot take hold of it with his fingers by reason of its moisture, nor put them up to the side of it because the passage is filled with its bigness, he must take a proper instrument, and put it up as far as he can without violence, between the womb and the child's head, observing to keep the point of it towards the head (for the child being dead before, there can be no danger in the operation), and let him fasten it there, giving it good hold upon one side of the bones of the skull, that it may not slide; and after it is well fixed in the head, he may therewith draw it forth, keeping the ends of the fingers of his left hand flat upon the opposite side, the better to help to disengage it, and by wagging it a little to conduct it directly out of the passage, until the head be quite born; and then taking hold of it with the hands only, the shoulders may be drawn into the passage, and so sliding the fingers of both hands under the armpits, the child may be quite delivered; and then the after-burden fetched, to finish the operation, being careful not to pluck the navel-string too hard, lest it break, as often happens when it is corrupted.
If the dead child comes with the arms up to the shoulder extremely swelled that the woman must suffer too great a violence to have it put back, it is then (being first well assured the child is dead), best to take it off at the shoulder joints, by twisting three or four times about, which is very easily done, by reason of the softness and tenderness of the body; after the arm is so separated, and no longer possessing the passage, the operator will have more room to put up his hand into the womb, to fetch the child by the feet, and bring it away.
But although the operator be sure the child is dead in the womb, yet he must not therefore presently use instruments, because they are never to be used but when hands are not sufficient, and there is no other remedy to prevent the woman's danger, or to bring forth the child any other way. And the judicious operator will choose that way which is the least hazardous, and most safe.
SECT. III. How a Woman must be delivered when the Child's Feet come first.
THERE is nothing more obvious to those whose business it is to assist labouring women, than that the several unnatural postures in which children present themselves at their births are the occasion of most of the bad labours and ill accidents that happen unto women in such a condition.
And since midwives are very often obliged, because of the unnatural situations, to draw the children forth by the feet, I conceive it to be most proper to show first how a child must be brought forth that presents itself in that posture, because it will be a guide to several of the rest.
I know indeed that in this case it is the advice of several authors to change the figure, and place the head so, that it may present the birth: and this counsel I should be very inclinable to follow, could they but also show how it must be done. But it will appear very difficult, if not impossible to be performed, if we would avoid the dangers that by such violent agitations both the mother and the child must be put into; and therefore my opinion is, that it is better to draw it forth by the feet, when it presents itself in that posture, than to venture a Worse accident by turning it.
As soon therefore as the waters are broken, and it is known that the child comes thus, and that the womb is open enough to admit the midwife's or operator's hand into it, or else by anointing the passages with oil or hog's grease to endeavour to dilate it by degrees, using her fingers to this purpose, spreading them one from the other, after they are together entered and continuing to do so till it be sufficiently dilated, then taking care that her nails are well pared, and no rings on her fingers, and her hands well anointed with oil or fresh butter, and the woman placed in the manner directed in the former section, let her gently introduce her hand into the entry of the womb, where, finding the child's feet, let her draw it forth in the manner I shall presently direct; only let her first see whether presents one foot, or both, and if but one foot, she ought to consider whether it be the right foot or the left, and also in what fashion it comes; for by that means she will soonest come to know where to find the other, which as soon as she knows and finds, let her gently draw it forth with the other; but of this she must be especially careful, viz., that this second be not the foot of another child; for if so, it be of the most fatal consequence, for she may sooner split both mother and child than draw them forth; but this may he easily prevented if she does but slide her hand up the first leg and thigh to the waist, and there find both thighs joined together, and descending from one and the same body. And this is also the best means to find the other foot when it comes with but one.
As soon as the midwife hath found both the child's feet, she may draw them forth, and holding them together, may bring them by little and little in this manner, taking afterwards hold of the legs and thighs as soon as she can come at them, drawing them so till the hips be come forth. Whilst this is doing, let her observe to wrap the parts in a single cloth, that so her hands, being already greasy, slide not on the infant's body, which is very slippery, because of the vicious humours which are all over it, and prevent one's taking good hold of it, which being done, she may take hold under the hips, so as to draw it forth to the beginning of the breast; and let her on both sides with her hand bring down the arms along the child's body, which she may then easily find; and then let her take care that the belly and face of the child be downwards, for if it should be upwards, there would be some danger of its being stopped by the chin over the share-bone; and therefore, if it be not so, must turn it to that posture; which may he dome easily if she take hold on the body when the breast and arms are forth in the manner we have said, and draws it with turning it in proportion on that side which it most inclines to, till it be turned with the face downwards, and so having brought it to the shoulders, let her lose no time, desiring the woman at the same time to bear down, that so at drawing, the head at that instant may take its place, and not be stopped in the passage. Some children there are whose heads are so big, that when the whole body is born yet that stops in the passage, though the midwife takes all possible care to prevent it. And when this happens she must not endeavour only to draw forth the child by the shoulders, lest she sometimes separate the body from the head, as I have known it done by the midwife, but she must discharge it by little and little from the bones in the passage with the fingers of each hand, sliding them on each side opposite the one to the other, sometimes above, and sometimes under, until the work be ended; endeavouring to despatch it as soon as possible, lest the child be suffocated, as it will unavoidably be if it should remain long in that posture; and this being well and carefully effected, she may soon after fetch away the after-birth, as I have before directed.
SECT. IV. How to bring away the Head of the Child when separated from the body, and left behind in the Womb.
THOUGH the utmost care be taken in bringing away the child by the feet, yet, if the child happens to be dead, it is sometimes so putrefied and corrupted, that with the least pull the body separates from the head, and remains alone in the womb, and cannot be brought away but with a manual operation and difficulty; so it being slippery, by reason of the place where it is, and from the roundness of its figure, on which no hold can be well taken; and so very great is the difficulty in this case, that sometimes two or three able practitioners in the art of midwifery have one after the other left the operation unfinished, as not able to effect it, after the utmost efforts of their industry, skill and strength; so that the woman, not being able to be delivered, perished. To prevent which fatal accident for the time to come, let the following operation be observed.
When the infant's head separates from its body, and is left alone behind, whether through putrefaction or otherwise, let the operator immediately, without any delay, whilst the womb is yet open, direct up his right hand to the mouth of the head (for no other hole can there be had), and having found it let him put one or two of his fingers into it and the thumb under his chin, then let him draw it by little and little, holding it so by the jaw; but if that fails, as sometimes it will, when putrefied, then let him pull forth his right hand, and slide up his left, with which he must support the head, and with the right let him take a narrow instrument called a crotchet; but let it be strong and with a single branch, which he must guide along the inside of his hand, with the point of it towards it for fear of hurting the womb, and having thus introduced it, let him turn it towards the head for to strike either into an eye-hole, or the hole of an ear or behind the head or else between the stature, as he finds it most convenient and easy; and then draw forth the head so fastened with the said instrument, still helping to conduct it with his left hind; but when he hath brought it near the passage being strongly fastened to the instrument, let him remember to draw forth his hand, that the passage not being filled with it may be the larger and easier, keeping still a finger or two on the side of the head, the better to disengage it.
There is also another way to this, with more ease and less hardship than the former, which is this: let the operator take a soft fillet or linen slip of about four fingers' breadth and the length of three quarters of an ell or thereabouts, taking the two ends with the left hand, and the middle with the right, and let him so put it up with his right as that it may be beyond the head to embrace it as a sling doth a stone; and afterwards draw forth the fillet by the two ends together. It will easily be drawn forth, the fillet not hindering the least passage, because it takes up little or no place.
When the head is thus fetched out of the womb, care must be taken that not the least part of it be left behind, and likewise to cleanse the woman well of her after-burden if yet remaining. Some have questioned whether the child's head yet remaining in the womb, and the after-birth too, which ought to be brought away first? The answer to which question may be by way of distinction that is to say, if the burden be wholly separated from the sides of the womb that ought to be first brought away, because if it still adheres to the womb, it must not be meddled with till the head be brought away; for if one should then go about to separate it from the womb, it might then cause a flooding, which would be augmented by the violence of the operation; the vessels to which it is joined remaining for the most part open as long as the womb is distended. which the head causeth while it is retained in it, and cannot close till this strange body be avoided, and then it doth by contraction and compressing itself together, as has been before more fully explained. Besides the after-birth remaining thus cleaving to the womb during the operation, prevents it from receiving easily either bruise or hurt.
SECT. V. How to deliver a Woman when the side of the Child's Head is presented to the Birth.
THOUGH some may think it a natural labour when the child's head may come first, but yet if the child's head presents not the right way, even that is an unnatural labour; and therefore, though the head comes first, yet, if it be the side of the head instead of the crown, it is very dangerous both to the mother and child, for the child may sooner break its neck than be born in that manner; and by how much the mother's pains continue to bear the child, which it is impossible unless the head be rightly placed, the more the passages are stopped; therefore, as soon as the position of the child is known the woman must be laid with all speed, lest the child should advance further in this vicious posture, and therefore render more difficult to thrust it back, which must be done in order to place the head in the passage right as it ought to be.
To this purpose therefore place the woman so that her hips may be a little higher than her head and shoulders, causing her to lean a little upon the opposite pick to the child's ill posture; then let the operator slide up his hand, well anointed with oil, by the side of the child's head, to bring it right, gently with his fingers between the head and the womb; but if the head be so engaged that it cannot be done that way, he must then put up his hand up to the shoulders, that so by thrusting them back a little into the womb, sometimes on the one side and sometimes on the other, he may by little and little give it a natural position. I confess it would be better if the operator could put back the child by its shoulders with both hands; but the head takes up so much room that he will find much ado to put up one, with which he must perform his operation with the help of the finger ends of the other hand, put forward the child's birth as when the labour is natural.
Some children present their face first, having their heads turned back, in which posture it is extremely difficult that a child should be born; and if it continue so long, the face will be swelled, and withal black and blue, that it will at first seem monstrous, which is occasioned as well by the compression of it in that place as by the midwife's fingers handling it too readily, in order to place it in a better posture, but this blackness will wear away in three or four days' time, anointing it often with oil of sweet almonds. To deliver the birth, the same operation must be used as in the former, when the child comes first with the side of the head; only let the midwife or operator work very gently to avoid as much as possible the bruising of the face.
SECT. VI. How to deliver a Woman when a Child presents one or both hands together with the Head.
SOMETIMES the infant will present some other part together with its head, which if it does, it is usually one or both hands; and this hinders the birth, because the hands take up part of that passage which is little enough for the head alone; besides that, when this happens, they generally cause the head to lean on one side; and therefore this position may be very well styled unnatural. When the child presents itself thus, the first thing to be done, after it is perceived, must be to prevent it from coming down more, or engaging further in the passage, and therefore the operator, having placed the woman on the bed with her head a little lower than her hips, must put and guide back the infant's hand with his own as much as may be, or both of them, if they both come down, to give way to the child's head, and this being done, if the head be on one side, it must be brought into its natural posture in the middle of the passage, that it may come in a straight line, and then proceed as directed in the forgoing section.
SECT. VII. How a Woman is to be delivered when the Hands or Feet of the Infant come together.
THERE is none but will readily grant, that when the hands and feet of an infant present together, the labour must be unnatural because it is impossible a child should be born in that manner. In this, therefore, when the midwife guides her hand towards the orifice of the womb she will perceive only many fingers close together; and if it be not sufficiently dilated, it will be a good while before the hands and feet will be exactly distinguished; for they are sometimes so shut and pressed together that they seem to be all of one and the same shape; but where the womb is open enough to introduce the hand into it, she will easily know which are the hands and which are the feet; and having well taken notice thereof, let her slide up her hand; and presently direct it towards the infant's breast; which she will find very near, and then let her very gently thrust back the body towards the bottom of the womb, leaving the feet in the same place where she found them; and then having paced the woman in a convenient posture, that is, to lay her hips a little raised above her breast and head (which situation should always be observed when the child is to be put back into the womb), let the midwife afterwards take hold of the child by the feet, and draw it forth, as is directed in the second section.
This labour, though somewhat troublesome, yet is much better than when the child presents only its hands; for the child must be quite turned about before it can be drawn forth; but in this they are ready, presenting themselves; and in this there is not much to do, but to lift and thrust back a little the upper part of the body, which is almost done of itself by drawing it alone by the feet.
I confess there are many authors that have written of labours who would have all wrong births reduced to a natural figure; which is, to turn it, that it may come with the head first; but those that have written thus are such as never understood the practical part, for if they had the least experience herein, would know that it is very often impossible, at least, if it were to be done, that violence must necessarily be used in doing it, that would very probably be the death of mother and child in the operation. I would therefore lay down, as a general rule, that whensoever an infant presents itself wrong to the birth, in what posture soever from the shoulders to the feet, it is the best way, and soonest done, to draw it out by the feet: and that it is better searching for them if they do not present themselves, rather than try to put it in the natural posture, and place the head foremost; for the great endeavours necessary to be used in turning the infant in the womb do so much weaken both mother and child, that there remains not afterwards strength enough to commit the operation to the work of nature; for usually the woman hath no more throws or pains fit for labour after she has been so wrought upon; for which reason it would be very difficult and tedious at best; and the child, by such an operation made very weak, would be in extreme danger of perishing before it could be born. It is therefore much better in these cases to bring it away immediately by the feet; searching for them, as I have already directed, when they do not present themselves; by which the mother will be prevented of a tedious labour, and the child be often brought alive into the world, who otherwise would hardly escape from death. And thus much shall suffice to be said of unnatural labours; for, by the rule already given, a skilful artist will know how to proceed in any posture in which the child shall present itself.
SECT. VIII. How a Woman should be delivered that has Twins, which present themselves in different Postures.
<illustration: position of embryos in a plural conception>
WE have already spoken something of the birth of twins in the chapter of natural labour; for it is not an unnatural labour merely to have twins, provided they come in a right position to the birth. But when they shall present themselves in divers postures, they come properly under the denomination of unnatural labours; and if when one child presents itself in a wrong figure, it makes the labour dangerous and unnatural, it must needs make it much more so when there are several, and render it not only more painful to the mother and children, but to the operator also, for they often trouble each other, and hinder both their births; besides which the womb is then so filled with them, that the operator can hardly introduce his hand without much violence, which he must do, if they are to be turned or thrust back, to give them a better position.
When a woman is pregnant with two children, they rarely present to the birth together, the one being generally more forward than the other, and that is the reason that but one is felt; and that many times the midwife knows not there are twins till the first is born, and that she is going to fetch away the afterbirth. In the fifth chapter, wherein I treated of natural labour, I showed how a woman should be delivered of twins, presenting themselves both right; and, therefore, before I close this chapter of unnatural labour, it only remains that I show what ought to be done, when they either both come wrong, or one of them only, as for the most part it happens; the first generally coming right, and the second with the feet foremost, or in some worse posture. In such a case, the birth of the first must be hastened as much as possible to make way for the second, which is best brought away by the feet, without endeavouring to place it right, even though it was somewhat inclining towards it, because it has been already tired and weakened by the birth of the first as well as its mother, that there would be greater danger of its death than likelihood of its coming out of the womb that way.
But if, when the first is born naturally, the second should likewise offer its head to the birth, it would be then best leaving nature to finish what she has so well begun; and it nature should be too slow in her work, some of those things mentioned in the fourth chapter to accelerate the birth may be properly enough applied: and if, after that, the second birth should be yet delayed, let a manual operation be deferred no longer; but the woman properly placed, as has been before directed, let the operator direct his hand gently into the womb to find the feet, and so draw forth the second child which will be the more easily effected, because there is way made sufficient by the birth of the first; and if the waters of this second child be not broken, as it often happens, yet intending to bring it by the feet, he need not scruple to break the membranes with his fingers: for though, when the birth of a child is left to the operation of nature, it is necessary that the waters should break of themselves, yet when the child is brought out of the womb by art, there is no danger in breaking of them; nay, on the contrary, it becomes necessary: for without the waters are broken it would be almost impossible to turn the child.
But herein principally lies the care of the operator that he is deceived, when either the hands or feet of both children offer themselves together to the birth; In this case he ought to consider the operation, as whether they be not joined together, or any way monstrous; and which part belongs to one child and which to the other, that so they may be fetched one after the other, and not both together, as might be, if it were not duly considered, taking the right foot of the one and the left of the other, and so drawing them together, as if they both belonged to one body, because there is a left and a right by which means it would be impossible ever to deliver them. But a skilful operator will easily prevent this, if having found two or three feet of several children, presenting together in a passage, and taking aside two of the forwardest, a right and a left, and sliding his band along the legs and thighs up to the twist, if forwards, or the buttocks, if backwards, he find they both belong to one body; of which being thus assured, he may begin to draw forth the nearest, without regarding which is the strongest or weakest, bigger or less, living or dead, having first put a little aside that part of the other child which offers to have the more way, and so despatch the first, whenever it is, as soon as may be, observing the same rules as if there were but one, that is, keeping the breast and face downwards, with every circumstance directed in that section where the child comes with its feet first; and not fetch the burthen till the second child is born. And therefore, when the operator hath drawn forth one child, he must separate it from the burden, having tied and cut the navel-string, and then fetch the other by the feet in the same manner, and afterward bring away the after-burden with the two strings, as hath been before showed. If the children present any other part than the feet, the operator may follow the same method as is directed in the foregoing section, where the several unnatural positions are fully treated of.