– Indications and best methods for terminating labor (H. C. Aldrich)
 Difficult labor 

womeninlabor Indications and best methods for terminating labor

How many of you have been called to the bedside of a woman in labor, in the city or town, or, perhaps, in the country, to find the progress of labor delayed and the patient becoming exhausted, the os uteri but slightly dilated, the uterine contractions irregular, feeble and, in the phraseology of the lying-in chamber, “doing little good.”
 The patient is one whom you feel that you cannot afford to leave to nature because of financial or other reasons and you see at once that either you will lose much valuable time or you must “do something.” In other words, you must stimulate the uterus to stronger and more regular contractions. How? 1st. By keeping the patient on her feet, as much as possible. 2d. By making use of hot water vaginal douches and hot sitz baths. 3d. By digital irritation and dilatation of the os uteri. 4th. By the administration of Quinine in appreciable doses, Chloral hydrate or other drugs that are so-called oxytoxics. 5th. By the application of Belladonna ointment to the cervix uteri for its cycloplegic action on the seemingly unyielding circular fibres. 6th. By the administration of some one of the many homoeopathic remedies, which, by a careful examination and questioning of the patient, we will find to be the similimum.
 Or, you can combine all of these methods and earn the reputation of being physicians who are resourceful.
 Suppose, again, that you have had a case showing marked symptoms of the so-called toxaemia of pregnancy, that for some reason has not yielded to the diet or the medication which you have recommended and you find, when you arrive hurriedly after a peremptory summons, that your patient has had or is now suffering from a convulsion, so-called eclampsia, what would you do, after administering Chloroform, giving Morphine, Veratrum viride, making use of hypodermoclysis or injecting the artificial serum or normal salt solution directly into the veins? Why deliver the foetus as soon as possible, would you not? Surely. Begin by dilating the os uteri rapidly, manually or instrumentally by use of the Bossi dilator or any other instrument which will do the work satisfactorily and rapidly. As soon as the cervix is dilated you would apply the forceps and empty the uterus, would you not?
 When you are consulted late in pregnancy because of a profuse or long continued or intermittent haemorrhage evidently of uterine origin, you naturally suspect placenta praevia and here again you must empty the uterus and usually rapidly.
 If there does not seem an imperative demand for immediate, rapid interference, then introduce a sterile catheter or bougie of soft rubber between the uterine wall and the membranes, avoiding the placenta, if possible, then pack the vagina well with sterile or Iodoform gauze and await developments, holding yourself in readiness for immediate emptying of the uterus if haemorrhage becomes excessive.
 Again, in the case of a primapara, where you have not had the opportunity of examining and measuring prior to labor, and you have become convinced, as has your counsel, that owing to foetal or pelvic dystocia, the child cannot be born naturally, then a Caesarean section is demanded, and should be done in a hospital preferably, but as rapidly as possible to save the lives of both mother and child.
 The indications for a premature labor or abortion are generally because of some abnormal state of the mother, as, for instance, the pernicious vomiting and other manifestations of the toxaemia of pregnancy; prolonged haemorrhage of placenta praevia, which has not resulted in spontaneous abortion; the existence of severe cardiac diseases, of pulmonary tuberculosis, of chorea, of hydramnios, or of pernicious anaemia.
 The therapeutic induction of premature labor should be performed in an absolutely aseptic manner to avoid the possibility of infection and can best be done by tamponading the uterine cervix with sterile gauze packing strip or by the introduction of a sterile bougie or catheter of soft rubber between the uterine wall and the amniotic sac or by rapid instrumental dilatation and removal of the uterine contents by digital or instrumental curettage.
Discussion 
 F. J. Becker, Iowa City: I quite agree with Dr. Aldrich, and think his number six might be placed first. After a great deal of experience along this line I have become convinced that we have four remedies – probably more, but always four that I think of, that will very materially hasten the first stage of labor, and we certainly, although we may try mechanical dilatation and things of that kind, must remember that where we have a rigid os and only spasmodic contraction, we must work from that standpoint. We have to change the character of the tissue or its innervation. We all know we cannot get the horse out of the barn until we have opened the door. These four remedies which I have found to give good and speedy results are Gelsemium first, Belladonna second, Caulophyllum third and Chamomilla fourth.
 The Gelsemium patient is nervous; she begins to shake and quiver before the pain comes on. The Chamomilla patient usually makes a dive for my hair. She is irritable. Especially if you try Dr. Aldrich’s way of mechanical dilatation. The Caulophyllum I give when there is no indication for the other three. I believe these remedies will hasten labor and with less danger of infection and more satisfaction to the patient.
 C. E. Walton, Cincinnati: One of the remedies I use frequently is Gelsemium. I also use Cimicifuga. There is a certain physical condition of the cervix, which determines the choice. If I find a cervix feeling like a hard, thin band, I give Gelsemium. If I find a cervix that feels like the lips, I give the Cimicifuga. This distinction has been quite practical in my experience.
 With regard to the procedure in case of convulsions, I don’t use the formula referred to by Dr. Aldrich. There is another formula which I think can be used to advantage. Some of you remember when the Republic was threatened with shipwreck, the wireless message was sent out, “C. Q. D.” (Come quick, danger). I get the forceps on and then send in the wireless message, C. Q. D. – Come quietly down.
 Dr. Forster, Kansas City: If I understand the doctor rightly, in the first class of cases there are no indications for haste except the patient is getting tired of waiting so long, or the doctor is in a hurry. It seems to me in that class of cases we can show our skill in no better way than by waiting. Give nature a chance to take care of the case and she will do it. One of the best things Dr. Walker said was “Learn to master inactivity.” I think there is no more applicable term than “Meddlesome Midwifery.” We should let the cases alone for nature, and only help along with the indicated remedy. For a great many years back my method has been, when in doubt, give Gelsemium for anything and everything. In these cases Gelsemium seems to meet the case better than anything else. Another agent I have applied is a cocaine suppository, or else swab the cervix with cocaine. The indication for its use is that when the pain comes on the patient will shrink and shriek; the pressure seems to be against that tense, hard cervix, and every time she will flinch and scream. Not only does the cocaine relieve the sensibility, but it dilates the cervix, too. I should try first the remedies before any instrumentation or digital dilatation. Depend on your homoeopathic remedy.
 With the second class of cases, placenta praevia, every one of you knows he must procure as rapid delivery as possible. I believe this is applicable to almost every case of placenta praevia. It is much safer than to depend upon the delivery through the placenta. You might poke a hole right through the center of it and remove the child, but at the time you take the chance of losing so much blood that the woman is almost exsanguinated before you get through or the child dies from the obstruction of the circulation. Caesarean section is the best and least harmful thing you can do. The thing is to empty the uterus as fast as you can. The most speedy and cleanly delivery possible should be performed or the woman and probably the child will die on your hands. Dilate the uterus as rapidly as possible with safety and get the contents out. In many cases the foetus is dead and giving rise to infection, is the decomposing center of responsibilty. It is permissible in this case to do a craniotomy in order to prevent any laceration of the cervix or perineum. Mutilate the child if dead, but if the child is alive the question comes up between Caesarean section and a normal, rapid delivery.
 Dr. Maxwell, of Toledo: I have used Gelsemium in a great many cases in years gone by, but in late years I have given very little of it, and in cases such as the doctor cited, in which the os was so very rigid, I use the Chamomilla. But for a number of years I have not used that. If you have a rigid os, with perfect asepsis and Chloroform do a manual dilatation and you get as good and much more prompt results and greater expressions of gratitude from your patient than where you wait for the indicated remedy.
 Dr. Crump, of New York: In that class of cases where it has been decided to rapidly deliver the woman, the remedies having failed to do their work, or where we cannot wait for nature on account of placenta praevia or haemorrhage, one of the safest and most rapid methods is the use of the Pomroy hydronamic bag. We all know the old Barnes’ bag and others, and with manual dilatation the hand becomes so tired that you are not in shape to go on and with careful technique deliver the case. The Pomroy bag was brought to the attention of the profession some years ago. It consists of a two-chambered rubber bag, which, when distended, simulates the shape of the foetus. One chamber makes the head of the child and the other the body. You can introduce the smallest of the three sizes, about the size of a five cent piece then distend the upper chamber. Fill the upper chamber with water, then the lower, and gradually with the hands dilate the cervix, and then after a minute or two you let the water out of the bag, allow the cervix to relax and you can again distend, and in a few minutes you have taken them to the degree of dilatation of the medium sized bag, and then with the large bag you finally bring the cervix to the full stretch. In nearly all cases this can be done in ten minutes. It is soft and pliable, and does not make a strain at any point. These bags can be had of Ralph Pomroy, of Boston.
 Dr. Bishop, of Cleveland: There is a very important point, not brought out in the paper, having to do with that class of cases where rapid delivery is to be accomplished in the early stages of gestation. It seems to me that every obstetrician should have recourse to vaginal Caesarean section, especially in the toxaemias of pregnancy. In the majority of cases, especially primapara, it is a safer operation than manual dilatation. I had a case of eclampsia, recently, in which the condition of the cervix pointed conclusively to this operation. The patient was in the fifth month of gestation, there was no uterine contraction and the cervix was rigid. Treatment had failed to check the convulsions and rapid emptying of the uterus was indicated. On account of the preference of another consultant, manual dilatation was chosen rather than vaginal Caesarean section. We got an extensive tear with severe haemorrhage and shock. There would have been nothing like the blood loss if we had done a vaginal Caesarean section. Even with the most careful technic, there is danger of bad lacerations in manual dilatation.
 Dr. Forster made a statement with which I would take issue, advising Caesarean section in cases of placenta praevia in which the haemorrhage comes on at or near term. It is true that section might be the operation of choice in an elderly primapara in which conditions would point to a delayed labor. In such a case, section would have no foetal mortality and the maternal mortality would be, probably, less than that of labor. But in the average case, present obstetric practice is to use the dilating bags and thus stop the haemorrhage and allow the case to go to delivery in the natural way. There is a new method of treatment of placenta praevia that appeals to me as one probably solving the question. Miller of Pittsburgh, has reported a series of cases in which he stopped the haemorrhage by ligation of the uterine arteries by direct palpation, after which he delivered in the usual way. In, I think, a series of twelve cases, he had but one death of the mother and no foetal mortality.
 Dr. Jewitt, of Cleveland: One or two things I want to emphasize: first, the question which arose about the dilatation of the cervix during the first stage of labor. This is very important. Assuming no necessity for rapid dilatation; supposing the woman has been in labor three or four days. You are called up by another physician who has become tired and the family have become nervous and the woman is excited. You find there is no emergency and dilatation is going on, and you should not interfere. You will repent it, no matter what the method. I would emphasize to the young men, that during the first stage of labor, if you are satisfied that everything is normal, let it wait and give the woman the advantage of normal delivery. Another thing is that the pains do not come on regularly, but they decrease as from day to night; they increase for some time and then decrease. You are called to a primapara and the pains have decreased until night, when they will recur with increasing severity. As to the indicated remedy, Belladonna, of course, controls the circular fibres and I have given it in the extract and from the high to the low, and the hypodermic, 1/100 grains or the 1/50 grain and never saw any effect from any other indicated remedy, choose the best I can. None have I seen dilate the undilated cervix.
 Dr. Fitz-Patrick, Chicago: As to the indications, first is the pulse, next the temperature, and the very painful pains as a result of long prolonged labor; next is the ballooning of the vagina, and Bondl’s ring; when you find the line rising above the pubes, you should empty the uterus. That will cover about all the indications for the necessity of terminating labor.
 Dr. Newton: Apropos of what Dr. Fitz-Patrick has said, I recall that in Dublin, 20 years ago, the indications for interference, as given by Dr. McCann, were divided into the condition of the mother and the condition of the child. The former is covered by what Dr. Fitz-Patrick has said.
 Dr. Walton: I would ask Dr. Jewitt how he gives the Cimicifuga? I don’t give the high potency. I give the C. E. W. potency, which consists of 2 drs. of Cimicifuga tincture in a half cup of hot water, two teaspoonfuls every 20 minutes. Don’t go far from the house.
 Dr. Jewitt: I never gave the 100 thousandth, or any attenuation, but I have given teaspoonful doses of the tincture repeatedly. If the cervix is soft and dilatable, in half an hour, if you have given enough, you will find it thoroughly dilated. On the other hand, if it is undilatable and you give your Cimicifuga and expect to find it dilated you will be disappointed.
 Dr. Aldrich (closing discussion): I thank you for tempering the wind to the shorn lamb. I purposely did not mention remedies, as I did not want to touch on every subject. Some things I left out purposely and some I forgot. Dr. Walton’s suggestions I know are good. His are always good, especially the C. E. W. suggestions. The dilatation with the bags is important and one thing I forgot to mention. 

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