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Painless Labors Following Presacral Neurectomy
PAINLESS LABORS FOLLOWING PRESACRAL NEURECTOMY GEORGE BLINICK,
lVI.D.,
NKVV YORK,
N. y.
(Frorn the Gynecological Service of Beth Israel Hospital)
HE following report is that of a patient who underwent presacral neurectomy for dysmenorrhea in 1941 and had painless labors associated with uterT ine inertia in 1942 and: 1944. No similar case of such profound uterine inertia and abolition of labor pains has been reported following presacral neurectomy. Cases of pregnancy following presacral resection indicate that there is no interference with the normal progress of labor. The first stage is generally agreed to be relatively painless, but no difference in the intensity or frequency of pain has been noted in the second tage. 1 Cotte2 • 3 stated that in more than fifty patients who had had resection of the superior hypogastric plexus no effect was noted in subsequent parturition. Davis4 reported two eases in whom labor was precipitate and relatively painless. Wetherell 5 described .the ease of a patient who became pregnant thirteen months after operation. Labor pains were irregular, weak, and confined to the back. She had no pains in front. The position waR right oecipitoposterior. The first stage was conducted under morphine and scopolamine and· lasted eighteen hours. The second stage lasted five hours aml was terminated by Scanzoni rotation and forceps extraction. Donaldson 6 observed three patients who became pregnant after operation and' states that the ''labor pains were the same as in an ordinary patient.'' Reed' in two patients found no change in nidation, pregnancy, and parturition, although in one N'sarean SPetion waR done for kidney failure and a fibroid uterus. Pearce 8 cited the case of a 20-year-old girl who was delivered uf a 9lf2-pound baby in 1932 after six days of labor. In 1937 presacral neurectomy was done. In 1938 she delivered an 81/2-pound baby in 11/z hours with only three hard pains. He states "that in some patients. probably only a small proportion, the first stage of labor is painless and rapid. or else unohRerved." Spackman, 0 in a series of 100 operations, had records of nine patients who subsequently gave birth to twelve children. lJabor was le~~ painful, especially in the first stage; the labor mechanism was not altered·. Hendrick10 reported two cases each of whom had two normal pregnancies. Rutherford, 11 in a careful analysis of eight cases who had obstetric followup, found no disorder of function as a result of the operation. Labor pains were absent during the first stage of labor in five of the eight cases. Pain was absent during the greater portion of the first stage in two other cases. It was found that the duration of labor may be Romewhat shortened. Salgado 12 reported an easy Hhort labor four .\~ear~ after presacral neurectomy.
Case Report Mrs. A. R., a 25-year-old housewife, was first seen un Feb. 1, 1941. Her menses had begun at 14 years of age, were regular every twenty-eight d·ays, and lasted four to five days. The flow was moderate in amount. She had had .148
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premenstrual cramps since the onset of her periods which had become progressively more severe, especially in the past four years. In the past year, the pain was much more intense and began five days after the completion of a period and continued up to the onset of the next period. Medical measures including various forms of endocrine therapy were unsuccessful in relieving her pain. She had: had an appendectomy elsewhere five years ago. She had never been pregnant. There was a right, well-healed pararectus scar. 'l'here was moderate tenderness throughout the lower abdomen, but no masses or rigidity were felt . . Vaginal examination disclosed a marital introitus. The cervix was normaL The uterus was slightly enlarged, irregular, and contained small fibroid nodules. The left ovary measured 3 by 4 em. in size. On Feb. 25, 1941, at laparotomy, the uterus was found to contain numerous superficial fibroid nodules measuring from a few mm. to 3 em. in size. The left ovary was cystic. A presacral neurectomy, multiple myomectomies, and resection of the left ovary were performed. The postoperative course was uneventful except for retention of urine for the first two postoperative days. She became pregnant seven months later and labor began on the expected date of delivery June 25, 1942. At 12:30 P.M. she complained of frequency of urination and fullness in the lower abdomen, and the .cervix was found to be two fingerbreadths dilated with a slight bloody show, although there had been no back or lower abdominal pain. The fetus was engaged in the right occipitoanterior position, and was smaller than usual. Uterine contractions were weak, painless, transient, and ineffectual, despite the administration of castor oil, a hot enema, and three doses of quinine sulfate (grains V). The following moming, at 5 :30 A.M., there had been no progress and 2 minims of thymophysin were given. It was felt that the uterine scars were small and superficial and that there was little danger of uterine rupture. Uterine contractions occurred every five minutes and lasted thirty seconds and were painless. At 7:30 A.M. the contractions were again weak and irregular, and 3 more minims. of the thymophysin 'were given causing moderate augmentation of contractions for the next hour. At 1:00 P.M., the cervix was three fingerbreadths dilated and uterine contractions were again weak and ineffectual. Pantopon grain % and scopolamine grain %00 were given in an attempt to hasten cervical dilatation and not because of any discomfort felt by the patient. 'rwo hours later 2 minims of thymophysin were given and contractions occurrell every three minutes and lasted thirty seconds. At 3 :12 P.M. the membranes ruptured spontaneously. At 3:30 P.M., she was fully dilated and, following the administration of an .additional 3 minims of thymophysin hard contractions occurred every two minutes and lasted for sixty seconds until delivery. She was encouraged to bear down with each contraction since she did not have any spontaneous impulse to do so. During the entire labor she had not experienced any pain even when the uterus underwent frequent firm contractions following the administration of thymophysin. At 4 P.M., the head crowned the perineum and she complained of pain for the first time during the entire first and second stages of labor. At 4:10 P.M., she was given gas, oxygen, and ether anesthesia. An episiotomy was • performed and a female child weighing 5 pounds was born spontaneously at 4 :13 P.M. The placenta was expelled at 4 :30 P.M. The total duration of labor was twenty-eight hours and thirty minutes. The postpartum course was uneventful and· she was discharged nine days after delivery. Her second delivery was on Feb. 3, 1945, and was in all respects similar to the first already described:, except that the onset of labor was initiated by the
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]llly. 1947
spontaneous rupture of the membranes on Feb. 2, 194;5, at ;:! P.M., and weak painless ineffectual contractions were noted. .After twenty-four hours of weak irregular ineffectual cramps, small repeated doses of thymophysin caused moderately strong uterine contraction>;, and she was delive1·ed at 7 P.~r. spontaneously of a 6 pound, 11 ounce hoy. Again no pain wa~ experienced until the head distended the perineum. The total duration of labor was twenty-nine hours and' twenty-three minutes. The postpartum cour!-ie 1vas uneventfuL At the present time she feels well and is menstruating regularly every 28 to 30 days for four days. She occasionally has slight lower abdominal discomfort and distention on the day prior to menstruation, hut has no actual cramps or pain. Her uterus is slightly enlargecl and iJ•regular.
Comment 'fhe actual and theoretical effects of presacral neurectomy upon labor cannot be understood without a knowledge of the innervation of the uterus. Unfortunately, there is considerable confusion both as to the anatomic pathways and physiologic mechanisms involved. ''All existing evidence points to the fact that the neFves to and within the uterus are not essential for parturition. " 13 - 15 However, the fact that labor can take place independ·ently of the extrinsic uterine :innervation does not mean that nervous impulses do not influence, at least in part, normal uterine motility and perception of pain. The presacral nerve contains both sensorv and motor fibers to the uterus, whereas the cervix, vagina, perineum, and pelvic floor are supplied through independent pathways/ 6 The presacral nerve lies above the promontory of the sacrum and is inconstant in morphology. It may vary fom a single or double strand to multiple and diffusely separated nerve fi1aments. 17 • 18 If this anatomic description is eorrect, then complete excision of the presacral nerve should theoretically interrupt both sensory and· motor impulses to the uterus, and result in painless laobr and some degree of uterine inertia, as described in the case reported here. On the other hand, tl1e normal pattern of contractility of the uterine musculature is probably controlled by endocrine factors and distention of the uterus, and is only partially dependent upon the extrinsic nerve supply. That the latter does play some role is best demon· strated by clinical experiments with caudal anesthesia. Peridural block extending to the eleventh thoracic root (where the sensory fibers originatt:' which course through the presacral nerve) abolishes the pain of uterine contractions without abolishing their force. 10 Extending the block to the fourth thoracic segment of the cord or higher (where the motor fibers originate which course through the presacral nerve) significantly impairs the strength of uterine contractions in 69 per cent of patients. 2 " In fact, caudal anesthesia at this level has been utilized to arrest premature labor to the delay of several weeks. 16 \Vhy alterations in labor to the degree experienced by this patient have not been previously described following presacral neurectomy cannot be answered. Furthermore, since this operation does not interrupt the innervation of the cervix and vagina, it is difficult to nnderstand wh.'' the pain of cervical distention was abolished. It is obvious that many factors beside those of innervation, such as size of the child, mechanism of descent, sensibility of the patient, etc., modify the pain and force of uterine contraction. It is possible that in this patient a favorable anatomic disposition of the plexus may have resulted in a more thorough excision than that ordinarily obtained; it may he that she was predisposed toward primary uterine inertia as a result of fibroids, uterine scars, or a hypothetical endocrine factor. The complete absence of pain even at the
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height of a thymophysin-induced uterine contraction during both first and second' stages would seem to indicate that the operation played a significant role in the production o£ the painless labor and the associated uterine inertia. Summary
1. A case in which two painless labors associated with primary uterine inertia occurred following presacral neurectomy is described. Pain was experienced only when the perineum was distended by the crowning head. No similar case of such profound uterine inertia and abolition of labor pains has been reported following resection of the superior hypogastric plexus. 2. Interruption of the innervation of the uterus by presacral resection may abolish the pain and force of uterine contractions in some patients, although it is well kno·wn that the extrinsic nerves ate not essential for parturition.
References 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20.
Collins, C. G.: :'-lew Orleans :M. & S. J. 91: 75, Hl3i'l. Cotte, G.: Zentrabl. F. Gy"llak. 57: 2252, 1933. Cotte, G.: AM. J. 0BST. & GYNEC. 33: 1034, 1937. Davis, A. A.: Brit. M. J. 2: I, 1934. Wetherell, F. S.: A.M .•J. OBST. & GYNEC. 29: 334, 1935. Donaldson, :M.: Proc. Royal Soc. Med. 29: 947, 1936. Reeb, M.: Gynecologic, 36: 617, 1937. Pearce, T. V.: Brit. M. J. 1: 87, 1940. Spackman, W. C.: Brit. M. J. 1: 637, 1940. Hendrick, J. W.: Texas State J. Med. 37: 26, 1941. Rutherford, R. N.: West. J. Surg. 50: 597, 1942. Salgado, C.: Rev. de ginec. a d 'obst. 1: 368, 1944. Reynolds, S. M. R.: Physiology of the Uterus, New York, 1939, Paul B. Hoeber. Davis, A. A.: Proc. Roy. Soc. Med. 29: 931, 1936. Ivy, A. C., and Danforth, D. N.: International Abst. Surg. 69: 351, 1939. Lull, C. B.: Control of Pain in Chili! birth, Philadelphia, 1945, J. B. Lippincott Co. Weinstein, B. B.: Burg., Gynee. & Obst. 74: 245,,1942. Labate, J. S.: Burg., Gynec. & Obst. 67: 199, 1938. Hineson, R. A., and Edwards, W. B.: J. A. M. A. 123: 538, 1943. Frankel, D. S.: Sur g., Gynec. & Obst. 80: 66, 1945.
55 EAST 86TH STREET
lVI.D.,
NKVV YORK,
N. y.
(Frorn the Gynecological Service of Beth Israel Hospital)
HE following report is that of a patient who underwent presacral neurectomy for dysmenorrhea in 1941 and had painless labors associated with uterT ine inertia in 1942 and: 1944. No similar case of such profound uterine inertia and abolition of labor pains has been reported following presacral neurectomy. Cases of pregnancy following presacral resection indicate that there is no interference with the normal progress of labor. The first stage is generally agreed to be relatively painless, but no difference in the intensity or frequency of pain has been noted in the second tage. 1 Cotte2 • 3 stated that in more than fifty patients who had had resection of the superior hypogastric plexus no effect was noted in subsequent parturition. Davis4 reported two eases in whom labor was precipitate and relatively painless. Wetherell 5 described .the ease of a patient who became pregnant thirteen months after operation. Labor pains were irregular, weak, and confined to the back. She had no pains in front. The position waR right oecipitoposterior. The first stage was conducted under morphine and scopolamine and· lasted eighteen hours. The second stage lasted five hours aml was terminated by Scanzoni rotation and forceps extraction. Donaldson 6 observed three patients who became pregnant after operation and' states that the ''labor pains were the same as in an ordinary patient.'' Reed' in two patients found no change in nidation, pregnancy, and parturition, although in one N'sarean SPetion waR done for kidney failure and a fibroid uterus. Pearce 8 cited the case of a 20-year-old girl who was delivered uf a 9lf2-pound baby in 1932 after six days of labor. In 1937 presacral neurectomy was done. In 1938 she delivered an 81/2-pound baby in 11/z hours with only three hard pains. He states "that in some patients. probably only a small proportion, the first stage of labor is painless and rapid. or else unohRerved." Spackman, 0 in a series of 100 operations, had records of nine patients who subsequently gave birth to twelve children. lJabor was le~~ painful, especially in the first stage; the labor mechanism was not altered·. Hendrick10 reported two cases each of whom had two normal pregnancies. Rutherford, 11 in a careful analysis of eight cases who had obstetric followup, found no disorder of function as a result of the operation. Labor pains were absent during the first stage of labor in five of the eight cases. Pain was absent during the greater portion of the first stage in two other cases. It was found that the duration of labor may be Romewhat shortened. Salgado 12 reported an easy Hhort labor four .\~ear~ after presacral neurectomy.
Case Report Mrs. A. R., a 25-year-old housewife, was first seen un Feb. 1, 1941. Her menses had begun at 14 years of age, were regular every twenty-eight d·ays, and lasted four to five days. The flow was moderate in amount. She had had .148
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premenstrual cramps since the onset of her periods which had become progressively more severe, especially in the past four years. In the past year, the pain was much more intense and began five days after the completion of a period and continued up to the onset of the next period. Medical measures including various forms of endocrine therapy were unsuccessful in relieving her pain. She had: had an appendectomy elsewhere five years ago. She had never been pregnant. There was a right, well-healed pararectus scar. 'l'here was moderate tenderness throughout the lower abdomen, but no masses or rigidity were felt . . Vaginal examination disclosed a marital introitus. The cervix was normaL The uterus was slightly enlarged, irregular, and contained small fibroid nodules. The left ovary measured 3 by 4 em. in size. On Feb. 25, 1941, at laparotomy, the uterus was found to contain numerous superficial fibroid nodules measuring from a few mm. to 3 em. in size. The left ovary was cystic. A presacral neurectomy, multiple myomectomies, and resection of the left ovary were performed. The postoperative course was uneventful except for retention of urine for the first two postoperative days. She became pregnant seven months later and labor began on the expected date of delivery June 25, 1942. At 12:30 P.M. she complained of frequency of urination and fullness in the lower abdomen, and the .cervix was found to be two fingerbreadths dilated with a slight bloody show, although there had been no back or lower abdominal pain. The fetus was engaged in the right occipitoanterior position, and was smaller than usual. Uterine contractions were weak, painless, transient, and ineffectual, despite the administration of castor oil, a hot enema, and three doses of quinine sulfate (grains V). The following moming, at 5 :30 A.M., there had been no progress and 2 minims of thymophysin were given. It was felt that the uterine scars were small and superficial and that there was little danger of uterine rupture. Uterine contractions occurred every five minutes and lasted thirty seconds and were painless. At 7:30 A.M. the contractions were again weak and irregular, and 3 more minims. of the thymophysin 'were given causing moderate augmentation of contractions for the next hour. At 1:00 P.M., the cervix was three fingerbreadths dilated and uterine contractions were again weak and ineffectual. Pantopon grain % and scopolamine grain %00 were given in an attempt to hasten cervical dilatation and not because of any discomfort felt by the patient. 'rwo hours later 2 minims of thymophysin were given and contractions occurrell every three minutes and lasted thirty seconds. At 3 :12 P.M. the membranes ruptured spontaneously. At 3:30 P.M., she was fully dilated and, following the administration of an .additional 3 minims of thymophysin hard contractions occurred every two minutes and lasted for sixty seconds until delivery. She was encouraged to bear down with each contraction since she did not have any spontaneous impulse to do so. During the entire labor she had not experienced any pain even when the uterus underwent frequent firm contractions following the administration of thymophysin. At 4 P.M., the head crowned the perineum and she complained of pain for the first time during the entire first and second stages of labor. At 4:10 P.M., she was given gas, oxygen, and ether anesthesia. An episiotomy was • performed and a female child weighing 5 pounds was born spontaneously at 4 :13 P.M. The placenta was expelled at 4 :30 P.M. The total duration of labor was twenty-eight hours and thirty minutes. The postpartum course was uneventful and· she was discharged nine days after delivery. Her second delivery was on Feb. 3, 1945, and was in all respects similar to the first already described:, except that the onset of labor was initiated by the
150
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]llly. 1947
spontaneous rupture of the membranes on Feb. 2, 194;5, at ;:! P.M., and weak painless ineffectual contractions were noted. .After twenty-four hours of weak irregular ineffectual cramps, small repeated doses of thymophysin caused moderately strong uterine contraction>;, and she was delive1·ed at 7 P.~r. spontaneously of a 6 pound, 11 ounce hoy. Again no pain wa~ experienced until the head distended the perineum. The total duration of labor was twenty-nine hours and' twenty-three minutes. The postpartum cour!-ie 1vas uneventfuL At the present time she feels well and is menstruating regularly every 28 to 30 days for four days. She occasionally has slight lower abdominal discomfort and distention on the day prior to menstruation, hut has no actual cramps or pain. Her uterus is slightly enlargecl and iJ•regular.
Comment 'fhe actual and theoretical effects of presacral neurectomy upon labor cannot be understood without a knowledge of the innervation of the uterus. Unfortunately, there is considerable confusion both as to the anatomic pathways and physiologic mechanisms involved. ''All existing evidence points to the fact that the neFves to and within the uterus are not essential for parturition. " 13 - 15 However, the fact that labor can take place independ·ently of the extrinsic uterine :innervation does not mean that nervous impulses do not influence, at least in part, normal uterine motility and perception of pain. The presacral nerve contains both sensorv and motor fibers to the uterus, whereas the cervix, vagina, perineum, and pelvic floor are supplied through independent pathways/ 6 The presacral nerve lies above the promontory of the sacrum and is inconstant in morphology. It may vary fom a single or double strand to multiple and diffusely separated nerve fi1aments. 17 • 18 If this anatomic description is eorrect, then complete excision of the presacral nerve should theoretically interrupt both sensory and· motor impulses to the uterus, and result in painless laobr and some degree of uterine inertia, as described in the case reported here. On the other hand, tl1e normal pattern of contractility of the uterine musculature is probably controlled by endocrine factors and distention of the uterus, and is only partially dependent upon the extrinsic nerve supply. That the latter does play some role is best demon· strated by clinical experiments with caudal anesthesia. Peridural block extending to the eleventh thoracic root (where the sensory fibers originatt:' which course through the presacral nerve) abolishes the pain of uterine contractions without abolishing their force. 10 Extending the block to the fourth thoracic segment of the cord or higher (where the motor fibers originate which course through the presacral nerve) significantly impairs the strength of uterine contractions in 69 per cent of patients. 2 " In fact, caudal anesthesia at this level has been utilized to arrest premature labor to the delay of several weeks. 16 \Vhy alterations in labor to the degree experienced by this patient have not been previously described following presacral neurectomy cannot be answered. Furthermore, since this operation does not interrupt the innervation of the cervix and vagina, it is difficult to nnderstand wh.'' the pain of cervical distention was abolished. It is obvious that many factors beside those of innervation, such as size of the child, mechanism of descent, sensibility of the patient, etc., modify the pain and force of uterine contraction. It is possible that in this patient a favorable anatomic disposition of the plexus may have resulted in a more thorough excision than that ordinarily obtained; it may he that she was predisposed toward primary uterine inertia as a result of fibroids, uterine scars, or a hypothetical endocrine factor. The complete absence of pain even at the
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height of a thymophysin-induced uterine contraction during both first and second' stages would seem to indicate that the operation played a significant role in the production o£ the painless labor and the associated uterine inertia. Summary
1. A case in which two painless labors associated with primary uterine inertia occurred following presacral neurectomy is described. Pain was experienced only when the perineum was distended by the crowning head. No similar case of such profound uterine inertia and abolition of labor pains has been reported following resection of the superior hypogastric plexus. 2. Interruption of the innervation of the uterus by presacral resection may abolish the pain and force of uterine contractions in some patients, although it is well kno·wn that the extrinsic nerves ate not essential for parturition.
References 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20.
Collins, C. G.: :'-lew Orleans :M. & S. J. 91: 75, Hl3i'l. Cotte, G.: Zentrabl. F. Gy"llak. 57: 2252, 1933. Cotte, G.: AM. J. 0BST. & GYNEC. 33: 1034, 1937. Davis, A. A.: Brit. M. J. 2: I, 1934. Wetherell, F. S.: A.M .•J. OBST. & GYNEC. 29: 334, 1935. Donaldson, :M.: Proc. Royal Soc. Med. 29: 947, 1936. Reeb, M.: Gynecologic, 36: 617, 1937. Pearce, T. V.: Brit. M. J. 1: 87, 1940. Spackman, W. C.: Brit. M. J. 1: 637, 1940. Hendrick, J. W.: Texas State J. Med. 37: 26, 1941. Rutherford, R. N.: West. J. Surg. 50: 597, 1942. Salgado, C.: Rev. de ginec. a d 'obst. 1: 368, 1944. Reynolds, S. M. R.: Physiology of the Uterus, New York, 1939, Paul B. Hoeber. Davis, A. A.: Proc. Roy. Soc. Med. 29: 931, 1936. Ivy, A. C., and Danforth, D. N.: International Abst. Surg. 69: 351, 1939. Lull, C. B.: Control of Pain in Chili! birth, Philadelphia, 1945, J. B. Lippincott Co. Weinstein, B. B.: Burg., Gynee. & Obst. 74: 245,,1942. Labate, J. S.: Burg., Gynec. & Obst. 67: 199, 1938. Hineson, R. A., and Edwards, W. B.: J. A. M. A. 123: 538, 1943. Frankel, D. S.: Sur g., Gynec. & Obst. 80: 66, 1945.
55 EAST 86TH STREET