The induction of labor by rupture of the membranes

REIWRENCES (1 ) slhpson, P. F. : Am. J. Obst. & Dis. Worn. 49: 333, 1904. (2) ?fO,UUk, E’.: Rurg. Ggnec. Obst. 4s: 26, 1926. (3) Weintrmb, S. A.: AM. J. OBST. & GYNEC. 21: 73.5, 1931. (4) BochQd: Rec. period. d’obs. de med.; de ehir., et pharm., Par. 5: Northwest. M. & R. J. 13: 376, 1856-7. (6 I 422, 1756. (5) Heise, A. W.: I;smonniere, G.: Bull. et m&n. Sot. obst. et gynec. de Par. 31, 1898. (7) Xw~1 uliff~: Gaz. d. H81r., Par. 80: “80, 1907. (8, Ynrtlk!/, T. H.: Am. .I. RI Sv. 1 : Phil. Tr., Lond. 10: 1017, 1743-50. (10) Bmntii!I318, 1846. (9) Myddleton, 8.: wn: Arch. f. Gyniik. 1: 335, 1870. (11) B&bon, I. d.: Fortschr. a. d. Geb. d. RGntgenstrahl. 39: 341, 1929. (12) Donnulmk, K.: 80. Jtwa, 1908. (13) (‘nrpf”thtcl, and l’rnc+iw .7. F.: Am. J. Obst. 20: 200, IfiR?. (14) 7)rl,re, .7. 1%: Priwiples of Obstetrics, cd. 5, 470, -171. I:%;

R~weac~c

AVENUE

THE INDUCTION

OF LABOR

BY R’UPTUR.E OF THE

MEMBRANES LEO (Prows

the

WILSOK, M.D., NEW YORK, N. Y.

Department

of

Obstetks,

Morsismvia

City

Llospital)

R

UPTURE of the bag of waters was probably the first method ever employed for the induction of premature labor. It was certainly used in England as early as the Eighteenth Century.l During recent years the method has regained some of its former popularity. Indeed, very satisfactory results have been reported for it when used in con.iunction with castor oil, quinine, and pituitrin.*j 3*4 Of all the nonmedicinal methods of induction, it is probably the simplest since ancsthesis and special apparatus are not required. Its use ent,ails hardly ;lny more danger of introducing infection than does an aseptic vaginal examination, perhaps even less because of the cleansing effect of the escaping fluid. In addition, no foreign body is left in the uterus for twenty-four hours or more as is the case with the bag and the bougie. 1#Ioreover, the method in somerespects is imitative of nature, resembling those cases in which the onset of labor follows the spontaneous rupture of the membranes. However, the method has certain limitations and cont.raindications, the extent and nature of which it is the purpose of this report to indicate. Shortly after the publication of the work of Guttmacher and Douglas,” it was decided to try their method on a primigravida who was three weeks overdue. She had already had two unsuccessful att,empts at induction by means of castor oil, quinine, and pituitrin according to Watson’s technic. After a preliminary dose of castor oil and quinine, the membranes were stripped and punctured. Pains commenced in one hour and labor terminated spontaneously twelve and one-half hours later. This excellent result served to encourage further trial of the method. The remaining cases consisted of 35 mnlt.iparas at or near

“66

AMER,ICAN

JOURNAI,

OF

OBSTETRICS

AND

GY,I;EC!OLOGF

term (thirty-one to fort,y-clll(t weeks i. Or’ these, ‘12 had been admitted to the hospital with false pains but were normal in cver~~ other Isespect. The other 13 patients were induced for the following reasons: Toxemia of pregnancy Organic heart disease Overdue Pyelitis Habitual death of the fetus Thrombosed varicose veins Cardiac neurosis

(i I, i I 1 I 1

TECHNIC

The following course wa.s carried out preliminary to stripping and rupture of the membranes : 7 A.M. castor oil (‘7 ounces); S A.M. hot soap-sud enema; 9 .4.X. quinine ( 10 grains). Within two to six hours after the quilline, the patient was placed on the tabh in the lithotomy position. The thighs and pubic region were shaved and cleansed with green soap and 1 per cent lysol solution. The preparation of the patient was completed with the vaginal instillation of 3 ounces of mereurochrome. In the late] cases, green soap was substituted for the mercurochrome and, finally, even t.he,greell soap was eliminated. No appreciable difference was noted when mereurochrome, green soap, or nothing was used. In the one case in which there was a mild post-

partum infection,

mercurochrome

had been employed.

Under strict aseptic precautions, one or two fingers were gently passed through the cervical canal and the membranes were stripped off the lower uterine segment as far as the finger could reach. The bag of waters was then perforated with an ordinary sharp-pointed orange stick. As much fluid as could be made to escapl’ without undue effort was slowly released (usually about 250 to 500 c.c.). However, the success of the method apparently did not depend solely upon the quantity of fluid released. In one case in which no fluid escaped although the membranes wer(’ perforated (the fetal scalp could be felt distinctly through a definite opening in the membranes), pains began in fifteen minutes and labor terminated spontaneousl? four hours later. In this case the induction must be attributed to the preliminary medication and the stripping of the membranes. It was not necessary to employ anesthesia in a single case nor was any appreciable di&ulty encountered in perforating the membranes. In sever+ cases, not included in this series, the membranes were stripped but not ruptured because the fetal head was floating, and it was feared that prolapse of the cord might result. With the exception of one breech, all the cases were vertex presentations. No twins were encountered. The method ~a.9 not used in primiparas, except in the first cast of the series, because it was felt that :t dry labor would increase the possibility of cerebral birth trauma. Nor was the method employed in multiparas in whom Pituitrin wan used in only one any doubt e-&ted regarding delivery per vaginam. case which had a greatly prolonged latent period. It was not used routinely because Guttmacher and Douglass showed that it did not appreciably shorten the length of the latent period, the latter being the period of time from rupture of thtS membranes until the onset of labor pains. RESULTS

Although labor will always set in after the bag of waters is ruptured, the latent period may be so prolonged that the induction can hatiy be considered successful. An efficient method of induction must produce

WILSON

:

INDUCTION

OF

LABOR

BY

RUPTURE

OF

XEIV~LIBRANES

367

results within a relatively short period of time. With this in mind, twenty-four hours has been chosen as representing a reasonable masimum latent period. The latent period in this series ranged from ten minutes to fifty-seven hours. Twenty patients went into labor within twenty-four hours, giving an efficiency of 80 per cent for this method. The remaining 5 cases had latent periods of 26, 38%, In these cases, the castor oil-enema-quiuinc 42%, 551/, and 57 hours respectively. sequence was repeated after 24 and 48 hours. In the 57.hour case, two subcutaneous injections of 3 minims of pituitrin half an hour apart were necessary to start labor. No constant relationship could be established between the length of the Iatcnt period on the one hand and the duration of pregnancy, age, color, parity, or qunn tity of fluid released on the other. One patient died fifteen minutes after membrane rupture and was not considered in relation to the duration of the latent perioll or of labor. The duration of lashor was fifteen hours or less in 24 out of 25 cases (96 per cent), which is well within the average range for normal labors. The remaining patient had uterine inertia. Induction was begun two weeks prior to term ou the assumption that the case belonged to the group designated as “habitual death of the fetus. ” This patient had stillbirths in her two previous pregnancies. Labor began after a latent period of one and one-half hours but the pains were weak and occurred at intervals of twenty minutes throughout the labor, After forty-eight hours of this slow-motion labor, it was decided to interfere lest the mother become exhausted. The cervix was now almost fully dilated and labor was easily eomplct,ed by low midforceps. A living baby was obtained. The placenta was retained for five and one-half hours when it separated spontaneously. This was the only oper:ltive delivery in the entire series. The great majority of the patients had rather short labors. Three delivered iu less than one hour after the onset of pains, 7 in less than two hours, 16 in less than r’ive hours, an& 21 in less than ten hours. Thus 64 per cent delivered within five hours and 84 per cent within ten hours, which bears out the stat.ement made by Slemons4 that the average duration of labor is shortened when this method of induction is used. Fetal iWortaZity.-There were 3 fetal deaths or a gross mortality of 12 per cent. The first was a premature infant of thirty-one weeks’ gestation. Its mother had essential hypertension with hypertensive encephalopathy. The baby lived only one day. Autopsy revealed no pathology and the death was attributed to prematurity. The second death was due to prolapse of the cord. This occurred immediately after the membranes were ruptured. Attempts to replace the cord v,ere unsuccessful. Labor was induced in this patient at the thirty-sixth week for essential hypertension with hypertensive retinopnthy. The third fetal death occurred in a patient with rheumatic heart disease, who was induced three weeks prior to term. The duration of labor was seven and onehalf hours. The infant died four hours after a spontaneous delivery and autopsy revealed an extensive tentorial hemorrhage without laceration. This was attributed to a rapid dry labor in a premature infant. Fetal

Morbidity.-None.

Maternal iWortaZity.--There was one maternal death in this series of 26 cases, giving a mortality of 3.9 per cent, The patient was a white woman, forty-two years old, grav. vi, para v, who had essential hypertension and hypertensive heart disease. She was admitted to the hospital three weeks before term with a blood pressure of 150/120. During the two days prior to admission, she had four milil

The patient was kept in Iml for twenty-four houses and rdur,ing tllis Imid she presented no sjgns of cardiac d~,~ompe,lsatio11. It xvas dwided ro incluce labor :\t; this time. X’ith the patient in thcb lithotomy l&Con, the nlrnlllranc~s \T<‘I’P I~npturcCl. Ilumtdiately following the swaps of about X0 C.V. of amniotic fluid,, she suddenly 1wwnw markedly cyanotic*, dyspwic*. aild l~~~lsclcss. This wts arcompanic~d hy :I violent cough productive of large quantit,ics of blood-tinged frothy flui(l. TAd moist rtles indicatirc of pulnton;tr~ edema wwwry evident. lhpi tr all ther;l pentic efforts, including voneswtion and atrojtine, the patient clifvl fifteen n!inntw r01wnt for :LutopH1’ \v:1s 1’c F1lWl. after the onset of thr pulmona~ p edema. M&emaZ Blorbidity.-Tltcw was only one lwstpartum infection an11 thi:: in :i colored patient who 1’311 :I J’ebrih courw for four days Following clt~li~er~-. Tltr maximum temperature was 102.t’” and tlw lochia was very foul. The l)atirnt mat11, an uneventful recovery. In this case, mercurochrome had been used as a vaginal antiseptic. The latent period was forty-two and onrs-half houw and thcx t
:L good recovery following delivery. The patient returned to us two years later (1932) in her second pregnancy and was admitted to the hospital about two months before term. She was kept in h:vI a~ld fully digitalized. During tllis period of observation slle presented no signs of drcompensation or of an active rheumatic infection. It ~vas dericlcll to inlluw~ labor three weeks before twm. With the patient in the sitting position, the mcmbranes were ruptured and a. rather large quantity of fluid escaped ialroat 750 C.P.J. _ilmost. instantaneously, the patient became very cayanotic and tlyspneic,. Numtwus lout1 Ibubbling Ales were audible throughout the chest and the frothy sputum that streamed from her mouth was streaked with blood. hit hiJIll’ kIteI’, she was ?om f&able again, having (leriwd considerahlc lelief from nxpgen inllxlationr, mo! phinv, and the upright sitting position. lTcncxection was uot perfwmcd. No r&s could hc heard the following day, T,abur began after a latent. periorl ui‘ fhirrgeight and one-fourth hours and terminatwl spontaneously seven and one-half hours later. There was no recurrence 01’ the pulmouary edema or of :~ny other signs of *>nl,tliac insufficirncp during labor or tlte puwlx-Cum.

The main objections that hart been made to membrane rupture as a means of inducing premature labor arc that it is uncertain and slow, that it carries a greater likelihood of fetal trauma, and that there is increased danger of sepsis. In the first place, none of the present nonmedicinal methods is free of any of these disadvantages. In regard to efficiency of induction and ineidenw of infection, membrane rupture compares very favorably to the bag and the bougie.” The question of fetal injury in a dry labor is very interesting but rather difficult to settle. The large number of eases alreadp reported of art.ifieial rupture

of the membranes for induction of labor shows that in uncomplicated cases the hydrostatic dilating wedge is not as important as previously regarded.“, 6 Of course: the fetal injuries observed in dry labors associated with a contracted pelvis, large baby, or abnormal position should not be entirely attributed to the absence of the bag of waters. Prcservation of the bag of waters is certainly desirable in these pathologic labors but its presence is of secondary importance. Usually, the membranes rupture spontaneously early in this type of labor so that the question is more often of academic than practical significance. The unusual experience encountered in the two cardiac patients of this series would seem to indicat.e that. membrane rupture is too (latlgerous a method for the induction of labor in pa,tients with heart disease. Although one hesitates to draw sweeping conclusions from so limited an experience, the dramatic suddenness of the appearance of pulmonary edema following rupture of the membranes was, perhaps. too impressive to be considered only a coincidence. The acute cardiac collapse is probably related to the sudden and marked reduction of intmabdominal pressure, a change that is more profound in cardiac patients than in normal pregnant women because of the relative hydramuios often associated with heart disease. Reports of others who have had experience with this method in cardiac patients should be very vaInabl(l.

1. A series of 26 cases of induction of labor at or near term by st.ril)ping and rupture of the membranes is reported. The technic of induction included a preliminary course of castor oil, enema, and quinine. 2. The results of this study show an efficiency of 80 per cent, maternal morbidity of 7.6 per cent, maternal mortality of 3.9 per cent, and a fetal mortality of 12 per cent. There was no fetal morbidity. 3. The high maternal morbidity and mortality were chiefly due to the development of acutr pulmonary edema in the two cardiac patients of the series. 4. Although this method of induction of premature labor has certain advantages not possessed by other methods, its use in paGents with organic heart, disease appears to be rather dangerous. REFEREKCES (1) DeLce, J. B. : The Principles and Practice of Obstetrics, ed. 5, Philadelphia, 192S, W. II. Saunders Co., p. 1103. (2) Jackson, D. L.: Trans. Am. Assoc. Obst., Gym., & Abd. Surg. 41: 315, 1928. (3) Guttsnncher, A. F., md Douglas, R. G.: AM. .T. OBST. & GYKEC. 21: 485, 1931. (4) Slemow, J. 31.: AM. J. OBST. & GYNEC. 23: 494, 1932. (5) M&ox, D. G:: AM. J. Oss,r. & (:YsR(‘. 26: 333, 19.13. (F) Musou, L. IV.: XX. J. ORST. $ Gx-KE:C. 26: 394, 1933.