Pregnancy is the most important epoch in the life of a woman and is the most important milestone in the racial, familial, social, emotional and genetic evolution of humankind. It is impossible to bring the very outcome of pregnancy in the living world without undergoing the process of labour. Hence labour is an indispensable part of procreation. It is a complex event which in fact is a fine tuned orchestra between the hormonal, neuromuscular and mechanical systems of the body. Normal labour is a tightly defined entity where the scope of deviations is narrow. Anything not fitting the pattern of normal labour is abnormal labour. The abnormality could range from functional to purely structural, psychological to anatomical, minimal to total, yet there is danger to life of the mother and the baby if not tackled well.
Hence, obstetrics is a special branch of medicine, practiced by thus trained professionals and is managed surgically and with modern medicine. The modern practices are fast taking place of the good old days and deliveries conducted by anyone other than an obstetrician are slowly becoming obsolete. Similarly surgical interventions are becoming common place and early in obstetrical practice to the benefit of the patient.
Homeopathic literature is rich in therapeutics for ailments during pregnancy in general and labour in particular. There are experiences of varied kinds scattered in the homeopathic literature suggesting a large scope of different remedies in tackling various pathological conditions. Its effective application leads to a safer, faster, gentler and natural cure of many of these conditions, often saving the painful surgical interventions. Contrary to the current practices, homoeopathy can be made useful at large with the correct knowledge, application and trust building between the obstetrician and homoeopathician to the benefit of all. In my experience of working in the obstetric department of over a year I witnessed a number of cases and learnt the basics of obstetrics as well as learnt about homeopathic application in some of them.
The following few cases of abnormal labour confirm the above mentioned observations and throw some light upon the scope of homoeopathy in obstetrics.
Before the cases, let us review few basic facts of normal labour for a better understanding of the clinical situations discussed in the cases.
Labour is called normal if it fulfills the following criteria:
- Spontaneous in onset.
- At term.
- With vertex presentation.
- Without undue prolongation.
- Natural termination with minimum aids.
- Without having any complications affecting the health of the mother and/ or the baby.
Any deviation from the definition of normal labour is called abnormal labour.
Stages of labour
It starts from the onset of true labour pain and ends with full dilatation of the cervix. Its average duration is 12 hours in primigravidae and 6 hours in multiparae.
It starts from the full dilation of the cervix and ends with expulsion of the foetus from the birth canal. Its average duration is 2 hours in primigravidae and 30 min in multiparae.
It has got 2 stages, namely propulsive phase and expulsive phase. The propulsive phase starts from the full dilatation to the descent of the presenting part to the pelvic floor. The expulsive stage is distinguished by maternal bearing down efforts and ends with the delivery of the baby.
It begins after the expulsion of the foetus and ends with expulsion of the placenta and the membranes. It averages 30 min in primigravidae and 15 min in multiparae.
This is a stage of observation for at least 1 hour after the expulsion of the after-births and general condition of the patient and behaviour of the uterus which are to be carefully watched during this phase.
Physiology and clinical events in labour
- The cause of onset of labour is obscure and hence the causes of pathologies are also obscure in many cases.
- It is spontaneous in onset, at term and essentially a foeto-maternal event where both contribute to the onset and progress of labour in peculiar ways.
- Hormonally speaking, secretion of ACTH by the foetal pituitary is the first event in the onset of labour. Cortisol, oestrogen, progesterone, oxytocin and most importantly prostaglandins are responsible in continuation and progress of labour.
- Actin and myosin in the uterine musculature are the contractile units which participate in the process of labour. Prostaglandins influence the contraction as well as relaxation of the muscle cells.
- Calcium and ATP are essential for the contractile units to work optimally.
- The uterus is divided functionally by the upper segment and the lower segment.
The upper segment contracts and retracts (muscle cells undergo permanent shortening), the lower segment relaxes and is taken up. Upper segments propels, lower segments accommodate the foetus. The wave of contraction starts in the upper segment (ostia), is strongest in the upper segment. It weakens as it passes down and ends at the lower segment forming a physiological ring at the junction of the upper and lower segment.
- Local neural plexus and the ganglia make the pains felt in the lower abdomen, thighs and back.
- Labour pains come once in 15- 20 minutes for about 20 seconds at the onset and become frequent and longer as labour progresses. In normal labour, pain is felt shortly after the contraction begins and dies out before the contraction passes off.
A full bladder or loaded rectum interfere with the quality of contractions and descent of the foetus.
- The cervix is ripe before the onset of labour, is thinned out and admits one finger. The cervix dilates to make for the birth passage. It dilates 1 cm per hour in the first stage. Likewise the effacement progresses from 20-30–-100%.
- The intra-amniotic and intrauterine pressure increases during contractions and reduces during relaxation leading to formation of bag of waters. Rupture of membranes naturally or artificially augments labour in most cases.
- Before labour the presenting part of the foetus usually descends in the pelvic cavity and can be felt as fixed on per abdomen examination. The bony pelvic cavity of the mother accommodates the presenting part of the foetus. Stretching of the pubis symphysis helps in the passage of foetus from the vaginal canal.
- The process of retraction continues with steady increase in the intrauterine pressure to lead to placental separation and delivery of the placenta and membranes.
Uterine vessels are literally clamped by the shortened muscles leading to spontaneous cessation of hemorrhage post complete delivery of the placenta and membranes.
- The process is completed in less than 18 hours in a primigravida and 8-10 hours in a multipara.
- It ends in delivery of a healthy baby and spontaneous recovery of the mother without any complications.
After reviewing normal labour, it is possible to contrast normal from abnormal. The following cases are examples which demonstrate the approach in handling abnormal labour with homeopathic remedies.
Induction of labour
Case 1 A post dated primigravida came for the complaints of no labour pains. She was stable and was advised admission and induction. She got admitted around 5 p.m. She was shaved, prepared and simple enema was given to her. She was observed for about 2 hours after enema which showed no changes. Homeopathic case taking was done and the constitutional remedy was arrived at. Silica was the constitutional remedy. The only available sign was inertia of uterus. Based on it and as a complementary relationship (acute of silica) to the constitutional, Pulsatilla was selected as the indicated remedy.
Pulsatilla has the following indications during labour which correspond to the case:
Pains too weak, too slow, ineffectual, ceasing, very slow labour. (Yingling, W.A.)
Pulsatilla 200 1 dose was given at 8 p.m. and was repeated initially after 1 hour and later every 30 min. A close watch was kept on her clinical condition and examination findings. Pains started after about 3-4 doses and increased steadily over the next 6-7 hours with corresponding dilatation and effacement of the cervix.
Pulsatilla was stopped after the contractions became regular and intense. Patient delivered a healthy baby at 6 a.m. The third and forth stages of labour remained uneventful.
This case demonstrates the benefit of knowing the constitutional remedy in an acute case. It also demonstrates the use of the concept of relationship of remedies in selection of the simillimum. In this case, Pulsatilla is repeated to the point of definitive reaction and is then withdrawn which points to the concept of minimum dose.
Case 2- A post-dated primi patient was admitted with weak labour pains. She was administered pitocin (synthetic oxytocin) to augment labour over the period of 16 hours without any response. There was complete cessation of pains with no other signs indicating spontaneous onset of labour. The obstetrician advised LSCS (lower segment cesarian section) if she did not deliver normally within the next 24 hours.
Homeopathic induction of labour was attempted with Caulophyllum 200 in 2 hourly and then 1 hourly repetitions for a period of 12 hours. Caulophyllum was prescribed on the basis of prominent action on uterus and want of tonicity of the womb. ( Phatak S). There were no pains and contractions and cervix was 2 cm dilated in that period. A full homeopathic case history was taken.
Silicea 200 single dose was given at 12 A.M and patient was left to rest. The patient delivered unexpectedly in 3 hours. The placenta and membranes were also delivered spontaneously. Post delivery both the baby and the mother were stable.
In contrast to the earlier case, this case has multiple forces used to induce labour. It is difficult to delineate the effect of each force and hence the final conclusion is difficult to draw. But it can be said with certainty that in cases requiring induction of labour, homeopathic history taking should precede the prescription making.
In this case the labour is hasty, since the combined duration of first and second stage is about 3 hours which is not desirable. In light of this observation, treatment strategies need to be modified and a more careful approach needs to be taken.
Case 3- A 26 year old married primi came with 5MA for a routine ANC visit. It was her first child after 2 years of marriage. On examination the foetal heart sounds were not detectable. USG confirmation revealed- SLIUG (single live intrauterine gestation) of 16.2 wks, with no cardiac activity, placenta anterior and os closed.
Patient was otherwise stable.
Patient and her relatives were explained the diagnosis and she was admitted for induction of labour.
|29/7/2009 at 4 P.M||no uterine contractions, os closed||tab. misoprost 100 mcg per|
|29/7/2009 at 10 P.M||weak pains, mild contractions, os||tab. misoprost 200 mcg per|
|30/7/2009 at 10 A.M||intermittent contractions, weak, os||tab. misoprost 200 mcg per|
|30/7/2009 at 12 noon||uterine contractions 1/10 min||no more misoprost can be given.|
|lasting for about 10-20 sec, cx- 1|
The obstetrician advised wait and watch or homeopathic treatment.
Homeopathic observations – Patient was looking sad; she stopped communicating with her relatives or the doctors. She was lying down with a staring look, but did not cry or say anything. Grief of losing the child was evident on her face. Appetite and thirst were diminished.
Totality of symptoms:
- Acute, silent grief
- Talk indisposed to
- Rigidity of os
Ignatia and Pulsatilla were differentiated.
Pulsatilla shows weeping tendency with desire for company and consolation. Also Pulsatilla has an atonic uterus giving rise to weak pains which lead to prolongation of labour.
Ignatia suffers an acute grief which is silent, unexpressed. There is a tendency to taciturnity with the grief and avoidance of support and consolation. Also Ignatia has a tight, rigid os which hampers the progress of labour which corresponds to the case.
Hence Ignatia was chosen as the indicated remedy. Ignatia 1M single dose was given at 12.30 p.m on 30/7/2009.
At 1.20 a.m patient had an urge for stools and she delivered the dead foetus in the toilet. Placenta and membranes required instrumentation because of maceration. But the post delivery status of the patient was stable. She also recovered faster from her grief and was discharged the next day.
This is a case of second trimester delivery, where after induction by prostaglandins the first stage of labour lasted for about 14 hours. Pathology in this case is, inability of the cervix to dilate in accordance with the uterine contractions. In absence of a structural problem, it signifies tightness and spasm of the fibrous tissues and muscles of the cervix.
The mental state of grief is also characterised by stillness of expressions, inability to let out the tears. There is a spasm in the mind as well as the body. There is one single theme which runs in the case, hence Ignatia heals the mind as well as relieves the spasm at the cervix and allows spontaneous expulsion of the dead foetus.
Kent’s approach was taken in this case due to the presence of characteristic mental concomitants. A strong concomitant mental state calls for a higher potency and 1 dose proves sufficient.
Case 4- Induction by cerviprime and pitocin had failed in a primigravida. She was observed for about 12-14 hours. Elective LSCS was planned for the next morning. Meanwhile homeopathic induction was done.
Caulophyllum 200 was prescribed as an organ remedy for its affinity to the uterus, to induce contractions. 1 dose was given every 1 hourly since the evening. Patient delivered normally at 3 A.M. Baby had passed meconium and was limp at birth. He was resuscitated and shifted to NICU.
This case clearly demonstrates successful induction by homeopathic intervention but also demonstrates the failure in achieving safe and gentle cure. Meconium passing and aspiration by the baby is not a favourable outcome of delivery. It points towards foetal distress during the process secondary to anoxia due to too strong contractions and insufficient relaxation in between the contractions.
Two conclusions are established from this observation. First, labour patient should be monitored more alertly and partogram must be charted in each case to understand the progress of labour. Second, posology of the case should be determined very carefully. Overstepping the potency or injudicious repetition even of the indicated remedy is dangerous and may lead to distress, morbidity or mortality. Hence dose of the remedy should be titered only after periodic and accurate clinical assessments.
Prolonged labour is a symptom (not a diagnosis) where combined duration of the first and second stage of labour is more than the arbitrary time limit of 18 hours.
Case 1- A 20 year old primigravida was brought in labour. There was a spontaneous rupture of membranes 12 hours ago with active labour pains, but she had not delivered.
On examination: Vitals stable, T- 99 PA- Uterus full term, Head fixed,
Contractions + FHS+ reg 140/min, PV- Cx 3cm dilated, Effacement 30-40%
Vertex Presenting part, Station high, Show +, Pelvis adequate, Bag of membranes absent.
She was admitted at around 12 A.M. Patient was shaved, prepared, bladder and bowel were emptied and observed for a period of about 4 hours.
|Time||Clinical observations||Homeopathic observations|
|12 a.m – 4 a.m||Frequency of labour pains was once in 3-4 minutes||Patient could not bear the pain.|
|lasting for||She was moaning continuously.|
|about 20-25 seconds. She was distressed with the pains.||She was weeping due to the|
|pains and wanted her mother to|
|On examination-||be near to her. She was|
|comforted by consolation and|
|vitals- stable, tongue moist, look||assurance by the doctors and the|
|distressed||nurses around her.|
|P/A- Ut hard, head fixed,||All felt pity for her.|
|FHS- 130-140/min||She was thirstless.|
|P/V- Cx- 3-4 cm dilated, 30-40%|
|effaced, caput +|
Diagnosis- Cervical dystocia
Totality of symptoms
- Over sensitive pain to
- Weeping pain with
- Desires consolation
- Thirstlessness during labour
- Pains short
- Pains ineffectual
- Rigid os
Pulsatilla 1M was given at 5AM.
Pulsatilla indications corresponding to the case :
Pains distressing, too strong or too weak, ineffectual. No thirst, very slow labour. Pains, with no progress.
She weeps and frets and fidgets and is very despondent. Useful in women with mild, tearful disposition. (Yingling W.A)
At 6am- the patient had stopped lamenting and pleading, looked more poised. The pains were intense but lasting for about 45 sec. She had already started bearing down. On PV examination now the cervix was 7-8 cm dilated with 70-80% effacement. At 6.30 am she was fully dilated and entered the second stage of labour. With a little bit of encouragement and guidance she could bear down well and delivered a baby girl at 7.05 am. Placenta was delivered spontaneously within 10 min. She bled profusely with the separation of placenta but it stopped spontaneously.
Case 2- A 28 year old female came with active labour pains at 6.30 a.m. She was in pain for about 6-8 hours and also had leaking PV since 4 hours.
Obstetric history- G2P1L1A0
G1- male FTND- 7 years old
0/E- vitals stable
P/A- uterus FT, contracted
Vertex presentation, fixed
FHS- regular + 160/min
PV- cervix 2-3 cm dilated
Patient was admitted at 6.45AM and was shaved and prepared. Simple enema was given and bladder was emptied.
Progress record: Pains came every 2-3 min lasting for 35-40 sec, and were intense distressing the patient. Pains were mainly in the lower back.
|7.30 AM||cx- 3cm||Effacement- 30-40%|
|9.00 AM||cx- 3cm||Effacement- 30-40%|
|10.45 AM||cx- 3-4cm||Effacement- 40%|
At 10.45AM the Gynaecologist was informed on phone about the status.
Inj. Epidosin 3 doses were given at intervals of 20 min each after 11 a.m as per gynaecologist’s orders. Gynaecologist advised to inform after 1 hour and sos prepare for LSCS.
Findings at 12.15PM-
Pains increased, were severe and unbearable to her. Pains coming every minute lasting for 50 sec. Patient was in distress, could not be in one comfortable position. Pains were more in the back and radiated all over. She complained that the first delivery was much easier as compared to this.
PA- contractions 1/1 min lasting for 45-50 sec , FHS+ reg 140/min
PV- Cx- 3-4 cm dilated, Effacement- 30-40%, Station -1, Bag of membranes absent, Show + Diagnosis- Cervical dystocia
It was suggested to treat the patient with homeopathy and gynaecologist’s consent was taken.
Totality of symptoms-
- Excessive painfulness, pains severe unbearable
- Back pain excessive labour during
- Labour pains radiating all over
- Rigid Os
- Labour progress slow
Caulophyllum 200 1 dose administered at 1.45PM
Severe, spasmodic, intermittent pains without progress. Tormenting, useless pains in the beginning of labour. Spasmodic pains, flying from one place to another but not going in the normal or right direction. Spasmodic, inefficient pains in various parts of the abdomen.
Extreme rigid os uteri, spasmodic contraction of the os. (Yingling W.A)
It was planned to repeat the dose after assessing the patient 1 hour after.
At 2.30 p.m patient was bearing down.
PV- Cx- fully dilated
Patient delivered a healthy male baby at 2.45 PM. The post- partem period was uneventful.
Case 3- Primigravida with 9MA came with labour pains for about 12 hours. She was admitted at around 5p.m.
O/E- vitals stable.
P/A- Contractions every 10-15 min lasting for 10-15 seconds.
PV- cervix 2 cm dilated, 30% effaced and station 0.
Patient was admitted, prepared and observed till 11.pm.
At 11 p.m examination findings suggested no substantial change.
Observation of the patient revealed: Patient felt pains mainly in the back, sometimes going towards the thighs and lower abdomen. She was irritated with the pains and complained about it. Her mood was overall uncooperative especially to answer. Pain was ameliorated by lying on the back. She was a chilly patient.
The gynaecologist was informed and consent was taken to prescribe homeopathic medicine. Totality of symptoms-
- Irritability pains with the
- Complaining, lamenting
- Vexed mood
- Back pain > lying on back.
- Labour pains felt mainly in the back
- Sluggish uterus
Diagnosis- Uterine inertia with cervical dystocia.
Indications of kali carb in case:
Sharp, stitching pains in the lumbar back. Pains begin in the back and instead of coming around in front like a regular pain, pass off down the buttock. (Yingling W.A) Fibrous tissues particularly affected are uterus , back. It corresponds to the conditions in which these tissues are relaxed. Suited to persons with tissues lacking tone which are soft. Labour pains insufficient, constant backache, stitching pains, better by pressure and by lying flat on the back. Vexed and irritated mood, irascible and passionate humor. (Clarke J.H)
Kali carb 200 1 dose was given at 1.30 a.m.
|Time||Frequency of||Duration of||Dilatation of||Effacement of||Action|
|1.30 a.m||1/15 min||10-15 sec||2 cm||20-30%||kali carb 200 1|
|2 a.m||1/10 min||20 sec||4 cm||30-40%||wait and watch|
|4 a.m||1/ 5-7 min||30 sec||6 cm||50-60%||wait and watch|
|5 a.m||1/3-4 min||30 sec||7-8 cm||60-70%||wait and watch|
|6 a.m||every 2 -3 min||40-45 sec||fully dilated||fully effaced||wait and watch|
Patient delivered a healthy baby at 6.15 a.m.
In all the above 3 cases, presenting complaint is prolonged labour and pathology is in uterus and or cervix. Yet all of them have been treated with different remedies. All the 3 prescriptions are made on the basis of totality of symptoms. That means individualisation of the case is inevitable. Kent’s approach is used because of characteristic mental concomitants and characteristic particular modalities.
All the 3 cases were monitored well and a careful approach was taken while repeating the remedy. In all of them there is no repetition required and a single dose of the well indicated remedy corrected the abnormality. These cases demonstrate the highest ideal of cure, which is rapid, gentle and permanent based on the homeopathic principles.
Case of an Un-cooperative patient
A 24 year old primigravida was in labour since morning. She was admitted in the afternoon, shaved and prepared. Generally of a good nature, she was tormented with the pains. By evening, she was frantic, crying, shouting, was angry and abusive. She was not willing to lie down. She demanded immediate relief from the pains by cesarian operation and would not cooperate for examination, medications or any other suggestion by the doctors and the staff. Although the progress of labour was good, she hardly cooperated for a normal delivery. Considering danger to the baby’s life, an urgent LSCS was planned and the staff started preparations. It was suggested to prescribe homoeopathy in the above condition.
Totality of symptoms:
- Oversensitive pains to
- Violent pains with the
- Abusive, pains with the
- Demands immediate pain relief
Chamomilla 1M 2 doses were given at an interval of 15 min.
Indications of Chamomilla corresponding to the case:
The common feature of the remedy is a particular derangement of the cerebral functions and the whole nervous system, a painful increase of the sentient action and a certain disorder of the mental faculties. There is excessive sensitiveness to pain and pain occasions violent derangement in the moral condition of the patient. Peevishness, ill humour, anger, rage with violence. Can’t be civil to the doctor. The pains are unbearable and drive to despair. The patient insists that the doctor shall cure them at once. (Clarke J.H)
After the second dose patient calmed down. She lay down on the delivery table, cooperated with the staff, bore down well and delivered normally within 30 min.
Mother and the baby both were healthy and stable after labour.
Labour pains invoke different reactions in patients, out of fear, misinformation or hypersensitivity. It is important to manage the reaction, reassure and take the patient through all the stages. This case is about severe abnormality in the emotional sphere leading to hindrance in the process of labour. This mental state of the patient posed a direct threat to the baby’s life.
Homeopathy has scope where modern medicine has none and has successfully averted a not so indicated cesarian surgery. This case teaches the importance of good observation even in the midst of chaos to make a successful prescription.
Case of retained placenta:
24 years primigravida was admitted with labour pains. The pains were weak and patient was overall comfortable. Her extremities were cold to touch but she desired fan and open air. She progressed well over 12 -14 hours and delivered normally at 8.30 a.m. After the birth of the baby, there were no signs of placental separation. Obstetrician waited for 30 min post delivery for spontaneous delivery of placenta and the membranes.
There was no pain
- no contractions of the uterus
- no lengthening of the cord
- no separation of the placenta spontaneously
- no separation of membranes spontaneously
Extremities were cold to touch, yet patient desired fan.
The cord was not lengthening.
There was passive oozing of blood.
Diagnosis- Retained placenta due to atonic uterus
- Attempted controlled cord traction- failed.
- Empty bladder
Inj. Methergin 0.1 mg IV stat Inj. Prostodin 250 mg IM stat
Inj. Pitocin 20 units in 500 ml in NS
Even after about 20 min of the above treatment there was no response. There was no change in the examination findings. Hence it was decided to do manual removal of the placenta and membranes.
Retained placenta- The placenta is said to be retained when it is not expelled out even 30 min after the birth of the baby.
Dangers of prolonged retention of placenta are:
- Haemorrhage and shock
- Puerperal sepsis
Atonic uterus is the commonest cause of post partum haemorrhage. As long as placenta remains unseparated, bleeding is unlikely. With the separation of the placenta, the uterine sinuses which are torn cannot be compressed effectively due to imperfect contraction and retraction, hence bleeding continues. (Dutta D.C)
Homeopathic intervention was suggested.
Totality of symptoms:
- Reaction, want of
- Numbness, insusceptibility
- Haemorrhage, passive oozing
- Desires fan
- Desire for open air
- Coldness of extremities
- Muscles lax
- Placenta adherent
Secale cor and Pulsatilla were differentiated.
Secale cor 200 1 dose was given.
10 min after the dose, uterus felt firm and placenta as well as membranes were delivered spontaneously with a gush of blood. Post labour patient’s clinical condition remained stable. There was no PPH.
This case demonstrates the importance of clinico- pathological correlation in homeopathic characterisation of the case and in the process of selection of remedy. Subnormal temperature with external coldness signify lack of reaction of the body to the stress of labour. Atonic uterus combined with lack of general reaction indicate poor vitality. This observation has been used to differentiate two close coming remedies, Pulsatilla and Secale cor in the case. Boger’s approach was used in this case, since it had characteristic pathological generals, characteristic location, and physical general concomitant. Once again this case demonstrates the importance of keen observation in good homeopathic practice. After studying the above cases the following observations and conclusions can be drawn.