Chapter XXIII

DELIVERY

Delivery is the process by which a woman gives birth to her offspring.

Puerperium is the interval between the terminations of labor (delivery) to the
complete return of the reproductive organ to its normal nonpregnant state.
Puerperium usually lasts from 6 to 8 weeks. The study of delivery is important
because proof of delivery is necessary in judicial action on the following:
1. Legitimacy
2. Abortion
3. Infanticide
4. Concealment of birth
5. In slander or libel
Methods of Delivery:
1. Natural Route: Expulsion of the products of conception through the
normal passage; that is, through the vaginal canal.

A. Spontaneous: When the products of conception passed out of the

vagina without the aid of physician, midwife, instrumentation or
surgical intervention.

B. Surgical Intervention: When delivery is effected with the aid of

surgery, e.g., Symphysiotomy.

C. Instrumentation: The second stage of labor is modified by the use of

instruments. Example: Forceps application.

2. Surgical Route: The expulsion of the products of conception is not

through normal
openings of the female generative tract but through some artificial
openings brought about by surgery.

A. Abdominal Caesarian Section: The child is delivered by opening

the abdominal wall and the anterior wall of the uterus.
 B. Vaginal Caesarian Section: The child is delivered thru the surgical
opening made through the vagina.

C. Post-mortem Caesarian Section: When the pregnant woman meet

sudden death either naturally or through violence and there is no
chance of life, any person may open the abdomen to get the viable
fetus en utero.

A. SIGNS OF RECENT DELIVERY:

1. Languid look, with pulse and temperature slightly increased: This
usually disappears normally in two or three days after delivery. However, these
symptoms may be present in other conditions or sickness, hence cannot be
conclusive.
2. Peculiar odor: The characteristic odor of the lochial discharge is present up
to the tenth day of confinement. The odor is fishy but sometimes the said odor is
present on women who are menstruating normally.
3. Changes in the breast: There is a sensation of tightness of the breasts and
milk may be expressed. The presence of colostrum corpuscles in the milk suggests
that parturition has just taken place.
4. Flaccidity of the abdominal wall: The laxity of the abdominal wall is due to
the distention when the uterus is gravid to accommodate the growing product of
conception en utero. However, a previous ascites or cystic condition of the ovary
or other internal pathology causing enlargement of the abdomen will also give rise
to laxity of the abdominal wall.
5. Linea Albicantes present in the abdominal wall: At first it is reddish in
color and is called linea rubra. It is brought about by the breaking of the capillaries
when the abdomen is distended. Later, a scar-like tissue develops from the area
and is called "Linea albicantes". This is also called striae of pregnancy.
6. Presence of Linea Nigra: During the course and development of the gravid
uterus, there develops on the abdominal wall from the region of the symphysis
pubis to the umbilicus or even above it a dark pigmentation of the skin. This
pigmentation which is usually in the form of a straight line in the median line
persists up to delivery. The origin of linea nigra is most probably hormonal.
7. Uterus is enlarged and palpable: Immediately after delivery, the uterus
does not return to its original size. It takes time for its sub-involution. Due to the
flaccidity of the abdominal wall, the enlarged uterus is easily palpable.
8. Laxity of the perineum with possible tear: The perineum is elastic and
may yield to distention provided it is given ample time to stretch and provided the
fetus is not so big in size. The passage of the fetus at the outer end of the birth
canal is responsible for the relaxation of the connective tissue and muscles of the
perineum. If there is abrupt distention, a perineal laceration may be produced.
Laceration of the perineum is frequent when the second stage of labor is
accentuated by push from the fundus of the uterus.
9. Vaginal canal is lax and with possible lacerations: The normal rugosities
of the wall of the vaginal canal is lost due to severe distention. Occasionally, in
severe perineal laceration, there is also involvement of the wall of the vaginal
canal.
10. Cervix of the uterus is flabby, patulous and may be torn: The normal
hard, doughly consistency of the cervix is lost, but instead it is soft "and flabby. In
most cases there is laceration of the orifice.
11. Presence of lochial discharge: Lochia is the discharge from the vagina
after delivery. First it is bloody but later it is almost colorless. When bloody, it is
called "lochia rubra" and when colorless, it is called "lochia serosa". When there is
infection of the uterus after delivery, the odor of the lochial discharge is foul and
usually black.
12. Evidence of placenta, umbilical cord and new-born child.
13. Positive Pregnancy Slide Test (supra p. 545).

B. SIGNS OF REMOTE DELIVERY IN THE LIVING:

1. Changes in the breast: The breast becomes pendulous and linea albicantes
are found on the skin on account of the retraction of its size. There is dark color
of the areolae and the consistency is soft. The nipples are prominent due to the
sucking of the child.
2. Vulva and perineum: Scar of the previous laceration may be present. There
is marked retraction of the fourchette and perineum.
3. Hymen: Remains of the hymen may only be present in the form of
carunculae myrtiformis. Very rarely is the hymen preserved after delivery.
4. Signs of previous laceration of the cervix: The opening of the cervical
canal may no longer be seen as a round hole but slit-like on account of the
previous laceration during delivery.
5. Presence of striae of pregnancy or linea atrophica on the abdominal
wall.

POST-MORTEM FINDINGS IN A WOMAN WHO DIED RECENTLY

AFTER DELIVERY:
1. Findings in the uterus:
a. Laceration or contusion of the cervix.
b. Uterus is enlarged and flabby.
c. The inner surface of the uterus is bloody and rugged-looking.
d. Dark color sloughy and gangrenous sinuses are evident at the
endometrial lining at the site of the former
placenta
e. There is relative hypertrophy and increase in thickness of the
uterine wall.

2. Findings in the ovary: There is presence of corpus luteum.

3. Findings in the other organs:

a. Hydremia of the blood.
b. Slight anemia depending upon the amount of hemorrhage in the
delivery and immediately thereafter.
c. Congestion and hypertrophy of the milk glands of the breast.

4. Pathology accountable for the cause of death:

a. Signs of eclampsia.
b. Findings of endometritis, peritonitis, toxemia, etc.
c. Signs of cardiac, renal or pulmonary affection.
d. Findings of rupture of the uterus.
e. Signs of severe loss of blood during delivery.