Rainy proposes to tampon, and instead of withdrawing the cotton when dilatation is supposed to be complete, not only to leave it in siiu, but to prevent its expulsion by supporting it with the 'hand during the pains, and pushing back in the interval; then, when a portion of the tampon has been expelled by the natural efforts, fifteen or thirty grains of ergot are administered, to aid the uterine contractions, and to insure its con traction after the expulsion of the child. If there is no bleeding, the after-birth is not extracted until after an interval. If fresh hemorrhage occurs, it is detached artificially. A fatal objection to this method lies in the fact that the foetal mortality is much greater when we wait for the natural termination of labor than it is when we empty the uterus at the proper moment. The following objections may be made to this method: 1. It is only applicable to cases of normal presentation, whereas faulty presentations are especially common in placenta prievia. 2. In some in stances, where the tampon is applied after rupture of the membranes, a serious internal hemorrhage occurs. 3. In leaving the tampon to be ex pelled by the uterine contractions, we assume that the latter are very powerful, whereas they are habitually feeble in these cases. We are usu ally called to the patient after she has been already exhausted by loss of blood, and after the membranes are ruptured and the uterus is contract ing feebly; the indication is to tampon at once, to restore the patient's strength with stimulants and broths, and, after the expiration of twenty four or thirty-six hours, to interfere and terminate the labor.
Finally, there is another objection to Bailly's method. He supposes that the os will be hermetically sealed as long as the tampon remains in the vagina; but, as the cervix dilates and retracts, it becomes removed from the tampon, so that a considerable space is formed between the two, in which a large amount of bloOd may accumulate. It is only excep tionally that we can employ this method, in cases where we are called at the beginning of labor, and find the membranes intact, the presentation normal, the contractions sufficiently powerful, and the patient still in good condition. We may lose the child then, but we shall certainly save the mother. If, however, the conditions are the reverse, the woman be ing exhausted and the labor retarded, we should prefer Depaul's plan— tampon, wait until there is sufficient dilatation, rupture the membranes, tampon again if the hemorrhage recurs, and as soon as labor can be ter minated without violence, terminate it. We shall then probably save the mother, and, if the child has still any chance of living, we shall have done all that we can to preserve it.
Granting that the termination of the labor is indicated, and that this is possible, how should we act? Two cases are presented, the insertion may be marginal or central. In the first instance, do not hesitate; the hand or instruments must be introduced where the path is open, that is, where the os is not covered by placenta. If the membranes are ruptured, enter by the natural passage, and search for a foot or apply the forceps.
If the membranes are intact, rupture them, introduce the hand or in struments, and deliver if the persistence of the hemorrhage indicates the necessity of so doing. But, if the bleeding is slight, and the head pre sents so as to form an internal tampon, and if the contractions are suffi ciently powerful—in short, if active interference is not called for—leave the labor to itself, and you will see it terminate rapidly and spontaneously.
In central placenta praavia the method of procedure should be some what different. Whether the membranes are ruptured or not, two courses are open to us: perforate the placenta, seek the feet of the child, and draw it through the opening thus made in the placenta, or, as Gendrin advises, detach the placenta completely at one side, enter by this artificial opening, seize a foot and extract. Both of these manoeuvres are ex tremely dangerous for the child, whose vascular connections with the mother are cut off, but the second seems to me to be much preferable to the first, because it is easier of execution, and causes less disturbance of the utero-placental circulation. We thus give the child some chance of sur viving, and do not imperil the mother.
The choice of the hand or instruments, after the separation of the pla centa has been effected, is governed by all the conditions (presentation, prolapse of a part, etc.) which regulate our conduct whenever the ques tion of artificial delivery presents itself. Only, we must not forget that, in cases of abnormal insertion, every moment is precious both for the child and for the mother, and we must resort to the procedure which seems to afford us the means of terminating the labor most promptly.
[The treatment of placenta pnevia advocated by Charpentier, is, we believe, faulty in many respects, and, like almost all methods, takes Namely any account of the life of the child. The tampon is favored to an extent not warranted by contemporaneous opinion, and, we would strongly insist, ergot, in however small a dose, is distinctly contra-indicated. The prac tice which we should favor may be outlined as follows: As soon as the diagnosis of placenta prievia has been reached, and this will ordinarily be the case on the occurrence of the first profuse hemorrhage, temporizing is out of the question, for the simple reason that the next hemorrhage may occur at any time, and might prove fatal before any of the indicated measures could be resorted to. In our opinion it is playing with two lives. certainly the maternal, to postpone active measures. As we have seen. the first hemorrhage from placenta prtevia ordinarily occurs after or at the seventh month, when the child is viable, and there can, therefore, be no reason for delay in the induction of premature labor. In case the seventh month had not been attained, we would only counsel delay in cases where the patient could be ander the immediate, constant care of the medical attendant. Induce labor, then, on the occurrence of the first hemorrhage, would be our advice.