Slight oozing is observed in some which the cord is abnormally short; this is also due to premature separation of the placenta.
4. Hemorrhage from the Vessels of the Cord.
This is due to rupture of the cord itself, or of its vessels, caused by: 1. Disease of the vessels, or a varicose condition of the umbilical vein. 2. Abnormal distribution of the umbilical vessels in cases of velamentous in sertion. 3. Shortness of the cord. The indications are to terminate the labor as soon as the source of the hemorrhage is discovered.
XIV. The Artificial Removal of the Placenta, and the Hemorrhages of the Third Stage of Labor.
The factors which call for interference with the natural completion of the third stage of labor are: Inertia of the uterus, excessive size of the placenta, rupture of the umbilical cord, spasmodic contraction of the uterus, adhesion of the placenta, hemorrhage, inversion of the uterus, rupture of the uterus and eelampsia. The last two we have already studied.
frictions over the fundus and tractions on the cord do not avail for ery, the hand must be inserted into the uterus and the placenta removed.
[Here, as in every other instance, we are absolutely opposed to any trac tion on the cord. It is never necessary, and may result in alarming com plications and injury to the mother.—Ed.] Weakness and Rupture of the Cord. of the cord may depend on the fact that the labor is premature, or because it is not inserted at the centre of the placenta, or else that the vessels divide within the mem branes. Even moderate traction, in these cases, may cause rupture, but this, we are obliged to add, is usually due to the fact that traction is ex erted before the placenta has entirely separated. In case of rupture, either there is no hemorrhage, when we should abstain from interference, or else there is, and then we must at once insert the hand into the uterus and deliver, when the uterus will contract and the hemorrhage cease. In every case where there exists what we may call simple retention of the placenta, intervention is easy, and it is here, as we have stated, that we may resort to the so-called Cred6's method of expression. We should never, however, forget that the third stage of labor is a natural, physio logical one, and that in the vast majority of cases it may be left entirely to nature, and that the complications of this period are often due to un timely interference. For our part we apply pressure over the uterus only when the third stage drags, or else when we fear uterine hemorrhage or inertia.
Adhesions of the have already referred briefly to the dis eases of the placenta, but we must dwell on them here further, because, as Gueniot says: " Very intimate union between the uterus and the pla centa is one of the most formidable complications of the third stage, es pecially when this adhesion is to the extent of fusion of the placental and the uterine tissue." These adhesions may be accompanied or not by
hemorrhage, and by spasmodic contraction of the uterus. What is the cause? While the majority of authors agree with Ilegar in the belief that adhesions are usually the result of inflammation of the uterus, of endometritis, of placentitis, of fibrous degeneration of the elements unit ing the organ to the uterus, Ganiot, instead of seeing in these instances a lesion the result of pathological alteration, detects the absence of a physiological factor, which engenders the anomaly. " When," he says, we find, after labor at term, degeneration of the placenta, instead of searching for a pathological cause, why not ask ourselves why these ad hesions, which are normal at four months, have not progressively weak ened during the second half of pregnancy ? why, in a word, the physio logical labor, which leads to disunion, has not progressed ?" This query is purely speculative. The researches of Hegar, of Schroeder, of Spiegel berg, point convincingly to pathological alterations, and Gueniot himself admits them in case of endometritis.
Adhesions of the placenta are recognized by the following signs: When, notwithstanding energetic contractions, the placenta is not found in the cervix at the end of ten to fifteen minutes, we should suspect adhesions. This suspicion becomes certainty if, making traction on the cord, we feel it grow tense during the traction and abruptly retract on cessation. At the same time, during the traction, the woman complains of acute pain in the uterus, pain which increases with the intensity of the traction. In such cases if we persist we see rupture of the cord, [and exceptionally, perhaps, but still possibly, inversion of the uterus.—Ed.] If the adhesion be complete there is, generally, no hemorrhage, or it is insignificant, and the uterus, under the palpating hand, is hard and resistant, or soft and compressible. If the adhesion be partial, the finger feels a portion of the placenta, at a greater or less height, and there occurs hemorrhage which may be profuse. In this case, as Gutniot says, " the uterus cannot regu larly contract, and the sinuses, which correspond to the detached portion of the placenta, remain open and give exit to the blood." The treatment consists in introducing the hand into the uterus, and re moving the placenta. Intervention of this nature is subordinated to the hemorrhage. If it be not present, we may well wait one hour to one hour and a half; but if it exist, we must interfere at once. We must be care ful not to administer ergot, which would only result in contraction of the uterus on the placenta, and closure of the internal os, when if the band could be introduced it would be at imminent risk of rupture of the uterus.