As for the treatment, we must distinguish two categories: 1. The incarceration is simple, and not complicated by hemorrhage.
2. The incarceration is complicated by hemorrhage.
In both instances, the placenta may be free or adherent.
In the first instance, evidently, there is no call for haste, and yet we should not wait too long. Antispasmodics, opiate enemata, emollient injections, may be tried, but if at the end of a few hours matters do not change, we believe it of advantage to pass the fingers, gently. one after another, through the neck of the sac, wherein lies the placenta, and ex tract it, peeling it off if adherent. The woman, of course, should be chloroformed, not to relax spasm, for we believe that the uterus resists its action even after the heart, but to spare her pain, control her move ments, and thus facilitate manipulation. (Fig. 153.) If this method does not succeed, then we may resort to Dubroca's, which consists in breaking up the placenta by means of one finger passed through the constriction. After this manoeuvre, the uterus should be washed out several times daily for a number of days.
In case the incarceration is complicated by hemorrhage, we must act immediately; overcome the obstacle, and extract the placenta whether adherent or not. Usually the obstacle is readily overcome. Ergot should then be given to maintain contraction of the uterus.
In exceptional cases, where the placenta cannot be removed, and is not expelled spontaneously, we see develop septicaemia, with all its dangers, to which we will return at the end of this work.
Postpartum Hemorrhage. —Under• this term are included the hemor rhages which occur after the birth of the child, during or after the ex pulsion of the placenta, and they are of the gravest possible import, for they may assume such magnitude that in a few moments the woman may be dead. The accoucheur needs all his courage and all his experience.
Practically, those hemorrhages may be divided into three varieties: 1. Hemorrhage accompanied by retention of the placenta.
2. Hemorrhage continuous or occurring after the expulsion of the pla centa.
3. Hemorrhage occurring a few days after delivery, which constitutes secondary puerperal hemorrhage.
There is a prime cause for the two first varieties, and this is uterine in ertia, which may be primitive or secondary.
The normal separation of the placenta is accompanied by loss of blood, except in those cases where the fcetus has been dead for some time. Con tractions of the uterus, however, soon check this flow, and it is simply necessary to watch the woman in order to forestall relaxation and further hemorrhage. Occasionally this normal loss becomes abundant, owing to feebleness or irregularity in the uterine contractions, and then the pla centa must be either partially or entirely separated, and the uterus does not retract.
Uterine inertia becomes, during the third stage of labor, a matter of extreme solicitude to the accoucheur. He should endeavor in every possible way to prevent it. When present, the uterine sinuses are wide open, the organ is capable of distension, a considerable amount of blood may accumulate in the cavity before appearing externally, and our inter vention must not only be quick but certain.
is met with: 1. In women excessively fat, in those in whom the uterus is greatly distended, (by hydramnios, twins, etc.), in case of prolonged labor—in a word, in women in whom the fibres of the uterus would seem to have suffered exaggerated distension, and thus to have lost their contractile property. It is more frequent in primipara, especially when they conceive late in life. 2. Where the onset of labor is sudden and its termination rapid, as though the muscular fibre had not had the time to develop its mode of action. 3. Where the course of labor is disturbed by emotion or fear, and where untimely traction is made on the cord, in order to hasten the third stage. 4. Finally, there are certain women who arc apparently predisposed to hemorrhage of this nature in successive confinements.
Inertia may be local or partial, and thus the gravity of the accident and the difficulty of intervention vary.