THE THIRD STAGE OF LABOR This third stage may be spontaneous, the placenta and mem branes being expelled through the efforts of nature, without interference. It may be natural, where the accoucheur assists only by a little traction. It may be artificial, where the accoucheur is obliged to interfere. We recur to this under the head of Dystocia.
Spontaneous Termination.—That this may be absolutely so, those cases prove where the ovum is expelled entire (foetus, membranes, placenta, together), or where, at the end of twelve, twenty-four or even more hours, the placenta is born unaided. Such cases are usually of miscar riage; but there are a few instances on record of the birth of the foetus, membranes, and placenta together. When not interfered with, the dura tion of the third stage of labor is very variable. Clarke, and most author ities, place it at from a quarter to one half an hour. The researches of Dubois, Cazeaux, and Depaul, however, prove that such an interval is entirely too short, and that the mean duration is from one to two hours. Stolz tells us that the third stage may be prolonged for from twenty-four to fifty hours. In such instances, active pains and hemorrhages have been noted, and the undelivered women have been restless and anxious. This, of course is objectionable. Spontaneous delivery, it seems to us, is not so rare as is believed; often has it happened to us, while occupied with the child, to be called by the woman, in from ten to fifteen minutes, and being told that something has passed from the vagina, to find the placenta in the bed either entire, or with the membranes alone in the vagina. Nevertheless, since such cases are exceptional, and since pro longed waiting has its objectionable points, the rule is not to await the spontaneous termination, but to resort to natural delivery so soon as this is possible or indicated.
.Nalural Termination.— Those authorities are in error who teach that the placenta begins to detach itself from the uterus during labor, or, as some contend, at the very beginning of labor. If this statement were true, during the course of labor, we would see more or less blood escape from the vagina, and this is not the case. Normal labor occurs without any hemorrhage whatever, and it is only in those cases where the pla centa separates prematurely, that we see, at the end of labor, just before the expulsion of the foetus, a slight trickling of blood from the vulva.
Ordinarily, indeed, it is only at the expiration of a variable interval, that we see this trickling at all.
[It is self-evident that Charpentier uses here the term hemorrhage in its broad sense, for it is certainly exceptional for the second stage, at least, to be completed without any loss of blood. We make this point here because the positive statement has been made that, during the course of normal labor, the woman ought not to lose a drop of blood. The ex perienced will simply laugh at such a statement; the inexperienced need to be told that the reverse is the truth.—Ed.] The uterus diminishes in volume, and retracts as it gets rid of the child, but this retractility does not become at all marked till a few minutes have elapsed from the birth of the child, and then it is that the third stage of labor begins. Three concurrent phenomena indicate the onset of this stage: 1st. Recurring uterine contractions, identical with those of labor, except that they are a trifle less intense. 2d. Change in the form, vol ume, and consistency of the uterus. This is apparent to the hand resting over the uterus, which hardens, becomes rounder, in a word, contracts. 3d.. The appearance at the vulva of blood in greater or less amount.
If now, for us, uterine retractility plays a part in the detachment of the placenta, this part is incomplete without contraction, and these two phe nomena, retractility and contractility, acting together complete the third stage of labor. To the three signs just mentioned, Caillaut adds another, which he says is perceptible on auscultation. He calls it the bruit of placental separation. " If," he says, "the child being born, the stethoscope be at once applied to the hypogastrium, at the end of a few minutes are heard a few indistinct sonorous riles. At the same moment the uterus contracts. These riles increase, and will be found to be syn chronous with the contractions of the uterus." Although Baudelocque and Velpeau granted but two phases of the third stage, to-day we recognize three: 1st. Separation of the placenta; 2d. Its passage through the cervix; 3d. Its passage through the vagina and vulva.