And what, rightly stated, is Cred6's method of placental expression ? At the outset, the uterus is never to be spurred into action by massage or by kneading, but the hand is to be kept quietly on the fundus, until the uterus is felt to harden, not faintly, not irregularly, but uniformly and strongly. Then expression is to be brought into play, and never before. The mean interval between the birth of the child, and correct resort to CredCs method, varies from fifteen minutes to one half hour—the latter figure is a nearer approach to the truth. Failure in the use of Crec16's method is due to the fact that efforts at expression are made too soon— before fifteen minutes, at least, have elapsed since the end of the second stage of labor. When the uterus is distinctly felt to harden, fric tion should at first be made over the fundus, and then the uterus is grasped by both hands, the fingers towards the pubes, and compres sion is made. If this first effort at expression fails, wait for a second, it may be a third or fourth contraction. The compressive force must be directed as far as possible in the axis of the uterus, in order to act to the best advantage. Thus now, except where there are morbid adhesions, the placenta may be forced into the bed, between the patient's thighs. It will be noticed that, by this method, abso lutely no handling of the cord and no vaginal examination are necessary. Indeed, in a normal case, where membranes and placenta are intact, the finger need never be introduced into the vagina after the completion of the second stage of labor. The placenta delivered, too much stress can not be laid on the fact that it must be twisted on itself, over and over again, in order that the membranes may be extracted entire. Inatten tion to this fact is a very common causa of retained shreds of mem brane. —Ed.; With the birth of the placenta there is a loss of blood, but the amount is variable, limited in general to ten to twelve ounces, although this loss may amount to as much as thirty ounces. The amount, it is apparent, will depend on the development of the vascular system of the uterus, and on the retractility and contractility of this organ. In general abun
dant, when the uterus retracts and contracts moderately, the loss of blood is, on the contrary, very slight when the uterus contracts energetically, as is usually the case when the third stage is completed spontaneously. The same holds, and the reason is evident, when the foetus is expelled a few days after its death, the utero-placental circulation having nearly, or al most, ceased. When, on the other hand, towards the end of labor, the uterine contractions are feeble, when the uterus is greatly distended, as • in case of hydramnios, twins, very large foetus, etc., then the uterus is deficient in retractile and contractile power, and hemorrhage may be great. It is in cases such as these that we meet with those frightful hemorrhages, of which we will speak in connection with the subject of the complications and the accidents of labor.
Delivery of the placenta in twin pregnancies.—The reasons tor not in terfering too soon during the third stage of labor are all the more appli cable to twin pregnancies: But with Naegele and Grenser we are opposed to the practice of making traction on both cords at once. In the first place, the placentas are frequently separate, and the one detaches itself before the other. Further, when the two placentas are united, pulling on both the cords will make trouble, in that the placenta masses will en deavor to engage at the same time. The best practice is to search for the cord belonging to that placenta which tends to engage, and, as soon as this placenta has reached the os, to make traction on the cord belong ing to it. [It is obvious, from what has gone before, that here, as well, CredPs method of placental expression will answer better than any such tractions on the cord.—Ed.] But we must watch with all the more care over the delivery, for hemorrhage, the result of uterine inertia, is com mon in such cases.
We represent here, figure 243, a curious example of the cord observed by Busch in a case of twin pregnancy, and in figure 245 the disposition of the cords and the placentas, in a case of triplets, observed by Martin.