I. ANTE-PARTUM —Excluding as of no moment the slight loss which may occur during the first stage from laceration of the cervix, we have to deal in this section with hemorrhage arising from a single cause—the premature separation of a normally situated placenta. To this form of bleeding the name " Accidental Hemorrhage" is very commonly applied. The blood, at first effused between the membranes and the uterine wall, may find its way almost immediately to the os and appear externally (Open Accidental Hemorrhage), or it may accumulate in quantity within the uterus, causing it to become distended and corre spondingly hard, and only after some time appearing externally (Concealed Accidental Ifiemorrhage). In rare instances the blood makes its way through the membranes into the amniotic cavity. The accident is a comparatively rare complication of midwifery, and many obstetricians in large practice have seen at most one or two cases. It is most likely to occur in a multipara. There is no method of prophylaxis known. The cases fall into two groups—in one (open accidental hemorrhage) the hemorrhage is not very marked, and the general symptoms are slight or absent; in the concealed form the amount of haemorrhage is considerable, and may be excessive, and general symptoms of shock and collapse are marked, and intense pain over the uterus is a prominent feature.
In the mild cases there is little necessity or scope for treatment. The patient may be allowed to deliver herself, but it is advisable to terminate the second stage as rapidly as possible, for fear that with the descent of the head and consequent retraction of the uterus further separation of the placenta may take place and the child's life be endangered if its passage through the vagina he delayed. It is advisable to put on a firm binder, which at least supports the uterus and makes the mother more comfort able. Whether it has much influence in checking the bleeding is doubtful. When the practitioner is confronted with a case of this kind he should first make quite certain that he has not to deal with a case of marginal placenta prievia, and in the second place he should not leave his patient, for fear of the hemorrhage increasing in amount.
In the severe cases several different lines of treatment arc open to the attendant, and a good deal of controversy has taken place as to which is the more satisfactory.
There is first of all the treatment suggested by Barnes of applying a firm binder and rupturing the membranes with a sterilised stilet, or by introducing a pair of bullet forceps closed through the cervix, opening them, and closing so as to catch the membranes, and then withdrawing.
Secondly, there is the Rotunda treatment, which is carried out as follows: A bowl is filled with small balls of cotton-wool as big as the top joint of the thumb sterilised by boiling and soaked in drachm to the pint solution of Lysol. The patient is put in the cross-bed position, and her vulva shaved, washed and douched with Lysol solution. The fingers of the left hand are introduced into the vagina, and serve as a speculum, and the right hand packs in the cotton balls, which are wrung out of the lysol solution as they are wanted. The fornices are packed first, so as to form a collar around the cervix, and the remaining plugs are tightly packed into the vagina so as to fill it completely. When the vaginal pack has been applied a tight binder is put on, and a napkin pinned to it is stretched over the vulva so as to prevent any bulging downwards of the vaginal plug. The plug is allowed to remain for 4 to 6 hours, and measures for the relief of collapse, saline transfusion, etc., are meantime instituted if required. When the plug is removed the os is softened and rapidly dilates, whereupon delivery is completed. If bleeding comes through the plug, it should be removed and reapplied.
Lastly, there is the method of immediate delivery either by rapidly dilating the cervix manually or with metal dilators, and then extracting the foetus by forceps or version or by operative delivery, whether Cesarean section or vaginal hysterotomy.