Third Stage.—After the delivery of the fmtus no attempt should be made to knead or compress the uterus, as the result is likely to be a partial and irregular contraction which will probably delay instead of hastening the extrusion of the placenta. The hand may rest lightly on the fundus, so that warning may be got if the organ becomes distended with blood from postpartum It is as well to roll the patient over on her back, as in that position air embolism is even a rarer accident than in the left lateral position, and expression of the placenta is more easily carried out. While waiting for the placenta to separate it is advisable to intro duce any sutures that may be necessary in the perineum. This is most easily done with a large half-circle needle, held either in the fingers or in a needle-holder and threaded with silkworm gut. The suture should pass through the skin and under the surface of the laceration, emerging in the middle line, to be reintroduced and brought out through the skin on the opposite side. Two or three such sutures suffice to unite even the most extensive lacerations. They may be tied immediately or secured with a single knot, which is completed by a second after the delivery of the placenta. The expulsion of the placenta from the uterus into the vagina is shown by the rising of the uterus higher in the abdomen, while it becomes smaller, firmer and better defined, and by the fact that on lifting it up wards the cord is not pulled on. Usually this occurs in 5 to 20 minutes after delivery of the child, but the placenta need not be treated as retained " and manually removed unless it is still in the uterus at the end of an hour. When the placenta has left the uterus normally the fundus should be grasped firmly and pressed downwards and backwards so as to drive the placenta out through the vulva. It is received in the
hand, and the membranes pulled away by gentle traction. They should not be twisted into a cord, as this is likely to result in tearing off of part of them. The expressed placenta and membranes are then examined to see that everything is complete. The vulva is sponged clean with antiseptic solution, an antiseptic pad is put in place, and the binder applied. When a laceration has been sutured the nurse should be warned to sponge the perineum with r in 2,000 perchloride every 4 hours for the first 3 days, every time the bowels or bladder act, and every night and morning for a fortnight. The attendant should not leave the patient's house for half an hour at least after delivery. Before leaving he should examine the uterus, and if it is not firmly contracted a drachm of Ext. Ergot. Liq. should be given or an injection of r c.c. of Pituitrin. If the patient's pulse is above ioo and the uterus flabby it is well to wait a further half hour for fear of post-partum hemorrhage.
Diet should be light and consist mainly of slops for the first 2 days. An aperient should be given on the second night, and after the bowels have acted the patient may have boiled fish, a little chicken or a lean chop, and gradually return to ordinary fare. She may rise at any time from the seventh to the fourteenth day, according to her condition; but 1 can see no possible advantage in forcing her to rise on the second day, as some German authorities have been advising recently. In this as in many other things it is as well not to have a hard-and-fast rule, but to be guided by the patient's condition and to some extent by her inclination.—R. J. J.