PLACENTA PREVIA.
The practitioner should never forget, in deciding what is to be the treatment in a given case—first, that a woman with placenta prxvia is in danger as long as she is undelivered; secondly, that the best results are got by totally disregarding the interests of the child; thirdly, that it is loss of blood that kills most of the fatal cases. and that even a small further loss in a patient already bled white may prove fatal; fourthly, that the fatal cases that do not die of loss of blood die of sepsis. The trump card in placenta prtevia, which should always be played when in the slightest doubt, is—turn, bring down a foot and let the patient deliver herself.
The operation of turning can always be performed when the os is sufficiently dilated to admit two fingers. and it is seldom, indeed, that this condition is not fulfilled when the symptoms of placenta prwvia have made their appearance. Should the practitioner be unfortunate enough to meet with a case where it is not, he should tightly plug the vagina with iodoform gauze or cotton-wool pledgets wrung out of lysol solution (drachm to the pint), and wait for four hours, when the plug should be removed, and the os will usually be found to have dilated sufficiently. If not, the plug should be reapplied for a further period of four hours. When the os will admit two fingers only, bipolar version must be done, since forcible dilatation of the os is bad practice, and is almost certain to result in tearing the placental site and so giving rise to a form of haemorrhage which is exceedingly difficult to check.
In carrying out bipolar version the patient should he under chloroform, unless urgent necessity to stop the hxmorrhage or the absence of any reliable assistant puts it out of the question. The patient should lie on her back, with the hips at the edge of the bed. The physician's hands and the patient's vulva must be carefully sterilised—the hands by scrubbing with soap, rinsing with 7o per cent. methylated spirit and immersing for 2 to 5 minutes in f in 2,000 Perchloride or Biniodide; the vulva by the removal of redundant hair, washing with cotton-wool mops soaked in soap and water and sponging with mops dripping from lysol solution (f drachm tor pint). Boiled india-rubber gloves may be worn, and must be worn if the hands are rough, chapped or abraded, or have been recently in contact with pus or forces; they should be long enough to reach half-way up the forearm. The whole hand is introduced into the vagina and two fingers inserted through the os. If the margin of the placenta can be
easily reached in any direction, rupture the membranes at the margin. If it cannot, go through the placental substance.
The head will now be felt resting on the fingers, and it is to be pushed away by them from its position over the internal os, while at the same time the left hand on the abdomen pushes the child's breech in the contrary direction, so as to get its body transverse with its legs and feet towards the os. When the child has been got into this position it is an easy matter to get hold of a knee or a foot, and so to get the foot between the two fingers. It is not easy to bring a foot through the os with two fingers, and the best thing to do is to pass a pair of sterilised yulsellum forceps up beside the two fingers in the os and to seize the foot under their guidance and draw it down. If a hand has been mistaken for a foot, push it up again and go hack for a foot. When it has been brought down a strip of gauze or a broad tape wrung out of antiseptic lotion should be tied round the leg, and left hanging from the vagina. Slight traction on this will at once stop any further bleeding that may occur. The patient is now allowed to conic out of the chloroform, and to deliver herself. Delivery usually takes place in from two to six hours.
When the us is sufficiently dilated to admit the whole hand unipolar version is performed, the whole hand being passed into the uterus and a foot seized and drawn down. The after-treatment is the same as with bipolar version. It is especially in cases of this kind that the practitioner is tempted to effect forcible delivery by traction on the leg, partly in the interests of the child and partly to save time. The weight of authority is almost entirely against so doing, on account of the danger of lacerating the cervix or even rupturing the uterus. The only justification that can be alleged is the improvement of the chances of life for the child, so that before even thinking of forcible extraction one should be convinced that the child is still alive, and that if born alive it will be likely to survive. To expose an exsanguine mother to the increased risk of a tear through the placental site or through a branch of the uterine artery with the attendant hemorrhage, for the sake of a premature infant which must have already been weakened by the maternal anmmia, is quite out of the question.