May occur either before or after the expulsion of the placenta.
Hemorrhage with retained placenta. When the management of the placenta was treated of, the causes which gave rise to its detention were enumerated. Where the case is combined with uterine hemorrhage, it arises in consequence of the placenta being wholly or in part separated.
Treatment. The general principles of treatment are the same as in retained placenta without hemorrhage; but, as the danger is here greatly increased, they must be more vigorously brought into action. It should be carefully remembered that the existence of the placenta in utero is not the cause of the hemorrhage, but a joint effect with it of some unfavorable condition of the womb: this, therefore, ought to be first inquired into, and the remedies employed accordingly. If the whole of the fibres of the womb were made to contract, the uterine vessels would he closed, and the bleeding, as a matter of course, would cease: to accomplish this object, therefore, is the first indication. Friction, and the liberal affusion of cold water upon the abdomen, are the two most powerful agents for this purpose; the secale cornutum may also be administered; and, as a last resource, the hand is to he introduced into the uterus, and the placenta separated. This latter mode of proceeding, however, is seldom required, excepting in cases where there is preternatural adhesion of it to the uterine surface, or where there is an irregular and spasmodic action of the womb. (See Retained Placenta.)
Hemorrhage after the birth of the placenta is by no means an uncommon occurrence. It arises from the same cause as hemorrhage under other circumstances, viz. from a want of contractile power in the uterus; and, in consequence of the whole placental surface being at this lime exposed, the flow of blood is often very alarming. The treatment is not different from the former variety. Application of cold and friction is to be vigorously employed; and considerable advantage ois often derived from graspig the fundus uteri through the abdominal parietes, and making strong pressure upon it, so as to double it upon itself.
Internal hemorrhage. It occasionally happens that, although the blood is issuing from the extremities of the uterine arteries, yet it remains concealed from view, in consequence of its being detained in the cavity of the womb. When the womb is examined externally, it will be found to be soft and gradually enlarging; the patient will be faint, and, in fact, will be labouring under ail the symptoms which are attendant on uterine hemorrhage occurring under other circumstances.
The treatment is precisely similar to the former. By some it has been recommended that the hand be immediately passed into the uterus, and the clots removed from its cavity; but in general this is wholly unnecessary, and indeed it is doubtful whether there would not be danger of increasing the hemorrhage by removing the coagula which might be adhering to the orifices of the vessels.
General observations on hemorrhage. From the immense quantity of blood which is pouring from the vessels in uterine hemorrhage at the full period of gestation, the danger will be at once acknowledged, and the necessity for promptitude of action be fully established: hence the propriety of paying vigilant attention to patients who shew the least tendency to this unfortunate event. In addition to the measures which have been recommended in detail, it is of consequence that nourishment be from time to time administered, and occasionally that some stimulus be employed. It is, however, a common error to use these remedies (stimulants) too early: the patient becomes faint, the attendants are alarmed, and a quantity of ardent spirit is instantly given her. But the prudent practitioner will bear in mind, provided the discharge has not been in an alarming quantity, that syncope is beneficial; for not only is the circulation greatly lowered during this state, but it is a well known fact that the blood has a greater disposition to coagulate, and may, consequently, by the formation of a clot, oppose a temporary barrier to its further irruption.
If, however, the hemorrhage continue, and the syncope become repeated, it is of the utmost importance to endeavour to prevent its recurrence, by occasionally administering a tablespoonful of brandy, or some warm milk to which spirit, ammon. aromat. Zi. has been added; taking care that it be given in small quantities, and frequently repeated. The stomach of these patients is, however, often so irritable that it will reject every thing, and therefore any attempt to administer food or medicine is productive of uneasiness and distress.
Occasionally, in the more severe cases of this kind, even although the stomach does for a time retain nourishment, a sensation of weight and oppression is felt at the scrobiculus cordis, and the patient is manifestly relieved when it is rejected by vomiting;. The dangerous symptoms may, however, continue or increase, the pulse becoming nearly or quite imperceptible at the wrist; the most powerful stimulants fail in producing more than a temporary rally; the patient's face becomes "hippocratic;" the extremities first, and afterwards the body generally, getting cold; the respiration deep and laboured; there is an incessant and uncontrolable desire to change posture; frequently a general convulsive attack, and then death closes the scene. In many instances this appalling state of things does not come on without warning: hour after hour is the unfortunate victim gradually, though certainly (under the ordinary modes of treatment), sinking into the grave; and this event may take place after the hemorrhage has been completely arrested by the thorough contraction of the uterus; the system having received so great a shock from the loss of blood that it cannot rally. When this result is apprehended, from the symptoms jut enumerated, and from the failure of stimulants to excite more than a temporary rally, (for it will generally be found, even in these desperate cases, that the pulse will rise for a time after the stimulus has been given, bit will soon sink again,) the accoucheur will be guilty of a gross dereliction of his duty, if he neglect to have recourse to.
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From Charles Waller
Elements of Practical Midwifery: Or, Companion to the Lying-in Room, 1829
