This may be either accidental or unavoidable: it is said to be accidental when it arises from a casual separation of the placenta from the sides of the uterus; unavoidable, when it occurs in consequence of this organ (the placenta) being attached over or near to the os uteri.
Accidental hemorrhage, or that which occurs from a partial separation of the placenta, is not usually attended with so much danger as that which occurs from unavoidable causes, though the irruption of blood in these cases is sometimes so sudden and profuse that, unless proper measures be instantly had recourse to, the female's life maybe sacrificed; but, if attended to early, and properly managed, the chances are greatly in favor both of the mother and the child. The two varieties of hemorrhage can only be distinguished by a careful examination per vaginam, when, if it be arising from accidental causes, the membranes will be felt presenting at the os uteri; the finger should then be carried round its whole circumference, in order to be certain that the placenta is not even partially attached to it. Where the vagina and mouth of the " womb are filled with coagula, a careless examiner might he rather puzzled in making his discrimination, especially before the parts were I dilated; but the difference in the feeling; communicated by the touch is so great, that an experienced finger cannot readily confound the smooth and easily lacerable surface of a clot of blood, with the firm, rough, unequal, and granular-like substance of the placenta. It not unfrequently happens that the irritation produced by this examination stimulates the uterus to contract, and the membranes will then be pushed down in a more decided manner: and this will greatly assist the diagnosis. It is to be observed, that the discharge is diminished, if not altogether arrested, during a pain.
Treatment. The treatment of this variety of hemorrhage is generally simple and easy: where it is slight, it sometimes happens that the mere vaginal examination, by increasing the force of the uterine contractions, at once puts a stop to the flow of blood, and nothing more will then be required from the accoucheur. Where, however, the symptoms increase or continue, the membranes containing the liquor amnii are to be ruptured: by the escape of the waters, the uterus is allowed to contract move forcibly round the body of the child, which will necessarily diminish the caliber of the bleeding vessels. The uterus is often also stimulated to greater exertion; the pains increase, and the child is expelled without further danger. The application of napkins, soaked in vinegar and cold water, to the abdomen and vulva, is also frequently useful. If the bleeding continue after the evacuation of the liquor amnii, the only plan of proceeding is to empty the womb of its contents; and the manner in which this is to be done depends upon the situation of the child. If the head be floating loosely above the brim of the pelvis, the operation of turning may be had recourse to. If it be engaged in the superior aperture, the long forceps, and if it has completely descended into the cavity, the short forceps, may be employed.
In cases of severe floodings, the secalo cornutum, in the usual doses (twenty-five grains), should be exhibited; though this must by no means supersede the measures just recommended.
Unavoidable hemorrhage. The placenta is usually situated at or near the fundus uteri, and consequently is quite out of the way during labour; but it occasionally happens that it is attached to the lower part of the cervix uteri, completely closing, as it were, the orifice of the womb. Where this is the case, the opening of the mouth of the womb must, of necessity, have the effect of separating the placenta from its sides, detaching the cells into which the uterine arteries are opening, and thus inevitably giving rise to hemorrhage; and, in consequence of this detachment taking place to a greater extent during the contractions of the uterus, the reason is at once seen why the flooding is increased under uterine action, (which is very different to what takes place in accidental hemorrhage.)
Sometimes the placenta is attached to a portion only of the os uteri, forming what has been termed a partial placenta presentation. On making an examination under such circumstances, the membranes may be felt protruding; but, by a careful introduction of the firmer a little within the womb, and by gently passing it round the os uteri, it may often be distinguished readily enough. In placenta presentations, the blood generally escapes in alarming quantities; the pains are frequently accompanied with very frightful gushes; arid, if aid be not promptly administered, in the majority of cases the patients would perish.
Treatment. Where the placenta is partially presenting, and the bleeding not very considerable, the mere rupture of the membranes, by allowing the uterus to contract, has been by some said to be sufficient. The hemorrhage is, however, frequently very profuse, and therefore in these cases, as well as in those where the placenta is completely fixed over the mouth of the womb, the only safety to the mother consists in emptying the organ, and it is of high importance that this be done as early as possible, before the patient is exhausted by the loss of blood. It is therefore considered a fixed principle to extract the child by the operation of turning, the very instant the soft parts are found to be in a state which will allow the hand to be introduced without risk of injury; and, in cases of severe hemorrhage, relaxation and dilatability is soon produced. Under those circumstances no man of prudence would think of waiting for uterine action; first, because he knows that, the longer the hemorrhage continues, the less chance would there be of the pains returning; and secondly, because, if these contractions should come on, it would be disadvantageous, inasmuch as they would obstruct the hand when introduced for the purpose of turning the child; and, by the opening of the uteri, (the natural effect of these pains,) the placenta attached to its circumference must be still further separated, and an increased flow of blood he the unavoidable result.
Where it is a partial presentation of the placenta, the hand should be introduced by the side of it, the membranes ruptured, and the feet grasped and brought down; but, where the presentation is complete, it is better to pass the hand through its substance; a method of proceeding certainly more hazardous to the child, in consequence of the foetal vessels being thus broken down, but more safe to the mother, because the necessity for a still further separation of the placenta from of the womb will thus be avoided. the delivery is so far advanced that of the child is passing the os uteri, in consequence of the pressure which is exerted upon the uterine vessels, the bleeding is considerably lessened, and therefore it may be right at this period to wait a short time; and, if there were still a want of pains, to exhibit a dose of the secale cornutura, to employ brisk friction over the uterine region, and, in cases of great exhaustion, to give the patient a tablespoonful of undiluted brandy.
After the birth of the child the placenta generally soon follows: if any difficulty arise, it may, from its situation, speedily be removed.
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From Charles Waller
Elements of Practical Midwifery: Or, Companion to the Lying-in Room, 1829
