If the contractions have not begun, they should be stimulated by the introduction of a Vorhees bag, which, at the same time, dilates the canal and mechanically shuts off the bleeding vessels by compression. In introducing the bag, the membranes may be ruptured so the bag will pass into the uterine cavity. When the implantation is central, the finger must tear a hole through the placenta, and through this opening pass the bag inside the uterus.
If the os is partially dilated, version may be done, and a foot brought down. The leg may then be pulled upon until it compresses the bleeding area and the traction maintained with a slowly developing pressure sufficient to check the hæmorrhage, until dilatation is advanced enough for delivery. Occasionally good results are obtained by tightly packing the cervix and vagina with gauze or cotton. (See Vaginal Tampon, p. [204].)
Cæsarean section may be done in the interests of the child, as well as the mother.
The fœtal mortality in placenta prævia is said to be 60 per cent and the maternal 10 per cent.
| Differential diagnosis between | |
|---|---|
| Accidental hæmorrhage and | Placenta prævia |
| Usually occurs in later months. | Any time after the twenty-eighth week. |
| May be concealed or open. | Always open and external. |
| Soon followed by labor pains. | Labor need not occur. |
| Uterus becomes larger if bleeding is concealed. | Uterus remains same size. |
| Uterus hard and woodeny. | Uterus, normal consistency. |
| In severe cases, signs of shock whether hæmorrhage is external or internal. | In severe cases, signs of shock follow the invariable external hæmorrhage. |
| No placenta can be felt. | Placenta can be felt through the os. |
| Hæmorrhage continues. | Hæmorrhage intermittent. |
| No history of previous attack. | Possibly history of previous attack. |
| No contractions after labor begins in serious cases. | Contractions as usual. |
| No bogginess of cervix. | Cervix boggy. |
Hæmorrhages may occur during labor from retention of the major part of the placenta while a portion is detached. This may be due to pre-existent disease, such as endometritis, or from uterine inertia.
Normally the placenta will separate and be discharged within an hour after labor and in the absence of hæmorrhage it may go even longer than this with safety. The occurrence of severe hæmorrhage, however, requires the immediate cleaning out of the uterus by inserting the hand and peeling the placenta from its attachments.
Post partum hæmorrhage includes all hæmorrhages that occur after the delivery of the placenta.
The “flooding” as it is called by the laity, is most apt to come on either immediately or within an hour or so after labor. If it comes on after the first twenty-four hours, it is called secondary hæmorrhage. Such predisposing causes as over-distention from twins may be present, but the hæmorrhage may follow a perfectly easy and apparently normal labor so suddenly and so profusely that the woman may die in half an hour.
There are four causes for post partum hæmorrhage: namely, (a) uterine exhaustion (atonia uteri); (b) mechanical obstacles to retraction, such as clots or retention of pieces of placenta or membrane; (c) and lacerations of some part of genital passage, such as the vulva, vagina, cervix, or lower uterine segment; and (d) the systemic condition known as hæmophilia.