These various means frequently require to be repeated several times before the contraction of the uterus becomes permanent, nor must we be discouraged by finding the uterus becoming soft again in a minute or two after ceasing to use them; for we may feel assured, with few exceptions, that if we can only keep the uterus, by this means, in a state of tolerable contraction for half an hour, it will ultimately become permanent, and remain so of itself.[132]
It is, in these cases, where pressure is of so much importance, not for the purpose of producing uterine contraction, as of maintaining it when once excited. By pressure applied at this moment, we may frequently keep the enfeebled uterus in a state of contraction, which, but for this support, would have yielded to the general force of the circulation, and have again expanded. For the same reason, whenever the uterus begins to swell again from internal hæmorrhage, and by the renewal of the above remedies, it becomes hard, but does not diminish in size: this shows that the contraction has not been powerful enough to expel the blood, which, in all probability, has already begun to coagulate in its cavity: where this is the case, the hand, or at least two fingers, should be passed, to dislodge the clots, and assist in their expulsion; after which, a cloth folded into a thick compress should be placed over the fundus, and firmly bandaged upon the abdomen by a broad towel.
Where every means has failed to induce a sufficient or permanent degree of contraction, we believe that the only certain means which remains, is putting the child to its mother’s breast. Under no circumstances do we see the sympathy between the uterus and the breast so beautifully displayed as here, and we may most truly affirm that we have never known it fail where the mother was sufficiently conscious to know that it was her own child. To a by-stander, ignorant of what was taking place, the sudden gush of blood mixed with coagula, which follows the application of the child, would be nothing less than a sign of renewed danger, while, in fact, it is a proof that the uterus is beginning to contract and expel its contents.
If the pulse has been seriously reduced by the loss of blood which the patient has sustained, a glass of wine, or a spoonful or two of brandy, will be of great service in rousing the vital powers; and this must be repeated or increased, according to the urgency of the circumstances; a little weak beef-tea, given from time to time, frequently appears to rouse the system, even more than the brandy, and is more refreshing to the patient; it can also be taken in larger quantities, for when the exhaustion is very great, stimuli appear to excite vomiting, which is by all means to be avoided. Where, however, it occurs spontaneously, it need not be looked upon in so formidable a light: thus Dr. Denman observes, “when patients have suffered much from loss of blood, a vomiting is often brought on, and sometimes under circumstances of such extreme debility that I have shrunk with apprehension lest they should have been destroyed by a return or increase of the hæmorrhage, which I concluded was inevitable, after so violent an effort: but there is no reason for this apprehension; for, though vomiting may be considered as a proof of the injury which the constitution has suffered by the hæmorrhage, yet the action of vomiting contributes to its suppression, perhaps by some revulsion, and certainly by exciting a more vigorous action of the remaining powers of the constitution, as is proved by the amendment of the pulse, and of all other appearances immediately after the vomiting.”
When a slight trickling of blood continues, although the uterus is tolerably hard and contracted, it will be desirable to make an examination, for we shall frequently find a long slender coagulum hanging through the os uteri into the vagina, upon the removal of which, the discharge will cease.
The application of the child to the breast is not less valuable for preventing any return of the hæmorrhage than for stopping it in the first instance: we are never perfectly secure against hæmorrhage coming on during the first few hours after delivery, even where every thing has turned out as favourably as possible: the exhaustion from the length or severity of the labour, the warmth of the bed, and in some cases, it would even seem, the relaxing effects of deep sleep, are all liable to be followed by inertia uteri and hæmorrhage. In no way can we ensure our patient so completely against this kind of danger as by putting the child to the breast; the uterine contraction which it excites is not only powerful, but permanent; nor do we consider that a practitioner is justified in leaving a patient in whom the uterus has shown a disposition to inertia without having ensured her safety by this simple but effectual safeguard.
There is a form of hæmorrhage after the birth of the child, which seems to depend upon an over-distended state of the circulation, and where its activity appears too great for the contractile power of the uterus; so that, in spite of the uterus being tolerably firm and hard, a profuse hæmorrhage is almost sure to follow the separation of the placenta. This condition has been described by the late Dr. Gooch, and still more recently by Professor Michaelis, of Kiel; to the former, especially, we are indebted, not only for having first pointed out this important fact, but for having placed it before us in the simplest and clearest light. “I had now witnessed,” says Dr. Gooch, “two labours in the same person, in which, though the uterus contracted in the ordinary degree, profuse hæmorrhage had nevertheless occurred: let me be understood—after the birth of the child, I laid my hand on the abdomen, and felt the uterus within, of that size and hardness, which is generally unattended by, and precludes hæmorrhage; in both instances, the labour had been attended by an excessively full and rapid circulation. I could easily understand that a contraction of the uterus, which would preclude hæmorrhage in the ordinary state of circulation, might be insufficient to prevent it, during this violent action of the blood-vessels; and the inference I drew was, that, in this case, the hæmorrhage depended not on a want of contraction of the uterus, but on a want of tranquillity of the circulation; and that if ever she became pregnant again, a mode of treatment which would cause her to fall in labour with a cool skin and a quiet pulse, would be the best means of preventing a recurrence of the accident.” This will be effected by an occasional venesection during the last weeks of pregnancy, by the use of saline laxatives; and if there be still much disposition to heat the surface, and excitement of circulation, by doses of nitre three times a day, and by strict antiphlogistic regimen.