“6. When the placenta is pierced, we augment the risk of the child; for in making the opening, we may destroy some of the large umbilical veins, and thus permit the child to die from hæmorrhage.
“7. By this method we increase the chance of an atony of the uterus, as the discharge of the liquor amnii is not under due control.
“8. That it is sometimes impossible to penetrate the placenta, especially when its centre answers to the centre of the os uteri; in this instance much time is lost that may be very important to the woman.” (Op. cit. § 1153.)
We have already stated why it is so particularly important not to use any force in passing the hand through the os uteri: the less we separate the placenta, the less also will be the hæmorrhage; and even this will be in great measure controlled by the presence and pressure of the hand itself. In no case of turning is it so important to have all the circumstances connected with the operation as favourable as possible, for the case itself is sufficiently dangerous without being increased by other unfavourable causes. To hurry the delivery would be only to increase the danger: the operation must be performed slowly and with caution: every rule which we have given, (see Turning,) for ensuring its safe and successful termination, must now be adhered to with double vigilence. “Should the woman,” says Dr. Dewees, “be very much exhausted before we commence our operations, we should use additional caution in the delivery. It should be very slowly performed, and we should have at each step of the progress assurances, if possible, that the uterus has not lost, or rather that it possesses, sufficient contractility to render the completion of the operation eventually safe, if performed with due and necessary care.” (Op. cit. p. 463.)
When once the os uteri is sufficiently dilated to admit the hand, there will not be much fear of the patient losing much blood during the turning, for during the first part of the operation the hand and arm act both as a compress and plug; and afterwards, when the body of the child is advancing, this will act in a similar manner. There is little danger of hæmorrhage coming on after the child is delivered, for the contraction of that part of the uterus to which the placenta has been attached is much greater in these cases than it is where the placenta is situated in the upper parts of the uterus under ordinary circumstances. The placenta, which is already separated to a certain extent by the introduction of the hand, usually comes away without any trouble as soon as the child is delivered. We once met with a case where it was firmly adherent to the os uteri on one side, and required to be artificially removed, which was effected without difficulty. In this instance, hæmorrhage returned after the labour from uterine inertia, and was checked by the means already recommended. (Med. Gaz. Sep. 2, 1837.) The after treatment should be conducted upon the same principles as in other cases of hæmorrhage.
Partial presentation of the placenta. Where this is the case, the danger is rarely so alarming, nor is it always necessary to effect artificial delivery by turning. The edge of the placenta frequently projects but a very little over that of the os uteri, feeling, as it were, like a second lip; at other times it covers a third or more of the opening, and is usually attached upon the anterior portion of it. Our own observations have rather led to the conclusion, that where the placenta is but partially attached over the os uteri, the first attack of flooding is rarely delayed until the full term of pregnancy, but makes its appearance some weeks earlier. We are inclined to attribute this to the os uteri being only in part covered with placenta; that its other portion, being free, is more capable of dilatation from slight causes, than it would be were the placenta centrally attached: from a similar reason we may understand why the hæmorrhage is seldom so profuse in these cases as to be dangerous, and why the os uteri usually dilates sufficiently soon to allow the head to descend and be born by the natural powers. We are confirmed in this view by what we have already quoted from Dr. Rigby respecting the os uteri being prevented dilating by the close adhesion of the placenta—an opinion which is, moreover, approved of by Dr. Dewees as being “both ingenious and probable.” Hence, also, we may reverse our position, and say, that in a case of partial presentation of the placenta, we shall seldom find the hæmorrhage very profuse, until the os uteri has attained a considerable degree of dilatation. Besides the portion of placenta which presents, there will be also a bag of membranes occupying the remaining portion of the opening; we shall rarely, if ever, meet with those difficulties connected with a contracted and unyielding state of the os uteri, which we described in cases of central presentation; and if the hand requires to be introduced, which is not often the case, it will seldom experience much opposition.
Treatment. In our treatment of partial presentation of the placenta, we must be guided, in a great measure, by the strength of the pains and the degree of dilatation which the os uteri has attained; the extent to which it is covered by the edge of the placenta, must also be taken into consideration. Where the pains are strong and active, the pressure of the membranes distended by liquor amnii against the mouth of the womb will be sufficient to check the hæmorrhage; if not, by rupturing them we shall be enabled to let off the liquor amnii, and thus allow the head to press directly upon the os uteri, and act in the double capacity of a plug and compress. Where the pains are slow and inactive, the rupture of the membranes will diminish the size of the uterus, and thus excite it to more powerful contraction; if not, a dose of secale cornutum, repeated according to circumstances, will be of great assistance. If the patient has suffered a good deal by the loss of blood, a little beef-tea, in small quantities frequently repeated, will rouse the powers; wine or a little brandy, may also be given at intervals; but unless the prostration be very serious, we have not found stimulants so useful as beef-tea, which is usually, also, much more grateful.