The Matron's Manual of Midwifery, and the Diseases of Women During Pregnancy and in Childbed / Being a Familiar and Practical Treatise, More Especially Intended for the Instruction of Females Themselves, but Adapted Also for Popular Use among Students and Practitioners of Medicine

by Frederick Hollick

The chief causes of flooding are, the too early or violent, separation of the placenta; insertion of the placenta over the mouth or on the neck of the womb; laceration of the womb or vagina; the bursting of a swelled vein; rupture of one or more of the blood vessels of the uterus; and breaking of the cord.

Probably the most frequent of these causes are the premature or violent separation of the cord, and the bursting of the blood vessels. The insertion of the placenta over the mouth of the womb, instead of on the fundus, occurs very seldom, but when it does severe flooding is nearly certain to follow, because the placenta has then to be torn, by the expansion of the parts, at the very commencement of the labor, and probably continues to pour out blood for a long time before the child is delivered, and it can be expelled. In fact this occurrence, unless the labor terminates very speedily, is nearly always fatal to the mother, and frequently to the child also. In most cases there is more or less hemorrhage from this cause during gestation, particularly after the sixth month, when the neck of the uterus begins to enlarge more than the placenta, and consequently tears away from it. Abortion frequently results also, if the flooding be not stopped. Madame Boivin tells us that in twenty thousand three hundred and fifty-seven deliveries there were but eight cases in which the placenta grew over the mouth of the womb; which is equal to one case in every two thousand five hundred and fifty-four. Dr. Churchill has collected the accounts of one hundred and seventy-four cases of this kind, and he finds that out of these forty-eight terminated fatally; or nearly one out of every three.

The rupture of the blood vessels may occur when they are too much engorged with blood, or when their coats are weakened and corroded by disease. Shortness of the cord may also produce a rupture of the vessels, by the strain it causes on them and on the membranes.

In many cases the flooding comes on suddenly, without any warning whatever, though most usually it is preceded by a sensation of weight, heat, and fluttering in the pelvis, pains in the thighs and back, flushed face, headache, and dizziness. The pulse also becomes irregular, the hands and feet grow cold, and the ears often ring, or buzz. The only certain sign that the hemorrhage has really commenced is the appearance of the blood itself, and this often occurs, as previously remarked, without any premonitory sign whatever.

The danger from hemorrhage during labor is greatest when it commences the earliest, because it has then the longest to last. From any of the causes mentioned it is evident that it must continue till delivery is accomplished, and therefore if it appears at the commencement of the labor it may cause the death of both mother and child, before the labor can be terminated. The danger is greatest however to the child, unless the flow be very profuse indeed, and then it is equally so to both. After delivery the danger is of course only to the mother; and the rapidity with which it may compromise her life is in some cases fearful. Dr. Lee thus speaks of such cases.

"But one of the most dangerous varieties of uterine hemorrhage is that which follows the expulsion of the placenta, or its removal from the uterus by art. Sometimes the blood escapes in great quantities from the uterus immediately after the removal of the placenta, and the pulse ceases at the wrist, and consciousness is entirely lost in a few seconds. There is no symptom before labor has commenced, or during its progress, to warn you of what is about to take place. The child has been safely delivered, the placenta has come away in a short time, and while you are perhaps congratulating yourself on the happy termination of the labor the blood begins to trickle over the bed upon the floor, or the patient suddenly complains of great faintness. In such cases there may be either a want of uterine contraction, or the contractions may not be permanent, but be followed by relaxation and the effusion of a large quantity of blood, which may either appear externally, or remain to become coagulated, and distend the uterus. For several hours after delivery, in some cases, this alternate relaxation and contraction goes on, to the great hazard of the patient, and if her condition be not clearly ascertained, and the proper remedies be employed, death may unexpectedly take place."

In regard to the treatment, he gives such excellent and practical rules, that I cannot do better than quote them.

"By far the most important remedies in these cases of uterine hemorrhage are constant and powerful pressure over the fundus uteri, the application of cold around the pelvis, and the free administration of wine, brandy, and other stimulants: ergot is indicated, but it most frequently produces no effect. The pressure and cold are always within our reach, however sudden the attack may be. The hypogastrium should be strongly compressed with the binder, and a pad of folded napkins placed under it, and in addition the hand should be firmly applied over the fundus uteri. I do not know who it was that first employed compression of the fundus uteri in cases of flooding after the birth of the child; but it has been often recommended, and there are few practitioners in this country who are not fully aware of the importance of the binder and pad, in exciting permanent and regular uterine contractions. Dr. M'Keevor states, that in 1815 it was recommended by Dr. Labatt in his lectures, and for a number of years before this Dr. Labatt was accustomed to recommend a thick firm pad, or compress over the pubes, previous to the application of the ordinary binder, where, in former labors, uterine hemorrhage had taken place. Dr. M'Keevor states, that of 6665 women delivered during the years 1819 and 1820, only 25 were attacked with hemorrhage after the birth of the child. Of these, 15 occurred before the expulsion of the placenta, ten afterwards, and in all the results was favorable. He saw only two fatal cases during the time he was in the Dublin Lying-in Hospital, and he attributes this small mortality partly to the process of parturition being left entirely to the unassisted gradual efforts of the uterus; partly to the patient having been kept cool and quiet, free from all sources of disturbance and irritation; but, above all, to the careful application of the binder immediately after delivery, by which means the expulsion of the placenta, and permanent contractions of the uterus, are most effectually secured, and whenever any tendency to hemorrhage did occur before the removal of the placenta, the first point invariably attended to was to tighten the binder, and in the event of this not succeeding, a thick firm compress, made by folding a couple of large coarse napkins into a square form, was placed over the region of the uterus, and the binder again adjusted. In the great majority of instances, these, with the admission of cool air, checked the discharge; if not sufficient, additional pressure was made with the hands.

"At the same time that you efficiently compress the fundus uteri with the binder and pad, cold should be vigorously applied to excite the contractions of the uterus. The best mode of doing this is to plunge a large napkin in a pitcher of cold water, and dash it suddenly against the external parts, the nates and thighs; and this should be repeated till the uterus contracts, and the violence of the hemorrhage is controlled. I am satisfied that this is the most efficacious method of applying cold to excite uterine contractions; it is far less formidable than pouring water from a height over the naked abdomen, but it is not less efficacious, and it possesses these decided advantages over the other method, that while the application is made to the external parts, nates, and thighs, the pressure of the binder and pad is not withdrawn from the hypogastrium, the position of the patient is not changed from the side to the back, the bed is not inundated with water, and the application can be repeated as often, and continued as long, as the urgency of the symptoms may require. The abdomen may be exposed once, and cold water poured over it from a height, and the uterus made to contract, and the flow of blood be arrested for a time, but relaxation of the uterus may follow after a short interval, and the hemorrhage be renewed again with equal violence as at first; but we cannot with propriety expose the abdomen a second time, and empty over it from a height the contents of a great decanter or kettle. Besides, by adopting this practice, we sacrifice the whole of the effects derived from pressure on the fundus uteri. The application of a napkin soaked in vinegar and water to the parts is often sufficient, along with the binder, to restrain the hemorrhage where it is not very profuse.