If there be another fœtus, the womb will remain much the same as before labor, and the child may also be felt. It is better however to make an examination internally, and then, in most cases, the membranes and presenting part of the second fœtus will be found at the upper strait. If there be any doubt after this it is even better to carry the hand a little way into the womb, than to remain in ignorance on such an important point. The delivery of the second fœtus usually follows close upon the first, though sometimes there will be a delay of some hours, or even days. And in general there is little or no difficulty with the second, owing to the parts having been already prepared; but the longer it is delayed the less easy it becomes.
Immediately the birth is fully effected the female feels, as most of them express it, in heaven; there is an almost instantaneous change, from the most agonizing pain to a state of perfect ease. She ceases her cries, and falls into a quiet and pleasing languor, strikingly at variance with the state of intense excitement she was in but a few moments before. This repose however, does not last long; the Placenta yet remains, and a new effort is required to expel that.
DELIVERY OF THE AFTER BIRTH, OR PLACENTA AND MEMBRANES.
Unlike the Fœtus the Placenta is fast to the walls of the Womb, and can only become separated from them by the contraction of their substance, which usually commences soon after the birth of the child, and is indicated by new pains, and a slight discharge of blood. In about a quarter of an hour, or twenty minutes, the accoucheur should enquire of the patient whether she has felt any of these pains, and he should also examine whether the Placenta has reached the mouth of the Womb, or Vagina, so that he may remove it. If the pains have not yet come on, and the Placenta is not in the passage, he should press one hand on the fundus of the Womb, to promote its contraction still further, and then gently draw upon the cord with the other, holding it as high up as possible, either by a piece of linen around it, or by looping it around the finger. It should be pulled very gently, but steadily, downwards and backwards. If it be snatched, or drawn too hard, it may break, and cause great trouble; or it may pull down the Womb, and either invert it or bring on falling of the Womb afterwards. The hand placed over the fundus can detect this accident, and if the uterus be felt to sink down the cord must not be drawn upon any longer. Pulling away the Placenta too soon, and with rudeness, has often led to deplorable accidents. In nearly every case it will gradually separate itself, and be delivered in about half an hour, and should only be assisted by slight drawing on the cord, and by pressing the fundus.
When the Placenta is completely detached there is seldom any difficulty in its passing the neck of the Womb, and down the Vagina, but it usually requires to be drawn through the external opening by the hand. In doing this the membranes may be twisted round the cord, so as to wind them altogether, and strengthen the cord.
In case the separation does not take place we must wait, and continue the slight strain on the cord and the friction over the fundus. It is not reckoned safe however, by most authors, to wait more than an hour; and if there is no sign of its coming by that time artificial delivery is resorted to. This is accomplished by carrying the hand carefully up into the Womb, and separating the Placenta from its walls with the fingers, and then bringing it down at once.
When the afterbirth has passed the Vulva, a careful examination should be made of it, to see that no part is left behind; and for still greater security it is advisable to explore the Vagina thoroughly, so that any detached portion may be removed. The membranes are very apt to become broken, and fragments of them left, which though ever so small may cause trouble. The finger should also be passed into the mouth of the Womb, so as to clear it; for sometimes a large clot of blood, or a piece of the membranes, will remain and keep it open, and thus cause severe flooding.
It is generally considered, by those who have bestowed attention on the subject, that assistance should always be rendered, if the afterbirth does not come very soon. There is danger, if it be left too long, of the mouth of the Womb contracting and retaining it; in which case it becomes absolutely necessary to abstract it, but exceedingly difficult, and even dangerous, to do so. Dr. Lee says it should never be left more than an hour at most, and that it is best never to delay removing it even so long as that.
When left purposely, for observation, it is found to be expelled spontaneously, and soon, only in a few cases; usually it remains several hours, and most frequently it requires to be removed by hand. No doubt it is natural for it to be expelled unaided, but it must be borne in mind that our females are usually too weak, and deficient in energy, to perform any unusual natural function without assistance. The accoucheur must use great caution, so as neither to intrude his help when not required, nor yet to refuse it when really needed; and above all he must not substitute violence for skill.