PLACENTA PRÆVIA.
Obermann (Arch. f. Gyn., B. 32 H. 1.) discusses the treatment of placenta prævia by version with the results obtained in sixty-four cases at the Leipsic clinic. The method, which has become known as Hofmeier’s method, he states as follows:
Perform bimanual version with deliberate extraction in case of much hæmorrhage. The podalic extremity of the child makes an effectual tampon. Massage of the uterus during extraction is advised to aid expulsion. Iodoform gauze tampon may be used in case of hæmorrhage in the early months. The colpeurynter is recommended in case of hæmorrhage with a closed cervix. Alcoholic stimulants are given early and often.
The results in the sixty-four cases were eighty-nine per cent. of the mothers and forty-seven per cent. of the children saved.
Nordmann, of Dresden, condemns early resort to operative procedures as a routine measure, a more expectant plan of treatment being competent in a certain proportion of cases.
Robt. Barnes (Br. Med. Jour., March 3d, 1887) sums up his views substantially as follows: The hæmorrhage in placenta prævia proceeds from so much of the lower zone of the uterus as is laid bare by separation of the placenta during canalization. This comprises all that portion of the uterus that lies below the equator of the fœtal head. When canalization is complete the hæmorrhage is almost invariably arrested spontaneously by retraction of the lower zone thus freed. Until canalization is completed flooding is liable to persist, but after that process is accomplished the case becomes practically a natural labor. The too prevalent idea that the hæmorrhage is unavoidable and must go on till delivery is erroneous and mischievous. Enough placental attachment usually remains after complete dilatation to preserve the life of the child. The fœtal life is not necessarily compromised except in certain extreme cases of complete central placenta prævia. His views of treatment follow as a corollary. Expedite the first stage, avoiding violence or precipitation. His caoutchouc bags accomplish this indication and control hæmorrhage. Detach the placenta with the finger from the zone below the equator of the head, thus permitting retraction and arrest of flooding. Rupture of the membranes and the use of the binder meet the indications in certain cases. The vaginal plug may be used in occasional instances if carefully watched. The os uteri moderately expanded and the placenta separated from the lower zone, hæmorrhage having ceased, wait. With sufficient dilatation, deliver, if necessary, by forceps, version, or craniotomy. Dr. Murphy’s success by this plan has been unexampled. [Dr. Barnes does injustice to version in placenta prævia, since he appears to assume that immediate extraction and violence to both mother and child are a necessary part of the procedure. The success of that plan he attributes in great part to the fact that, in carrying out the operation of turning, the placenta had probably been detached from the lower zone. These criticisms certainly cannot apply in case of external or bipolar version. With reference to Barnes’ bags, it is safe to say, “the German teachers” are not the only practitioners who have found them, in many cases, more or less impracticable.]
OBSTETRIC SEPSIS AND ANTISEPSIS.
Auvard, writing to the Annals of Gynec., April, 1888, says, while before the days of antiseptics it was better for a woman to be delivered in the street than in a hospital, the hospital ward is now less dangerous than the isolated lying-in chamber of the out-patient obstetric service. He points out the importance of improving the resisting power by use of tonics before the labor, in debilitated patients. In Auvard’s practice every woman takes a thorough bath at the beginning of labor. The whole vulvar and vaginal surfaces and cervical canal are sterilized before expulsion begins, before obstetric wounds are developed. Asepsis before and during the birth is more effectual than the use of antiseptics at the close of labor and renders the latter unnecessary.
Sublimate soap and the sublimate solution, with which this soap makes a lather, are well rubbed into the surfaces to be cleansed by aid of the fingers. The dangers of sublimate poisoning do not obtain while the surfaces are intact.
In the event of septic developments during the puerperal period he thinks sublimate irrigation insufficient for genital antisepsis. The vulva and vagina should be scrubbed by aid of the fingers with the sublimate soap and solution. The uterus should be scraped with the curette. Auvard has devised for this purpose a curette with a hollow stem through which a stream of the antiseptic solution is kept flowing during its use. [The mercurial salts may be replaced with a 1:1000 hydronaphthol solution for use within the passages after labor, though the danger from the former antiseptic may be greatly diminished by washing away the mercurial with a final injection of plain boiled water.]