POST-PAETUM HiEMOEEHAGrE.?BY A. E. HALL.
A SUGGESTION REGARDING POST-PARTUM
By A. E.
HALL, Surgeon, Royal Artillery.
It has occurred to
me that there is a possible cause of labor which has not been specially noticed by midwifery. I allude to the occasional tying of the
flooding during Writers
umbilical cord before pulsation has ceased in it. We are told, in works on Obstetrics, that if the child has cried or breathed, its communication
the mother is no
that the cord may be tied immediately.
necessary, and No notice is directed
taken, whether the cord is pulsating or not. ceeding involves perfect safety as regards the child;
This probut may
it not do harm to the mother ?
Before considering what is the state of affairs directly after the expulsion of the child, let me quote some passages from a book by Dr. Lumley Earle, Obstetric Surgeon to the Queen's
Hospital, Birmingham, entitled " Flooding after Delivery." At page 104, under the heading Partial Separation of the not morbidly adherent placenta," he writes :?" After the birth of the infant, the uterus generally remains quiescent for a short time before it contracts to detach the placenta. Dr. Murphy has given to that condition of the uterus the very appropriate term of'suspended action,' in contradistinction to that of true inertia. Now, a not uncommon cause of hemorrhage is the partial detachment of the placentabefore the uterus begins to contract. The only safeguards against flooding are either adhesion of the entire placenta, or firm contraction of the uterus, its cavity being perfectly empty. Both these points are wanting when haemorrhage occurs from partial separation of the placenta during an uncontracted state of the uterus. The blood flows through the uterus unimpeded, and escapes out of the uterine sinuses lately covered by the detached portion of the placenta. The healthy afterbirth is so loosely connected to the uterine wall, that very slight disturbances may give rise to its partial detachment, e.g., exertion of the patient; coughing; the application of strong or unequal pressure on the uterus' during the absence of contraction; contraction of only a small portion of the uterus ; and premature traction on "
Now, as stated above, a not uncommon cause of hemorrhage is the partial detachment of the placenta before the uterus begins What is the cause of this partial displacement ? to contract. The uterus has not re-commenced to contract for the expulsion of the
Its action is
suspended. If the last contracexpel the child had produced it, blood would immediately begin to flow as soon as the child had entirely passed through the vulva. This sometimes does happen; but most of the cases of post-partum htomorrhage met writh occur after ligature of the cord; many of them almost directly after. If, then, the child has been born without any immediate flooding, and the uterus is quiet, what is the I believe it cause of the partial detachment of the placenta ? Let us take an ordinary case may be explained as follows. been born; the blood is still of flooding. The child has circulating through the cord ; the pulsations are distinctly felt ; the child breathes, and a ligature is applied to the cord. What follows ? The blood coming from the uterus into the placenta is suddenly stopped at the junction between the two ; it cannot proceed, because of the blood in front having been brought to a stand-still by the ligature on the cord ; the healthy after-birth is very loosely connected to the uterine wall, and very slight disturbances may give rise to its partial detachment. Blood is, I assume, poured out between the uterus and placenta, because that is the weakest part that the blood comes in contact with, and will first yield to the pressure from behind. A partial detachment of the placenta takes place, and placenta.
tions of the uterus to
consequently haemorrhage into the cavity of the uterus. Can hasty or too early application of the ligature to the pulsating cord, and consequent sudden separation of the placental attachment, are the real causes of certain cases of post-partum haemorrhage? Such may be regarded as merely a suggestion on my part; but if there is any truth in it, this cause of flooding can be so easily avoided, that I have thought, it worth while to draw attention to it. As a rule, there is seldom any necessity for haste in the division of the umbilical cord. If the child has hot begun to breathe, it requires the blood which is circulating through the cord; for although out of the uterus, it is still drawing lifhe from te mother. If it is necessary to try and excite respiration, cold water can be dashed on it, or other direct stimulants can be applied, without entailing any risk to either mother or child. If, on the other hand, the child has breathed, the pulsation in the cord will become less frequent, and cease in a short time ; no blood will then be flowing into the placenta, and the ligature may be applied without any chance of doing harm. Dr. Earle, in the above quoted work, devotes a chapter to the " Preventive Treatment," and his suggestions are most practical. it be then that too
But he makes no allusion to the state of the cord when the is about to be applied, whether it is pulsating
I have therefore been induced to put certain thoughts or not. which have occurred to me on paper. I bring forward the subject as one based, of necessity, on a theory ; and in doing so, I am fully aware how fallacious theories sometimes prove.
Still, as it has not been treated of iu our standard works Midwifery, these remarks may have the effect of drawing the attention of medical men to the subject ; and if, as a rule, not applied on the umbilical cord whilst it is a ligature were pulsating, it is possible that cases of post-partum haemorrhage might be less frequent than they now are. on
Barrackpore, May 18th,