Vomiting in labor frequently occurs near the end of the first stage. It is due to the sympathetic excitement of the nerves of the stomach as the last fibers of the os uteri give way. It requires no treatment.

Hyperemesis in labor is very rare, but when it does occur, the delivery should be expedited.

HÆmorrhages may occur either before, during, or after labor. HÆmorrhage is always serious.

HÆmorrhage before labor arises either from a premature detachment of a normally implanted placenta or from placenta prÆvia. The first is sometimes called “accidental hÆmorrhage” to distinguish it from the latter, or “unavoidable hÆmorrhage.”

Accidental hÆmorrhage may be the result of an injury or a blow, but in many cases, there is no such history. The hÆmorrhage is most frequent in the later months of pregnancy, and may be without any apparent cause. The hÆmorrhage may be entirely inside the uterus (concealed hÆmorrhage) or it may appear externally.

The hÆmorrhage, when concealed, takes place back of the placenta or between the membranes and the uterine wall. If the hÆmorrhage is concealed, it is usually followed by an attempt to expel the child. If the hÆmorrhage is pronounced, systems of shock appear.

The diagnosis is made by the symptoms which are summarized in differentiating this condition from placenta prÆvia (p. 231).

From this affection, nearly all the children and half the mothers die.

When the hÆmorrhage is external and slight, the treatment may possibly be expectant for twelve hours, if carefully watched, but usually the symptoms become so serious that immediate emptying of the uterus is required either by the Vorhees bag, digital dilatation, version and extraction, or CÆsarean section, the method chosen being dependent upon the amount of the hÆmorrhage, the vigor of the mother and the condition of the cervix, os, pelvis, and child.

Placenta prÆvia is the name given to a placenta that is attached low down in the uterus so that its margin or a large part of its mass overlies the os. This happens through the action of the egg which embeds itself too far down on the endometrium—too close to the cervix.

Three different kinds are known and named from their manner of encroaching on the os, as marginal, partial, or central implantation of the placenta.

The hÆmorrhage is from a loosening of the placental attachment owing to the stretching and growth of the uterus.

There is only one symptom of placenta prÆvia—sudden, painless, causeless hÆmorrhage. The bleeding seldom appears before the twenty-eighth week, and no suspicion of a placenta prÆvia may arise before the appearance of hÆmorrhage, which, as a rule, is soon repeated.

Labor frequently comes on prematurely and malpresentations naturally result from the inability of the presenting part to fit itself into the pelvis.

There is no bag of waters, hence the first stage is longer and bloodier and fraught with much danger.

Interference is regularly indicated to save the life of the mother, while the child also has a high mortality. Puerperal infection is not uncommon.

Placenta prÆvia is always an emergency. If the patient can be kept under observation in a good hospital, one may temporize, but under other conditions the uterus must be emptied at once, even if only a single hÆmorrhage has developed. The indications are, (a) to control the bleeding, and (b) to empty the uterus. The life of the child must be disregarded and the mother alone considered.

If the contractions have not begun, they should be stimulated by the introduction of a Vorhees bag, which, at the same time, dilates the canal and mechanically shuts off the bleeding vessels by compression. In introducing the bag, the membranes may be ruptured so the bag will pass into the uterine cavity. When the implantation is central, the finger must tear a hole through the placenta, and through this opening pass the bag inside the uterus.

If the os is partially dilated, version may be done, and a foot brought down. The leg may then be pulled upon until it compresses the bleeding area and the traction maintained with a slowly developing pressure sufficient to check the hÆmorrhage, until dilatation is advanced enough for delivery. Occasionally good results are obtained by tightly packing the cervix and vagina with gauze or cotton. (See Vaginal Tampon, p. 204.)

CÆsarean section may be done in the interests of the child, as well as the mother.

The foetal mortality in placenta prÆvia is said to be 60 per cent and the maternal 10 per cent.

HÆmorrhages may occur during labor from retention of the major part of the placenta while a portion is detached. This may be due to pre-existent disease, such as endometritis, or from uterine inertia.

Normally the placenta will separate and be discharged within an hour after labor and in the absence of hÆmorrhage it may go even longer than this with safety. The occurrence of severe hÆmorrhage, however, requires the immediate cleaning out of the uterus by inserting the hand and peeling the placenta from its attachments.

Post partum hÆmorrhage includes all hÆmorrhages that occur after the delivery of the placenta.

The “flooding” as it is called by the laity, is most apt to come on either immediately or within an hour or so after labor. If it comes on after the first twenty-four hours, it is called secondary hÆmorrhage. Such predisposing causes as over-distention from twins may be present, but the hÆmorrhage may follow a perfectly easy and apparently normal labor so suddenly and so profusely that the woman may die in half an hour.

There are four causes for post partum hÆmorrhage: namely, (a) uterine exhaustion (atonia uteri); (b) mechanical obstacles to retraction, such as clots or retention of pieces of placenta or membrane; (c) and lacerations of some part of genital passage, such as the vulva, vagina, cervix, or lower uterine segment; and (d) the systemic condition known as hÆmophilia.

“Bleeders” (hÆmophilias) are women whose blood lacks coagulability, owing to the absence of fibrin-producing elements.

Post partum hÆmorrhage is usually an external hÆmorrhage, but the woman may bleed to death into her own uterus.

Besides the external signs, the patient may show the symptoms of acute anÆmia, such as the rapid pulse, hurried, shallow respiration, pallor, cold sweat, yawning, dizziness, etc.

Nearly all these cases can be saved by prompt recognition and efficient treatment.

The first step is to grasp the uterus. If the hÆmorrhage is due to a tear low down, the uterus may be hard, but generally it is relaxed and requires vigorous massage with both hands before it shows any signs of contraction. In the absence of the doctor, the nurse must know how to undertake this maneuver. The uterus, after labor and especially when relaxed, is sometimes difficult to identify and the nurse can only make deep massage in the pelvis until the organ responds and its hard globular mass can be appreciated. As soon as the uterus contracts, clots and contained blood are expelled, and in many cases its bleeding ceases at once. (See Conduct of Third Stage, p. 149.)

It may be necessary to keep the uterus contracted by manual massage in this way for several hours. As soon as possible, the nurse, or someone whom she directs, prepares a hypodermic of pituitrin—10 to 15 ??. An injection of ergot may follow because its effect is more lasting than pituitrin. Next, a hot douche is made ready and the materials for packing the uterus are assembled.

When the doctor arrives, he sterilizes his hands, puts on gloves and introduces two fingers or the whole hand into the uterus to remove clots or any retained fragments of placenta.

The hot intrauterine douche may follow, and if the contraction is not firm and the hÆmorrhage checked, the uterus must be packed with gauze. If hÆmorrhage comes from cervix, it should be grasped with long forceps, pulled down, and sutured. If from perineum, pack first, and afterward sutures may be introduced.

If the patient is exsanguinated, the foot of the bed is raised, coffee given by mouth, camphorated oil hypodermically, and normal saline transfused under the breasts.

Pituitrin may be continued in larger doses. 1 c.c. will raise the blood pressure very definitely. Adrenalin also may be employed for this purpose.

The following summary may be found convenient:

Etiology, Functional.—

Atony of the uterus, especially after rapid artificial or natural emptying of the organ.

More common after uterus has previously been greatly distended.

Premature version and extraction.

Hydramnios and twins.

Imperfect development of uterine musculature.

Precipitate labors.

Haste or improper management of third stage.

Etiology, Mechanical.—

Retention of placenta—partial, total or solitary cotyledons.

Inversion of the uterus.

Placenta succenturiata.

Inflammation of decidua serotina.

Conduct of third stage, i.e., wait until placenta separates.

Etiology, Systemic, HÆmophilia.—

Kind of hÆmorrhage.

HÆmorrhage before expulsion of placenta due to laceration of the soft parts, or

Partial release of placenta and failure of uterus to contract, or

Placenta may be attached to periphery or to one side.

Attempts to expel placenta without waiting for uterine contraction are sometimes productive of hÆmorrhage.

HÆmorrhage after expulsion of placenta.

HÆmorrhage in interval between pains—comes from placental site.

HÆmorrhage in stream not checked by uterine contraction is due to laceration of the canal.

HÆmorrhage in abnormal quantities at beginning of pains.

Pure atony—comes early.

HÆmophilia again.

Diagnosis.—

Palpation of uterus through abdomen.

Placental site excluded from contraction (paralysis).

View of vulva.

Injuries. Flow continuous, fluid and bright red, shows arterial origin, probably from cervix. Examine.

Atony—bleeding at intervals, clotted and dark.

HÆmorrhage from a tear begins at once.

Uterus contracted and hÆmorrhage continues. Look for tear.

If hÆmorrhage does not begin within ten or fifteen minutes after labor it is not from a tear.

Always have hÆmophilia in mind.

Management.—

Third stage must be conducted properly.

Before expulsion of placenta—early expression.

CredÉ or manual removal—then secure contraction by massage.

Pituitrin, Ergot, or both.

After Third Stage.—

Restore an inverted uterus. Repair lacerations. See that cavity is clear and clean.

Massage, intrauterine hot water douche, hand in uterus and hand outside and rub, ergot.

Pituitrin hypodermically. Pack uterus with sterile gauze or weak iodoform gauze. Strict asepsis for all intrauterine maneuvers.

Treat anÆmia with transfusion, elevation of foot of bed, coffee, external heat, hot rectal enemas, stimulation, bandaging of legs.

Strychnine sulphate, adrenalin, or camphorated oil may be required in usual dosage.

Hypodermoclysis. (See Minor Operations, p. 206.)

After the bleeding stops, the food must be most nutritious—milk, eggnog, rich soups, chicken and mutton broths, oyster stew, and beef steak as soon as she can take it. A diet of fluids and stimulating foods that raise the blood pressure will most quickly relieve the symptoms.

Eclampsia occurs in the last three months of pregnancy as a rule, and most frequently just before or during labor.

In about one sixth of the cases only, the attack may follow labor. The attack is characterized by violent convulsions, which come on with little or no warning unless the urine has been carefully watched.

The prodromal symptoms have already been described under albuminuria in pregnancy (p. 77). The marked features may be repeated for emphasis: persistent headaches, disorders of vision, spots before the eyes, blindness, edema of cheeks, eyelids, feet and hands, pain at the pit of the stomach, dizziness, nausea and vomiting and ringing in the ears. Suddenly the convulsion occurs, the facial muscles twitch, then the limbs and body are shaken by violent muscular spasms. The body becomes rigid, the tongue protrudes and the face is livid and cyanotic. The spasm usually lasts from one to five minutes and is succeeded by coma that lasts an hour or more. In some instances there is no return to consciousness before the next attack, which comes on every hour or half hour, though occasionally only one seizure is noted.

The blood pressure is greatly increased and the urine is diminished, the temperature rises to 101° or 102° F. When death ensues, it is most frequently due to edema of the lungs or cerebral hÆmorrhage.

The greater the number of convulsions, the more serious the outlook as to life, and it is said that after twenty seizures fifty per cent of the mothers die. Under the best treatment approximately fifty per cent of the babies die.

There is no routine treatment for eclampsia.

The principles of management for the attack are (1) to empty the uterus, on the theory that the disease is a toxÆmia of gestational origin, (2) to eliminate the poison, and (3) to control the convulsions.

The albumin in the urine and other eclamptic symptoms demand urgent attention in prophylaxis.

For the pre-eclamptic period (see Albuminuria of Pregnancy, p. 77) a rigid milk diet is indicated. The bowels, kidneys, skin and blood vessels must all be brought into service.

In the full blooded patient, venesection may be done and after drawing off ten or twelve ounces of blood, an equal amount of normal saline may be poured into the same vein.

Subcutaneous transfusion or the submammary introduction of saline solution may be done. The skin is stimulated by hot wet packs and the bowels by saline cathartics and frequent irrigation of the colon.

During the attack, the patient must be kept from injuring herself. A spoon wrapped in gauze or a small, long roller bandage should be slipped between the teeth to keep the tongue from injury. The clothing must be loosened or removed. No food, but only water is given by mouth, until the patient is conscious.

The convulsions are controlled by morphine, chloral, or both.

Morphine sulphate, ¼ gr. is given hypodermically, followed in an hour by 30 gr. of chloral by mouth. Two hours later the morphine is repeated and six hours after the first dose of chloral, it is repeated. In this method (Stroganoff’s), four doses of chloral and six of morphine are given in twenty-four hours. That is all. When the stomach will not retain the chloral it may be given by rectum in milk. If a general anÆsthetic is used, it should not be chloroform, but ether.

The labor, if begun, should be expedited by forceps, or version and extraction. Bleeding during delivery should be looked upon as desirable. If more rapid measures of delivery seem demanded and obstacles exist, such as pelvic contraction, imperfect dilatation, or the prospect of a prolonged first stage, CÆsarean section or forcible delivery (accouchment forcÉ) may be attempted.

If the labor has not begun, when the convulsion occurs and a quick delivery by the normal passage does not seem feasible, then the CÆsarean operation may be the best treatment.