Edward Rigby

PLACENTAL PRESENTATION, OR PLACENTA PRÆVIA.

History.—Dr. Rigby’s division of hÆmorrhages before labour into accidental and unavoidable.—Causes.—Symptoms.—Treatment.—Plug.—Turning.—Partial presentation of the placenta.—Treatment.

There are few dangers connected with the practice of midwifery which are more deservedly dreaded, and which are wont to come more unexpectedly, both to the patient as well as to the practitioner, than that species of hÆmorrhage which occurs in cases where the placenta is implanted either centrally or partially over the os uteri. Well has a celebrated teacher observed, that “there is no error in nature to be compared with this, for the very action which she uses to bring the child into the world is that by which she destroys both it and its mother.” (NaegelÉ, MS. Lectures.) In other words, where there is this peculiar situation of the placenta it becomes gradually detached, either in proportion as the cervix expands during the latter months of pregnancy, or as the os uteri dilates with commencing labour, and is thus unavoidably attended with a profuse discharge of blood, which generally increases as the dilatation proceeds.

The peculiar feature of this species of hÆmorrhage, necessarily accompanying the commencement of every labour where the placenta is implanted over the os uteri, was first fully described in this country in 1775, by the late Dr. Rigby, in his classical Essay on the Uterine HÆmorrhage which precedes the Delivery of the full-grown Foetus, a work which has been justly looked upon, both in England and the Continent, as the great source to which we are indebted for our practical knowledge in the management of these dangerous cases.

History. There is abundant evidence to prove the sudden attacks of hÆmorrhage during pregnancy, attended with circumstances of great danger to the life of the mother and her child, were known from the earliest times, and especially noticed by Hippocrates where he says, “that the after-burden should come forth after the child, for if it come first, the child cannot live, because he takes his life from it, as a plant doth from the earth.” (De Morbis Mulierum, lib. i. quoted by Guillemeau.)

Hippocrates, therefore, evidently supposed that this presentation of the placenta at the os uteri was owing to its having been separated from its usual situation in the uterus, and fallen down to the lower part of it.

This view has been closely adopted by Guillemeau, to whom we are indebted for having called our attention to the above passage. He has devoted his fifteenth chapter[140] to the management of a case where the placenta presents, and shows that “the most certain and expedient method is to deliver the patient promptly, in order that she may not suffer from the hÆmorrhage which issues from the uncovered mouths of the uterine veins, to which the placenta had been attached; that, on the other hand, the child being enclosed in the uterus, the orifice of which is plugged up by the placenta, and unable to breathe any more by the arteries of its mother, will be suffocated for want of assistance, and also enveloped in the blood which fills the uterus and escapes from the veins in it which are open.”

The operation of turning, which had been newly practised by his teacher, Ambrose ParÉ, and still farther brought into notice by himself, at that time formed a great Æra in midwifery, for it furnished practitioners with a new and successful means of delivering the child in cases where urgent danger could only be avoided by hastening labour; hence, therefore, in all cases of profuse hÆmorrhage coming on before delivery, it was a general rule, if the case became at all dangerous, to turn the child.

Guillemeau’s explanation of the nature of placental presentations was still more explicitly adopted by Mauriceau, La Motte, and many others. Mauriceau invariably speaks of the placenta, when at the os uteri, as “entirely detached;” and adds that “even a short delay will always cause the sudden death of the child if it be not quickly delivered; for it cannot remain any time without being suffocated, as it is now obliged to breathe by its mouth, for its blood is no longer vivified by the preparation which it undergoes in the placenta, the function and use of which cease the moment it is detached from the uterine vessels with which it was connected: the result of this is the profuse flooding which is so dangerous for the mother; for if it be not promptly remedied she will quickly loose her life by this unfortunate accident.” (Vol. i. p. 332, 6th ed.) He also adds, “it must be observed that the placenta, which presents, is nothing more than a foreign body in the uterus when it is entirely separated,” (p. 333,) “for when it comes into the passage before the infant, it is then totally divided from the womb.” (Chamberlen’s Transl. p. 221. 8th ed.) In the sixteen cases which he has detailed, he has distinctly mentioned the fact in thirteen that the placenta was entirely separated from the uterus, and presented at the os uteri. In two of these he has expressly stated his conviction that the placenta had been detached from the uterus, by the mother having been exposed to a violent shock, when the cord was shortened from being twisted round the child.

These facts prove that Mauriceau, considered presentations of the placenta to arise solely from its having been separated by some accident from the fundus, and fallen down to the os uteri.

Dr. Robert Lee, in his “Historical Account of Uterine HÆmorrhage in the latter Months of Pregnancy,” (Edin. Med. and Surg. Journal, April 1839,) has omitted all mention of this circumstance, and from the account which he has given of Mauriceau’s observations, would infallibly lead his readers to suppose that Mauriceau was fully acquainted with the real nature of these peculiar cases. Thus, he commences with saying, “The symptoms and treatment of cases of placental presentation are here accurately described, and in all cases of hÆmorrhage from this cause he recommends immediate delivery;” and again, he observes, “The rules for the treatment of these cases are laid down with the greatest precision. When the placenta was entirely separated, then only did he consider it as a foreign body, and recommend its extraction before the child.” The student would be led by such a statement to suppose that Mauriceau did not consider the entire separation of the placenta as the most usual occurrence in these cases, and will therefore naturally infer that in the majority of cases of placental presentation, he recognised the implantation of the placenta upon the os uteri. That such was very far from the case, we have already shown by quotations from various editions of his work. Dr. Lee has collected sixteen, (not seventeen,) cases of placenta prÆvia from Mauriceau, and has given a short summary of them. Out of the thirteen cases in which Mauriceau has distinctly mentioned that the flooding had been caused by the entire separation of the placenta which presented, Dr. Lee has noticed it in only three; and in one of these he has reversed the expression by saying, “placenta presenting and entirely detached:” thus leading his reader to infer that the placenta had presented at the os uteri, but had become detached from it. Nor is the case (No. 423,) to which Dr. Lee has referred “as a proof that Mauriceau, was aware of the fact, that the placenta had not been wholly detached from the uterus,” at all tend to show that he had any idea of the placenta being implanted upon the os uteri.

By stating that “Mauriceau has also recorded the histories of thirty-seven cases of uterine hÆmorrhage in which the placenta did not present, but had adhered to the upper part of the uterus and been accidentally detached,” Dr. Lee has confirmed the erroneous inference that the implantation of the placenta upon the os uteri was known to this valuable author; whereas, we have proved by numerous quotations, that Mauriceau distinctly supposed that in all cases of hÆmorrhage before labour, whether the placenta was found presenting or not, it had been originally attached “to the upper part of the uterus.”

Paul Portal was the first, as far as we are acquainted, who describes the placenta as adhering to the os uteri. He has recorded eight cases, “in which,” as Dr. Rigby observes, “he was under the necessity of delivering by art, on account of dangerous hÆmorrhages, and in all of them he found the placenta at the mouth of the womb.” (Essay on Uterine HÆmorrhage, p. 22, 6th ed.) In these he distinctly mentions the placenta adhering to the os uteri. In several of these he separated it from the os uteri and brought it away; and in seven he turned the child. In the other (Case 39,) the head burst its way through the placenta. In one case only (51,) does he attempt to make any practical inference whatever, having in all the others contented himself with merely stating the fact of the placenta adhering to the os uteri. In this instance, however, he has described the real nature of the case, and pointed out the cause of the hÆmorrhage. On introducing his hand he “found the after-burden placed just before and quite across the whole inner orifice, which had actually been the occasion of the flux of blood; for by the opening of the orifice the said after-burden then being loosed from that part where it adhered to before, and the vessels containing the blood torn and opened, produced this flooding, which sometimes is so excessive as proves fatal to the woman unless it be speedily prevented.” (Portal’s Midwifery, transl. p. 167.)

There is no doubt, as Dr. Renton has very justly observed, “that Portal in 1672 (not 1683) knew as much on the subject of uterine hÆmorrhage occasioned by the displacement of the placenta from the os uteri, and the practice necessary for its suppression, as we do at the present time.” (Edin. Med. and Surg. Journ. July, 1837.) But we cannot coincide with him in the passage which follows, viz. “It is to him unquestionably that we are indebted for our knowledge on the subject,” because, as Dr. Renton himself has shown, all the authors in midwifery up to the time of Roederer and Levret (1753) were ignorant of Portal’s explanation. We do not even except Giffard, as there is sufficient evidence to show that he, for some time, entertained the prevailing erroneous opinions of Mauriceau, until he at last discovered the real nature of the case himself. We attribute the omission solely to the above observation of Portal being so short and isolated, and to its having been entirely unaccompanied by any other practical remarks or inferences which might have been expected from so remarkable a fact. To this reason alone can we attribute the circumstance of its not having been expressly mentioned by Dr. Rigby when alluding to Portal’s cases. In a similar way we can explain why Portal has not had the merit of a valuable improvement in the operation of turning which has been attributed to Peu, viz. the passing the hand between the membranes and uterus up to the fundus before rupturing them, solely because he mentions it as a cursory observation, without any farther notice or practical inference.

The next author who has at all alluded to the real nature of placenta prÆvia is Giffard, whose posthumous work was published in 1734. The value of his evidence on this subject is considerably modified by his having made no allusion to the implantation of the placenta upon the os uteri in the first ten cases of flooding, where he found the placenta presenting, but repeatedly describes the placenta as being wholly separated and lying in the passage, and in some, he expressly mentions that the placenta had fallen down to the os uteri. In cases 115, 116. and 224. he gives a perfectly correct explanation of the cause of flooding, but the opinion is expressed with such a degree of hesitation, and so cursorily, that we doubt much if it attracted more notice than the observations of Portal, above alluded to, more especially as in the six cases of placenta prÆvia, which occur between the last two above-mentioned (viz. 120, 121. 158. 160. 185. and 209.,) he returns again to his former mode of describing them. We, therefore, regret that Dr. Renton has not mentioned this circumstance, and that in quoting from “two of the numerous cases which he relates,” he has not stated that these were two out of the only three cases which Giffard had described correctly.[141]

It is, therefore, to the above-mentioned circumstances of Giffard having given what is now recognised as the correct explanation, in only three out of nineteen cases, that we can explain why so little notice was taken of the subject at that time; why Dr. Smellie, when speaking of it, makes no allusion to Giffard; and why Dr. Rigby, in his Essay on Uterine HÆmorrhage, was led to suppose that he was ignorant of the real nature of these cases: certain it is that his opinion could scarcely be called a decided one.

Smellie mentions that “the edge or middle of the placenta sometimes adheres over the inside of the os internum, which frequently begins to open several weeks before the full time; and if this be the case, a flooding begins at the same time, and seldom ceases entirely until the woman is delivered; the discharge may, indeed, be intermitted by coagulums that stop up the passage, but when these are removed it returns with its former violence, and demands the same treatment that is recommended above.” His cases contain no observation beyond the recital that a considerable hÆmorrhage had occurred, the placenta had been found presenting, and that he had turned the child. In his sixth case (Collect. 33, No. 2.) which is dated 1752, it is evident that he was ignorant of what had been said on the same subject by Giffard and Portal; for he observes, “This case being uncommon, I was uncertain at first how to proceed; but at last considering with myself, if I broke the membranes to evacuate the contained waters, so as to allow the uterus to contract and restrain the flooding, the foetus would be lost by the pressure of the head against the funis (which presented) in the time of delivery. I resolved in order to prevent this misfortune to turn the child, and bring it along in the preternatural way, which would give it a better chance to restrain the one, and save the other, if the operation could be performed in a slow cautious manner.” This forms the amount of his observations on this important subject, and, therefore, justifies the observation which Dr. Rigby has made, viz. that there are no practical inferences drawn from the cases; nor in his directions about the management of floodings, are there any rules given relative to this situation of the placenta.

Roederer decidedly stands pre-eminent, as being the first author who gave a distinct and complete description of this species of hÆmorrhage; he points out the cause of it, and accurately describes its symptoms and mode of attack; he shows that the placenta may be entirely or partially attached to the os uteri; that in the one case the hÆmorrhage will be very profuse, and artificial assistance will be required; in the other it will be slighter, and in many cases it may be left to nature.[142]Levret cotemporaneously with the first edition of Roederer’s work, published at Paris, a valuable paper on placental presentation, which, with the above-mentioned chapter of Roederer, must be looked upon as the first observations in which this form of hÆmorrhage was made a distinct subject of consideration. Although Levret has in no wise claimed the merit of being the first who had noticed the fact of the placenta being implanted upon the os uteri, still there can be no doubt that to him and Roederer we are indebted for having first investigated the subject and called the attention of the profession to its peculiar characters.

Levret has reduced his observations under three heads, viz. that the placenta is occasionally implanted over the os uteri, that hÆmorrhage under such circumstances is inevitable, and that the safest mode of remedying this accident is the accouchement forcÉ. He has also added a few valuable remarks, but by far the greater part of the essay is occupied with theoretical arguments to prove that it is impossible for the placenta, which had been attached to the fundus, to sink down to the os uteri. Indeed, beyond stating the three above-mentioned positions, which are undeniably of great practical value (although by no means original,) Levret has added but little which is not contained in Giffard, his chief merit being that of making it a subject of distinct consideration, and establishing it as a matter beyond doubt.

Levret cannot, however, be looked upon as the first who considered that the flooding, in cases of placenta prÆvia, was “inevitable,” although, from his not having quoted Giffard, we willingly concede to him the merit of originality, as far as he himself was concerned: it was Giffard, however, as far as we know, who first pointed out that hÆmorrhage was the necessary consequence of placental presentation, as is shown from what we have already quoted from him, although, to a certain extent, it was hinted at by Portal, in his fifty-first case. Levret’s memoir was afterwards reprinted in his large work, entitled L’Art des Accouchemens: the third edition, which appeared in 1766, was quoted by Dr. Rigby in the first edition of his Essay on Uterine HÆmorrhage, 1775,[143] in farther proof of the placenta being implanted over the os uteri, and being the cause of hÆmorrhage.

We are chiefly indebted to Dr. Rigby for a complete exposition of this important and interesting subject. His well-known essay on the uterine hÆmorrhage which precedes the delivery of the full-grown foetus has stood the test of time, and will ever remain, not less remarkable for its practical value, than “for the perspicuity and simplicity of its style.” (Renton, op. cit.) To Dr. Rigby, without doubt, is due the merit of having first distinguished hÆmorrhages, which occur before delivery, into accidental and unavoidable, a division so truly practical and appropriate, as to have placed this subject in the clearest and simplest possible light. “He was,” as Dr. Collins has justly observed, “the first English author who fully established this most important practical distinction in the treatment of uterine hÆmorrhages, although Levret had many years before published a somewhat similar statement.” Dr. Rigby’s arrangement has been adopted by Dr. Merriman, Dewees, and every other modern author of any note; and the medical world have amply testified their sense of its value, as well as of the work itself in general, by the numerous editions which it has undergone in this, and translations and reprints in other countries.

We have entered into an historical detail of the literature of this subject, from its having been asserted that Dr. Rigby “published an abstract of the doctrines of Puzos and Levret with the addition of some cases from his own practice,” (Burns, Principles of Midwifery, 9th ed., 1837, p. 364;) that he availed himself of the discoveries of Dr. Smellie and M. Levret, while he contrived to make the profession believe that his doctrines were original, (Hamilton, Practical Observations, &c., 1836, vol. ii. p. 238;) and that “no fact of the slightest importance has since (Smellie) been discovered relating to the causes and treatment of uterine hÆmorrhage in the latter months of pregnancy.” (Dr. R. Lee, Edin. Med. and Surg. Journ., 1839, vol. li. p. 389.) We, therefore, deem it only just to our readers, and also to the author, to lay before them his own account of what, at the time, he supposed to be a discovery, and how far he considered himself justified in laying claim to its originality.

“A case of hÆmorrhage, in which I found the placenta attached to the os uteri, occurred at a very early period of my practice; but not finding such a circumstance recorded in the lectures which I had attended, or taken notice of in the common elementary treatises on midwifery, I considered it at first merely as a casual and rare deviation from nature. In a few years, however, so many similar instances fell under my notice, as to convince me, that it was a circumstance necessary to be inquired after in every case of hÆmorrhage: and this conviction was confirmed by the perusal of cases in midwifery; for I then found that the fact of the placenta being thus situated had been recorded by many writers, though in no instance which had then reached me, had any practical inferences been deduced from it. It appeared to me, indeed, most extraordinary that such a fact, known to so many celebrated practitioners, should not long before have led to its practical application, and in consequence to more fixed principles in the treatment of hÆmorrhages from the gravid uterus; and I may, perhaps, be allowed to say, that I congratulated myself, young in years and practice as I was, in being, probably, the first to suggest an important improvement in the treatment of one of the most perplexing and dangerous cases in midwifery; and that I committed my observations on the subject to paper, not only under a conviction of their practical utility, but certainly also under an impression that my suggestions were original.

“Not long after the first edition was at press, indeed before the first sheet was printed, Levret’s dissertation on this subject fell into my hands, and in a note I referred to it as additional testimony in proof of the placenta, in these cases, being originally attached to the os uteri.

“I have been led into this little detail, because it has been suggested that I have borrowed my theory from Levret. After remarking the gross folly I should have been guilty of in quoting Levret, had I furtively adopted his opinions, it will, I trust, be sufficient for me unequivocally to declare that my original ideas on the subject were derived solely from my own personal observation and experience; and that having previously neither read nor heard of the placenta being ever fixed to the os uteri, the knowledge of such a circumstance, derived as before observed, came to me and impressed me as a discovery.

“I was, certainly, afterwards struck with the coincidence of the sentiments of Levret and myself on the subject, with the similarity of our practical deductions, and, allowing for the difference of language, even with the sameness of our expressions. I am farther not reluctant to acknowledge, that after reading Levret’s dissertation, I felt less entitled to the claim of absolute originality on the subject; and I now rest perfectly satisfied to divide with him the credit arising from the mere circumstance of communicating a new physiological fact. But were I even denied all claim to originality, I should still not be without the satisfaction of having, at least, materially contributed to diffuse the knowledge of an important fact, and of having established its practical utility on the unequivocal testimony of experience; for, had I seen Levret’s dissertation sooner, or had even my attention been first directed to the subject by its perusal, ought it to have superseded my publication? Was the practice in this country, at that time, at all influenced by Levret’s dissertation? or has it even since been translated into the English language? Was it, at that time, generally known that the attachment of the placenta to the os uteri was a frequent cause of hÆmorrhage? and were any directions for our conduct in these cases, founded on the knowledge of the fact, given by those who there lectured on the art of midwifery?

“Levret’s facts, moreover, though they proved that the placenta might be originally attached to the os uteri, (and a single instance would establish this,) were scarcely sufficient to prove the frequency of its occurrence, from which alone arises the necessity of practically attending to it in every case of hÆmorrhage. His observations (perhaps even more creditable to him for being founded on such scanty materials) were derived from four cases only, and of these, but two were under his own immediate cognizance; whereas, in the first edition of this essay my opinions were supported by 36 detailed cases, in 13 of which the placenta was found at the os uteri; and in the fourth edition the number was increased to 106, 43 of which were produced by this peculiar original situation of the placenta.” (Preface to the 5th ed.)

The causes of this peculiar deviation from the usual situation of the placenta are little if at all known. The condition of the decidua shortly after the entrance of the ovum into the cavity of the uterus, will probably influence the situation of the placenta considerably. Under the ordinary circumstances, this effusion of plastic lymph has already attained such a degree of firmness and coherence as to prevent the ovum from passing beyond the uterine extremity of the Fallopian tube from which it has emerged; but in cases of placental presentation it may be presumed that at this period the decidua was still in a semi-fluid state, had formed little or no attachment to the walls of the uterus, and had, therefore, no effect in preventing the ovum gravitating to the lower part, or even to the mouth of the uterus itself. We state this, of course, as a mere matter of theory, since the difficulty of investigation at such early periods, and the comparative rarity of placental presentations, will probably ever prevent our ascertaining the real cause.

Symptoms. The first symptom which warns us that the placenta is presenting, is the sudden appearance of hÆmorrhage, which is usually more copious than ordinary hÆmorrhage, and apparently comes on without any assignable reason: it is usually the more profuse the nearer the patient is to the full term of pregnancy, for not only now are the ruptured vessels larger, but the separation of the placenta is generally greater. If she has still some time to go, the discharge will be probably slight, and with rest and quiet, &c., will cease, to return again in ten days or a fortnight with increased violence: this usually happens at what would have been a catamenial period. The suddenness of its attack, the profuseness of the discharge, and its coming on without any evident cause, are peculiarly suspicious.

It has been stated that the abdomen is less distended in these cases than usual, from the placenta not being in the upper parts of the uterus: it is an observation, however, which requires to be confirmed, and certainly our own experience, as yet, has not led us to such a conclusion.

On examination, the os uteri is found to be larger and thicker than ordinary: it has a loose spongy feel, for its vessels are now as immensely distended as those of the fundus, when the placenta has its usual situation. If the placenta be partially attached over the os uteri, it is generally upon the anterior lip, which is much thicker. In this case we shall feel the edge of the placenta projecting at one side of the os uteri, and the bladder of membranes, and probably the presenting part of the child at the other. Whereas, if the placenta be centrally attached, we shall find it attached to the whole circumference, except perhaps where the separation is, from which the hÆmorrhage proceeds. We shall distinguish the placenta by its spongy mass, by its soft irregular surface, and by the stringy feel which it communicates where it has been torn.

The character of the hÆmorrhage is also different from that of common hÆmorrhage, inasmuch as it increases during a pain, and diminishes or ceases during the intervals, whereas, in hÆmorrhage under ordinary circumstances it is the reverse.

Where the hÆmorrhage takes place at some distance of time from the full period of utero-gestation, it probably arises from the gradual development of the cervix during the latter months of pregnancy: where, on the other hand, it does not appear till just before labour, the separation of the placenta will have been produced by the incipient dilatation of the os uteri itself. It might therefore be supposed, that the period of the attack would, in great measure, depend upon whether the placenta was centrally, or only partially, attached to the os uteri; that in the former case the placenta would be more liable to be separated by the gradual development of the inferior segment of the uterus; and that, therefore, hÆmorrhage would come on several weeks before the full term; whereas, if only a portion of it cover the edge of the os uteri, the patient would probably go to the very end of pregnancy before any flooding appeared. Although this view is supported by the high authority of Professor NaegelÉ, still we can scarcely agree with it, since not only do a considerable majority of recorded cases show that a patient with central presentation of the placenta may go to the full time without an attack of flooding, but also several of those which have come under our own observation lead to a similar conclusion.

The most alarming attacks of hÆmorrhage are doubtless at the full term, when the os uteri is beginning to dilate from commencing uterine contractions, and the placenta is centrally attached over it: in these cases the discharge experiences little or no abatement beyond an occasional short remission, but returns with the pains, increasing in profuseness as the gradually dilating os uteri produces a still farther separation of the placenta. Such cases, if left to themselves, would almost necessarily prove fatal. The first fainting fit or two would probably produce a temporary cessation of the discharge, and favour the formation of coagula in the upper part of the vagina; but with returning contractions of the uterus, the hÆmorrhage would be renewed with increased violence, and quickly reduce the vital powers. In such cases the patient will probably die undelivered, or soon after the birth of a dead child. In some rare instances, the pains have been sufficiently powerful to force the head through the placenta, and thus enable the mother to be delivered by the natural means, although with little chance of the child being born alive, from the injury which the foetal vessels in the placenta have received. Portal’s twenty-ninth case terminated in this way. A similar and very interesting case was lately communicated to us by Mr. W. White, of Heathfield, in Sussex, where the placenta appears to have been centrally attached to the os uteri, and where, in consequence of two or three powerful pains, the head was forced through, tearing it quite across. The child was born dead, but the mother did well.

In a few rare cases the placenta has been entirely separated and expelled before the child, but these have usually been attended with a most alarming loss of blood. In almost all the cases related by Mauriceau, and in the majority of those by Giffard, the placenta is stated to have been entirely detached from the uterus, but this was evidently under the mistaken supposition of the placenta having been originally separated from the fundus. “It is extremely rare to meet with a total separation of the placenta. Dr. Clarke informed me that he met with but one case of total separation; the patient dying before he reached the house.” (Collin’s Pract. Treatise, p. 92.) A still more remarkable instance is recorded by Dr. Collins, where the placenta had been expelled many hours (probably about 18) before the birth of the child. “The membranes had ruptured, and the waters been discharged a fortnight previous to admission, from which time, until the evening before she was brought to the hospital, she had more or less hÆmorrhage. It was now ascertained that the placenta had been expelled the evening before her admission, and separated by the midwife in attendance. She left the hospital well on the thirteenth day.”[144] (Op. cit. p. 103.) In all these cases the child has been born dead, and must ever be so, where any period of time has elapsed between the expulsion of the placenta and that of the child. The only case we know of where a living child was born after the expulsion of the placenta is recorded by F. Ould. “I found this woman in imminent danger, being seized with faintings and hiccough, having her face pale and Hippocratic. Upon examination, I found the placenta presented to the orifice of the womb, which I immediately extracted; and although the head was far advanced in the passage, I put it back into the womb, and taking hold of the feet brought a living though very weakly child into the world. The mother also recovered, though with much difficulty.” (Treatise on Midwifery, p. 77.) La Motte has described a similar case, but where the child died immediately after birth. (Obs. 238.)

The irregularity with which cases of placental presentation have appeared at different times, have more than once excited notice: thus it frequently happens to ourselves that several years have elapsed without our meeting with a single case, although connected with a large lying-in hospital; whereas, at other times two or three cases have followed each other at comparatively short intervals. In selecting ten successive years from the period during which Dr. Rigby observed the numerous cases recorded in his essay, we see this irregularity remarkably exemplified.

In 1779 three cases.
In 1780 four cases.
In 1781 none.
In 1782 five cases.
In 1783 one case.
In 1784 five cases.
In 1785 two cases.
In 1786 two cases.
In 1787 one case.
In 1788 two cases.

A still more remarkable variation has been described by the celebrated Matthias Saxtorph, of Copenhagen. Having stated that placental presentation had occurred only once in 3600 cases, he adds, “the reader will be astonished when I assure him that this case, which is so rare that I had only seen it twice in so many years, and that I had met with it but once out of so many thousand labours at our lying-in hospital, occurred to me in the last six months, eight times.” (Collect. Soc. Med. Havn. 1774, vol. i. p. 310.) Professor NaegelÉ has made a similar remark in his lectures, and states, that in some years placental presentation was so frequent that it seemed as if it were almost epidemic.

Experience proves beyond doubt, that, of the serious floodings which occur during the last weeks of pregnancy, the majority arise from the attachment of the placenta to the os uteri. Dr. Rigby also states “that this attachment of the placenta to the os uteri is much oftener a cause of floodings than authors and practitioners are aware of, I am from experience fully satisfied; and so far am I convinced of its frequent occurrence, that I am ready to believe that most, if not all, of those cases which require turning the child, are produced by this unfortunate situation of it.”

The period of pregnancy at which hÆmorrhage may come on from placental presentation, varies very considerably. Although, in by far the majority of these cases, it does not come on until the last four or six weeks, it now and then occurs at a much earlier period, viz. the sixth or even the fifth month, and sometimes even earlier. Where this is the case, it must rather be looked upon as one of “accidental” hÆmorrhage or abortion, for it can scarcely be supposed that any changes about the os or cervix uteri could have been sufficient to have produced an “unavoidable” separation of the placenta at this time. Thus, for instance, in Dr. Rigby’s seventy-fifth case, the first attack of hÆmorrhage had appeared when the patient “was about three months gone with child;” and at that early period could hardly have been attributed to the peculiar situation of the placenta, but to the more common causes of hÆmorrhage connected with abortion. In his forty-third case, the hÆmorrhage, which came on about the twenty-sixth week, appears at first to have been purely “accidental,” although it was afterwards produced by “unavoidable” attachment of the placenta. “We very seldom meet with unavoidable hÆmorrhage before the sixth month of pregnancy; it is not until the cervix uteri begins to distend freely, and the changes that take place previous to the approach of labour commence, any suspicions are observed; consequently, it will be in the last three months of utero-gestation that hÆmorrhage of this nature is found to occur.” (Collins, op. cit. p. 93.)

The examination of a case where the placenta presents is not always easy; the natural position of the os uteri during the latter months of pregnancy in the upper part of the hollow of the sacrum makes it very difficult for the finger to reach so completely as to afford us the means of ascertaining satisfactorily whether the placenta be attached to it or not. “For this purpose, however, the usual method with one finger will not always suffice, but the hand must be introduced into the vagina, and one finger insinuated into the uterus; for in several of the following cases it will appear, that though the women were frequently examined in the usual way, the placenta was not discovered till the hand was admitted for the purpose of turning the child.” (Essay, 6th ed. p. 35.)

Treatment. We have already stated that the earlier the period at which the flooding comes on, the less profuse it will be; the treatment, therefore, where the hÆmorrhage is inconsiderable, differs but little from that in an ordinary case of abortion or miscarriage. The indications, in fact, are the same, viz. to stop the discharge, and allay any disposition to uterine contraction.

The patient must be placed upon a mattress, and covered as lightly as possible with safety and tolerable comfort to herself. If the circulation be active, the pulse strong, with more or less heat of surface, it may even be desirable to reduce this by means of the lancet. “Under any kind of active hÆmorrhage, when the pulse is vigorous, the taking away blood from the arm has uniformly been found useful, by producing contraction by the mere unloading of the vessels, and more especially in diminishing the velocity of blood within them.” (Dewees, Compend. Syst. of Midw. p. 441.) Cold cloths must be applied to the vulva, loins, and over the symphisis pubis; gentle saline laxatives with nitrate of potass should be given if the bowels are confined; and if there be the slightest appearance of the pains, an injection of twenty or thirty drops of Liq. Opii Sedat. into the rectum will be necessary. This may be given immediately where the bowels are not confined, or, if they are, after the rectum has been washed out by a large domestic enema. If necessary, she should also take an opiate by the mouth. Her food must consist of little else than plain drinks, as tea, milk and water, &c., all of which must be taken cold; and she must preserve the most perfect quiet of body as well as mind. We cannot agree with Dr. Dewees in permitting “our patients, under treatment for uterine hÆmorrhage, to be five or six days without a discharge from the bowels;” as a loaded state of the lower bowels cannot fail in our opinion to obstruct seriously the free return of the circulation from the pelvic viscera, and thus greatly increase the disposition to congestion and hÆmorrhage.

The longer the patient has still to go, the more desirable is it that we should, if possible, control the symptoms, and prevent them from proceeding to such extent as to require artificial delivery. It is of the utmost consequence that we should take such measures as will enable the pregnancy to go on safely, if not to the full time, at least to a later period, for by this means the uterus will have attained such a degree of development as will enable the turning to be undertaken with ease to the practitioner and with safety to the mother; the child also will have so far advanced towards maturity as to give it a better chance of surviving the operation.

Wherever hÆmorrhage has occurred during the last three months of pregnancy, which has come on suddenly and without any assignable reason, we should earnestly warn the patient and her friends to summon the practitioner the moment there are any symptoms of its return; for if it be a case of placental presentation, it assuredly will return, and as certainly much more profusely than at first.

Where the patient has gone nearly or quite to her full time, the first attack is much more alarming; the hÆmorrhage frequently appears with a sudden gush, and in a few minutes a serious and even dangerous quantity of blood is lost; thus a patient whom we had seen but a few hours previously in perfect health, was suddenly seized with profuse flooding as she was standing at the door of her house speaking to a person, and before she could move, a large pool of blood had formed at her feet; in another case, the patient while standing at her tea-table was attacked in a similar manner, and in a moment the floor was deluged with the discharge.

Although artificial delivery by turning the child is required in every case of central presentation of the placenta during the latter periods of pregnancy, it is evident that this will not apply during the earlier months, when the uterus from its size will preclude the possibility of such an operation. Dr. Rigby has established a valuable axiom on this point, viz. “that when the uterus is too small for the admission of the hand, the expulsion of the placenta and foetus will happily be timely effected by nature. It is well known that in the early months, instances of fatal termination by floodings have been very rare, as abortion sooner or later puts a stop to the discharge. It has been likewise before observed, that in floodings at any period of pregnancy, women seldom die, at least not in the first instance, unless a considerable quantity of blood has been suddenly lost. Now, as the danger of a great and sudden loss must obviously depend upon the size of the uterine vessels, and as the enlargement of the vessels is in exact proportion to the increased size of the uterus, it becomes probable that when the vessels have acquired such a magnitude, that when detached from the placenta they would bleed largely and suddenly, the uterus itself must have attained to such a capacity as to admit the hand for artificial delivery.” (Op. cit. p. 48, 6th ed.) He farther observes, “that as the most material increase of the uterus does not take place until the end of the sixth month of pregnancy, a hÆmorrhage before that period will seldom require artificial delivery; and after that period, should it become necessary, that it is probable the hand may then be admitted for that purpose.” (Ibid. p. 51.)

In almost every case where the patient is some time short of her full time, the os uteri will be found unyielding and but little dilated; it will, therefore, seldom be possible, and scarcely ever proper, to introduce the hand into the uterus under such circumstances; the os uteri either entirely resists our efforts, or if we do overcome it, the degree of force required to effect this has been so great, as will in all probability have been attended with serious injury to the part itself. In no case is it proper or safe to force delivery by artificially dilating the os uteri, when it is contracted and unyielding (see Turning;) but where the placenta is presenting, it is peculiarly dangerous, for even slight laceration of the os uteri will be followed by serious consequences. Where the placenta is situated in the upper part of the uterus, it is of very little consequence if the edge of the os uteri has been torn somewhat during labour; but in the present case it is very different; the os uteri now plays the part of the fundus, its vessels are immensely dilated, and large ones are ruptured, which cannot be closed by the firmest contraction of the uterus.

“In recommending early delivery, I think it right, however, to express a caution against the premature introduction of the hand, and the too forcible dilatation of the os uteri before it is sufficiently relaxed by pain or discharge; for it is undoubtedly very certain that the turning may be performed too soon as well as too late, and that the consequences of the one may be as destructive to the patient as the other.” (Rigby, op. cit. p. 37.) Cases have occurred where the os uteri has been artificially dilated, where the child was turned and delivered with perfect safety, and the uterus contracted into a hard ball; in fact, every thing seemed to have passed over favourably; a continued dribbling of blood has remained after labour, which resisted every attempt to check it; friction upon the abdomen and other means for stopping hÆmorrhage by inducing firm contraction of the uterus were of no use, for the uterus was already hard and well contracted; the patient has gradually become exhausted, and at last died; on examination after death, Professor NaegelÉ has invariably found the os uteri more or less torn.

“It must be acknowledged, indeed,” says Dr. Rigby, “that it may sometimes happen that at the very first coming on of the complaint, if the discharge be small, and more especially, if it be the patient’s first child, and the parts be close and unyielding, the admission of the hand into the vagina, as I have directed, will be attended with the utmost difficulty, and, perhaps, be almost impracticable: in this case let us wait (but let it be with the patient) till the discharge increases, and has continued long enough to relax the parts; for certainly, if the woman be able to bear losing a little blood, which at first she may safely do, the examination will be thereby rendered more easy, and the turning of the child, if necessary, be more practicable and safe.” (Op. cit. p. 36.)

We have already shown (see Turning, p. 236.) that there is no means of rendering a rigid os uteri yielding and capable of admitting the hand equal to the relaxation produced by loss of blood: wherever the powers of the system have already suffered from the effects of hÆmorrhage, we may feel almost certain that we shall find the os uteri capable of dilating, even if it be so little open as barely to admit the finger. Where the patient has become faint or fallen into actual syncope, the relaxation of the soft parts is very striking, and frequently to an extent which could scarcely be believed by those who have not felt it; all resistance seems to be at an end for the time, and the hand enters the flaccid passages with scarcely a sensation of pressure from them, but rather (as has been aptly compared, to that of some wet bladder wrapped around it.)

“It has been advised (observes Dr. Rigby) never to introduce the hand till nature has shown some disposition to relieve herself by the dilatation of the os uteri to the size of a shilling, or a half-crown; and this rule is certainly founded on a rational principle, for when it is so much dilated, there is no doubt but the turning may be easily and safely effected; but from some of the annexed cases it appears that a dilatation to this degree sometimes does not take place at all; and that even when the woman is dying from the great loss of blood, the uterus is very little open; the reason for which, seems to be, that when the discharge has been considerable, and more particularly when much blood has been suddenly lost, such a faintness is brought on, that though the uterus be totally relaxed, and might, therefore, be opened by the most gentle efforts, yet nature is unable to make use of these efforts; and, moreover, if there be slight pains, the adhesion of the placenta to the internal surface of the mouth of the womb, counteracts their influence, and thereby hinders its giving way to a power, which would otherwise, probably, very easily open it.” (Op. cit. p. 39.)

Plug. Where, however, the case is at that doubtful period of early pregnancy, when even under the most favourable circumstances, as above-mentioned, the hand must experience considerable difficulty in entering the os uteri, and yet the expulsion of the child cannot be safely trusted to the natural powers, it becomes necessary, as in certain cases of premature expulsion, to have recourse to such means as shall enable the os uteri to go on dilating without the danger of farther hÆmorrhage; in other words, we must plug the vagina. “If, after the commencement of a flooding, we favour the formation of a coagulum by means of a plug, are we not aiding nature? It brings on labour much sooner, and the os uteri has time to dilate without farther loss of blood.” (Leroux, Sur les Pertes de Sang. § 309.) By means of the plug, we enable the patient to go on with perfect security until the pains have produced a sufficient dilatation of the os uteri to admit the hand; after a time we may withdraw it, and if then not satisfied with the state of the os uteri, it must be again introduced until our object be effected. (For directions as to the use of the plug we must refer to p. 152.)

“This remedy should be early employed, as it will, by proper management, save a prodigious expenditure of blood. We gain by its application important time; time that is essential for the successful delivery of the foetus; for, by it, the woman’s strength is preserved; pain is permitted to increase; and, eventually, though tardily, the os uteri is dilated, the placenta and foetus thrown off, and the flooding almost immediately controlled. The other means which we have constantly pointed out, should also be tried: they may aid the general intentions, and render the operation of the tampon more certain.” (Dewees, Compend. Syst. of Midw. § 1142.)

Although Dr. Rigby has given a short account of Leroux’s views respecting the use of the plug in these cases, we cannot but agree with Dr. Dewees, in regretting that he either did not “put his plan in execution,” or that if he did, he has not given us the details of his experience upon it. From what Dr. Gooch, however, has stated in his Account of some of the more important Diseases peculiar to Women, there is every reason to suppose that Dr. Rigby was latterly in the frequent habit of using the plug, and that he thought highly of it. The plug is not only useful in keeping the hÆmorrhage under due control until the os uteri be sufficiently dilated, but may occasionally prove of the greatest value in cases of extreme exhaustion from loss of blood, where the patient is too much reduced to undergo the act of delivery, without running the risk of dying during the operation; the plug will enable us to wait with safety until the system has had time to rally its powers and be recruited by the administration of proper nourishment. “Mr. Grainger, of Birmingham, on visiting a poor woman with placenta prÆvia, and apparently in a moribund condition, immediately filled the vagina and os uteri with linen cloths, and waited two days before he durst hazard delivery, which he accomplished with an auspicious result.” (Ingleby, on Uterine HÆmorrhage, p. 155.)

Turning. The operation of turning the child will, in no wise, differ from that under more ordinary circumstances, and will require to be conducted according to the rules which we have already given. In no case is it more important to preserve the membranes unruptured until the hand has fairly entered the uterus than here; the hand should be carefully insinuated between the os uteri and placenta; if possible, this should be done at the part where the separation which has caused the flooding has already taken place, in order to avoid all unnecessary detachment of the placenta; the pressure of the hand prevents any great discharge of blood; and as it gradually makes its way between the membranes and the uterus, the arm which now occupies the vagina will effectually act as a plug. Portal, was, probably the first who practised this mode of operation, viz. passing his hand between the os uteri and placenta, and then between the uterus and membranes before rupturing them: in this respect he anticipated Peu, whose work appeared nine years after, (see Turning, p. 234.) and would have undoubtedly been looked upon as the originator of this improvement in turning, had he given any reasons for this mode of practice, or deduced any inferences from it.

Some discrepancy of opinion has existed as to whether it is better to perforate the placenta, or to follow the plan we have just recommended. Dr. Rigby’s authority has rather tended to confirm the former opinion, although he afterwards modifies it so much so as to make us almost suppose that he must have preferred the other method. He states, “that by this means, (perforating the placenta,) not more of the placenta may be separated than is necessary for the introduction of the hand, and, consequently, that as little increase of bleeding as possible may be produced by the operation; but if it be impracticable, as I have more than once found it, and it must ever be when the middle of the placenta presents to the hand, from the thickness of it near the funis, it must be carefully separated from the uterus on one side, and the hand passed till it gets to the membranes.” (Op. cit. p. 61.)

To Dr. Dewees are we chiefly indebted for having put the inexpediency of perforating the placenta in the strongest possible light. “We are advised by some,” says he, “to pierce the placenta with the hand; but this should never be done, especially as it is impossible to assign one single good reason for the practice, and there are several very strong ones against it.

“1. In attempting this, much time is lost that is highly important to the patient, as the flooding unabatingly, if not increasingly, goes on.

“2. In this attempt we are obliged to force against the membranes, so as to carry or urge the whole placentary mass towards the fundus of the uterus; by which means the separation of it from the neck is increased, and consequently, the flooding augmented.

“3. When the hand has even penetrated the cavity of the uterus, the hole which is made by it is no greater than itself, and consequently much too small for the foetus to pass through without a forced enlargement, and this must be done by the child during its passage.

“4. As the hole made by the body of the child is not sufficiently large for the arms and head to pass through at the same time, they will consequently be arrested; and if force be applied to overcome this resistance, it will almost always separate the whole of the placenta from its connexion with the uterus.

“5. That when this is done, it never fails to increase the discharge, besides adding the bulk of the placenta to that of the arms and head of the child.

“6. When the placenta is pierced, we augment the risk of the child; for in making the opening, we may destroy some of the large umbilical veins, and thus permit the child to die from hÆmorrhage.

“7. By this method we increase the chance of an atony of the uterus, as the discharge of the liquor amnii is not under due control.

“8. That it is sometimes impossible to penetrate the placenta, especially when its centre answers to the centre of the os uteri; in this instance much time is lost that may be very important to the woman.” (Op. cit. § 1153.)

We have already stated why it is so particularly important not to use any force in passing the hand through the os uteri: the less we separate the placenta, the less also will be the hÆmorrhage; and even this will be in great measure controlled by the presence and pressure of the hand itself. In no case of turning is it so important to have all the circumstances connected with the operation as favourable as possible, for the case itself is sufficiently dangerous without being increased by other unfavourable causes. To hurry the delivery would be only to increase the danger: the operation must be performed slowly and with caution: every rule which we have given, (see Turning,) for ensuring its safe and successful termination, must now be adhered to with double vigilence. “Should the woman,” says Dr. Dewees, “be very much exhausted before we commence our operations, we should use additional caution in the delivery. It should be very slowly performed, and we should have at each step of the progress assurances, if possible, that the uterus has not lost, or rather that it possesses, sufficient contractility to render the completion of the operation eventually safe, if performed with due and necessary care.” (Op. cit. p. 463.)

When once the os uteri is sufficiently dilated to admit the hand, there will not be much fear of the patient losing much blood during the turning, for during the first part of the operation the hand and arm act both as a compress and plug; and afterwards, when the body of the child is advancing, this will act in a similar manner. There is little danger of hÆmorrhage coming on after the child is delivered, for the contraction of that part of the uterus to which the placenta has been attached is much greater in these cases than it is where the placenta is situated in the upper parts of the uterus under ordinary circumstances. The placenta, which is already separated to a certain extent by the introduction of the hand, usually comes away without any trouble as soon as the child is delivered. We once met with a case where it was firmly adherent to the os uteri on one side, and required to be artificially removed, which was effected without difficulty. In this instance, hÆmorrhage returned after the labour from uterine inertia, and was checked by the means already recommended. (Med. Gaz. Sep. 2, 1837.) The after treatment should be conducted upon the same principles as in other cases of hÆmorrhage.

Partial presentation of the placenta. Where this is the case, the danger is rarely so alarming, nor is it always necessary to effect artificial delivery by turning. The edge of the placenta frequently projects but a very little over that of the os uteri, feeling, as it were, like a second lip; at other times it covers a third or more of the opening, and is usually attached upon the anterior portion of it. Our own observations have rather led to the conclusion, that where the placenta is but partially attached over the os uteri, the first attack of flooding is rarely delayed until the full term of pregnancy, but makes its appearance some weeks earlier. We are inclined to attribute this to the os uteri being only in part covered with placenta; that its other portion, being free, is more capable of dilatation from slight causes, than it would be were the placenta centrally attached: from a similar reason we may understand why the hÆmorrhage is seldom so profuse in these cases as to be dangerous, and why the os uteri usually dilates sufficiently soon to allow the head to descend and be born by the natural powers. We are confirmed in this view by what we have already quoted from Dr. Rigby respecting the os uteri being prevented dilating by the close adhesion of the placenta—an opinion which is, moreover, approved of by Dr. Dewees as being “both ingenious and probable.” Hence, also, we may reverse our position, and say, that in a case of partial presentation of the placenta, we shall seldom find the hÆmorrhage very profuse, until the os uteri has attained a considerable degree of dilatation. Besides the portion of placenta which presents, there will be also a bag of membranes occupying the remaining portion of the opening; we shall rarely, if ever, meet with those difficulties connected with a contracted and unyielding state of the os uteri, which we described in cases of central presentation; and if the hand requires to be introduced, which is not often the case, it will seldom experience much opposition.

Treatment. In our treatment of partial presentation of the placenta, we must be guided, in a great measure, by the strength of the pains and the degree of dilatation which the os uteri has attained; the extent to which it is covered by the edge of the placenta, must also be taken into consideration. Where the pains are strong and active, the pressure of the membranes distended by liquor amnii against the mouth of the womb will be sufficient to check the hÆmorrhage; if not, by rupturing them we shall be enabled to let off the liquor amnii, and thus allow the head to press directly upon the os uteri, and act in the double capacity of a plug and compress. Where the pains are slow and inactive, the rupture of the membranes will diminish the size of the uterus, and thus excite it to more powerful contraction; if not, a dose of secale cornutum, repeated according to circumstances, will be of great assistance. If the patient has suffered a good deal by the loss of blood, a little beef-tea, in small quantities frequently repeated, will rouse the powers; wine or a little brandy, may also be given at intervals; but unless the prostration be very serious, we have not found stimulants so useful as beef-tea, which is usually, also, much more grateful.