Fehling (Sammlung Klin. Vorträge, No. 308) compares the views and
practice of authorities in the treatment of the third stage of labor.
The various methods of placental delivery that have been advocated by
different writers are recounted. The reaction against Credé in favor of
expectancy, first started by Dohrn and Ahlfeld, has resulted in proving
the inferiority of the latter plan, and in a return to more active
methods. In a large number of German clinics, the uterus is allowed to
rest immediately after the expulsion of the child, without friction.
When the placenta lies detached in the lower uterine segment, which is
generally the case after fifteen or twenty minutes, nothing is to be
gained by longer waiting. The author is favorably disposed toward the
practice of Credé, which as he says, has never been shown by its
adversaries to be capable of harm when properly conducted. With
reference to the mechanism of placental separation, both theoretical
considerations and clinical observations favor the views of Duncan, yet
the question is not settled. Retained membranes may be removed with the
aseptic hand. Yet Credé and Olshausen consider the retention of even the
whole chorion free from danger, and clinical experience has shown better
results by the expectant plan in case of retained membranes than by
interference. These results, the author thinks, in the light of
Döderlein’s researches, are explained by the fact that the hand may
transport the peccant germs from the vagina into the uterus. The active
plan, with a preliminary vaginal disinfection and a vigorous asepsis
throughout, should yield better results than expectation. Interference
with these precautions is, at least, justified in case of atony and
hæmorrhage or fever, including, if need be, the use of the curette and
subsequently ergot. Dührssen’s method of tamponing the uterus in
post-partum hæmorrhage with iodoform gauze is favorably mentioned.
In the event of cervical tears causing troublesome hæmorrhage,
Kaltenbach, Schroeder and Leopold practice immediate suture. The author
thinks the vaginal tamponade is generally to be preferred. Yet, in
certain cases the suture may also be required, or the application of the
perchloride of iron on cotton pledgets to the bleeding surfaces.
Credé (Arch. f. Gyn., B. 32, H. 1) again discusses and defends his
method of managing the placental delivery which he prefers to call the
external method.
The duration of the third stage need not in the majority of normal
labors exceed fifteen to thirty minutes. In many instances a more
expectant plan of treatment is better. In occasional cases more rapid
delivery is demanded in the interest of the mother. Since the method is
free from danger when properly conducted, the expulsion of the placenta
may be hastened within reasonable limits if for no other purpose than to
save the time of the attendants and to spare the sufferings of the
patient. He claims that the amount of blood-loss is diminished under his
treatment of the placental stage, and that the membranes are not more
frequently retained. Furthermore, he believes the retention of portions
of the membranes or placenta to be harmless in an aseptic condition of
the passages.
The method of Credé, briefly restated, is as follows: First apply
gentle, painless friction in a circular direction over the anterior wall
of the uterus, laying the hand flat upon the abdomen. Bring the axis of
the uterus in conformity with the axis of the pelvic inlet. If the
placenta is not expelled after three or four pains assist the next
contraction, at its acme only, by compressing the upper segment,
grasping the fundus with the thumb in front and the fingers behind, at
the same time using gentle downward pressure. Use slight friction only
but no compression during the intervals between the pains nor even
during the contraction except at its height. Success usually attends the
eighth or tenth pain.