Symposium on Hemorrhage and shock ? Hemorrhage of the third and fourth stages of labor (postpartum atonic Hemorrhage and shock)

Abstract

In spite of the relative high number of mothers who still die from puerperal infection and toxemia, hemorrhage is the most frequent cause of maternal death.We shall limit our considerations in this paper, to the post-partum atonic hemorrhage. It is perhaps the only obstetric complication by which one verifies how quickly an inadequate treatment can transform a functional anomaly of the parturient uterus into an irreversible condition of the maternal organism. According to B~ECHA~r (1939): "the average time between delivery and death is five hours and twenty minutes, long enough for treatment". Out of a total of 168 maternal deaths, he verified that more than 70 % of the caseswere preventable, 62,5 % might have been avoided by the obstetrician and 9,5% by the patient herself, but 28% were not preventable.W3~. J. DIVe, MANN and collaborators (1947) announced, in the United States, for the biennial 1944-45, a rate of 30% of maternal deaths from hemorrhage. Some women did not die from hemorrhage, but in consequence of infection for their vital resistance is greatly reduced; he calls to our mind PASTO~E'S assertion (1937), that the pro bability of infection in puerperimn increases 400% in patients with hematocrit below-30 %. P.S. GOFFI, in the Maternity of Sgo Paulo (1947), found, in 19.887 eases, a maternal mortality of 4.37~ , with shock as cause of death in 39.1%; and puerperal infection and toxemia, each, in 24,1%. The eases of shock observed in private patients attained 29 %, and in poor patients 71%. The author attributes this disparity to predisposing factors. Such percentages prove how serious the problem of hemorrhage and shock still is, and how badly we need greater diffusion of obstetrical knowledge among physicians, nurses, midwives and patients themselves.SC~MID, in Germany (1927), expressed identical opinion. "We find death from hemorrhage of women in labor or neo-puerpera among the saddest facts of obstetric practice. Such events, that usually affect strong women, in the prime of life, are much to be deplored, considering Symposium on Hemorrhage and Shock. 175 that, in most cases, if properly treated, they might have been avoided. Cases of bleeding in the third stage, or immediately after, without any complication, such as that of a placenta previa or premature separation, in consequence of bad assistance, unconsciousness or highly deficient asepsis, are commonly preventable, and, although particularly tragic, cannot be attributed only to misfortune, but also, not rarely, to professional blame. LAB~ARDT (Basel) had the impression that one can be more easily consoled, in case of death from eclampsia or placenta previa, than from atonic hemorrhage1. ''In hemorrhage of the third stage, we must settle the difference between separation and expulsion of the placenta. It has been studied by WE~T~, ZA~GEMEISTEE and WEIBEL, but for the basic knowledge we are indebted to ST~I~ Senior and to BAUDELOCQUE. W1-NCKEL and A~L~LD investigated particularly the difference between adherent and retained placenta.The durati...