ON THE 
Relations of the Placenta 
TO 
POSTPARTUM HEMORRHAGE 
WALTER COLES, M. D, 
CONSULTING PHYSICIAN TO ST. ANN’S LYING-IN ASYLUM, ST. LOUIS. 
READ BEFORE THE ST. LOUIS MEDICAL SOCIETY, MARCH sth, 1880. 
[Reprinted from the St. Louis Medical and Surgical Journal, Mar. 5, 1880.J 
Mr. President :—ln 'postpartum hemorrhage the general ad- 
vice of obstetrical authorities is embraced in two injunctions; 
secure uterine contraction, and, if the placenta is still retained, 
see that it is promptly delivered. Now, since it is a universally 
admitted fact that a tonically contracted uterus cannot bleed, it 
must be conceded that the former of these aphorisms is a sine qua 
non. But the second, in regard to the. removal of the placenta, 
admits of qualifications which we would do well to study. 
First, let us inquire in what way the presence of the placenta 
within the uterus contributes to the hemorrhage or to its contin- 
uance. It is claimed that a retained placenta may produce hem- 
orrhage for two reasons, (1) because it offers a mechanical 
obstacle to perfect uterine contraction; (2) because, if partial!}? 
adherent, it directly promotes the bleeding. (When there is no 
detachment of the placenta there can, of course, be no hemor- 
rhage.) It will be readily seen that two physical elements must 
necessarily enter into all cases of postpartum hemorrhage. 
There must be imperfect uterine contraction and partial or com- 2 
plete placental separation. As a rule, it will be found that the 
profuseness of the hemorrhage will be in direct ratio to the uterine 
inertia, and inversely proportional to the area of adherence of 
the placenta. That is to say, the flow of blood will be in di- 
rect proportion to the laxity of uterine fibre, and to the extent 
and number of ruptured vessels in the utero-placental site. If 
this be true, it is evident that in ordinary labor the presence of 
the placenta in utero can only promote hemorrhage in so far as it 
offers a mechanical obstacle to uterine contraction, whilst it really 
lessens it to the extent of its adherent surface. Although we are 
aware that this latter proposition is in direct conflict with high 
authority, we think it tenable on physiological and clinical 
grounds, and hence we are justified in concluding that the only 
prossible good which can accrue from a speedy delivery of the 
after-birth in postpartum hemorrhage is the mere mechanical one 
of clearing the cavity of the womb of so much foreign material 
in the same manner, and for the same reason, that we would 
sweep out so much clotted blood, simply to get rid of it, and in 
order to clear the way for local styptics within the uterine cavity. 
I desire to provoke a discussion of this question, because I am 
satisfied that there is much to be said on both sides of it, and for 
the reason also that most of our text books offer very loose and 
empirical advice on the subject, which is well calculated to mis- 
lead students and practitioners who are taught to regard the 
presence of the placenta in the uterus as a thing necessarily hurt- 
ful, and to be gotten away at all hazards and as speedily as pos- 
sible. Entirely too much stress being laid upon the retention of 
the afterbirth and too little upon the fundamental fact that the 
placenta has, in nine cases out of ten, nothing whatever to do 
with the bleeding, which is rather due to absence of uterine con- 
traction, to inertia. In proof of this assertion, it is only neces- 
sary to recall the fact that in ordinary labors the retention of the 
placenta, whether partially or wholly detached, does not produce 
hemorrhage. Common experience teaches us this, and so long 
as we are convinced that the uterus is firmly contracted upon the 
placental mass, we all are accustomed to feel satisfied and await 
with composure and confidence the advent of secondary pains, 
and when finally, after a rest of fifteen or twenty minutes, the 
placenta is thrown off, its expulsion is accompanied by no abnor- 
mal flow of blood. Yet it must be evident to any mind that if 
the placenta wore the offending cause in these cases, every mother 3 
would bleed nearly to death before this body could be gotten rid 
of in the course of nature. 
We repeat that most of our obstetrical works are not suffi- 
ciently discriminating and explicit on this point; they do not ex- 
plain with clearness the mechanism of the hemorrhage, and the part 
which the retained placenta plays in promoting it, but leave the 
student to infer that its retention is really the foundation of all 
the trouble. The practice in these cases partakes too much of a 
blind, routine procedure. For instance, Leishman, in his chapter 
on “Hemorrhage After Delivery,” reminds the student in the first 
paragraph that “Retention of the placenta and consequent hemor- 
rhage may be the result of mismanagement.” Undoubtedly this 
is true in some instances, but upon reading a general statement 
like this upon the very threshold of the subject, the inexperienced 
practitioner, who naturally looks to his books for advice, will 
reason thus; if the hemorrhage is a “consequence ” of retention 
of the afterbirth, and such retention the result of a palpable 
“mismanagement,” then, of course, the proper course is to empty 
the uterus as the first step towards eradicating the mischief. And 
he will probably pi’oceed to do this even in the absence of uterine 
contraction, a measure, which in the latter case, while accom- 
plishing no possible good, would probably make matters worse. 
Still, in every event, whether there be inertia or not, the student 
has the same dogmatical advice to guide him, for, this author, 
on the next page, “In all these cases the treatment is the same, 
and consists in the speedy removal of the placental mass,” (p. 
391). Dr. Playfair, whose work is the best recently published, 
the usual stress upon the importance of emptying the uterus. 
“When the placenta is retained it is the more essen- 
tial, as the hemorrhage cannot possibly bo checked as long as the 
uterus is distended by it.” Now, we ask, is this proposition of 
Dr. Playfair’s true ? Is it a fact that the mere bulk of an ordi- 
nary placenta (not abnormally adherent) can sufficiently distend 
the uterus to provoke serious hemorrhage ? A moment’s reflec- 
tion will soon convince anyone to the contrary. Indeed, I think 
that the author has elsewhere in his work, clearly answered this 
question in the negative. We have already called attention to 
the fact that when the uterus contracts pi’oporly there is, in com- 
mon labor, no hemorrhage during the interval between the 
birth of the child and the natural extrusion of the placenta, a 
period covering from ten minutes to half an hour, and hence 4 
the conclusion is irresistible that so long as the womb performs 
its part faithfully, the mere mechanical presence of the placenta 
is incapable of harm. So true is this, that Dr, Playfair, in his 
chapter on the “Management of Labor,” takes particu- 
lar care to warn his readers against “undue haste” in removing 
the afterbirth, a practice which he very properly believes “tends 
to increase the risk of postpartum hemorrhage (p, 279). He 
moreover adopts the rule laid down by McClintock, that fifteen 
or twenty minutes should elapse before making any attempt to 
deliver the afterbirth. 
Before discussing this question further it would be well to 
revert briefly to the mechanism of postpartum hemorrhage. 
What are the causes of hemorrhage and whence comes the blood ? 
I answer that in flooding from the utero-placental site, the causes 
are various but the source of the blood is always the same. It 
is important to remember that dangerous and even fatal hemor- 
rhage may occur postpartum, which is quite independent of the 
placenta, as in intra-uterine fibi’oids, laceration of the cervix, 
vagina, etc., but such being excluded from present consideration, 
leaves us to deal with but three classes of cases. The first of 
these, and by far the most common, is uterine inertia; the second 
is abnormally adherent placenta, in which case the placenta, 
through structural changes in the decidua serotina, becomes so 
firmly fastened to the uterine wall as to interfere with proper con- 
traction of the organ. Here we may have a normal disposition 
on the part of* the uterus to contract, but with an inability to do so, 
in consequence of the firm placental engraftment, the result being 
irregular and imperfect contraction. It is to this class of cases 
that what is known as hour-glass contraction usually belongs. 
There is also a third class of cases, due either to disease of the 
the uterine fibres, to old uterine adhesions from previous inflam- 
mation, or to deranged innervation in which there is likewise 
defective contraction. The source of the blood in all three of 
the classes of cases under consideration is, not from the sepa- 
rated surface of the placenta, but from the torn ends of uterine 
vessels, the arteries and veins, both of which, but chiefly the 
latter, contribute to swell the torrent. The well known views 
of Hamilton and Sir James Y. Simpson upon the mechanism of 
hemorrhage in partially detached placenta have created an im- 
pression upon the professional mind in keeping with the great 
weight of their authority, and I am satisfied that the writings, 5 
more particularly of the latter, have contributed largely to er- 
roneous views of practice. It was contended by Dr. Simpson 
that in uterine flooding the hemorrhage was exclusively venous, 
and that the blood escaped, not from the denuded uterine wall, 
but from the venous radicles of the detached portion of placenta. 
Of course, if the view of Simpson be accepted, which is unfortu- 
nately vaguely done by rakny, there could possibly be no better 
alternative than to put in practice his operation, and at once 
separate the entire placenta and thus cut off the flow. But there 
can be no question that Dr. Simpson carried bis theory too far, 
and that the theory itself was based upon a misinterpretation of 
facts. Such is now the almost unanimous conclusion of all mod- 
ern obstetrical authorities who have given the subject special 
attention. 
How, Mr. President, I do not desire to be understood as ad- 
vocating anything like a revolution in the matter under dis- 
cussion, but my object is to call attention to certain practical 
considerations based upon strictly physiological data, and which 
I think are calculated to promote more rational views of prac- 
tice ) for the fact is that no physician or surgeon can success- 
fully cope with any grave emergency, unless he has clearly fixed, 
in his own mind at least, substantial reasons for whatever he 
may feel called upon to do. Empiricism often succeeds, but in 
the majority of cases, and always sooner or later, it leads to 
disaster. 
In order to state more clearly the relationship of the pla- 
centa to the etiology and treatment of postpartum hemorrhage, 
I would present and defend the following jmopositions: 
Ist. The placenta can only participate in causing postpartum 
hemorrhage when it is either of abnormal size, or abnormally 
adherent—thus offering a physical bar to uterine contraction. 
2d. Simple retention of the placenta when detached, or par- 
tially adherent by normal attachment, does not of itself contrib- 
ute to the production of hemorrhage. 
The first thing for the practitioner to do in a case of post- 
partum hemorrhage, is to examine the uterus externally and as- 
certain its condition as regards shape, size and rigidity. These 
interrogations can all be readily answered by an experienced 
hand, placed upon the abdomen of the patient. If the uterus 
appear firm, but oblong and somewhat irregular in shape, he 6 
is justified in concluding that there is something within it 
that otters a mechanical obstacle to perfect contraction and 
he knows from the feel that this obstruction must be either 
in the nature of a tumor, or an abnormally adherent pla- 
centa. Having satisfied himself that the uterus is willing to per- 
form its part, he gently passes a hand within its cavity, in order 
to ascertain the nature of the hindrance, and if he finds the 
placenta partially adherent he endeavors to detach it. This is 
sometimes a difficult matter, and may fail of perfect accomplish- 
ment, even in the hands of the most skillful. But the complete- 
ness of contraction and the stoppage of bleeding will in this case 
ce in proportion to the amount of placenta detached, for when 
this has been pretty thoroughly done, the uterine fibres are left 
free to contract, and the uterus will generally close down upon 
the placenta and hand and extrude both into the vagina. Again, 
the attendant may find on external manipulation that the uter- 
ine body is much larger and not so firm as it should be; it is 
also rounded and more uniform in its outline than in the case 
previously described. Here we have a mixed case, where there 
is partial inertia together with distension from constantly increas- 
ing blood clots. The distension in this case directly contrib- 
utes to the bleeding, and should be relieved by passing in the 
hand and turning out the eoagula. This should however be 
preceded and accompanied by the usual remedies for inertia. It 
is not necessary, in a case like this, to worry over the placenta, 
(unless abnormally adherent) until the uterine atony is over- 
come, in which event the uterus will take care of itself, whether 
the afterbirth is within it or not. 
To my mind, abnormal adhesion, or abnormal size of the pla- 
centa, constitutes the only valid reason for its manual detach- 
ment and delivery as a curative means in postpartum hemor- 
rhage, inasmuch as these cover the only conditions in which 
the placenta is a factor in the production of bleeding. When, 
however, in much the largest class of cases, the flooding is due 
to uterine inertia, the relation of the placenta to the flooding 
is entirely different. Here the fault lies exclusively with the 
uterus, or rather with the nerves supplying the uterus; here 
there is no such imperative demand for active interference with 
the placenta, since it is simply a passive element in the case. The 
inertia is the thing to be gotten rid of and not the placenta, as is 
often taught and practiced. In order to accomplish this, ergot,. 7 
friction over the abdomen, ice, inside and outside of the uterus, 
and other active measures should be resorted to, but forcible re- 
moval of the afterbirth is not one of these, unless, as we have 
said, it be deemed advisable to clear the uterus out, for the pur- 
pose of applying per sulphate of iron, vinegar or some other 
styptic directly to the bleeding vessels. But these remedies are 
not usually resorted to until many other readier methods have 
failed. 
I have already said that if the placenta is detached, or not 
preternaturally adherent, it can of itself otfer no obstacle to 
a perfectly safe degree of contraction. If any evidence were 
needed upon this point beyond our daily experience in natural 
labor, the testimony of Euysch, Wm. Hunter and many others 
•of their school, who adopted the practice of leaving the placenta 
in utero for hours and days, till nature herself threw it oft, with- 
out hemorrhage—would seem to definitely settle this point. 
Again, if the placenta be of normal adhesion, the less the area 
of surface detached the better, so long as atony continues, be- 
cause the bleeding surface is at a minimum. Here the attach- 
ment of the placenta, so far from being an evil requiring to be 
broken up, is a fortunate circumstance, and is due to the inertia— 
to the fact that the uterus has not contracted sufficiently to slide 
it off. Forcible detachment with the hand under these circum- 
stance# is certainly very questionable practice, and should not be 
resorted to without due consideration. 
Yet there are few of our text books that contain any clear in- 
struction on this point. The late Prof. Bedford, however, has 
with his usual vigorous style, presented this matter in its true 
light. In his lecture on the management of “ external hemor- 
rhage,” he says, u Flooding may occur when the placenta is com- 
pletely or partially detached and yet within the uterine cavity, 
or it may occur after this mass has passed from the organ. It is 
a very singular fact that many practitioners imagine the sine qua 
non of success in the management of hemorrhage to be the re- 
moval of the placenta, and hence in these cases, the very first 
thing attempted is to extract this body, under the impression 
that with its delivery the flooding will cease. There never was 
a more perfect delusion. Why, gentlemen, the afterbirth in 
strict truth has nothing to do with the hemorrhage j it is not a 
bleeding surface, and whether it be within or outside the uterus 
is a matter of utter indifference, so far as the great object is con- 8 
cerned—the inducing of uterine contraction. The practice is 
founded upon vague and indefinite notions with regard, in the 
first place, to the true cause, and secondly to the true source of 
the hemorrhage.” 
It only requires a little reflection,,! think, to convince us 
that this position of Dr. Bedford is unimpeachable, and that the 
successful treatment of post partum hemorrhage must depend 
upon rational therapeutics, addressed to the cause. In the hands 
of a skillful and vigilant physician it can scarcely ever occur that 
anything like a fatal hemorrhage could depend upon any other 
cause than inertia uteri. Other causes may induce severe bleed- 
ing, but rapidly fatal hemoi'rhages are almost always the result of 
uterine atony. This is the class of cases which demand prompt 
action, clear judgment and discrimination, and these teach us 
that our efforts should be directed to the induction of uterine 
contraction, rather than in exciting our already nervous patient 
in unnecessary haste to detach and deliver the innocent placenta. 
I am satisfied, Mr. President, that there is a great deal of 
misjudgment and false reasoning in connection with the manage- 
ment of the placenta in such cases. Because the hemorrhage 
frequently ceases on the forcible delivery of the afterbirth, such 
removal is credited with the result, but, as I have already said, 
the post hoc, ergo propter hoc argument in this case does not bear 
critical analysis; for when this happens, the stoppage of the 
hemorrhage is simply an incident due to the stimulation of the 
uterine walls during the act of detachment and delivery of the 
placenta. But since the presence of the placenta did not cause 
the inertia in the first place (exactly the reverse being 
its detachment (when normally adherent) and delivery cannot 
possibly, within themselves, cure it. The same amount of 
intrauterine stimulation would produce the same result inde- 
pendently of the placental delivery. And, on the other hand, 
if the inertia be profound, and is dependent, as is often the case, 
on extreme nervous exhaustion, the manual detachment of the 
placental mass will possibly fail to awaken contraction; in which 
event the hemorrhage will be increased in proportion to the 
number of additional uterine sinuses thus laid open. 
The fact is that the more we study the pathological physi- 
ology of these cases, the more apparent does it seem that the 
real cause of the inertia lies hidden back in the deeper recesses 
of the nervous system; causes that we have not yet fully fath, 
omed, but which are doubtless intimately connected with the 
secret springs of the female economy. These must needs be 
touched before we reach the true physiological remedy, either in 
the way of prophylaxis or treatment.