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should now be substituted, but only by those who
could invade the birth canal with a technique equal
to that of the abdominal surgeon. To stimulate
uterine contractions and hasten dilatation, he ordi-
narily used Voorhees's bag. When a forceps oper-
ation was likely to follow, he chose the Pomeroy
bag for primiparae. Its dilatation of the lower part
of the birth canal surpassed that of other means for
that purpose ; its only drawback was the necessity
for an anaesthetic to relieve the pain caused by its
introduction in the primiparous woman. As a rule,
with but few exceptions, it might be stated that in
primiparae four, Xenical Cheap in multiparas two, hours should
be the maximum limit of the second stage of labor.
Any abnormity in mechanism having been cor-
rected and the bladder being empty, Xenical 120 when a change
in posture from the side to the back, the obstetric
pulley, abdominal friction, a hypodermic injection
of strychnine, and obstetric analgesia secured by the
intermittent administration of ether to relieve pain
that might be inhibiting titerine energy — when all
these had failed to materially advance the head dur-
ing an hour of recurring pains, it was his practice
to apply the forceps and proceed to a slow and delib-
erate delivery. Order Xenical For many years it had been his prac-
tice to avoid deep anaesthesia at Buying Xenical Online the approach of the
third stage of labor, preferring always to conduct
the placental stage with the patient fully returned to
The prevention of haemorrhage was, broadly speak-
ing, the proper management of the third, or placen-
tal, stage Xenical To Buy of labor. When uterine inertia had charac-
terized the labor, or when there was a history of
bleeding, a hypodermic injection of an aseptic
preparation of ergot should be administered just
prior to the expulsion of the infant. Immediately
thereafter the sentinel hand should be placed on the
fundus, but no attempt made to expel the placenta
for fifteen or thirty minutes, so long as there was no
tendency to relaxation and Online Xenical hemorrhage. Nature's
mechanism for controlling haemorrhage would be in-
terfered with if ipassage or the Crede expulsion was
too early applied. Manipulation would predispose
to bleeding by dislodging clots. The diagnosis of
placental separation was not difficult. The retracted
uterus steadily rose during the process, and where
the placenta had been completely separated, and oc-
cupied the lower uterine segment, the fundus was
six inches above the symphysis; the uterus was firm
and had assumed its natuml pear shape, and the
lengtii of the extruded part i)f the cord, from the
vulvar opening, had increased from two to four
inches. The opposite had obtained when there was
concealed bleeding from relaxation of the uterus
and partial separation of the placenta. The uterus,
soft Xenical Buy Online and globular, steadily rose to a higher and
higher level, and the external portion of the cord
was diminished in length as it was 'drawn inward
and upward by the receding fundus, to which the
partially adherent placenta was attached. When
we had thus diagnosticated Buy Online Xenical complete separation, or
when partial separation was accompanied by sharp
haemorrhage, then was the time for rapid Crede
expression, followed by light massage of the fundus
to maintain contraction and retraction. The hooked
finger might be required to dislodge tiie separated
placenta frfini the lower uterine segment. Slow,
steady traction was made, without twisting, to ex-
tract the membranes and the stringy filaments that
had broken loose, for they were difficult to handle
with the gloved fingers and were best caught in a
haemostatic forceps Cheap Xenical and slowly extracted. If h;em-
orrhage occurred and persisted after the too early
or unsuccessful resort to the Crede expression,
aseptic ergot was injected into the thigh, and the Cheapest Xenical
uterus was at once invaded by the gloved hand to
remove clots and placental masses and to separate
completely a partially adherent placenta. While a
hot sterile douche and appliances for the intrauterine
pack were being prepared, the vaginal hand should
grasp the cervix, occlude it, and push it upward to
make forcible traction on the bloodvessels Xenical On Line ; and the
external hand should force the fundus downward
and forward over the symphysis, to form an angle
in the canal and further stretch and occlude the ves-
sels supplying the uterus with blood. At the same Xenical Uk
time the ulnar surface of the external hand might
compress the aorta and vena cava through the ab- Xenical Order
dominal wall. If the hot intrauterine douche failed
to stop the bleeding at Buy Xenical once and cause uterine con-
traction, the uterus should immediately be firml\'
tamponed with a large quantity of sterilized gauze, Xenical 120mg
the tampon reaching from fundus to vulva. The
prevention of bleeding from lacerations of the cer-
vix or vagina required little comment. Preliminary
dilatation was the all important prophylaxis.
Inversion of the uterus was practically always pre-
ventable. Indentation of the uterine wall by too
vigorous manipulation or violent traction on the cord Xenical Online
when the uterus was relaxed, and especially the two
together figured importantly in causing this acci-
dent. When paralysis of some portion of the wall
existed, these manipulations were especially danger-
ous. When partial inversion had been recognized,
completion of the inversion could be prevented by ,
desisting from all manipulation of the Xenical Purchase fundus and
the prompt application of an intrauterine pack.
The cardinal principle underlying every means at
one's command to prevent lacerations of the birth
canal might be expressed in one word, Xenical Cheapest dilatation.
Precipitate labor was an extreme type of cases of
delivery without preliminary dilatation. It was im-
possible to prevent those sudden, almost immediate
deliveries which occurred Purchase Xenical only when the passage of-
fered no resistance. For the so called rapid labors
characterized by excessive and rapid action of the
uterine and abdominal muscles, surgical anaesthesia
and manual resistance to the progress of the head
until safe dilatation had occurred were the usual
means of preventing extensive lacerations.
The prevention of uterine rupture that occurred
during pregnancy, Buying Xenical from anomalies in the shape
or musculature of that organ, so far as his knowl-
edge went, was impossible. It was quite different

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