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In 1952-4 the caesarean section rate was under 2% and many women died of complications of vaginal birth. The Report listed 190 deaths in an appendix under various causes including 'contracted pelvis', once common due to rickets. Pelvic measurement was part of antenatal care. In doubtful cases 'trial of labour' often ended in forceps delivery. A 10% fetal loss rate was considered acceptable. Home births could end in forceps delivery by GPs who had no postgraduate training and relied on their student experience. In the 1955-7 Report, 33 women died after forceps delivery at home or in a maternity home. In the 1960s 'prolonged labour' (> 24 hours) was blamed on 'inco-ordinate uterine action'. In 1969 in Dublin Kieran O’Driscoll introduced 'active management' for first-time mothers in hospital, showing that normal labour could safely be achieved with an intravenous oxytocin 'drip'. Early CEMD Reports criticised GPs but in the 1960s their comments became more constructive. The BMJ ran a series of articles, 'Obstetrics for GPs', written by leading obstetricians. By the late 1970s only 2% of births were home deliveries and the Reports no longer discussed place of birth.
The process of placental delivery and the subsequent involution of the uterus during the puerperium are often described as the third and fourth stages of labor. This chapter presents a brief historical review concerning third- and fourth-stage events, followed by a discussion of the physiology of placental separation and uterine involution. The diagnosis and treatment of retained placenta and membranes (secundines), uterine inversion, postpartum hemorrhage and atony, and hematomas are considered. Important cultural and historical events in world history have been directly influenced by complications of involving the third stage of labor. Active management of the third stage of labor consists of the immediate administration of oxytocin after delivery of the infant, early cord clamping, and gentle traction on the cord, combined with gentle uterine massage to prompt placental separation. Periurethral lacerations, which often bleed freely, appear in the thin tissues on either side of the clitoris or urethra.
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