After the placenta separates and descends into the lower uterine segment, it produces a bulging just above the symphysis, while the fundus may be felt as a firm, hard mass above the umbilicus. Since the placenta is entirely separated from the uterus at this time, its complete expulsion is usually aided, when it does not occur spontaneously, by gentle pressure upon the fundus. The accoucheur holds his hand just below the vaginal outlet, to receive the placenta (Fig. 99), which he turns over and over in his hands, thus twisting the membranes, and gradually draws it away from the mother, the membranes trailing after in the form of a tapering cord. (Fig. 100.) It is important that the placenta and membranes be carefully examined to make sure that they are intact, for if fragments of either are retained within the uterus they will prevent its firm contraction and thus may be a cause of post-partum hemorrhage. For this reason, only very gentle pressure and traction are used in expressing the placenta and withdrawing the membranes, for the use of force might leave small particles adhering to the uterine lining, which would otherwise separate with the rest, in due time, as a result of the uterine contractions. [Illustration: FIG. 99.—Delivery of the placenta. ] Having been inspected, the placenta should be placed in a covered receptacle to be disposed of as the doctor directs, as many physicians make a routine laboratory examination of the placenta and wish to have it kept for this purpose. With the birth of the placenta comes a gush of blood, as the uterine vessels, some of which are as large as a lead pencil at this time, are left wide and gaping. The bleeding usually subsides very shortly, however, as the blood vessels are closed by involuntary contraction of the network of uterine muscle fibres in which they are enmeshed, and which are sometimes referred to as “living ligatures.” If the bleeding continues, these contractions should be stimulated by massage. This is done by grasping the uterus through the abdominal wall firmly with one hand and kneading vigorously. Rubbing the top of the fundus with the fingers usually is not enough. The fundus should be grasped by the entire hand; the thumb curved across the anterior surface and the fingers, directed deep into the abdomen, behind it. (Fig. 101.) Pituitrin or ergot, or both, are frequently given to further stimulate contractions of the uterine muscles. Since the action of pituitrin is quick, but evanescent, and the effect of ergot is slower and more lasting, both a quick and lasting effect is obtained by giving them together. [Illustration: FIG. 100.—Twisting the membranes while withdrawing them from uterus. ] The expulsion of the placenta ends the third stage and completes the process of labor. [Illustration: FIG. 101.—Grasping fundus through abdominal wall in giving massage to stimulate uterine contractions. ]