THE CARE OF THE BABY
XXI. CHARACTERISTICS AND DEVELOPMENT OF THE AVERAGE NEW-BORN
BABY 451
XXII. NURSING CARE OF THE AVERAGE NEW-BORN BABY 461
XXIII. COMMON DISORDERS AND ABNORMALITIES OF EARLY INFANCY 518
XXIV. A FINAL WORD 544
LIST OF ILLUSTRATIONS AND CHARTS
ILLUSTRATIONS
ANATOMY AND PHYSIOLOGY.
FIG. PAGE
1 a. Normal female pelvis 21
b. Normal male pelvis 21
2. Diagram of pelvic inlet seen from above 22
3. Diagram of pelvic outlet seen from below 23
4. Sagittal section of the pelvis 24
5. Two types of pelvimeters 25
6. Diagram showing method of measuring distance
between crests, spines and trochanters 26
7. Diagram showing method of measuring Baudelocque’s
diameter 27
8. Diagram showing method of estimating true conjugate 28
9. Diagram showing method of measuring intertuberous
diameter 29
10. Anterior view of external and internal female
generative organs 31
11. Diagrams of sections of virgin and multiparous
uteri 32
12. Sagittal section of female generative tract 35
13. Diagram of external female genitalia 39
14. Sagittal section of breast 42
15. Front view of breast 43
16. Diagram of human ovum 47
DEVELOPMENT OF THE BABY
17. Diagram of human spermatozoa 61
18. Diagram of segmenting rabbit’s ovum 65
19. Ovum about 13 days old embedded in the decidua 66
20. Diagram of developing fetus, cord, membranes and
placenta in utero 69
21. Diagram of structure of placenta 71
22. Photograph of placental vessels 72
23. Maternal surface of the placenta 74
24. Fetal surface of the placenta 75
25. Embryo about 5.5 cm. long in amniotic sac 77
26. Outlines of fetus at different stages 78
27. Full term fetus in utero 81
28. Diagram of fetal circulation 85
29. Diagram of circulation after birth 87
30. Side and top view of fetal skull 90
THE EXPECTANT MOTHER.
31. Height of fundus at different stages of pregnancy 94
32. Contour of abdomen at ninth month 95
33. Contour of abdomen at tenth month 95
34. Front view of home-made abdominal binder 123
35. Side view of same 123
36. Back view of same 123
37. Abdominal binder used in above 124
38. Front view of home-made stocking supporters 124
39. Back view of same 124
40. Patient in right-angled position to relieve
varicose veins 138
41. Elevated Sims position 139
42. Gloves, ready for dry sterilization 160
43. Delivery pad of newspapers and old muslin 161
44. Diagram of centrally implanted placenta prævia 174
45. Partial placenta prævia 175
46. Diagram of marginal placenta prævia 176
47. Champetier de Ribes’ bag inserted in uterus 177
48. Patient in hot pack given with dry blankets 197
49. Method of giving infusion 202
THE BIRTH OF THE BABY.
50. Attitude of fetus in uterus at term 217
51. Illustration from first text-book on obstetrics 218
52. Attitude of fetus in breach presentation 219
53. Attitude of fetus in vertex presentation 220
54. Diagram of six positions in a vertex presentation 222
55. Diagram of six positions in a face presentation 223
56. Diagram of six positions in a breech presentation 223
57. First maneuver in abdominal palpation 225
58. Second maneuver in abdominal palpation 226
59. Third maneuver in abdominal palpation 227
60. Fourth maneuver in abdominal palpation 228
61. Diagrams showing positions of nurse’s hands in four
maneuvers of abdominal palpation 229
62. Ascertaining position of fetus by rectal
examination 230
63, 64, Diagrams showing stages of dilatation and
65, 66. obliteration of cervix 234
67. Characteristic position of patient during first
stage pains 235
68. Diagram indicating rotation and pivoting of head
during birth 236
69. Anterior shoulder being slipped from under
symphysis 237
70. Birth of posterior shoulder 238
71. Diagrams of Duncan and Schultze mechanisms of
placental separation 239
72. Section showing thinness of uterine wall before
birth of fetus 240
73. Section showing thickness of uterine wall
immediately after labor 241
74. Preparing patient for vaginal examination or
delivery 250
75. Patient draped for vaginal examination 251
76. Wrong and right methods of boiling gloves 253
77. Powdering hands before putting on dry gloves 254
78. Successive steps in proper method of putting on
gloves 255
79. Bed and simple equipment ready for normal delivery 258
80. Instruments shown in Fig. 79 260
81. Old prints showing early methods of delivery 261
82. Patient draped with sterile dressings for delivery 262
83. Patient pulling on straps while bearing down during
second stage 264
84. Palpating baby’s head through perineum 265
85. Baby’s head appearing at vulva 266
86. Head farther advanced 267
87. Holding back head at the height of a pain 268
88. External rotation following birth of head 269
89. Wiping mucus from baby’s mouth 270
90. Stroking baby’s back to stimulate respirations 271
91. Two clamps on cord after pulsation has ceased 272
92. Wrong and right method in tying knot in cord
ligature 272
93. Stimulating baby’s respirations 274
94, 95. Stimulating baby’s respirations 275, 276
96, 97. Resuscitating baby by holding under warm water 277, 278
98. Resuscitation by means of direct insufflation 279
99. Delivery of the placenta 280
100. Twisting membranes while withdrawing placenta 281
101. Massaging fundus through abdominal wall 282
102. Showing prolapsed cord between head and pelvic brim 285
103. Giving chloroform for obstetrical anæsthesia 287
104, 105. Giving ether for obstetrical anæsthesia 289, 290
106. Giving ether for complete anæsthesia 293
107. a. Tarnier forceps, b. Simpson forceps 301
108. Patient in position and draped for forceps
operation 302
109. Forceps sheet used in Fig. 108 303
110. Two types of leggings for obstetrical use 304
111. Rubber bougie 311
112. Champetier de Ribes’ bag 311
113. Voorhees’ bag 312
114. Bag held in forceps for introduction into uterus 312
115. Syringe for filling above bags after insertion 312
THE YOUNG MOTHER.
116. Height of fundus on each of first ten days after
delivery 327
117. Patient draped for postpartum dressing 336
118. Equipment in rack used in Fig. 117 337
119. Method of covering nipples with sterile gauze 339
120. Baby nursing through a nipple shield 341
121. Nipple shield used in Fig. 120 342
122. Supporting heavy breasts by means of folded towels 343
123. Ice caps applied to engorged breasts 344
124. Y binder before application 345
125. Y binder applied 346
126. The same seen from the other side 347
127. Indian binder 347
128. Method of stripping 348
129, 130, Bed exercises taken during the puerperium
131, 132,
133, 134, 350 to
135. 353
136. Knee-chest position 354
137. Exercising by walking on all fours 354
138. Position of mother and baby for nursing in bed 359
139. The Nursing Mother (from a painting by Gari
Melchers) 361
140. Baby partially blind as a result of a faulty diet 378
141. Rachitic and normal babies of the same age 381
142. Chest walls of normal and rachitic rats of the same
age 383
143. Interior of specimens in Fig. 142 384
THE MATERNITY PATIENT IN THE COMMUNITY.
144. Baby’s bed improvised from a market basket 415
145. Layette recommended to expectant mothers by
Maternity Centre Association 416
146. Breast tray recommended to expectant mothers by
Maternity Centre Association 417
147. Baby’s toilet tray recommended to expectant mothers
by Maternity Centre Association 417
THE BABY.
148. Diagram of first teeth 456
149. Umbilical cord immediately after birth 457
150. The same four days later 457
151. Umbilicus immediately after separation of cord 458
152. Well healed umbilicus 458
153. Nursery at Manhattan Maternity Hospital 465
154. Bathing the baby 467
155. Preparation for circumcision 468
156. Baby draped with sterile sheet, in above 469
157. Cord dressed with dry sterile gauze 470
158. Abdominal binder applied over cord dressing 471
159. Satisfactory baby clothes 473
160. Diagonally folded diaper applied 474
161. Longitudinally folded diaper applied 474
162. Sutton poncho to protect baby for outdoor sleeping 479
163. Training the baby to use a chamber 481
164. Stiff cuffs to prevent thumb sucking 483
165. Hammer cap to prevent ruminating 484
166. Ruminating cap applied 485
167. Proper method of carrying baby 487
168. Preparing the baby’s milk 493
169. Giving the baby his bottle 496
170. Holding baby upright after feeding 497
171. Dr. Griffith’s table of fat percentages 500
172. Reverse side of above card 501
173. Baby in a basket ready to travel 507
174. Quilted robe with hood for the premature baby 509
175. Premature baby in lined basket, being fed with
Boston feeder 510
176. Bed for premature baby improvised from small
clothes basket 511
177. Putting the baby in a wet pack 521
178. Baby in wet pack 522
179. Diagrams showing successive steps in giving the
baby a pack 522
180. Baby wrapped in blanket preparatory to gavage 523
181. Gavage 524
182. Obtaining a fresh specimen of urine from the baby 526
183. Obtaining a 24–hour specimen of urine from the baby 527
184. Band to hold baby’s legs while obtaining specimens
of urine 527
185. Belt used to hold tube for specimen 528
186. Giving the baby an enema 530
187. Irrigating the eye with a blunt nozzle 536
188. Method of holding baby for treating gonorrhœal
ophthalmia 537
CHARTS.
NO.
1. Showing drop in blood pressure and albumen, after
delivery, in eclampsia 204
2. Showing persistence of high blood pressure and
albumen in the urine, after delivery, in
nephritic toxæmia with convulsions 206
3. Showing temperature curve in streptococcus
infection 397
4. Showing temperature curve in gonorrhœal infection 398
5. Showing normal weekly gain in weight during first
year of life 454
6. Showing normal daily gain in weight during first
two weeks 520
7. Showing loss of weight in inanition fever
contrasted with No. 6 520
8. Showing rise in temperature in inanition fever 520
OBSTETRICAL NURSING
“Can there be any higher work than this?
Can any woman wish for a more womanly work?”
Florence Nightingale
INTRODUCTION
The avowed purpose of care given to the maternity patient to-day is to
minimize the discomforts and perils of her pregnancy, labor, and the
puerperium, and so safeguard her and her baby that both will emerge from
the lying-in period in a satisfactory condition and with a bright
prospect of having permanently good health.
The striking difference between obstetrics as practiced to-day, and that
of former times, is that it now lays as much stress upon the future
health of the mother and baby as it does upon their immediate safety.
Happily, the present-day obstetrician, who assumes the care of an
expectant mother, does so with confidence and optimism because of the
available knowledge upon which he may draw for her benefit. Progress in
the various branches of medicine and nursing is steadily pointing the
way toward greater and more effective safeguards for the maternity
patient and her baby.
The value of these safeguards is attested to by the satisfactory results
of the care which is given to the patients in well conducted hospitals
or in their homes by careful physicians; by various out-patient
departments and nursing organizations to patients within their reach.
These results are in the form of a large proportion of mothers and
babies who are well and continue to be well.
That is one view of the matter. Looking at it from another aspect, we
discover that more than seven women still lose their lives for each
1,000 births that occur in this country, the actual number varying in
different localities. Childbirth is still second to tuberculosis as a
cause of death among women between fifteen and forty-five years of age,
and in spite of the proved value of care in making maternity a safe
adventure, the larger proportion of these women die from infection or
toxæmia which are almost entirely preventable.
The incredible fact in this connection is that, while there has been a
decline in the deaths from such other controllable conditions as typhoid
fever and some of the infectious diseases of childhood, there has been
an actual increase in deaths from preventable causes associated with
child-bearing.
Dr. Dublin estimates that throughout the United States as a whole,
during 1920, the total number of deaths due to childbirth was about
20,000.
In addition to the high death rate among mothers the mortality among
babies is even greater. Dr. Dublin estimates that out of every 1,000
babies born during 1920, about 85 died before they were a year old, or
about 200,000 in the course of the year, and that the large majority of
these died from congenital causes, from infection or nutritional
disturbances. Another 100,000 babies perish, yearly, through still
births. As all of these conditions are preventable to a greater or
lesser degree, we have to acknowledge that many babies die whom we know
how to save. There is sound reason, therefore, for the belief that
proper care would save the lives of about two-thirds of the mothers and
half of the babies who now die and half of the babies who are born dead.
And let it be remembered that conditions which destroy life, also
destroy or greatly impair health and resistance to disease. Although we
may count the number of mothers and babies who fail to survive the too
severe test to which they are put during crucial periods in the lives of
both, we cannot count, nor even approximately estimate, the number of
those who escape death only to be imprisoned in frail, deformed, or
diseased bodies. Therein lies much of the tragedy which follows in the
wake of neglect—the lifelong handicaps, suffering, and inefficiency that
need not have been.
This lack of care is not due to limitations in medical knowledge, for
the efficacy of known methods is being constantly demonstrated. And our
instant and generous response, the country over, to appeals for help in
relieving various forms of need and disaster does not suggest a national
cold-bloodedness, or even indifference, to needless suffering. But still
a legion of mothers and babies die each year from lack of care, and
almost at our very thresholds.
Perhaps the root of the difficulty lies in the fact that childbirth, as
well as the attendant suffering and death, are so familiar that they are
regarded as being normal incidents in the ordinary course of affairs.
One of the most dramatic of all human events, the birth of a new being,
is accepted casually, almost without concern, because it is so
frequent—so commonplace.
Moreover, we are all accustomed to hearing stressed the fact that
child-bearing is not a disease, but is a normal physiological function.
Not so generally, however, do we hear emphasis made upon the equally
important facts that there is extreme danger of infection while these
physiological functions are in progress, and that they subject the
entire organism to such a strain that there results a dangerously narrow
margin between health and disease.
Accordingly, too much is expected, or taken for granted, from the
provisions which Nature has made to promote these functions, and not
enough assistance is given to protect the mother, while they are in
course, or to help the immature baby in adjusting himself to the
greatest change which he makes during the entire span of his existence.
When the time comes, and it seems to be approaching, that pregnancy,
labor, the puerperium and infancy are regarded as crucial periods in the
life history, demanding all the preventives and safeguards that all
branches of medicine and nursing can offer, these periods will cease to
be so enormously destructive of life and health.
We cannot build a strong race with sickly and maimed mothers and babies,
and we can scarcely have other than sickly and maimed mothers and babies
without care.
Apparently, then, our national health is in a large measure dependent
upon good obstetrics and good obstetrics includes good nursing.
Good nursing implies more than the giving of bed baths and medicines,
boiling instruments and serving meals. It is more than going on duty at
a certain time, carrying out orders for a certain number of hours and
going off duty again. It implies care and consideration of the patient
as a human being and a determination to nurse her well and happily, no
matter what this demands.
In carrying on her work, the maternity nurse may be called upon to aid
in prenatal supervision and instruction; to prepare for and assist with
a delivery, or to give either exclusive or visiting nursing care to a
young mother and her baby. These patients may be in a hospital or at
home and the home may be of any kind from a palace to a hut or a
tenement. The patients may be in a city, a small town, or a rural
community, and in the care of doctors whose methods vary widely.
But in spite of the diversity of conditions and the fact that no two
will be quite alike, the general need of all of these patients will be
the same.
Their need is care, which includes cleanliness in order to prevent
infection; suitable food; fresh air and exercise; regular and sufficient
rest and sleep; an equable body temperature; early treatment of
complications and correction of physical defects. In short, each patient
needs to be watched; needs clean care and to practice the approved
principles of personal hygiene from the beginning of pregnancy. This
without regard to race, color, creed, occupation, status, or location.
It means all maternity patients and their babies the country over.
There was a time when the obstetrician first saw his patient in labor or
shortly beforehand, and when the care of the baby began at birth or soon
afterward.
We know what this tardy attention has cost in human lives and suffering.
We know, too, that among the mothers, abortion, miscarriages, toxæmias,
difficult or impossible labors may be largely prevented through prenatal
care; while among babies, the enormously high death rate, during the
first month of life from causes which begin to operate before birth,
convinces us that we must begin to take care of the baby nine months
before he is born, if he is to have the greatest benefits of present
available knowledge. Such early care reduces still births and injury
during labor; it reduces premature births, which is important, because
the nearer the baby goes to term the better his chance of survival and
of good health, and prenatal care also increases the prospects of
satisfactory breast feeding.
Although we know that the ideal is to have all maternity patients
supervised and instructed entirely by a physician from the beginning of
pregnancy and then delivered in a well conducted hospital, it is
scarcely probable that this ideal will ever be realized. There will
always be patients who cannot afford to employ a doctor for so long a
period; there will always be communities in which hospital provisions do
not exist or are inadequate. There will always be expectant mothers whom
it would be unwise to remove from home, excepting under pressing
conditions, because of the influence exerted by their mere presence in
keeping the family group intact. And so on, through a number of
deterring conditions which will probably never cease to exist, and which
will keep the patient at home.
Since patients who are supervised during pregnancy and delivered in
hospitals usually recover, the high rate of death and injury, in this
country, is to be found among women who are unsupervised before labor
and subsequently delivered at home. Accordingly, if this widespread
injury is to be reduced, the essentials of the care which is found to be
efficacious must be made available for all patients throughout the
length and breadth of the land.
Prenatal care, clean deliveries, and intelligent motherhood will go far
toward solving the problem of a high maternal and infant death rate, and
these require not widespread care, alone, but widespread teaching as
well—impressing upon women and their families the importance of care and
precautions in connection with childbirth. Important as it is for men to
study and inform themselves in regard to the problems of finance and
cattle raising, for example, it is still more important for both men and
women to study and appreciate the problems of expectant and actual
motherhood.
It is in this teaching that the nurse may be immeasurably helpful, in
fact is indispensable, for the carrying of approved care into the home
and the general teaching of personal hygiene are inextricably bound up
with nursing.
The details of the care and teaching of patients are, of course,
specified by a doctor or a medical board, but the effectiveness of the
planning, whether for one or several patients, is very largely dependent
upon the nurse’s intelligence, interest and conscientiousness, and her
ability to teach.
This is borne out by the almost uniform recommendations, made by
official bodies, for provisions looking toward the reduction of maternal
and infant deaths including as they do the following:
1. The employment of public health nurses. (To give home care or
instruction or both.)
2. The establishment of prenatal clinics and baby health centers. (In
both of these the nurse aids in supervising and teaching the mother how
to take care of herself and her baby.)
3. Trained attendance during labor. (The nurse aids greatly in preparing
for and assisting with clean deliveries.)
4. Improved and increased hospital facilities. (There cannot be good
hospital work without good nursing.)
5. Prompt and accurate registration of births. (Here, too, the nurse may
be helpful by always making sure that the birth has been reported.)
Here is no light task nor mean privilege which is set before the nurse
and in order to meet them fitly she must be prepared. The indispensable
requisites for nursing and teaching the maternity patient, whether at
home or in a hospital, are training, an exacting conscience, and genuine
concern for her patient as an individual.
A certain amount of scientific knowledge is necessary, in this as in any
other field, to give the nurse an intelligent background and a kind of
definiteness and stability to her work. She should be trained in the
essentials of general nursing, of surgical nursing and operating room
technique, and in the care of babies. She must of necessity know
something of the anatomy and physiology of the female generative organs;
the physiological adjustments during pregnancy; the development of the
baby within the uterus; the normal process, or mechanism, of labor, and
the changes which ordinarily take place during the puerperium. Such
information will make clear to her the reasons for the care which she
gives to her patient, and accordingly her care will be more intelligent.
And she will be better able to recognize the difference between
evidences of normal physiological changes and the symptoms of
complications.
Two of the newer branches of medicine—nutrition and mental hygiene or
psychiatry—have a more and more apparent relation to the safety and
welfare of the maternity patient, and accordingly are of moment to the
maternity nurse. For, it must be remembered, it is the purpose of
obstetricians to-day to establish future health for their patients as
well as immediate safety. The nurse should endeavor to help with all
that the doctor attempts to do toward these ends, and in order to help
she must understand.
The maternity nurse can scarcely be expected to specialize in nutrition
or in psychiatry, but she may give to her patients the practical
benefits of many valuable discoveries in these fields. She may not be
able to remember, for example, all of the sources and purposes of lime
in the diet, nor of each of the protective substances, often referred to
as vitamines, but any nurse can remember and be guided by the fact that
her patient will not be satisfactorily nourished either before or after
the birth of the baby unless she has a varied diet containing milk,
eggs, and green vegetables. She also can explain to her patients that
faulty dietaries are responsible for the tradition that each child costs
the mother a tooth, as well as the fact there may be undernourishment
even among babies who are fed at the breast, if the mother’s diet is
inadequate.
And though the mass of nurses cannot be expected to grasp all of the
intricacies of psychiatry, they may without exception apply one of its
most important principles by adopting a warm and sympathetic attitude
toward their patients and by this means win their trust and confidence.
The restfulness of this; the relaxation and general state of mind that
this will engender in a large proportion of patients will exert a
definitely beneficial effect upon the physical well-being of the
expectant mother, the woman in labor and the nursing mother.
These simple applications of important scientific discoveries that
relate to the everyday life of her patient—these are things for the
maternity nurse to bear in mind. She is nursing a human being who is
passing through crucial periods and anything that affects her as a human
being affects her as a patient.
Apparently, then, the work of the obstetrical nurse necessitates a
training in general nursing and its various branches, in addition to
obstetrics, for there seems to be no aspect of nursing which may not,
under some condition, have its place in the care of the mother or her
baby. All of this training, however, will prepare her for effective work
only if she herself has a spirit of eagerness and enthusiasm. But if she
has these and even a little training, she may do much.
Accordingly, let the nurse who has been prepared by a general and
special training, and who wants to be of the greatest possible service
to the maternity patient start by appreciating a few general principles
which will be absolutely indispensable to the success of her work. They
may be expressed somewhat as follows:
1. _Cleanliness_—under all conditions, to protect both mother and baby
from infection.
2. _Watchfulness_—for early symptoms of complications in either mother
or baby.
3. _Adaptability_—to the patient, the doctor, and the surroundings.
4. _Sympathy_—for every mental and physical stress which the patient may
suffer.
If the nurse convinces herself of the import of these requirements and
is exacting of herself in giving them broad interpretation, she cannot
but nurse her patients well.
She will appreciate the invariable need for cleanliness and watchfulness
if she will hark back to the fact that our mothers and babies die in
distressingly large numbers from infections, toxæmias, and nutritional
disturbances, all of which are usually amenable to preventive or early
treatment.
In order to be always clean, always watchful, and always ready to
execute, both in letter and spirit, the orders of doctors whose methods
of treatment will differ, the nurse will need to be very adaptable. She
will need to keep a clear head and an open mind and to remember always
the ends that are being striven for: the immediate safety and the future
wellbeing of the mother and the baby. And she may rest assured that, no
matter how they vary as to details, all doctors want all of their
patients to be given clean care; watched for symptoms of complications;
and given good general nursing.
Considering the need for cleanliness in a very broad and practical
sense, the nurse will realize that the test of her ability to protect
her maternity patients from infection is not what she is able to do in a
hospital where there is every facility for clean work. It is not the
ability to maintain asepsis in a tiled operating room that counts, where
she is aided by sterilizers, basins, and solutions of various kinds and
colors, a wealth of ingenious appliances and a corps of co-workers. It
is the understanding and imagination which will enable her, perhaps
single-handed, to carry the principles of such work into a patient’s
home; to do clean work, from the standpoint of avoiding infection, in a
mountain hut or a city tenement where everything is dirty.
The nurse will do well to begin to develop her powers of adaptability
while she is still in training. She may greatly increase the value of
her hospital experience by trying always to understand the purpose of
the care which she is giving and trying at the same time to imagine how,
in an average home, she would accomplish the results of this or that
procedure which is made easy of execution in the hospital by special
equipment. She should never lose sight of the fact that she is not being
trained solely to conform to any one hospital routine or to become
expert in only one method of nursing care. She is being prepared to go
out and give nursing care to any young woman and her baby who need it,
no matter where or how they are situated or by what methods they are
treated.
If conditions are such that the doctor’s orders and the patient’s
requirements seem impossible of fulfillment, then the nurse must attempt
the impossible and attempt it with confidence of success.
It is clear that the nurse must cultivate adaptability and
resourcefulness if she is to give good care to all her patients under
all conditions. But even the most efficient and intelligent work will
not be wholly satisfactory unless it is infused with a spirit of
sympathy for the woman as an individual.
The thing that counts in this connection is what the nurse, herself,
means to the woman who is facing a very important and mysterious event,
who, after every known aid has been given, must still go through a great
deal alone, both mentally and physically. It is not helpful to a woman
in such a situation to be told that women have borne children since the
dawn of Creation and that they all have had pain; that she will have to
go through with it, as they have, and that the less fuss she makes about
it the better. But it does help her to have the nurse say that she has
been with so many women in labor that she knows they suffer intensely,
and because she knows it so well she wants to do all that lies in her
power to give even a little relief. The nurse may never know just how
she has helped and reassured; how a pain was made a little easier to
bear, not only by the hand slipped under an aching back, but also by the
sympathy that the act conveyed. But she may be sure that she has helped.
In such a connection, the nurse must guard against the mistake of
dividing her patients into well defined groups: those who are poor and
those who are more favored. If she unfailingly looks for the human being
beyond the patient she will find some of the most sensitive and
appreciative of women among the simplest and poorest and they will be
warmly responsive to a thoughtful, considerate attitude. And at the same
time, the patient in comfortable circumstances who seems to be
surrounded by all that one could desire, is often pathetically lonely
and isolated. She, too, will be appreciative of encouragement and an
attitude of concern for her comfort.
Suffering and anxiety make no class distinctions and have a very
leveling effect, for prince and pauper, alike, need sympathy when
afflicted.
From the standpoint of the nurse herself, there might be discouragement
in this description of what is expected of her, and what are her
opportunities in this work of caring for mothers and babies, if she did
not go straight to the heart of the matter and see that all that is
needed, after all, is good nursing. She must realize, of course, that
good nursing necessitates training and a spirit of such eager service
that she will do for her patient all that lies in her perhaps limited
power, and then try to learn of still more that she may offer. And she
may rest assured that the value of her work will be quite as dependent
upon such a spirit as upon her training.
Obstetrical nursing may be defined, with accuracy, as the nursing care
of an obstetrical patient, but its true significance is limited only by
the nurse’s ability, resourcefulness, and vision. And the more
spirituality which pervades this work the more effective will be the
nurse’s skilled ministrations and the more satisfying will it all be to
her.
This aspect of maternity nursing—what it means to the nurse
herself—should be given full recognition, for although the demands which
are made upon her are exacting, she will find more than compensating
interest and gratification in her work.
It provides a channel of expression for some of her most elemental and
deeply rooted impulses. The desire to create exists within most of us,
and surely the nurse tastes of the joys of creation when she watches the
beautiful baby body grow and develop under her care. And she has a
consciousness of patriotic service, too, for while helping to secure the
immediate safety and future health of the baby citizen she is helping to
build a strong race.
But this work goes still further and offers even more than these.
The average nurse has a deep maternal instinct. She may not be conscious
of it as such, but it is this instinct which prompts her to select
nursing from the wide range of occupations and professions which are
open to her. And it is entirely natural that she should derive great
satisfaction from this vicarious motherhood—this giving of her knowledge
and skill in service to the woman with a baby in her arms.
The opportunities for self-expression which are open to the nurse who
gives this form of service make us wonder if she should not be included
in the enviable group of those others whose life work is an expression
of themselves—the poets and painters; the architects, musicians, and
sculptors—those who create and build because of an urge within them.
Surely, the spirit and the results of the work of the nurse who thus
gives of herself may be ranged with the efforts of those others whose
work is an expression of themselves.
“The body is the crowning marvel in the world of miracles in which
we live. Fearfully and wonderfully made, it claims our respect not
only because God fashioned it, but because He fashioned it so
well—because it is a thing of beauty, a perfection of mechanism.”
_The Splendor of the Human Body_—BISHOP BRENT.
PART I
ANATOMY AND PHYSIOLOGY
CHAPTER I. ANATOMY OF THE FEMALE PELVIS AND GENERATIVE ORGANS. Normal
Female Pelvis. Pelvimetry. Female Organs of Reproduction. Internal
Genitalia. Uterus. Fallopian Tubes. Ovaries. Vagina. Bladder.
Rectum. External Genitalia. Mons Veneris. Labia Majora. Labia
Minora. Vestibule. Vaginal Opening. Fossa Navicularis. Bartholin
Glands. Perineum. Breasts.
CHAPTER II. PHYSIOLOGY. Puberty. Ovulation. Menstruation.
Modifications of Menstruation. Menopause.
CHAPTER I
ANATOMY OF THE FEMALE PELVIS AND GENERATIVE ORGANS
NORMAL FEMALE PELVIS
The present broad knowledge of the anatomy of the female pelvis has
resulted in an enormous reduction in death and injury among obstetrical
patients and their babies.
This knowledge of the pelvic anatomy, relating as it does, to both
normal and malformed pelves, has made possible a system of taking
measurements, termed _pelvimetry_, which gives the obstetrician a fair
idea of the size and shape of his patient’s pelvis. Such information,
coupled with observations upon the size of the child’s head, gives a
foundation upon which to base some expectation of the ease or difficulty
with which the approaching delivery is likely to be accomplished.
Since each patient’s pelvic measurements are considered from the
standpoint of their comparison with normal dimensions, it is manifestly
important that the obstetrical nurse have a clear idea of the structure
of the normal female pelvis, and also of its commonest variations.
Viewed in its entirety, the pelvis is an irregularly constructed,
two-storied, bony cavity, or canal, situated below and supporting the
movable parts of the spinal column, and resting upon the femora or thigh
bones. (Fig. 1, A. and B.).
Four bones enter into the construction of the pelvis: the two hip bones
or _ossa innominata_, on the sides and in front with the _sacrum_ and
_coccyx_ behind.
=The innominate bones= (ossa innominata), symmetrically placed on each
side, are broad, flaring and scoop-shaped. Each bone consists of three
main parts, which are separate bones in early life, but firmly welded
together in adults: the _ilium_, _ischium_ and _pubis_. The ilia are the
broad, thin, plate-like sections above, their upper, anterior
prominences, which may be felt as the hips, are the _anterior superior
spinous processes_ used in making pelvic measurements. The margins
extending backward from these points are termed the _iliac crests_.
The ischii are below and it is upon their projections, known as the
_tuberosities_, that the body rests when in the sitting position, and
which also serve as landmarks in pelvimetry. The pubes form the front of
the pelvic wall, the anterior rami uniting in the median line by means
of heavy cartilage and forming the _symphysis pubis_.
=The sacrum and coccyx= behind are really the termination of the spinal
column, the sacrum consisting, usually, of five rudimentary vertebrae
which have fused into one bone. It sometimes consists of four bones,
sometimes six, but more often of five. The sacrum completes the pelvic
girdle behind by uniting on each side with the ossa innominata by means
of strong cartilages, thus forming the _sacro-iliac joints_. The spinal
column rests upon the upper surface of the sacrum. The coccyx, a little
wedge-shaped, tail-like appendage, which ordinarily has but slight
obstetrical importance, extends in a downward curve from the lower
margin of the sacrum, to which it has a cartilaginous attachment, the
_sacro-coccygeal joint_. This joint between the sacrum and coccyx is
much more movable in the female than in the male pelvis.
We find, therefore, that although the pelvis constitutes a rigid, bony,
ringlike structure, there are four joints: the symphysis pubis, the
sacro-coccygeal, and the two sacro-iliac articulations. As the
cartilages in these joints become somewhat softened and thickened during
pregnancy, because of the increased blood supply, they all permit of a
certain, though limited amount of motion at the time of labor. This
provision is of considerable obstetrical importance, since the
sacro-coccygeal joint allows the child’s head to push back the
forward-protruding coccyx, as it passes down the birth canal, thus
removing what otherwise might be a serious obstruction. And when, as is
sometimes necessary, because of a constricted inlet, the pubic bone is
cut through (the operation known as pubiotomy), the hingelike motion of
the sacro-iliac joint permits of an appreciable spreading of the two hip
bones and a consequent widening of the birth canal.
[Illustration:
A. Normal female Pelvis.
]
[Illustration:
B. Normal male Pelvis.
FIG. 1.—Normal Pelves. Note the broad, shallow, light construction of
the female pelvis, A, as compared with the more massive male pelvis,
B.
]
=The pelvic cavity= as a whole is divided into the _true_ and _false
pelves_ by a constriction of the entire structure known as the _brim_ or
_inlet_. The inlet is not round, its antero-posterior diameter being
shortened by the _sacro-vertebral joint_ which protrudes forward and
gives the opening something of a blunt, heart-shaped outline. (Fig. 2.)
[Illustration:
FIG. 2.—Diagram of the pelvic inlet, seen from above, with most
important diameters.
]
As the pelvis occupies an oblique position in the body, the plane of
this brim is not horizontal, but slopes up and back from the
symphysis-pubis to the promontory of the sacrum. Being swung upon the
heads of the femora, the relation of the pelvis to the entire body
differs in the sitting and standing positions. When a woman stands
upright, her pelvis is so markedly oblique in its position that she
would tip backward but for strong tendons attached to the pelvis and
running down the front of the thighs. Added strain upon these tendons
during pregnancy may account for some of the apparently undue fatigue
experienced by the expectant mother.
The shallow, expanded portion of the pelvis above the brim is the large,
or false pelvis, its walls being formed by the sacrum behind, the
fan-like flares of the ilia on each side, with the incompleteness of the
bony wall in front made up by abdominal muscles.
=The false pelvis= ordinarily serves simply as a support for the
abdominal viscera, which do not occupy the true pelvis unless forced
down by some such pressure as that caused by tight, or poorly fitting
corsets. The false pelvis is of little obstetrical importance, its
function during pregnancy being to support the enlarged uterus, while at
the time of labor it acts as a funnel to direct the child’s body into
the true pelvis below.
[Illustration:
FIG. 3.—Diagram of pelvic outlet, seen from below, with most important
diameters.
]
=The true pelvis=, on the other hand, is of greatest possible
obstetrical importance since the child must pass through its narrow
passage during birth. It lies below and somewhat behind the inlet; is an
irregularly shaped, bottomless basin, and contains the generative
organs, rectum and bladder. Its bony walls are more complete than those
of the false pelvis, and are formed by the sacrum, coccyx and innominate
bones. Its lower margin constitutes the _outlet_, or _inferior strait_,
and being longer in its antero-posterior dimension than in its
transverse measurement, its long axis is at right angles to the long
axis of the inlet. (Fig. 3.) A baby’s head, accordingly, must twist or
rotate in making its descent through this bony canal, for the long
diameter of the head must first conform to one of the long diameters of
the inlet, either transverse or oblique, and then turn so that the
length of the head is lying antero-posteriorly, in conformity to the
long diameter of the outlet, through which it next passes.
The posterior wall of the pelvis, consisting of the sacrum and coccyx,
forms a vertical curve and is about three times as deep as the anterior
wall formed by the narrow symphysis pubis. The structure as a whole,
therefore, curves upon itself, resembling a bent tube with its concavity
directed forward. (Fig. 4.)
[Illustration:
FIG. 4.—Diagram of sagittal section of the pelvis showing curve of the
bony canal, with most important diameters.
]
Thus it becomes apparent that the structure of the pelvis requires the
child’s head, not only to rotate in its passage through the birth canal,
but also to describe an arc, since the part of the head which passes
down the posterior wall travels farther in a given time than the part
which passes under the pubis.
This twisting and curving of the birth canal must be appreciated in
order to understand the mechanism of labor.
In considering the question of pelvimetry, we find that there are both
external and internal measurements to be taken, all for the purpose of
estimating as accurately as possible the shortest diameter of the inlet
through which the baby must pass. (Fig. 5.)
According to a common system of mensuration, the first external
measurement is the _inter-spinous_, the distance between the
anterior-superior spines, those bony points which are uppermost as the
patient lies on her back. This distance is normally 26 centimetres.
(Fig. 6.)
[Illustration:
FIG. 5.—Two types of pelvimeters frequently used in taking
measurements of the pelvic inlet and outlet.
]
The second measurement is the _inter-crestal_, or the distance between
the iliac crests, and is normally 28 centimetres.
_Baudelocque’s diameter_ is the third measurement and is taken with the
patient lying on her side. (Fig. 7.) It is the distance from the top of
the symphysis to a depression just below the last lumbar vertebra. This
depression is easily located as it also marks the upper angle of a space
just above the buttocks, which in normal pelves is quadrilateral. In
malformed pelves this quadrangle may be so misshapen as to become almost
a triangle with the apex directed either up or down. This dimension is
sometimes called the _external conjugate_ and ordinarily measures 21
centimetres.
The fourth measurement is the distance between the _great trochanters_,
or heads of the femora, and normally is 32 centimetres.
All of these measurements, which after all are only approximate, relate
to the top of the pelvis and are valuable in that they help in
estimating the dimensions of the inlet, which are the important ones,
and obviously cannot be measured on a live woman.
[Illustration:
FIG. 6.—Diagram showing method of measuring distances between iliac
crests and spines and the trochanters.
]
The inlet has four measurements of obstetrical importance: the
_antero-posterior_, or _true conjugate_, which is the distance from the
top of the symphysis pubis to the prominence of the sacrum, and is
normally 11 centimetres; the _transverse diameter_, which is at right
angles to the true conjugate and is the greatest width of the inlet,
measuring from a point on one side of the brim to the corresponding
point on the other, is normally 13.5 centimetres, and the two diagonal
measurements, known respectively as the _right_ and _left oblique
diameters_, which are normally 12.75 centimetres.
Although it is very important to the expectant mother that all of these
dimensions be of normal length, the length of the true conjugate, or
_conjugata vera_, is of the gravest importance of all because it is the
shortest diameter through which the child’s head must pass. If it is
shorter than normal, the channel may be too constricted for the
full-term baby’s head to pass through comfortably, thus making a
spontaneous delivery extremely difficult, or even impossible.
[Illustration:
FIG. 7.—Diagram showing method of measuring Baudelocque’s diameter.
]
The length of the all important, true conjugate is estimated by
introducing the first two fingers of one hand into the vagina until the
tip of the second finger touches the promontory of the sacrum. (Fig. 8.)
The point at which the inner margin of the symphysis then rests upon the
forefinger is measured, thus giving the length of the _diagonal
conjugate_. This normally measures 12.5 centimetres or more, and is
estimated as being 1.5 centimetres longer than the true conjugate.
The most important measurement of the outlet is the _intertuberous
diameter_, the distance between the tuberosities of the ischii. This is
the shortest diameter through which the child must pass in the inferior
strait, and normally measures something more than 8 centimetres, usually
about 11 centimetres. (Fig. 9.)
It is possible, by studying such measurements as these, made upon an
expectant mother, and comparing them with dimensions which have been
accepted as normal, to form a reasonably accurate estimate of the size
and shape of her pelvis.
[Illustration:
FIG. 8.—Diagram showing method of estimating the true conjugate by
measuring the length of the diagonal conjugate.
]
A delivery may be, and frequently is, accomplished through a pelvis
which is not entirely normal in size or shape. But the obstetrician of
to-day is closely observant of the patient whose pelvic measurements
depart from the normal by more than the accepted margin of safety, and
he plans for labor in accordance with the indications in each case.
Disproportion between the measurements of the mother’s pelvis and the
size of the child’s head must be considered in this connection. A small
pelvis may permit of the spontaneous delivery of a small child, but be
too narrow for the passage of a full-sized baby, while a woman with a
normal pelvis may have an extremely difficult labor because of an
unusually large child.
The size and shape of the pelvis is found to vary among different races
and in different individuals. And the size and contour of the inlet may
be so altered by rickets, lack of proper exercise during early life, or
by growths upon the pelvic bones, as to seriously interfere with normal
labor.
[Illustration:
FIG. 9.—Diagram showing method of measuring the inter-tuberous
diameter.
]
The various kinds of malformed pelves may be loosely classified as
generally contracted or small; flat; simple funnel; generally contracted
funnel; and the rachitic pelves, both flat and generally contracted.
There may be a contracted inlet, or a contracted outlet, or both may
occur in the same pelvis.[1]
Rachitic pelves are common among negroes and not altogether rare among
white women.
The normal _male pelvis_ is deep, narrow, rough and massive as compared
with the female structure (see Fig. 1.), and the angle of the pubic
arch, formed by the two pubic bones, is deeper and more acute in the
male than in the female skeleton.
The normal female pelvis, on the other hand, is light, broad, shallow,
smooth and large, giving evidence of the infinite wisdom and skill that
entered into constructing it for the high purpose it was designed to
serve.
FEMALE ORGANS OF REPRODUCTION
The female organs of reproduction are divided into two groups, the
_internal_ and the _external genitals_. With them are usually considered
certain other structures: the _ureters_, _bladder_, _urethra_, _rectum_
and the _perineum_, because of their close proximity (Fig. 10.); and the
breasts, because of their functional relation to the reproductive
organs.
=Internal Genitalia=. The internal organs of generation are contained in
the true pelvic cavity and comprise the _uterus_ and _vagina_ in the
centre, an _ovary_ and _Fallopian tube_ on each side, together with
their various ligaments, membranes, nerves and blood vessels and a
certain amount of fat and connective tissue.
The =uterus= is the largest of these organs. In its nonpregnant state,
it is a hollow, flattened, pear-shaped organ about three inches long,
one and a quarter inches wide, at its broadest point, three-quarters of
an inch thick and weighing about two ounces.
[Illustration:
FIG. 10.—Anterior view of female generative tract, showing both
external and internal organs. Drawn by Max Brodel. (Used by
permission of A. J. Nystrom & Co., Chicago.)
]
Ordinarily it is a firm, hard mass, consisting of irregularly disposed,
involuntary (unstriped or plain) muscle fibres and connective tissue,
nerves and blood vessels. The arrangement of the uterine muscle fibres
is unique, for they run up and down, around and crisscross, forming a
veritable network. This strange arrangement of the fibres is favorable
to the growth of the uterine musculature during pregnancy, and a factor
in preventing hemorrhage after delivery.
The abundant blood supply to the uterus merits a word. It is derived
from the uterine arteries, arising from the internal iliacs, and the
ovarian artery from the aorta. The arteries from the two sides of the
uterus are united by a branch where the neck and body of this organ
meet, thus forming an encircling artery. A deep cervical tear during
labor may break this vessel and a profuse hemorrhage occur as a result.
[Illustration:
FIG. 11.—Diagrams of sections of virgin and multiparous uteri.
]
The uterus is covered, front and back, by a fold of the _peritoneum_,
except the lower part of the anterior wall where the peritoneum is
reflected up over the bladder. It is lined with a thick, velvety, highly
vascular mucous membrane, the _endometrium_, the surface of which is
covered by ciliated, columnar epithelium. Embedded in the endometrium
are numerous mucous glands which dip down into the underlying, muscular
wall.
The uterus as a whole is comprised of three parts: the _fundus_, that
firm, rounded, head-like part above; the _body_, or middle portion, and
the _cervix_, or neck, below. It is in the body and cervix that we find
the long, narrow uterine cavity, divided by a constriction into two
parts. The cavity of the body is little more than a vertical slit, being
so flattened from before backward that the anterior and posterior
surfaces are nearly if not quite in apposition. It is somewhat
triangular in shape with an opening at each angle. (Fig. 11.) The lower
of these openings leads into the cavity of the cervix through a
constriction termed the _internal os_, while at the _cornua_, or two
upper angles, are the openings into the Fallopian tubes.
The cavity of the cervix is spindle-shaped, being expanded between its
two constricted openings, the internal os above and the _external os_
below, which opens into the _vagina_. The external os in the virgin is a
small round hole but has a ragged outline in women who have borne
children.
This oblong, muscular body, the uterus, is suspended obliquely in the
centre of the pelvic cavity by means of ligaments. In its normal
position the entire organ is slightly curved forward, or ante-flexed,
the fundus being directed upward and forward and the cervix pointing
down and back. This position is affected by a distended bladder or
rectum, and also by postural changes in the body as a whole. The
_cervix_ protrudes into the anterior wall of the vagina for about
one-half inch and almost at right angles, since the vagina slopes down
and forward to the outlet.
The upper part of the uterus is held in position by means of ligaments,
the lower part being embedded in fat and connective tissue between the
bladder and rectum. This more or less of a floating position makes
possible the enormous increase in size and upward push or extension of
the uterus during pregnancy. The pregnant uterus becomes soft and
elastic as it grows. At term it is about a foot long, eight to ten
inches wide, and reaches up into the epigastric region. This growth is
due in part to the development of new muscle fibres and in part to a
growth of the fibres already existing in the uterine wall.
After labor the uterus returns almost, but never entirely, to its former
size, shape and general condition.
=The Fallopian tubes= are two tortuous, muscular tubes, four or five
inches long, extending laterally in an upward curve, from the cornua of
the uterus and within the folds of the upper margin of the _broad
ligament_, by which they are covered. At their juncture with the uterus,
the diameter of these tubes is so small as to admit of the introduction
of only a fine bristle, but they gradually increase in size toward their
termination in wide trumpet-shaped orifices, which open directly into
the peritoneal cavity. Finger-like projections called _fimbriæ_, fringe
the margins of these openings.
The mucous lining of the tubes is covered with ciliated epithelium and
is continuous with that of the uterus. At the fimbriated extremities of
the tubes this lining merges into the peritoneum, the serous lining of
the abdominal cavity.
Just here it will be well to say a word about the peritoneum because of
the possibility of its becoming infected during labor and the lying-in
period, and the very grave consequences of such infection. It is a
delicate, highly vascular, serous membrane which both lines the
abdominal cavity and covers the abdominal and pelvic organs, which press
into its outer surface and are covered much as one’s fingers would be
covered by pushing them into the outer surface of a child’s toy balloon.
The continuity of this membrane is broken only where it is entered by
the Fallopian tubes.
=The ovary=, the sex gland of the female, is a small, tough ductless
gland, about an inch long and three-quarters of an inch wide, or about
the size and shape of an almond. It is greyish pink in color and
presents a more or less irregular, dimpled surface. An ovary is
suspended on either side of the uterus, in the posterior fold of the
broad ligament, by which it is partly covered. Its outer end is usually
attached to the longest of the fimbriated extremities of the Fallopian
tube, the _fimbria ovarica_, which has the form of a shallow gutter, or
groove. The inner end of the ovary is attached to the _ovarian
ligament_, which in turn is attached to the uterus below and behind the
tubal entrance.
The ovary consists of two parts, the central part or _medulla_, composed
of connective tissue, nerves, blood and lymph vessels, and the _cortex_,
in which are embedded the vesicular _Graafian follicles_ containing the
ova. At birth each ovary contains upwards of 50,000 of these ova, which
are the germ cells concerned with reproduction and the process of
menstruation.
These ovarian glands perform two vital functions, for in addition to
their prime function of producing and maturing the germinal cell of the
female, they provide an internal secretion which exercises an
immeasurably important, though imperfectly understood, influence upon
the general well-being of the entire organism.
[Illustration:
FIG. 12.—Sagittal section of female generative tract. Drawn by Max
Brodel. (Used by permission of A. J. Nystrom & Co., Chicago.)
]
=The vagina= is an elastic, muscular sheath or tube, about four inches
long, lying behind the bladder and urethra and in front of the rectum.
It leads interiorly up and backward from the vulva to the cervix, which
it encases for about half an inch. The space between the outer surface
of the cervix that extends into the vagina, and the surrounding vaginal
walls, is called the _fornix_. For convenience of description, this is
divided into four sections or fornices: the anterior, posterior and
lateral fornices.
Between the posterior fornix and the rectum a fold of the peritoneum
drops down and forms a blind pouch known as _Douglas’ cul-de-sac_. At
this point the delicate peritoneum is separated from the vagina by only
a thin, easily punctured, muscular wall. This is a fact of grave
surgical significance, for unless instruments and nozzles introduced
into the vagina are very gently and skillfully directed, they may easily
pierce this thin partition. Septic material may thus gain entrance to
the peritoneal cavity and peritonitis result.
The bore of the vaginal canal ordinarily permits of the introduction of
one or two fingers. It is somewhat flattened from before backward, and
on cross section resembles the letter H. During labor this canal becomes
enormously dilated, being then four or five inches in diameter, and
permits the passage of the full term child.
The vagina is lined with a thick, heavy, mucous membrane which normally
lies in transverse folds or corrugations called _rugæ_. These folds are
obliterated and the lining stretched into a smooth surface as the canal
dilates during labor.
Attention must be drawn to the fact that the vagina, cervix, uterus and
tubes form a continuous canal from the vulva to the easily infected
peritoneum, a fact which makes absolute surgical cleanliness in
obstetrics virtually a matter of life or death to the patient.
This muscular tube is lined throughout its entire length with mucous
membrane, which, though continuous, changes somewhat in character along
its course. The epithelial cells of the lining of the tubes and body of
the uterus have hair-like projections, cilia, which maintain a constant
waving motion from above downward. The effect of this sweeping current
is to carry down toward the outlet any object or secretion which may be
upon the surface of the lining of the tubes or uterine cavity. The
unfertilized ovum is thus swept down to meet the germ cell of the male
and become fertilized.
Along this variously constructed canal, at different periods in the life
of the individual, pass the matured ovum, the menstrual flow, the
uterine secretions, the fetus, the placenta and lochia, (the discharge
which occurs during the puerperium).
Although the bladder and rectum are not organs of reproduction, they are
contained in the pelvic cavity and lie in such close proximity to the
internal genitalia that at least a passing word must be devoted to their
description.
=The bladder= is a sac of connective tissue which serves as a reservoir
for the urine and is situated behind the symphysis pubis and in front of
the uterus and vagina. Urine is conducted into the bladder by the
_ureters_, two slender tubes running down on each side from the basin of
the kidney across the pelvic brim to the upper part of the bladder,
which they enter somewhat obliquely, at about the level of the cervix.
It is thought that pressure of the enlarged pregnant uterus upon the
ureters at this point may be one factor in the causation of pyelitis, a
frequent complication of pregnancy. The bladder empties itself through
the _urethra_, a short tube which terminates in the _meatus urinarius_,
a tiny opening in the vulva.
=The rectum=, the lowest segment of the intestinal tract, is situated in
the pelvic cavity behind and to the left of the uterus and vagina. It
extends downward from the sigmoid flexure of the colon to its
termination in the anal opening. The _anus_ is a deeply pigmented,
puckered opening situated an inch and a half or two inches behind the
vagina. It is guarded by two bands of strong circular muscles, the
_internal_ and _external sphincter ani_. The skin covering the surface
of the body extends upward into the anus where it becomes highly
vascular and merges into the mucous lining of the rectum. Pressure
exerted during pregnancy by the enlarged uterus is felt in both the
rectum and bladder, frequently causing a good deal of discomfort and
almost painful desire to evacuate their contents.
The blood vessels in the anal lining just within the external sphincter
sometimes become engorged and inflamed, even bleeding during pregnancy,
as a result of the pressure exerted by the greatly enlarged uterus. The
distended blood vessels, which in this condition are called hemorrhoids,
not infrequently protrude from the anus and become very painful.
After having considered the structure and relative positions of the
pelvic organs one is able to picture more clearly the arrangement and
disposition of the _uterine ligaments_, all of which are formed by folds
of the peritoneum. They are twelve in number, five pairs and two single
ligaments, namely: two _broad_, two _round_, two _utero-sacral_, two
_utero-vesical_, two _ovarian_, one _anterior_ and one _posterior_
ligament.
=The broad ligaments= are in reality one continuous structure formed by
a fold of the peritoneum, which drops down over the uterus, investing
the fundus, body, part of the cervix, and part of the posterior wall of
the vagina. It unites on each side of the uterus to form a broad, flat
membrane which extends laterally to the pelvic wall, dividing the pelvic
basin into an anterior and posterior compartment, containing
respectively the bladder and rectum. Between the folds of the broad
ligament are situated the ovaries and ovarian ligaments, the Fallopian
tubes, the round ligaments and a certain amount of muscle and connective
tissue, blood vessels, lymphatics and nerves.
=The round ligaments=, one on each side, are narrow, flat bands of
connective tissue derived from the peritoneum and muscle prolonged from
the uterus, and containing blood and lymph vessels and nerves. They pass
upward and forward from their uterine origin just below and in front of
the tubal entrance, finally merging in the mons veneris and labia
majora.
=The utero-sacral ligaments=, of which there is one on each side, arise
in the uterus and, extending backward, serve to connect the cervix and
vagina with the sacrum.
=The utero-vesical ligaments=, one on each side, extend forward and
connect the uterus and bladder.
=The ovarian ligaments=, as previously described, are attached to the
uterine wall and to the inner end of the ovary, one on each side.
=The anterior ligament= is a portion of the peritoneum which dips down
between the bladder and uterus, forming a pouch. It is known also as the
uterine-vesical pouch, or the vesico-uterine excavation.
=The posterior ligament= is formed in much the same manner by a portion
of the peritoneum dipping down behind the uterus, in front of the
rectum, and forming the recto-vaginal pouch. This is the Douglas’
cul-de-sac previously referred to.
=External Genitalia.—The vulva=, or external genitalia, are situated in
the _pudendal crease_ which lies between the thighs at their junction
with the torso, and extends posteriorly from the pubis to a point well
up on the sacrum. (Fig. 13.)
=The mons veneris= is a firm cushion of fat and connective tissue, just
over the symphysis pubis. It is covered with skin which contains many
sebaceous glands and after puberty is abundantly covered with hair.
[Illustration:
FIG. 13.—Diagram of external female genitalia. (Redrawn from
Dickinson.)
]
=The labia majora= are heavy ridges of fat and connective tissue,
prolonged from the mons veneris and extended down and back almost to the
rectum, on each side, forming the lateral boundaries of the groove. They
are lined with mucous membrane and covered with skin and hair, the
latter growing thinner toward the perineum until it finally disappears.
=The labia minora= are two small cutaneous folds lying between the labia
majora on each side of the vagina. Like the larger folds, they taper
toward the back and practically disappear in the vaginal wall. Their
attenuated posterior ends are joined together behind the vagina by means
of a thin, flat fold called the _fourchette_. The labia minora divide
for a short distance before joining at an angle in front, thus forming a
double ridge anteriorly. In the depression between these ridges is the
_clitoris_, a small, sensitive projection composed of erectile tissue,
nerves and blood vessels and covered with mucous membrane. The meatus
urinarius is just below the clitoris and between two small folds of the
mucous membrane.
=The vestibule= is the triangular space between the labia minora, and
into it open the meatus urinarius, the vagina and the more important
vulvo-vaginal glands.
=The vaginal opening= is below the vestibule and above the perineum. It
is partially closed by the hymen, a fold of mucous membrane disposed
irregularly around the outlet, somewhat after the fashion of a circular
curtain. The hymen is ragged or more or less scalloped in outline, and
varies greatly in size in different women, in some instances extending
so far over the opening as nearly or quite to close it.
=The fossa navicularis= is a depressed space between the hymen and
fourchette, so named because of its boat-like shape.
=The Bartholin glands=, probably the largest and most important of the
vulvo-vaginal glands, are situated one on each side of the vagina and
open into the groove between the hymen and labia minora. Reference is
made to these glands because of the danger of their becoming infected. A
gonorrheal infection of these glands is particularly troublesome.
=The perineum= is a pyramidal structure of connective tissue and muscle
which occupies the space between the rectum and vagina, and by forming
the floor of the pelvis serves as a support for the pelvic organs. The
lower and outer surface of this mass, representing the base of the
pyramid, lies between the vaginal opening and the anus and is covered
with skin. As the anterior part of the perineum is incorporated in the
posterior wall of the vagina, the entire structure becomes stretched and
flattened when the vagina is dilated during labor by the passage of the
child’s head.
Unless very carefully guarded at the time of delivery, and often even
then, the perineum gives way under the great tension undergone at that
time, and a tear is the result. The injury may be only a slight nick in
the mucous membrane or it may extend to, or into the _levator ani_, the
most important muscle of the perineal body, or if a “complete tear” will
extend all the way through the perineum and completely through the
sphincter ani. Such a tear is lamentable, as a break in the ring-shaped
sphincter muscle guarding the anal opening robs a woman of control of
her bowels, and is repaired with difficulty.
BREASTS
=The breasts= are large, specially modified skin glands of the compound,
racemose or clustering type, embedded in fat and connective tissue and
abundantly supplied with nerves and blood vessels. They are situated
quite remotely from the pelvic organs, but because of the intimate
functional relation between the two, the breasts of the female may be
regarded as accessory glands of the generative system. They exist in the
male, also, but only in a rudimentary state.
Although the breasts sometimes contain milk during infancy, their true
function is to secrete, in the parturient woman, suitable nourishment
for the human infant during the first few months of its life.
These glands are symmetrically placed, one on each side of the chest,
and occupy the space between the second and sixth ribs extending from
the margin of the sternum almost to the mid-axillary line. A bed of
connective tissue separates them from the underlying muscles and the
ribs. (Fig. 14.)
They vary in size and shape at different ages, and with different
individuals, particularly in women who have borne and nursed children,
when they tend to become pendulous. But in general they are
hemispherical or conical in shape with the nipple protruding from
one-quarter to one-half inch from the apex. The nipples are largely
composed of sensitive, erectile tissue and become more rigid and
prominent during pregnancy and at the menstrual periods. Their surfaces
are pierced by the orifices of the milk ducts, which are fifteen or
twenty in number. (Fig. 15.)
[Illustration:
FIG. 14.—Sagittal section of breast showing structure of secretory
apparatus.
]
The breasts are covered with very delicate, smooth, white skin,
excepting for the _areolæ_, those circular, pigmented areas one to four
inches in diameter, which surround the nipples. The areolæ are darker in
brunettes than in blonds, and in all women grow darker during pregnancy.
The surface of the nipples and of the areolæ is roughened by small,
shot-like lumps or papillæ known as the _tubercles of Montgomery_. This
roughness becomes more marked during pregnancy, since the papillæ grow
larger and sometimes even contain milk.
[Illustration:
FIG. 15.—Front view of breast showing areola, tubercles of Montgomery
and orifices of milk ducts.
]
The secretory apparatus of the breasts is divided into fifteen or twenty
lobes, these in turn being divided into clusters of lobules. The lobules
in turn are composed of tiny, secreting cells, called _acini_, in which
the milk is elaborated from the blood. The acini are minute globules
lined by a single layer of cells and enveloped by a very delicate
membrane. Tiny ducts carry the milk from the acini to the main duct of
the lobule, around which the acini cluster. These ducts empty the milk
into the larger duct of the lobe, which runs straight to the nipple and
opens upon the surface. Just before reaching the surface, each of these
lactiferous sinuses expands into an _ampulla_, a minute reservoir for
collecting the milk, which is secreted during the periods between
nursings.
These clusters of acini uniting to form lobules with tiny ducts leading
into the main duct of each lobule, closely resemble a bunch of grapes.
The separate grapes correspond to the acini, their small stems
correspond to the tiny ducts of the glands which lead to a larger one,
and the central stem of the grape cluster, to the milk duct that opens
upon the nipple.
The secretory tissue really constitutes a small part of the breasts
until they begin to function. But during lactation the acini become
enormously developed and enlarged. After lactation ceases, the acini
assume a more or less tubal form, many of them undergoing atrophic
changes.
CHAPTER II
PHYSIOLOGY
=Puberty= is that period during which childhood develops into sexual
maturity, and the individual becomes capable of reproduction.
The age at which puberty occurs varies with climate, race, occupation
and with individuals of the same status. But the average age for girls,
in temperate climates, is from the twelfth to the sixteenth year; for
boys from the fourteenth to the seventeenth year. Girls in southern
climates sometimes mature as early as the eighth or ninth year, while in
colder regions puberty may be delayed until the eighteenth or twentieth
year.
At this time there are many physical and psychical manifestations of the
maturing changes in the internal female generative organs. The
undeveloped girl grows rapidly at this stage. Her entire body rounds out
and assumes a more graceful contour; her breasts increase in size; her
hips broaden; the external genitalia enlarge and hair appears over the
pubis and on other parts of the body.
As this physical maturity progresses, there is a dawning sex
consciousness and the developing girl becomes shy, modest, retiring and
introspective. She is very likely to be emotional and hysterical and to
display a lack of stability and nervous control, which are not in accord
with her usual temperament. A formerly dependable child may become
capricious, erratic, and perplexingly inconsistent. One day she may be
quite her normal, little-girl self and the next show inexplicably mature
qualities. Or she may display a bewildering number of moods and fancies
in the span of one short day.
Too much cannot be said of the importance of wise supervision and
guidance of the girl’s physical, mental and emotional life at this
critical, emotional period. Many gynecological, obstetrical and
neurological difficulties in her later life may be averted by her
observance of sane rules of personal hygiene.
Vigorous and regular out-of-door exercise; a simple, nourishing and
well-balanced diet; adequate sleep in a well-ventilated room; regular
bathing, and correction of any discoverable physical defects are the
essentials.
But of equal, if not greater, importance is an understanding and
sympathetic oversight of the girl’s mental and emotional life, a
steadying sort of comradeship.
Her extreme sensitiveness and impressionability should be recognized and
borne in mind, and every effort made to save her from strain and shock.
Her nervous forces should be sedulously conserved by protecting her
against experiences and diversions which would be unduly stimulating or
irritating. Nor should demands be made upon her uncertain nervous
endurance which she is able to meet only by great strain, if at all.
It is important to her future poise and health that her confidence be
courted, and when it is won, that all of her outpourings be received
with a respect and seriousness commensurate with their great importance
to her. Ridicule, and even unresponsiveness or indifference to her
interests, may, and often do, result in a hurtful repression of one form
or another. The logical consequence of such repression is an
increasingly damaging neurosis later on in her life, capable of greatly
impairing her health, happiness and usefulness.
In short, all phases of the life of the adolescent girl should be made
as wholesome, tranquil and free from stress and strain as is humanly
possible.
These comments upon the importance of mental hygiene at puberty may seem
irrelevant to a discussion of obstetrical nursing. But the preparation
of the entire female organism for its supreme function—that of
child-bearing—is of concern to the obstetrical nurse, and should be
understood by her. Moreover, every nurse is inevitably a health teacher,
either by precept or example, or both. An awareness on her part of the
maturing girl’s needs will fit her to help many perplexed mothers whom
she meets along the way to a happy solution of this grave and vexing
problem.
The occurrence of puberty marks the establishment of _ovulation_ and
_menstruation_. These two functions are usually performed once a month,
ovulation probably occurring about midway during the intermenstrual
period.
=Ovulation=, which is the prime function of the ovary, may be defined as
the formation and development of the ovum, and its expulsion, when
mature, from the ovary.
The formation of each woman’s full quota of ova is probably complete at
birth, though the process may continue until about the second year. At
this time it is variously estimated that each of the two ovaries
contains from 50,000 to 70,000 ova, but they remain unmatured until
puberty, the period at which ovulation is most active.
[Illustration:
FIG. 16.—Diagram of human ovum.
]
As the entire complex human body has its origin in this tiny ovum, its
course of development is of momentous importance to us, and at the same
time it provides a tale of intense interest.
In its unmatured state, the ovum, termed a _primordial follicle_, or
_oöcyte_, is a single cell, 1/125 inch in diameter, consisting of clear
protoplasm, the _vitellus_, and a surrounding _vitelline membrane_
composed of small, spindle-shaped epithelial cells. The protoplasm
contains a fairly large _nucleus_, or _germinal vesicle_, within which
lies a _nucleolus_ known as the _germinal spot_. (Fig. 16.)
The primordial follicle probably lies dormant in this state until
puberty, when developmental changes take place, though it is the belief
of some authorities that follicles are in the process of development
from birth until the end of sexual life, though none fully mature until
puberty.
With the advent of puberty the cells composing the vitelline membrane
change in character and proliferate rapidly, with the result that the
ovum is surrounded by several layers of epithelial cells. Some of the
inner cells degenerate and liquify, thus surrounding the ovum with fluid
which is contained in a membrane of vascular connective tissue, the
_theca folliculi_; this in turn is lined with epithelial cells, the
_membrana granulosa_. This structure constitutes a _Graafian follicle_,
named for Dr. de Graaf who first described it, and in the course of its
maturation is pushed toward the surface of the ovary, where it presents
more or less the appearance of a clear blister.
At one point in the enveloping membrana granulosa, the cells proliferate
into a mass in which the floating ovum becomes embedded. This mass is
termed the _discus proligerus_ and the fluid which surrounds it is the
_liquor folliculi_.
Usually for some strange reason, one, and only one, ovum ripens
regularly each month during the years from puberty to the menopause,
excepting during pregnancy, when this function is suspended.
Occasionally, however, several ova mature at once, a condition which may
be one factor in the development of twins. After puberty the ovary
contains ova in all stages of development, from the primordial follicle
to the Graafian follicle just described.
When a Graafian follicle containing a matured ovum reaches the ovarian
surface, its membrane becomes thinner and finally ruptures because of
increased tension in the ovary, due to certain circulatory changes. The
ovum surrounded by the discus proligerus is thus discharged into the
peritoneal cavity near the fimbriated end of the tube. Some ova enter
the tube and others float about in the peritoneal cavity, finally
disintegrate and are lost.
The torn envelope of the follicle which remains in the cortex of the
ovary becomes filled with blood, which forms into a clot. This clot is
first surrounded, and then invaded, by cells containing bright yellow
pigment called _lutein_. The membrane formed from these cells compresses
the clot and brings about other changes which speedily transform it into
the _corpus luteum_.
If the discharged ovum becomes fertilized, the corpus luteum remains
practically unchanged for months and is termed the _corpus verum_ or
corpus luteum of pregnancy. Its secretion is believed to influence the
implantation of the ovum and to promote the woman’s general well-being
during the period of gestation. It continues to exist throughout
pregnancy, and until after delivery, when it is soon absorbed and
replaced by normal ovarian tissue, without the formation of scar tissue.
If fertilization does not occur, the body in the ovarian cortex, which
is then termed the corpus luteum of menstruation, or _false corpus_,
undergoes rapid degenerative changes and is almost wholly absorbed
within a few weeks.
By means of this rather complicated procedure the ovary is saved from
becoming a steadily enlarging mass of scar tissue, and consequently
devoid of reproductive powers, which would be the case if the wound made
by the rupturing of each Graafian follicle were to heal by the usual
formation of cicatricial tissue.
Ordinarily the ovum remains unfertilized and is propelled down the
Fallopian tube, by the cilia in its lining, to the uterine cavity, where
it is lost in the uterine secretions and ultimately carried out in the
menstrual flow.
Each time that an ovum matures, however, and is discharged from the
ovary the lining of the uterine cavity increases in vascularity and
becomes thicker and more velvety; a condition which facilitates an
attachment of the ovum in case of fertilization. This preparation of the
endometrium is termed “pre-menstrual swelling,” or in popular language,
nest-building.
Of the enormous number of ova existing in each woman, relatively few
mature and it is apparent that still fewer are fertilized, since each
impregnation results in an abortion, a premature labor or a full term
child.
Nature’s lavish provision of something more than 100,000 ova for each
woman, who uses only about 500 in the course of her life, excites no
little wonder. But whatever the purpose of this enormous supply, its
existence makes possible the removal of all but a small fragment of
ovarian tissue in cases of disease, without interference with the
process of ovulation, which in turn permits reproduction.
=Menstruation=, which is the evidence of sexual maturity, is a monthly
hemorrhage from the uterus which escapes through the vagina, normally
recurring throughout the entire child-bearing period, except during
pregnancy and lactation. The duration of this child-bearing period, or
sexual activity, is about thirty years and continues from puberty to the
menopause.
The frequency of the menstrual periods varies in different women from
twenty-one to thirty days, but the normal interval between periods is
twenty-eight days, which corresponds in point of time to the menstrual
cycle. Thus it is usually four weeks, or a lunar month, from the
beginning of one period to the beginning of the period following, making
thirteen menstrual periods during each calendar year.
Just why menstruation occurs about every twenty-eight days is not known,
but the belief is that, although menstruation is in some way dependent
upon ovulation, its periodicity is regulated by the corpus luteum. It is
also believed that the corpus luteum of pregnancy holds menstruation in
check during the nine months of gestation.
The menstrual cycle is divided into four stages, and though there is not
entire unanimity of opinion concerning the changes which take place
during these four stages, the preponderance of evidence is in favor of
the following processes.
=The first or constructive stage= lasts about seven days. It is during
this stage that the preparative changes, which have been described, are
made for the reception of the matured ovum. The uterus becomes engorged
with blood and is somewhat enlarged and softened as a result. The
endometrium grows deep red, thick and velvety, partly because of the
greatly augmented blood supply, and partly because of an actual increase
of connective tissue in its structure. There is also an increase in the
size and activity of the uterine glands and in the amount of their
secretions. If the ovum remains unfertilized, which is usually the case,
it does not attach itself to this elaborately prepared lining, but
passes out with the uterine discharges, and all of this preparation and
increased vascularity not only go for naught, but must be undone.
=The second stage=, therefore, which lasts about five days, is the
destructive stage, during which the newly developed tissues are broken
down and the menstrual discharge occurs. During this period the greatly
increased secretions of the uterine glands mix with the blood that oozes
from the engorged endometrium and with the disintegrated uterine
tissues, and pour from the vagina as the menstrual flow.
=The third, or reparative stage=, which follows, occupies about three
days. During this stage the destroyed uterine tissues are regenerated by
new growth from the deeper, uninjured tissues, and the entire organ
returns to its normal state.
=The fourth, or quiescent stage=, now follows, the damage having been
repaired, and lasts twelve or fourteen days. This is the time remaining
before Nature with unwearying patience begins all over again to prepare
for the reception and attachment of the next matured ovum, in case of
its possible fertilization.
It will be seen that the duration of the menstrual period, which is
coincident with the destructive stage of the menstrual cycle, is about
five days, but it is entirely within normal bounds if it varies in
length from two to seven days.
The discharge is usually scant at the beginning of the period,
increasing in amount until about the third day, after which it
diminishes steadily until its cessation. The normal odor of this
discharge, consisting as it does of blood and uterine secretions, has
been likened to that of marigolds.
The average amount of blood lost is from six to ten ounces, but it
varies greatly among women who are otherwise normal and in good health.
Some women regularly lose what seems to be an alarming quantity of blood
at each period without suffering any apparent ill effect. Others lose so
little that they are scarcely aware of their menses.
As a rule the menstrual flow is more profuse among women in warm
climates than in cold regions. English women, for example, frequently
menstruate profusely while in India, and upon their return to England
note a marked decrease in the amount of the discharge. The same is often
true of American women who move from Southern to Northern states, while
removal from a low to a high altitude usually results in a more profuse
flow.
The quantity of the menstrual discharge is affected also by diet, living
conditions and by any form of mental or physical excitement or
stimulation.
Accordingly, the highly strung, richly nourished women living in
luxurious circumstances are likely to menstruate more freely than those
less favored who are overworked and poorly nourished.
A shock or great grief, or any great emotional experience; a sea voyage
or a long railroad journey may bring on a period before it is due, while
the regularity of the periods may be much disturbed, temporarily, by a
marked change of climate or altitude, a serious illness or a decided
change in one’s daily régime.
The function may be entirely suspended for several months or a year in
women who suddenly take up hard work or violent exercise, and persist
with it regularly. In such cases the periods gradually recur and finally
become normal and regular.
The menstrual period is frequently attended by evidences of marked
mental and physical disturbances. While many women are fortunate enough
to suffer little or no inconvenience during menstruation, the vast
majority are more or less wretched and miserable at this time, although
in good health in all other respects. Many are tired, have less
endurance than usual and are likely to take cold easily. Headaches with
a sense of fullness, dizziness, and heaviness are common accompaniments.
Backache is a frequent source of discomfort, while abdominal pain,
varying from an uncomfortable sense of dragging heaviness to almost
unendurable agony, is the rule rather than the exception. And there may
be pain in the hips and thighs as well.
This state of wretchedness is sometimes increased by a loss of appetite,
nausea and even vomiting. At the same time there are changes in the
breasts which are much the same as, though slighter than, those
occurring during pregnancy. They are firmer, may be somewhat increased
in size, and many women experience a burning, tingling sensation,
soreness and even pain. The nipples are turgid and prominent and the
pigmented areas grow darker for the time being.
The skin over the rest of the body sometimes changes in appearance and
pimples are common; some women are pale and others are flushed during
their periods.
These physical disturbances accompanying menstruation vary so widely in
different women, and in the same women at different times and under
different conditions, that it is not possible to draw a classical
picture of the condition. But all of the symptoms above described will
persist with more or less severity throughout the entire menstrual life
of one woman, while perhaps only one or two of them will occasionally
disturb another. Whatever discomfort there may be usually begins from
one day to a week before the discharge appears; is at its height during
the following day and from that time subsides steadily, until the
normally comfortable state is regained. In fact, many women feel better
at the end of their periods and during the days immediately following
than at any other time during the cycle.
Heat applied to the abdomen and lumbar region during the uncomfortable
days; hot baths, rest and quiet, will usually give great relief, as
might be expected when there is local congestion and general nervous
irritability. In this connection, it is worth mentioning that the
discomfort of many women is needlessly increased by their heeding the
widespread but fallacious belief that general bathing during
menstruation is injurious. While cold plunges and cold showers are not
recommended, certainly warm baths are innocuous and immensely
satisfying.
In addition to the physical discomfort which is coincident with
menstruation, and quite as common, are the evidences of mental and
nervous instability. These often show themselves in the form of
unwarranted irritability, and in a lack of poise and self-control.
Drowsiness and mental sluggishness are not uncommon, and many otherwise
cheerful women are almost overwhelmed by depression during menstruation.
All of these departures from what we are accustomed to regard as the
normal, or average, mental and physical state of women are very
baffling, as they may persist after every discoverable defect has been
corrected.
But aside from all other considerations it is of obstetrical importance
for the sufferer to ascertain the cause of her discomfort if possible.
For example, a misplacement of the uterus is a frequent cause of
dysmenorrhea and, if it remains uncorrected, may make conception
impossible; or if conception perchance does take place, the malposition
of the uterus may later be the cause of an interrupted pregnancy.
Endometritis is another cause of menstrual difficulty and if allowed to
persist may be one factor in the causation of abnormalities in the
attachment of the placenta.
There is evidently an intimate relation between the process of
menstruation and the functions of the ductless glands throughout the
body; a relation which is far from being understood.
For example, the administration of various preparations of ductless
glands for maladies which are apparently unrelated to menstruation,
results not alone in an improvement of the condition treated, but
frequently in much more comfortable menstrual periods, as well.
It should be borne in mind, also, that the influence exerted by a
woman’s mental, or psychic, state upon her menstrual periods is so
apparent that it is being given increasingly serious recognition. It is
frequently observed that patients who are under treatment for nervous
and mental disorders, who are also sufferers from painful menstruation,
grow more comfortable during their periods as their neurosis improves.
We have constantly before us examples of painful menstruation being
relieved coincidently with an improved mental state among women situated
at the two extremes of the social and financial scale. Indolent,
self-centred and unoccupied women at one end often become excessively
nervous and irritable, and suffer great pain with each period, while the
overworked, harassed, poverty-stricken women at the other extreme have
similarly trying menstrual experiences. When the self-indulgent sister
can be persuaded to engage in some form of physical activity and to
interest herself in some work which requires mental effort, and which
perhaps makes an emotional appeal as well, she frequently finds that her
menstrual difficulties become less troublesome.
In the case of the woman in poorer circumstances, an improvement in her
mode of living which approaches the normal, and a relief from undue
stress and anxiety, will very often be followed by more comfortable
menstruation.
A recognition of these rather intangible facts is of consequence to the
nurse, as it deepens her appreciation of the necessity for nursing her
patient as a complete entity, mentally, physically, spiritually and
emotionally. We are insistently reminded at every turn that no one part
of the patient, no one aspect of her condition can be separately
considered and the remainder overlooked.
The patient can be nursed quite satisfactorily only when she is nursed
completely.
=Relation Between Ovulation and Menstruation.=—Menstruation and
ovulation are apparently associated and interdependent, but the exact
relation between the two is still obscure and puzzling. It is generally
accepted that complete removal of the ovaries stops ovulation and is
followed by a cessation of menstruation, and yet cases have been
recorded which suggest that these two functions are not invariably
correlative.
Evidence of this possible independence is that, although pregnancy must
be preceded by ovulation, it has occurred before puberty or after the
menopause. And not infrequently pregnancy occurs during lactation, a
period when the menstrual function is usually suspended.
It has been claimed by some observers that menstruation has occurred
after the complete removal of both ovaries, which would, of course,
preclude the possibility of further ovulation. It is possible, however,
that in such cases either the ovaries were not entirely removed, though
believed to be, or that an accessory ovary existed, since a very small
fragment of ovarian tissue will permit the occurrence of ovulation.
As to their chronological relation, information available at present
suggests that ovulation occurs about ten or twelve days after the close
of the preceding period, and that the corpus luteum formed at the site
of the rupture reaches its highest development some ten or twelve days
later, and that the degenerative changes in the corpus luteum, in case
of non-fertilization of the ovum, give rise to menstruation.
=Modifications of Menstruation.= =Dysmenorrhea= is painful menstruation.
=Menorrhagia= is an abnormally copious menstrual flow.
=Amenorrhea= is irregularity or, to be exact, suppression of the menses.
The suppression may be due to an obliteration of the neck of the uterus,
or to an occlusion of the vaginal opening.
=Vicarious menstruation= is an escape of blood from other parts of the
body coincident with menstruation. Blood may ooze through the skin
covering the breasts; also from hemorrhoids or from the surface of
ulcers. Or there may be nose-bleeding, vomiting of blood or pulmonary
hemorrhage, particularly among tuberculous patients. Vicarious
menstruation usually occurs among nervous, high-strung women and may be
regarded as an evidence of ill health. The amount of blood lost in this
way is much less than the amount of the menstrual flow.
=The menopause=, also termed the climacteric and the change of life,
marks the permanent cessation of menstruation and of sexual activity. It
occurs ordinarily between the ages of forty and fifty; the majority of
women stop menstruating at their forty-sixth year. The menopause has
occurred as early as the twenty-fifth year, and as late as the eightieth
or ninetieth year. But such cases are, of course, extremely rare and
their infrequent occurrence is of interest rather than of importance in
an effort to ascertain the general average.
As the child-bearing period is normally about thirty years in duration,
the prevailing belief is that the menopause comes earlier to women who
began menstruating early, than to those who did not reach puberty until
later. Some authorities contend, however, that early menstruation
indicates extreme vitality, and that this vitality tends to prolong the
child-bearing period. According to this theory, then, the menopause
would come late to those who matured early and vice-versa.
As the menopause approaches, menstruation occurs irregularly; the
discharge sometimes increases slightly but usually diminishes in amount
and finally disappears altogether, while the generative organs all
undergo atrophic changes.
Bearing in mind the disquieting effect of adolescence, and of ovulation,
upon the general nervous, mental and physical state, we may reasonably
expect that a complete cessation of the ovarian function would be
attended by more or less disturbance of the general well-being.
It is true that very many women suffer a certain amount of nervous
instability at the menopause; they tire easily; have “hot flashes” and
possibly headaches. But under ordinary conditions the discomfort is not
great, and after the function has entirely ceased and they become
physiologically adjusted to the new order of things, these women often
enjoy better health than ever before.
Unfortunately wide currency has been given to exaggerations concerning
the symptoms of the menopause. The result is that serious organic
diseases which are in no way related to the climacteric are not
infrequently attributed to it. For this reason excessive bleeding, heart
symptoms and what not are all too often accepted as a matter of course,
and accordingly neglected until the patient is beyond medical aid. This
is particularly and tragically true of cancer of the uterus.
It is a wise precaution, therefore, to regard with apprehension an
increase in the amount of the menstrual flow of any woman past thirty,
and not to accept it as a normal forerunner of the menopause.
In the dark womb where I began
My mother’s life made me a man.
Through all the months of human birth
Her beauty fed my common earth.
—JOHN MASEFIELD.
PART II
THE DEVELOPMENT OF THE BABY
CHAPTER III. DEVELOPMENT OF THE OVUM, EMBRYO, FETUS, PLACENTA, CORD
AND MEMBRANES. The Ovum. The Spermatozoon. Fertilization. Heredity.
Sex-determination. Most Favorable Age for Motherhood. The Morula.
Growth in the Uterus. The Decidua. Ectoderm. Mesoderm. Entoderm. The
Chorion and Placenta. The Amnion. The Umbilical Cord. The Fetus.
Growth by Months. Factors Influencing the Size of Child. Multiple
Pregnancy. Extra-uterine Pregnancy.
CHAPTER IV. GROWTH AND PHYSIOLOGY OF THE FETUS. Circulation. Kidneys.
Bowels. Head. Fontanelles. Occipital Measurements.
CHAPTER V. SIGNS, SYMPTOMS, AND PHYSIOLOGY OF PREGNANCY. Duration of
Pregnancy. Date of Labor. Signs of Pregnancy: Presumptive, Probable,
and Positive. Physiological Changes in the Maternal Organism:
Uterus. Cervix. Vagina. Tubes and Ovaries. Abdomen. Umbilicus.
Breasts. Cardio-Vascular System. Respiratory Organs. Digestive
Tract. Urinary Apparatus. Bony Structures. Skin. Carriage.
Temperature. Mental and Emotional Changes. Ductless Glands.
CHAPTER III
THE DEVELOPMENT OF THE OVUM, EMBRYO, FETUS, PLACENTA, CORD AND MEMBRANES
As we learned in the last chapter, some of the ova which are discharged
into the peritoneal cavity enter the fimbriated end of the tube, while
very many others perish. As a rule an ovum enters the tubal opening
adjacent to the ovary from which it has been discharged, but it is
possible for this tiny cell to travel across the body and enter the tube
on the opposite side.
This migration of the ovum, as it is termed, has been demonstrated in
cases in which pregnancy has followed removal of the ovary on one side
and the tube on the other.
[Illustration:
FIG. 17.—Diagram of spermatozoa, the male cells of germination.
]
There are various theories as to how and why an occasional migrating
ovum, floating around in a relatively large cavity, ever enters the
tubal opening, which, after all, is not large. The most widely accepted
belief is that the motion of the cilia lining the tubes creates a
suction which draws the microscopical cell into the opening, the same
cilia being the means by which the ovum is later propelled downward
through the tube to the uterus.
This journey of the ovum through the tube is of enormous consequence.
During its course occur the events which decide whether the ovum shall,
like most of its fellows, be simply swept along to no end and lost, or
whether by chance it is to receive the mysterious impulse which begins
the development of a new human being.
The amazing power which enables this cell to reproduce itself, and to
develop with unbelievable complexity, is acquired somewhere in the tube
by meeting and fusing with a _spermatozoon_, the germinal cell of the
male. (Fig. 17.)
The spermatozoa look very much like microscopic tadpoles, with their
flat, oval heads, tapering bodies and long tails. As these tails serve
somewhat as propellers, the male cells are capable of very rapid motion.
But in spite of their strange appearance, they are cells after all, and
resemble the female cells in that each one contains a nucleus, or
germinal spot.
An almost inconceivably large number of spermatozoa, floating in the
seminal fluid, is deposited in the vagina at the time of intercourse.
Nature evidently supplies the male and female cells with equal
lavishness, in order to provide for the large number of both kinds which
must inevitably be lost, and still have enough survive to accomplish the
high purpose of their creation. A very considerable number of
spermatozoa enter the uterus, and are enabled through their powers of
motility, to travel up into the tubes, in spite of the downward current
created by the cilia. And in the tube, usually in the upper end, they
meet a recently matured and discharged ovum which is being swept
downward, and are attracted to it somewhat as bits of metal are drawn to
a magnet. Although the ovum which is destined to be fertilized is
surrounded by several spermatozoa, only one actually enters and fuses
with it.
This fusion is termed _impregnation_, _fertilization_, or, in lay
parlance, _conception_, and the instant at which it occurs marks the
beginning of pregnancy. The establishment of this fact is of no little
importance, since it does away with any possible controversy concerning
the time at which a new life begins. The origin of the child is exactly
coincident with the fusion of the male and female germinal cells.
And furthermore, the sex of the child and any inherited traits and
characteristics are also established at this decisive instant. No amount
of dieting, exercise nor mental effort on the part of the expectant
mother can alter or influence them in the smallest degree, for the
father has made his complete contribution toward the creation of the new
being, and after this event the mother provides nourishment only.
All told, probably more than five hundred theories have been advanced to
explain what it is that decides of which sex the forthcoming child will
be.
In 1907 Dr. Schenck attracted world wide attention by announcing his
belief that either sex could be produced in the expected child through
the simple expedient of regulating the mother’s diet. Liberal feeding
would result in boys, the sturdier sex, and frugality in girls, the
smaller, frailer type of baby. But as the results of applying Schenck’s
theory have scarcely borne out his claims, it is given but scant
attention to-day.
The present belief regarding the causation of sex is that although there
is but one kind of ovum, there are two kinds of spermatozoa, one capable
of producing a male, and the other a female child. These two kinds are
evidently deposited in the vagina in about equal numbers, and the
sex-determining form that fertilizes any one ovum is a matter of the
merest chance. Statistics show, however, that more male than female
babies are born, the usual proportion being about 105 boys to 100 girls
among those that reach full term. Among abortions and premature births
there is also a larger number of boys than girls, and in elderly
primiparæ the ratio increases to about 130 boys to 100 girls. But as
more boys die in infancy than girls, the two sexes about even up in the
number of those living to adult age.