Some physicians think it advisable to have an X-ray examination of the

teeth made as a routine, in order to discover any existing pockets of

pus at the apices of devitalized teeth. They feel, that because of the

somewhat unstable condition of the pregnant organism, these localized

infections are more of a menace to the expectant mother than to the

ordinary individual, and that in some cases they should be drained.

As to daily care of the teeth, the patient should use dental floss and

brush her teeth after each meal, and use an alkaline mouth wash several

times daily, particularly after vomiting and before retiring. Much

damage may be done by the acid secretions in the mouth if they are

allowed to bathe the teeth through the long night stretches. Common

cooking-soda, lime-water or milk of magnesia make excellent mouth

washes.

TRAVELING. In this day, when people travel so much and so easily, it is

common to hear discussions as to its advisability for the prospective

mother. Like many other details of prenatal care, this point cannot be

settled once for all women, nor for all stages of pregnancy. Each

patient’s general condition must be considered; her tendency to nausea;

the length of the journey and the ease with which it may be made, and

whether or not she has ever had, or been threatened with an abortion. In

general, traveling is less hazardous for the expectant mother to-day

than it was formerly, to just the extent that it causes less strain,

discomfort and fatigue. But as a rule it is considered wise for her to

avoid traveling during the first sixteen and the last four weeks of

pregnancy, and at the times when menstruation would ordinarily occur.

Obviously, then, in the interests of prevention, a journey should not be

undertaken at any time without a physician’s approval.

The _marital relation_ is usually considered inadvisable in all cases

after the eighth month of pregnancy, and among women who have had

abortions or miscarriages it is best omitted throughout the entire

period of gestation. This is particularly true of elderly primiparæ.

COMMON DISCOMFORTS DURING PREGNANCY

There are many minor disturbances which overtake the pregnant woman, and

though not serious in themselves, her comfort is greatly increased by

having them relieved, and this promotes her general welfare. The relief

of these discomforts, when they are slight or only temporary, sometimes

resolves itself into little more than a question of nursing. When long

continued or severe, however, they constitute complications which the

doctor treats accordingly.

=Nausea and vomiting= are probably the commonest disturbances of

pregnancy and vary from the slightest feeling of nausea when the patient

first raises her head in the morning, to persistent and frequent

vomiting which then assumes grave proportions and is termed “pernicious

vomiting.” Although it is possible that even the slightest nausea is due

to a mild toxemia, there can be no doubt that in many instances the

patient’s mental attitude is an important factor.

Dr. Slemons makes the interesting observation, that women who are

unaware of their pregnancy for several months are seldom troubled with

nausea, while those who erroneously believe themselves to be pregnant

will suffer from this well-known symptom of pregnancy, until convinced

of their mistake. The nausea then subsides.

As there is a marked tendency toward nausea during early pregnancy, it

may be brought on by slight causes which would not produce it under

ordinary conditions. Anxiety, grief, fright, shock, incessant worrying,

fits of rage, introspection, brooding, or any great emotional stress may

cause nausea when the diet is entirely satisfactory. But indiscretions

in diet, rapid or over-eating also may cause nausea and vomiting in the

expectant mother.

We seem to get back to the principles of personal hygiene as preventives

of nausea during pregnancy, for simple, light food, taken in small

quantities five or six times daily, eaten slowly and masticated

thoroughly; the cultivation of a happy frame of mind; exercise and fresh

air all tend to avert this very uncomfortable condition. Its prevention

is of great importance, as the habit of vomiting is easily acquired but

broken with difficulty. The common causes of nausea, and their

prevention, should therefore be explained to the average patient, for

she will then be able to help herself in warding it off.

Should “morning sickness” occur, however, it may be relieved in many

cases, by eating two or three hard, unsweetened crackers or pieces of

toast, with nothing to drink, immediately upon awakening and then lying

still afterwards for half or three quarters of an hour. The sufferer

should then dress slowly, sitting down as much as possible while doing

so, and eat her regular breakfast. Lying flat, without a pillow, and

keeping very quiet for a little while after meals, or whenever feeling

the slightest premonitory symptom, will frequently prevent, and also

relieve nausea, and sometimes comfort is derived from the use of either

hot or cold applications to the abdomen. Some patients are relieved by

having hot coffee or even a full breakfast before arising.

=Heartburn=, so called, which is experienced by many pregnant women, has

nothing to do with the heart. It is caused solely by an excess of

hydrochloric acid in the stomach, and is usually described as a burning

sensation first in the stomach, then rising into the throat. It may be

prevented, as a rule, by taking a tablespoonful of olive oil, or a

cupful of cream or rich milk, fifteen or twenty minutes before meals,

and avoiding fat and fried food at the meals immediately following.

This apparent inconsistency in treatment is due to the facts that fat

taken into the empty stomach tends to inhibit the secretion of acid,

while fat and fatty foods taken with meals tend to prolong their stay in

the stomach and this in turn stimulates the secretion of hydrochloric

acid, the thing to be avoided.

A patient with a tendency to heartburn will be wise, therefore, if she

generally eliminates oils, fats and fatty foods from her meals, and

definitely avoids them when the burning occurs. Since the painful,

burning sensation is directly due to an excess of acid in the stomach,

the obvious step toward relief is to take an alkali at once. A

tablespoonful of lime-water is often satisfactory; a teaspoonful of

sodium bicarbonate in water; a small piece of magnesium carbonate may be

nibbled by itself, or any alkaline water that the patient fancies may be

taken.

=Distress.= There is another form of discomfort, often vague and

ill-defined, commonly called “distress” and occurring after eating. It

may be neither heartburn nor pain, but resemble both and make the

patient very miserable. It is usually seen in women who eat rapidly, do

not chew their food thoroughly or eat more at one time than the stomach

can hold comfortably. The prevention, naturally, lies in taking small

amounts of food slowly and masticating thoroughly.

=Flatulence= may or may not be associated with heartburn, but it is

fairly common and rather uncomfortable. It is usually due to bacterial

action in the intestines, which results in the formation of gas. As has

been previously explained, the pressure of the enlarged uterus upon the

intestines and absence of pressure by the abdominal muscles, retards

normal peristalsis, with the result that gas sometimes accumulates to a

very uncomfortable extent. It is clear, therefore, that a daily bowel

movement is of prime importance in preventing and relieving flatulence,

and also that foods which form gas should be carefully excluded from the

diet. The chief offenders are parsnips, beans, corn, fried foods, sweets

of all kinds, pastry and very sweet desserts. Various intestinal

disinfectants are employed, as in non-pregnant states, and also yeast

cakes, cultures of Bulgarian bacilli and artificially fermented milk

containing bacteria that are antagonistic to the gas-producing forms.

In the opinion of some doctors, flatulence is sometimes an early symptom

of toxemia.

=Diarrhea.= Although diarrhea is not one of the commonest disturbances

of pregnancy, neither is it infrequent, and must be borne in mind in

connection with digestive troubles. Of course, a pregnant woman may have

an attack of diarrhea from the same causes that produce it in any one

else, and its relief would be obtained by the usual methods, chiefly the

correction of dietetic errors. But on the other hand, it may be due

entirely to the uterine pressure on irritable intestines. Like

flatulence, it is regarded by some doctors as a possible symptom of

toxemia.

PRESSURE SYMPTOMS. Under the general heading of pressure symptoms are

several forms of discomfort resulting from pressure of the enlarged

uterus on the veins returning from the lower part of the body, thus

interfering with the flow of blood back to the heart. As both the cause

and relief of these symptoms are associated with the force of gravity,

the nurse will usually know what to do in mild cases without further

explanation. In general the heavy abdomen should be supported by a

binder or properly fitting corset, the patient should keep off her feet

as much as possible and elevate the swollen part.

The commonest pressure symptoms are swollen feet, varicose veins,

hemorrhoids, cramps in the legs and shortness of breath, and though they

may appear at any time during the last half, of pregnancy, they grow

progressively worse as pregnancy advances.

=Swelling of the feet= is very common, and when very slight may not be

serious nor particularly uncomfortable. The edema may be confined to the

back of the ankle, which grows white and shining, or it may extend all

the way up the legs to the thighs and include the vulva. Sitting down,

with the feet resting on a chair, or lying down with the feet elevated

on a pillow will naturally give a certain amount of relief. If the

swelling and discomfort are extreme the patient may have to go to bed

until they subside, but very often she will secure adequate relief by

elevating her feet for even a little while, several times a day. But

while employing these harmless, and clearly indicated measures, to make

her patient comfortable, the nurse must be keenly alive to the fact that

while edema of the feet, legs and vulva may be of solely mechanical

origin, they are also symptoms of toxemia, about the most dreaded

complication of pregnancy. And as recognition of the earliest signs of

toxemia is among the triumphs of prenatal nursing, even the slightest

swelling must be reported to the doctor and immediate steps taken to

have the urine measured and examined.

[Illustration:

FIG. 40.—Right angled position, to relieve edema or varicose veins of

feet and legs. (By courtesy of The Maternity Centre Association.)

]

=Varicose veins= are not peculiar to pregnancy, but are among the

pressure symptoms which frequently accompany this condition during the

later months, particularly among women who have borne children. The

superficial veins in the legs will often be equal to the tension put

upon them the first time, but will give way as the strain is repeated

during subsequent pregnancies. The distension of the veins is not

serious as a rule, but may be very uncomfortable; this, coupled with the

unsightly appearance, sometimes has a bad mental effect. Varicose veins

may occur in the vulva, but they are usually confined to the legs, and

both legs are about equally affected. But as the position of the child

_in utero_ may exert greater pressure on the right than on the left

side, the veins on that side may be more distended; or the right side

alone may be affected.

Relief is obtained by keeping off the feet, and particularly by

elevating them and also by the use of elastic bandages. When a woman

finds it difficult or nearly impossible to sit or lie down for any

length of time, she may accomplish a great deal in a few moments by

lying flat on the bed with her legs extended straight into the air, at

right angles to her body, resting against the wall or head board, as

shown in Fig. 40. This right-angled position for five minutes, three or

four times a day will accomplish wonders in reducing varicose veins.

In addition to posture, a spiral elastic bandage will give relief and

help to prevent the veins from growing larger, if applied freshly after

each time that the leg is elevated. The most satisfactory bandages, from

the standpoint of expense, comfort and cleanliness, are of stockinette

or of flannel cut on the bias, measuring three or four inches wide and

eight or nine yards long. If made of flannel, the selvedges should be

whipped together smoothly so that there is neither ridge nor pucker at

the seam. The bandage should be applied spirally with firm, even

pressure, starting with a few turns over the foot to secure it, and

leaving the heel uncovered, carried up the leg to a point above the

highest swollen vessels. As a rule, it may be left off at night.

There are satisfactory elastic stockings on the market, but they are

expensive, often cannot be washed and seem to offer no advantage over

the bandages.

Engorged veins in the vulva may be relieved by lying flat and elevating

the hips, or by adopting the elevated Sims’ position for a few moments,

several times a day. (Fig. 41).

[Illustration:

FIG. 41.—Elevated Sims’ position to relieve varicose veins of the

vulva. (By courtesy of The Maternity Centre Association.)

]

=Hemorrhoids= are virtually varicose veins which protrude from the

rectum, but, unlike those in the legs, are extremely painful. As it is

the straining incident to constipation that causes these engorged veins

to prolapse, this condition constitutes one more reason for preventing

constipation. A pregnant woman whose bowels move freely every day rarely

has hemorrhoids.

Should hemorrhoids appear, the first step is to have them gently pushed

back into the rectum. The patient can usually do this for herself, quite

satisfactorily, after lubricating her fingers with vaseline or cold

cream. Lying down, with the hips elevated on a pillow; the application

of an ice bag, cold cloths or witch-hazel compresses to the anus will

almost always give relief. When the condition is severe, the physician

may prescribe medicated ointments, lotions or suppositories, but

operation is seldom resorted to during pregnancy, for fear of bringing

on labor prematurely. Sometimes the hemorrhoids are worse during the

first few days after labor, but as a rule they disappear with the

removal of the cause, which in this case is pressure made by the

enlarged uterus.

=Cramps in the legs=, numbness or tingling may be caused by the pressure

of the large, heavy uterus upon nerve trunks supplying the lower

extremities. The recumbent position; applying heat and rubbing the

painful areas will often give comfort.

=Shortness of breath= is sometimes very troublesome toward the end of

pregnancy, and, as may be easily seen, is due to the upward, and not

downward pressure of the uterus. For this reason it is aggravated by the

patient’s lying down and relieved by her sitting up or being well

propped up on pillows, or a back rest.

=Vaginal discharge.= The normal vaginal discharge is greatly increased

during the latter months of pregnancy, as was pointed out in Chapter V,

so that ordinarily the moderately profuse yellowish or white discharge

at this time has no particular significance. Its existence should be

noted, however, and brought to the doctor’s attention, for a very

profuse discharge is likely to be regarded as a possible evidence of

gonorrhea. For this reason a smear is usually made, when the discharge

is excessive, to establish or eliminate this diagnosis; if it is

positive, it indicates the necessity for treatment to safeguard both

mother and baby.

As the normal vaginal discharge has antiseptic properties, it should not

be removed by douches, which many patients are eager to take; but if it

is irritating and causes itching or burning the patient may be made

entirely comfortable by avoiding the use of soap and by bathing the

vulva with a solution of sodium bicarbonate or with olive oil.

=Itching of the skin= is a fairly common discomfort, and is possibly a

result of irritating material being excreted by the skin glands and

deposited upon the surface of the body. The local irritation usually may

be allayed, if not very severe, by bathing the uncomfortable areas with

a solution of sodium bicarbonate, or a lotion consisting of a pint of

lime-water, half an ounce of glycerine and thirty drops of carbolic

acid. It is a good plan, also, for the patient to increase the amount of

fluids which she is taking, in order to promote the activity of the

skin, kidneys and bowels, and thus dilute the material that may be

responsible for the itching and increase its elimination through all

channels. In other words the itching may be due to a mild toxemia.

Some women complain of discomfort caused by the stretching of the skin

over the enlarged abdomen, which becomes so tense it feels as though it

might tear apart. There is a very old and widely current belief that

this sensation may be relieved by rubbing the abdomen with some kind of

an oil or ointment. And, moreover, that such oiling will not only

increase the elasticity of the superficial layers of the skin, but the

deeper layers as well, and that by this means striæ may be prevented.

There seems to be little foundation for the fear that the skin will

tear, or belief in the efficacy of the oiling, but if a woman fancies

that she is safer and more comfortable after oiling her abdomen, there

is certainly no reason why she should not do so.

EARLY SIGNS OF COMPLICATIONS OF PREGNANCY

It is evident that by teaching the principles of personal hygiene to the

expectant mother so convincingly that she will adopt them, and

sometimes, by employing simple nursing procedures to relieve the various

discomforts of pregnancy, much will be accomplished toward promoting the

welfare of both the patient and the expected baby. But this is not

enough. The nurse must also be on the alert to detect and report the

early symptoms of complications, for there may be times when she will be

the first one to see the patient after a symptom has developed.

The principal complications of pregnancy which are amenable to

preventive or early treatment are the toxemias, premature terminations

of pregnancy and hemorrhage.

The causes of these conditions and the details of treatment and nursing

care are so inextricably associated with each other that they are

discussed together and at some length in another chapter. But their most

conspicuous, early signs are briefly noted here, since watching for them

constitutes a part of routine prenatal care.

The =toxemias= are apparently caused by disturbed metabolism and

impaired or inadequate excretory processes. Their prevention is to be

accomplished largely by observing the principles of personal hygiene

previously described, and in quickly treating early symptoms. One of the

commonest of these symptoms is headache, sometimes persistent and very

severe. Others are disturbed vision, dizziness and more persistent or

severe vomiting than could reasonably be called “morning sickness”;

puffiness under the eyes, or elsewhere about the face, or of the hands;

anything more than very slight swelling of the feet and ankles; high or

increasing blood pressure; mental depression; albumen in the urine,

amounting to more than a trace, and epigastric pain, are all possible

symptoms of toxemia. A patient in whom even one of these symptoms

appears is usually placed under close observation; frequently put to bed

and her diet restricted to milk, or even water, until the symptoms

subside.

The common symptoms of =premature termination of pregnancy=, (an

abortion, miscarriage or premature labor) are bleeding, with or without

pain in the small of the back, followed by cramp-like pains in the

abdomen. Bleeding or a bloody discharge, therefore, irrespective of pain

should be regarded as a symptom of pending labor and the patient should

be put to bed promptly, and kept quiet. Preventive treatment, after

pregnancy has begun, consists largely of rest, particularly at the time

when menstruation would ordinarily occur; avoidance of physical shocks

and of overwork during the later weeks. Prolonged failure on the part of

the patient to feel fetal movements or of the nurse or doctor to hear

the fetal heartbeat after they have once been manifest usually indicates

the death of the child and precedes its expulsion.

=Bleeding=, or a sudden increase in the size of the uterus with a rapid

pulse or general symptoms of shock, may be the symptoms of hemorrhage

caused by placenta prævia or premature separation of a normally

implanted placenta; upon the appearance of any one of these signs the

patient should be put to bed and kept absolutely quiet.

To sum up, we find that the following symptoms may be forerunners of

serious complications, and therefore should be watched for and reported

to the doctor immediately upon their discovery:

1. Persistent or severe vomiting.

2. Persistent or severe headache.

3. Dizziness.

4. Disturbed vision or the appearance of black spots before the eyes.

5. Puffiness under the eyes, or elsewhere about the face.

6. Swelling of the feet, ankles or hands.

7. Sharp pains, particularly in the epigastric region.

8. Prolonged failure to feel fetal movements after they have once been

felt.

9. Cessation of the fetal heartbeat, or a marked change in its rate or

rhythm.

10. Bleeding, or a bloody discharge.

11. Pain in the lumbar region, followed by cramp-like pains in the

abdomen, before the expected date of confinement.

12. Albumen in the urine.

13. High, or increasing blood pressure.

14. Unwarranted mental depression, anxiety or apprehension.

These are generally accepted as the cardinal danger signs of pregnancy,

any one of which, alone or in combination with one or more of the

others, is of significance and should be reported to the doctor at once.

When all is said and done, our wish for the expectant mother is for

little more than that she shall live a normal, wholesome life; that she

shall be willing, and also be able to weave into her every day life the

principles of personal hygiene which every one should adopt; that she

shall be carefully watched for complications throughout the entire

period of pregnancy, and that these complications shall be speedily

treated.

Adoption of personal hygiene, then, and prevention of complications by

their early detection and treatment—these we want for every woman who is

looking forward to motherhood.

For lack of these things there are sick and blind and maimed babies and

invalid women; there are lonely, motherless children and bereaved

mothers in every corner of our land.

CHAPTER VII

MENTAL HYGIENE OF THE EXPECTANT MOTHER

It is only once in a long time that the obstetrical nurse has a patient

who is suffering from such a marked mental disturbance that her

condition is diagnosed and treated as a psychosis. But more often than

not she has a patient who is secretly suffering a good deal of mental

stress and pain, which is not recognized and not treated.

In fact, by virtue of the deep significance of the states of pregnancy

and motherhood, and the long period of time through which they continue,

it is scarcely possible for them not to produce a mental effect of some

sort upon the average woman. Sometimes this effect is a very happy one;

but all too often it is quite the reverse. It is safe to say that the

majority of maternity patients are passing through deep waters, and the

nurse’s usefulness to these charges will be greatly broadened if she has

at least some understanding of the cause and character of these mental

sufferings.

In the ordinary course of events, from birth to death, we all of us are

being called upon continuously to adjust ourselves to all sorts of

experiences, situations and emotional strains peculiar first to early

childhood, then the school epoch, the period of emancipation from home

and finally to the life work. And as we take our way, we develop habits

of meeting the sorrow and disappointments that come; the anxiety,

criticism, success, failure, illness, poverty and what not.

Some individuals habitually face the issues of life, whether large or

small, and habitually overcome difficulties for themselves and for other

people. They are described by the psychiatrists as being grown up, or

psychologically evolved.

Others follow the course of least resistance; never face their problems;

are thoughtless and inconsiderate in their demands; are unable to make

decisions and accordingly live upon the mental and moral strength of

others. Such people are referred to as being infantile, or

psychologically undeveloped. They are not unlike the baby who gets “what

he wants when he wants it” by the unreasoning method of screaming and

pounding upon his high chair with a spoon. He is scarcely more

irresponsible than the hysterical adult who gains her point by

developing a headache or fainting, flying into a rage or tearing her

clothes and smashing china. Such people make little or no adjustment to

unsatisfactory conditions and have poor capacity for endurance or

sacrifice.

With not a few women this poor capacity is a result of lifelong

indulgence or protection by unwise parents, and they never reason out

the question of obligation or responsibility because they never have to.

Everything is done for them. All rough places are so consistently

smoothed out that they never entertain the idea that effort or

adaptation on their part could possibly be in order.

There are others who cherish trouble, make difficulty where there need

be none and steadfastly refuse to acknowledge good fortune or see the

silver lining. This is their method of securing attention, much as the

baby cries or screams to the same end.

Between these extreme types are ranged people who display innumerable

shadings and degrees of psychological development. Some cope

satisfactorily with their life situation because that situation is

neither difficult nor beyond their capacity for adjustment. Others need

a little bolstering up now and then to bridge over the gap between the

demands made upon them and their ability to meet these demands. Still

others have to be literally carried when disaster overtakes them, or

they break down.

As might be expected, our ability to stand the big tests or strains that

may come to us; our manner of meeting them and their effect upon us

depend very largely upon how we have habitually met the lesser trials

that have come to us previously, how we have habitually adjusted

ourselves to the experiences of life. For after all the test of life is

a measure of one’s capacity for adaptation to these experiences and to

surroundings.

The strain that measures our ability to adapt ourselves may be one big

stroke or it may be a long drawn out trial which would be of small

consequence were it of short duration. It is the persistency and the

monotony of a lesser care that so often wears away the rock of our

endurance.

If a strain proves to be too much for our adaptive capacity, and we

break down under it, our manner of breaking will be characteristic of

us, or an accentuation of what might have been called our bendings under

lesser difficulties in the past.

The expectant mother is no exception to these general principles. She

does not develop nervous breakdowns either more or less frequently than

the non-pregnant woman who is under an equal strain. She is merely a

human being whose adaptive capacity is being tested. But the test is

severe for there is, perhaps, no greater strain upon the adaptive

capacity of a human being than that to which a woman is subjected during

pregnancy, confinement and the months directly following the birth of a

child. She may be expected to meet this strain just as she would meet

another equally great demand upon her adaptive capacity.

Otherwise, pregnancy of itself does not affect the brain or the mind,

any more than it affects the kidneys, for example. But like the kidneys,

the brain or the mentality may have difficulty in coping with the

additional strain that is put upon it during pregnancy, and if the

strain is greater than the ability to function in either case there is

likely to be a breakdown.

It is now generally believed, therefore, that there is no psychosis

which is typical of pregnancy. But that during pregnancy one may see all

types of neuroses and psychoses which are frequently associated with

other severe strains upon the individual. We see depressions,

excitement, paranoid trends, delusional and hallucination states,

hypochondriasis, obsessive fears, anxiety attacks, hysterical

manifestations as well as the so-called “neurotic vomiting.”

Aside from the delirium-like experiences often associated with the

toxemias of pregnancy, none of the above mentioned conditions are

referable to any disturbance of the physiologic or metabolic functioning

of the patient, so far as science can demonstrate. They are merely

accentuations of poor habits of adjustment to difficulties, which the

patient has betrayed all her life.

The psychoses of pregnancy and the puerperium require skilful handling

and the nurse is not called upon to care for them except under the

constant supervision of a physician.

She is, however, constantly brought face to face with facts of fear and

worry and conflicting desires which play a tremendous rôle in the

well-being of the patient during the months of pregnancy and

confinement. The chief source of happiness and of unrest is the mother’s

attitude toward the coming of the baby.

Just here it may be helpful to have a word about what is meant by

“conflict” and the “mechanism” which produces it. As a starting point

there must be a recognition of the fact that the deepest and most

influential feminine instinct is maternal—the desire to have and care

for a child. It is primal. It has been in women since the dawn of

Creation and although in many women it is put down, stifled or

complicated by other desires, it cannot be destroyed. Not a few women

deny this instinct, but back of their denial is some reason, conscious

or unconscious, which is not harmonious with the idea of motherhood. The

woman may be selfish, for example; she may be vain and not want to lose

her grace and charm through pregnancy.

When some such feeling is strong it conflicts with the deeper one of

maternalism and there is a lack of harmony or a “conflict.” It is just

that—a conflict or struggle between two emotions and the result is a

state of mental unrest. A homely comparison might be found in the

digestive disturbance which may follow an effort to cope with two

incompatible articles of food at the same time. The patient may have

nausea, vomiting, pain or even more severe symptoms. The severity of the

symptoms and their effect upon the patient depend somewhat upon the

average vigor or stability ordinarily displayed by the digestive tract

under a lesser strain. People with so-called delicate digestions may be

greatly upset by combinations of food which others are able to cope with

and suffer little or no inconvenience.

When a well evolved individual has a desire which results from our

culture or civilization (a wish to preserve her grace or her luxuries,

for example), that is in conflict with a deeper primal instinct, she

will often be able to reason out the situation, and in the case of

approaching motherhood, decide that the baby is worth any sacrifice, any

inconvenience, and go joyfully through her period of expectancy. She

will glory in the consciousness of her ability to realize the supreme

purpose of a woman’s creation. In other words she adjusts herself to the

situation, harmonizes the discordant desires and is mentally

undisturbed.

A less well evolved woman, like a person with a delicate, easily upset

digestive tract, will have difficulty in making an adjustment—in

harmonizing her instinctive desire for motherhood and her acquired

desire for comfort, attention and the things demanded by convention. The

conflict may be violent enough to greatly upset her. This is

particularly true if the demands of our cultural state make it necessary

for the patient to keep this turmoil below the surface with no safety

valve to relieve the pressure.

This problem of the mother’s attitude toward the coming of the baby is

very general and varied as well. The mothers of families already large

and poverty stricken are usually quite frank in expressing their dismay

over the expected birth and lament the prospect of this extra burden,

but at the same time they decide to make the best of it and they succeed

in making a pretty satisfactory adjustment. Moreover, they do not feel

the necessity for concealing their feelings or do not “repress” them,

and accordingly find some relief in being candid.

The mothers of the middle and upper classes, however, are often

surrounded by an atmosphere of conventional codes that are stifling to

mental honesty. Accordingly they are less genuine in expressing their

true attitude toward the coming child. To many of them—the selfish,

self-centered type—the new baby will bring inconvenience rather than

hardship. The importance of their ego will be dimmed. There will be a

cutting down of luxuries and of freedom for social activities, and

increased responsibility with closer confinement to the home. And while

they give utterance to joy and pleasure over the prospect of having a

baby, this does not quite reflect their inmost feelings.

Not a few women find an outlet for the tension caused by their conflict

by being fretful and irritable or through conduct which they would have

displayed if annoyed or chagrined about something other than the

approaching birth of a child. Because of this outlet they are not so

likely to break down.

It is by no means the rôle of the nurse to pry into the affairs of her

patients, but she can often become the avenue of ventilation for a

patient suffering from a mental conflict, and with very happy results.

For one of the most helpful things that such a person can do is to talk,

and little by little bring out and put into words the buried thoughts,

dreads or shame that may be causing the conflict. Very often the

listener will say surprisingly little and will express no definite

opinions, but by a sympathetic, responsive attitude encourage the

worried person to pour out the content of her mind.

Another source of unrest in the mind of the expectant mother, especially

during her first pregnancy, is the fear of death during labor, or the

development of complications. She is reluctant to speak of these things

to her husband, family or friends, lest they laugh at her or regard her

as a coward at the prospect of pain. Or she may be unwilling to distress

those who love her by admitting her fear.

Fear of death and disease are very common traits and equally common is

the hesitancy we all have in acknowledging them. And so the patient

keeps these things to herself and turns them over and over in her mind;

buries them and tries to put them out of her thoughts. But they stick.

Her fear and her dread color everything that she hears, and very often

and unwittingly her friends and relatives make matters worse by

recounting the unhappy experiences of other mothers that they have

known. At the same time these communicative friends do not tell of the

immeasurably greater number of women who have come through safely, nor

does the patient dwell upon these in her mind. She remembers the women

who had convulsions or fever or a hemorrhage, or the one who died.

The nurse who sees the human being beyond the obstetrical case will

appreciate the pain which such a conflict causes and by being

sympathetic and responsive will try to make it easy for her patient to

talk it over. The patient should invariably find her nurse ready to

listen and to give assurances of the proved value of the precautions

that are being taken to safeguard her and her baby. For not a few women

are torn, not alone by the fear that things will go wrong with

themselves, but with the fear that harm may come to the baby that they

long to take into their arms and keep.

Other women are upset because of a habitual inability to make decisions

that will bring about a marked change in their lives. They find it

difficult to accept pregnancy because its consummation will definitely

alter their state. Life may prove to be more satisfactory because of the

baby, or it may be less so. But in any event it cannot be the same and

they dread making an irrevokable change.

Still another cause of distress is the current belief as to hereditary

influence, and the possible effect upon the unborn child of unsuccessful

attempts at abortion which the patient has made early in her pregnancy.

Every family has its skeleton of a relative who is “queer,”

feeble-minded, epileptic or who has died in a sanitarium or state

hospital for the insane. The fear that the child may “strike back” to

one of these individuals, and suffer retardation in his mental

development, often amounts to little less than an obsession.

The nurse may often dispel such an anxiety by drawing upon even her

slender knowledge of embryology and reassure her patient that we know

very little about inheritance, but that the evidence is that environment

and early training are such important determining factors, that a child

is more likely to be affected by the example and guidance of his parents

during his first few years than through transmission from their blood.

Attempted abortions during the early months of pregnancy are more common

than is generally supposed. Of their effect upon the offspring we know

very little. We do know, however, that an attempt to produce an abortion

often gives rise to a good deal of secret worry on the part of the

expectant mother. It is the nucleus of many a vague depression during

pregnancy, not only because of remorse over wrong-doing, but also

because of fear that the child who is coming, in spite of the attempt to

destroy him, may suffer the consequences. This is another of the

anxieties which the patient can seldom bring herself to discuss with her

family or even with her physician. But it so occupies her mind that she

may allude to it, in a roundabout way, to the nurse who becomes her

constant companion, as though describing the act of a friend. The nurse

who reads between the lines may often relieve a serious tension caused

in this way by discussing the matter casually and impersonally. Above

all she must not assume an attitude of disapproval, for it is not within

her province to go into the ethics or morality of the act. Her function

at this time is solely to give the patient an opportunity to ventilate

her thoughts.

Another real cause of worry during pregnancy is the patient’s fear of

her own inadequacy to care for and to rear a child in the best possible

manner. The idea of assuming the physical care and the moral guidance of

another human being is often little less than terrifying to a young

woman whose responsibilities in the past have been shared or carried by

some one else. Or to the one who has gone through life hunting for, and

exaggerating, the difficulties in a situation, before attempting to meet

it; and perhaps to the one who is habitually conscientious in all of her

relations with other people.

Still another type, and one which presents a much simpler situation, is

the expectant or young mother who is scarcely suffering from a mental

strain, but has a little let-down in her customary poise and

self-control, such as we so often see in convalescents and chronic

invalids.

Pregnancy, labor, and the puerperium are normal physiological processes,

it is true, but they impose a physical tax and the patient is sometimes

physically tired and after labor may suffer something akin to surgical

shock.

The physical weariness may be due to an insufficiency on the part of

some one of the internal secretions. But in any event the patient feels

tired and may show the same sensitiveness or irritability that any of us

show when tired and exhausted and she will merit considerable

forbearance on the part of those who surround her.

But when we understand, even faintly, the conflicts which are possible

in the mental life of the expectant mother—the incompatibility of her

age-old maternal instinct and the desires born of our culture and

civilization, it is not difficult to see that her adaptive capacity may

be sorely tested.

The cause of her trouble is not apparent to the patient’s associates but

they are aware of its manifestations in the shape of moods, temper

tantrums, strange conduct and all sorts of nervous and mental symptoms.

If such a patient does not get relief through talking things over, but

continues to brood and worry alone—to repress the cause of the

conflict—she may not be sufficiently adaptive to endure its ravaging

effects, and have a nervous or mental breakdown as a result.

It is hoped that the nurse may understand from this discussion that the

conflicting thoughts which her patient does not discuss, but buries and

keeps below the surface of her mind, are the factor that works harm in

her mental life. If the nurse can get her patient to ventilate these

thoughts, they will be robbed of much of their power to injure. But this

patient, like any one else, will talk freely only when she talks

spontaneously and she will do this only when she senses in her nurse a

sympathy and a sincere concern over her troubles.

Accordingly, the nurse should try to so attune herself as to be

receptive to evidences of the patient’s moods and impulses, and possibly

from a chance remark get a clue to the repressed desires which are

working harm. She will then be able to meet the patient on that ground.

It is not that the relief of the patient by means of mental catharsis is

necessarily a nurse’s function. It is simply that a patient suffering

from a conflict should talk freely to some one, it does not matter who,

and by virtue of the long hours which they spend together, the nurse

very often happens to be that some one. People do not ordinarily find it

easy to lay bare their inmost thoughts before the members of their

family and the patient may not discuss her conflict with her physician,

which of course is the ideal, because his visits are relatively short

and do not favor the ambling, desultory conversation into which the

nurse and patient may so easily drift.

On the other hand, the nurse must not look for trouble, in order to be

useful, nor by the slightest intimation give her patient an idea that it

is a common practice among expectant mothers to worry, be fearful or

alarmed. If the patient displays these emotions the nurse must be ready,

but she must not be suggestive. Her attitude must be entirely passive

for she is simply a receptacle into which the patient may pour her

conflicting thoughts. But the receptacle must be always available.

The positive course which the nurse may take is to be unfailingly

hopeful and courageous and take it for granted that her patient is

filled with joy and pride over her pregnancy. The gratification is there

by instinct, but it may be so buried and complicated by other emotions

that the patient is not wholly aware of it. It may be surprisingly

clarifying for the nurse to say quite simply, “But, after all, it is a

wonderful thing to have a baby and you are proud and glad that he is

coming. He will be worth any sacrifice.”

If the nurse will so far put herself in the patient’s place that she is

glad, sincerely glad, that the baby is coming, this attitude will

communicate itself to the expectant mother. Happiness and enthusiasm are

very infectious.

To sum it all up: The expectant mother who habitually has not made

satisfactory adjustments during her life may be bending under a mental

burden that is a little heavier than her slender, unevolved powers can

bear. The nurse’s part is to recognize this possibility and realize that

while she cannot attempt to correct the difficulty she can be a prop by

simply being optimistic and reassuring. A patient who may be suffering

from a mental conflict is often saved from a breakdown by little more

than a ready sympathy which is born of understanding.

CHAPTER VIII

THE PREPARATION OF ROOM, DRESSINGS AND EQUIPMENT FOR HOME DELIVERY

It sometimes devolves upon the nurse to give advice in selecting and

preparing the room to be used for a home confinement, and very often to

help the prospective mother in preparing and assembling adequate

equipments for the delivery and for the care of herself and the baby

afterwards.

Under such circumstances the nurse must feel under compulsion to do all

in her power to make the home delivery satisfactory, from the standpoint

of the patient’s happiness and contentment and from the standpoint of

surgical cleanliness and efficiency as well, so that normal cases, at

least, may be attended with reasonable safety at home.

We know that the deaths, incident to childbirth, throughout this country

at large, have not declined during the past decade, in spite of improved

obstetrical methods and skill and the large percentage of recoveries in

hospitals where they are applied. In the homes, in general, young

mothers continue to die in distressingly large numbers, chiefly from

infection, which we know is largely preventable. Apparently, then, in

some important particulars the conditions surrounding the majority of

home deliveries are still such as to be almost a menace to life and

health. And as it is manifestly impossible for all obstetrical patients

to be cared for in hospitals, home deliveries need to be made safer,

which virtually means, made _cleaner_.

This grave need cannot be dismissed by the nurse as something outside of

her province. She may aid greatly, and therefore is under obligation to

do so, in making home confinements surgically clean, by being

conscientious and thoughtful and thorough in her preparations and

assistance.

A relatively small percentage of obstetrical patients require operative

assistance, but without a single exception they all require cleanliness;

cleanliness of appliances and cleanliness of methods.

As the first labor is usually longer and more difficult than later ones,

and the percentage of lacerations and operative interference is higher,

primiparæ should be delivered in hospitals when possible, as well as all

cases presenting any complication or abnormality. But women who are

normal, particularly multiparæ, and these constitute the vast majority

of obstetrical patients, should be able to remain at home in safety.

In most instances the patient who is to be delivered at home will have

to occupy her accustomed room and there is no alternative. Should there

be a choice of rooms, however, one should be selected that is cool and

shady, if the confinement takes place during the summer, but bright and

sunny for occupancy during most of the year; it should be conveniently

near a bathroom if possible, and have an adjoining room for the nurse

and baby to occupy.

The arrangement and furnishings of the room will not of necessity vary

greatly from those of a room which is to be occupied by any patient.

Carpets, upholstered furniture, heavy draperies and curtains are no more

suitable in this than in any patient’s room.

The ideal is: A room with a washable floor with small, light rugs;

freshly laundered curtains at the windows; a single, brass or iron

bedstead, about 30 inches high, with a firm mattress, and so placed as

to be accessible from both sides and with the foot in a good light,

either by day or by night; a bedside table and two others (folding card

tables are a great convenience); a bureau; a washstand, unless there is

a bathroom on the same floor; one or two comfortable chairs, two or

three straight chairs and a couch or _chaise longue_, all of which

should be of wood or wicker or covered with freshly laundered chintzes.

Barrenness is not only unnecessary but is to be avoided, for the room

should be as cheerful and pretty as is compatible with cleanliness.

There is usually no objection to pictures on the wall, but the room

should be free from useless, small articles which are dust catchers,

give the nurse unnecessary work, and occupy space needed for other

things. Between such a room as this and the one which the nurse finds

must be used, there may be a dismaying difference, and so once more she

must exercise her ingenuity and resourcefulness; change and improve

where it is possible and make the best of conditions that cannot be

altered, for the baby is coming and the mother must be safeguarded from

infection and other disaster, no matter what the room is like.

Much as we should like ideally to equip and prepare every room to be

used for a home confinement, we cannot overlook the importance of having

preparations made with as little disturbance as possible to the patient

and her household. Preparations made with bustle and ostentation are

suggestive of inefficiency; are bad for the patient, frequently causing

her great alarm, and in the main had better be omitted. The nurse who is

able to go into a home quietly and unobtrusively and accept what she

finds, even carpets and draperies, and still do clean work, is doing

better nursing than the one who arranges a faultless room but upsets her

patient and disrupts the household in the process.

Common sense, judgment and tact, then, will sometimes be as important in

preparing a room for home delivery as are washable floors, curtains and

furniture.

While we do not advise nor elect to have carpets, draperies and

upholstery in a delivery room, we know that they need not menace the

patient’s welfare if all details of the work about the patient, herself,

are scrupulously clean. That is the one point which the nurse must bear

constantly in mind, the paramount importance of clean work about the

patient.

The room should be given a thorough housecleaning about two weeks before

the expected date of delivery. If there is carpet on the floor, there

should be a large canvas or rubber, or an abundance of newspapers

available to protect it, about, and under the bed; and if the bed is of

wood, the sideboards and foot should be covered to protect them from

injury by soap, water and solutions which may be spattered or spilled

during labor. If the bed is low, there should be four solid blocks of

wood prepared, upon which to elevate it, after removing the casters, and

it is also a good plan to have a large board, or table leaves, in

readiness to slip under the mattress to make it firm, particularly if

the bed is soft or sinks in the middle.

So much for the room.

In preparing the dressings and assembling the various articles to be

used the nurse will do well to remember that, although it is possible to

use a number of things during labor, it is also possible to do excellent

work with a meagre equipment supplemented with a cool head and ingenuity

and training and above all, an exacting conscience. The average nurse

will wish, usually, to follow a median course in her preparations,

having everything at hand that will facilitate the work; be adequately

equipped for emergencies but not burdened with non-essentials.

As the wishes and methods of different doctors vary, the articles needed

in assisting them must of necessity vary also. But in addition to the

instruments which will be used, the following articles will meet the

ordinary requirements during a home confinement, and many of them, or

adequate substitutes, are to be found in the average household.

=For the Mother and the Delivery=:

Plenty of sheets, pillow cases, towels and night gowns.

4 or 6 T. binders or sanitary belts.

1 piece rubber sheeting or oilcloth, 1 × 1½ yards.

1 piece rubber sheeting or oilcloth, 2 × 1½ yards.

Two or three dozen safety pins.

Hot water bag with flannel cover.

1 two-quart fountain syringe.

1 douche pan.

1 bed pan.

2 covered slop jars or covered pails.

3 basins, about 16, 14 and 12 inches in diameter.

2 stiff nail brushes, nail scissors and file or orange stick.

3 agate or enamel pitchers, holding at least one quart each.

Medicine glass.

Medicine dropper.

2 bent glass drinking tubes.

100 bichloride tablets.

4 oz. chloroform.

4 oz. boric acid powder.

4 oz. green soap.

1 pint grain alcohol.

Small jar of vaseline to be sterilized.

Lard, olive oil, vaseline or albolene to oil baby.

Roll adhesive plaster 1 inch wide.

1 pkg. absorbent cotton.

1 thermometer.

In addition to these, a certain supply of sterile dressings will be

needed. Complete outfits of such dressings, sterilized and ready for

use, may be obtained from any one of a number of firms, or the following

may be prepared by the nurse or by the patient, under the nurse’s

direction:

=Dressings=:

1 doz. sterile towels.

5 or 6 doz. perineal pads.

2 or 4 delivery pads, made of gauze and common cotton with top layer of

absorbent cotton, or newspapers covered with muslin.

5 or 6 doz. gauze sponges.

2 or 3 doz. gauze squares, 4 inches square.

4 or 5 doz. cotton pledgets.

1 pr. leggings, made of canton or outing flannel, either loose fitting

hose or a yard square folded diagonally and stitched. (See Fig.

110.)

3 sheets.

6 pieces cord-tie of bobbin or narrow tape, 9 inches long.

These may be put up into packages in the usual manner, using muslin for

wrapping, and sterilized in the patient’s home as follows: Fill a wash

boiler about ¼ full of water and fashion a hammock from a towel or

strong piece of muslin, tied securely with strings at each end and hung

from the handles so that the bottom of the hammock in about half way

down in the boiler. As the weight of the dressings makes the hammock sag

low, in the middle, it is usually necessary to place a rack, or support

of some kind, in the bottom of the boiler to hold the dressings well

above the bubbling water, at the point where they hang lowest. Pile the

dressings into the hammock, cover the boiler tightly and keep the water

boiling vigorously for one hour; dry the packages in the sun or by

placing them in the oven for a few moments, and at the end of

twenty-four hours repeat the steaming and drying process, wrap the

packages in a clean sheet or paper and put them away in a drawer or

covered box where they should remain until time to prepare for the

delivery. The brushes, douche pan, irrigation-bag, and other articles

which must be surgically clean may be sterilized in the same way. The

gloves may be sterilized in this way or boiled immediately before

delivery. If sterilized by steam, the gloves should be thoroughly dried,

dusted with talcum inside and out to prevent them from sticking

together, and may be wrapped in packages or placed in individual cases

(Fig. 42). A small towel or piece of soft muslin and a ball of gauze

containing talcum powder, if placed in the case and sterilized with the

gloves, are often a convenience to the doctor in putting on the gloves.

[Illustration:

FIG. 42.—Gloves with cuffs turned up, lying with small towel and

powder puff of gauze and talcum, on double envelope case in which

they may be dry-sterilized. (From photograph taken at the Brooklyn

Hospital.)

]

The newspaper delivery pads offer excellent protection and are made of

six thicknesses of paper covered with a piece of freshly laundered

muslin, which is folded over the edges and basted in place. (Fig. 43).

These pads may be made virtually sterile by ironing them on the muslin

side with a very hot iron, folding the ironed surface inside without

touching it; again ironing on the outside and wrapping in a clean muslin

or sheet, also recently ironed, and putting away in a place protected

from dust.

The nurse herself should have:

A hypodermic syringe and 4 or 6 needles.

1 pr. long forceps to use as dressing forceps.

1 pr. short forceps.

1 pr. blunt pointed scissors.

2 artery clamps.

[Illustration:

FIG. 43.—Reverse side of pad made of newspapers and old muslin to

protect bed during a home confinement. If muslin is held in place

with safety pins it may be removed easily, washed and used for

another pad. (Courtesy of The Maternity Centre Association.)

]

The doctor will usually supply himself with any articles needed beyond

those which have been enumerated, but the nurse should be sure about the

following in order that she may prepare whatever he may lack:

Instruments and sutures.

Hypodermic tablets.

Pituitrin and ergot, or ergotole.

Gauze packs.

Gloves and sterile gown.

Rubber apron.

Filtered, sterilized salt solution and infusion needles.

Chloroform inhaler.

In planning the baby clothes, there are a few important factors to bear

in mind. The clothes should be simple; not more than twenty-seven inches

long; warm, but light in weight, and large enough to fit loosely. Like

the dressings, complete layettes may be bought outright, but if the

mother wishes to make the little garments herself, the following list

will be found to provide an adequate supply of clothing for the new

baby. (See also Fig. 159.)

=For the Baby, Layette=:

2 to 4 doz. diapers, preferably 18 in. square.

3 flannel bands, 6 or 8 inches wide and 27 in. long unhemmed.

3 shirts, size No. 2, of cotton and wool, silk and wool but not all

wool.

4 flannel petticoats, Gertrude style.

4 flannel nightgowns or slips.

6 white slips.

3 knitted bands with shoulder straps, to use after the cord separates.

Flannel kimono or square, one yard, to be used as extra wrap in cool

room.

Cloak and cap or other wrap for out-door use.

=Additional Articles Which Are Needed or Useful in the Care of the

Baby=:

Bath tub, tin, enamel, agate or rubber.

Drying frames for shirts and stockings.

Rubber bath apron.

Flannel, or Turkish toweling bath apron.

Low chair without arms.

Low table.

Screen to protect baby during bath.

Rack upon which to hang clothes to warm during bath.

Scales, with beam and basket and scoop, not the spring variety.

Hot water bag and cover.

Crib, basket or box, to be used as bed.

Folded felt pad, blanket or hair pillow for mattress.

Rubber or oilcloth to cover mattress.

6 crib sheets.

1 thermometer.

2 crib blankets.

Soft towels and wash cloths.

An old blanket to be used for bath blanket.

3 or 4 dozen safety pins, assorted sizes.

Castile soap.

Boric acid powder.

Olive oil or albolene.

Absorbent cotton pledgets, preferably sterile.

Enamel pail and cover.

The above lists of dressings and articles for the baby can be

considerably modified and still be satisfactory. The leaflet of “Advice

for Mothers” issued by the Maternity Centre Association, New York City

(see p. 429), gives a somewhat curtailed list of equipment which proves

to be adequate and within the means of most of the patients with whom

the Association works.

It is usually a good plan for the nurse to advise the patient to have

her dressings ready by about the end of the seventh calendar month, and

the layette by the end of the eighth month. A baby born before this time

would probably be so frail that it would be wrapped in cotton and not

require the clothes ordinarily prepared for a full-term baby.

CHAPTER IX

COMPLICATIONS AND ACCIDENTS OF PREGNANCY

The prenatal care which was outlined in an earlier chapter becomes more

impressive when one considers the disasters which it is designed to

prevent. And the nurse will be more eager and able to watch her patient

intelligently, and instruct her convincingly, if she appreciates and

understands something of the conditions which she is helping to avert.

She will give more effective nursing care, too, when complications do

occur, if she gives it understandingly. In the toxemias, particularly,

the importance of the nursing care looms large, for it is painstaking

attention to details that makes this care so nearly a matter of life or

death to the patient.

In considering the complications of pregnancy, the nurse in training

needs a reminder that hospital experience is likely to give her an

exaggerated idea of the relative frequency with which they occur. This

is due to the fact that most maternity patients in hospitals are there

because they are known to be abnormal in some way, or because they are

pregnant for the first time, and first pregnancies are more likely to

end in difficult and complicated labors than later ones. The vast

majority of cases run practically uncomplicated courses, for pregnancy,

labor and the puerperium are normal physiological processes. It is

extremely serious, however, to allow them to become abnormal.

Watchfulness throughout pregnancy, then, in the interest of preventing

disaster, cannot be too insistently advocated.

Some complications that are watched for during pregnancy are peculiar to

that condition alone, and these may be divided into three general

groups:

=1. The premature terminations of pregnancy=, which are designated

as abortions, miscarriages and premature labors.

=2. Ante-partum hemorrhages=, due to either a placenta prævia or a

premature separation of a normally implanted placenta, the latter

being termed “accidental hemorrhage.”

=3. The toxemias=, including pernicious vomiting, pre-eclamptic

toxemia, eclampsia and possibly nephritic toxemia, though this

condition is not invariably associated with pregnancy.

There are other conditions, not necessarily inherent to the state of

pregnancy, but which should be detected and treated early, since their

development coincidently with expectant motherhood may threaten the

safety of the patient or the child, or both. Probably the most serious

of these is syphilis, though gonorrhea, impaired kidneys, heart lesions,

tuberculosis or a general state of poor nutrition also may prove to be

grave.

Any chronic, organic disease is likely to be increased in severity by

the strain which pregnancy puts upon the impaired organs, in common with

the rest of the maternal body. But acute diseases usually run about the

same course in pregnant, as in non-pregnant women, except when an

infection causes an abortion, the shock of which, in turn, reduces the

patient’s resistance against the complicating disease.

As we consider these various, dreaded complications which may arise

during pregnancy, infrequent though they be, we feel that no amount of

effort is too much to make, if we can, thereby, save one mother or one

baby from their destructive effects. We are stirred by the urgency of

preventing a premature ending of pregnancy, for example, when we see it,

not so much as simply another obstetrical emergency, but in its true,

tragic light as the loss of an infant life and the bereavement of an

expectant mother.

PREMATURE TERMINATIONS OF PREGNANCY

The termination of pregnancy before the expected time is termed an

abortion, miscarriage, or a premature labor or birth, according to the

stage to which the pregnancy has advanced, but there are wide variations

in the accepted meanings of these terms, among both lay and medical

people.

In the lay mind, abortions are usually associated with criminal practice

and the term is seldom used, while miscarriage is a term which is

loosely applied to all deliveries occurring before the child is viable,

or before the seventh month. It is not uncommon, however, to hear the

term abortion used to designate the termination of a pregnancy before

the end of the fourth month; miscarriage, one which occurs between the

end of the fourth and seventh months, and premature labor as one which

takes place any time after the seventh month, but before the expected

date of confinement.

Medical people, on the other hand, seldom use the term miscarriage, but

designate as abortions all terminations of pregnancy which occur before

the end of the seventh month; and premature labor, those occurring from

that time until the estimated date of confinement. It is these meanings

which will be intended when the terms abortion and premature labor are

used in the following pages.

ABORTIONS. In the nature of things, it is impossible to say how often

abortions occur. They sometimes happen so early in pregnancy that the

patient is unaware of the accident; or, if she does know of it, she may

take no notice of it or regard it of so little consequence that she does

not consult a doctor; while in many cases it is intentionally concealed

because of having been criminally induced. But such information as is

available suggests that at least one out of every five pregnancies ends

in an abortion.

Since the ovum is insecurely attached to the uterus until the sixteenth

or eighteenth week, an abortion is more likely to occur during this time

than later, while of this period, the second and third months seem to be

the most perilous.

Abortions are less likely to happen during first pregnancies than

succeeding ones; they occur more often among women over thirty-five

years old than in younger ones, and in all cases are most likely to take

place at the time when the menstrual period would fall due were the

woman not pregnant. Their frequency probably increases with the number

of pregnancies, because of the tendency of multiparous women to have

endometritis, which, as we shall see later, is a causative factor.

=Causes.= There is a variety of causes of abortions and miscarriages,

some entirely unavoidable, but many which are preventable, and it is

well for the nurse to be familiar with those which operate most

frequently, as follows:

=1. Certain abnormalities of the developing fetus= are inconsistent

with life, and are, therefore, a frequent cause of abortion. Dr.

Mall, of Johns Hopkins University, showed after years of

investigation that at least one-third of the embryos obtained from

abortions were malformed and would have developed into monstrosities

had they lived to term. It is often a great comfort to the expectant

mother who loses her baby early in pregnancy to realize that had she

carried her baby to term it might have been a monster, and that,

therefore, she has not lost a beautiful, normal child. Just why

these abnormalities occur is not known, nor is there any known

method of preventing or correcting them. There also may be such

defects in the placental development, that the fetus does not derive

sufficient nourishment to continue its development, and dies very

early as a result.

=2. Abnormalities in the generative tract= may cause abortions, the

most common of these being inflammation of the uterine lining and a

malposition of the uterus itself. Gonorrheal infection is a frequent

cause of such an inflammation, which so alters the decidua that a

satisfactory implantation of the ovum is impossible, and it perishes

from lack of nourishment. Uterine misplacements, particularly

retroflexion and prolapse, are important causative factors in

abortions. This is because the malposition interferes with the blood

supply and lesions in the endometrium result. This also presents an

unsatisfactory lodgement for the ovum and it cannot survive for

long.

=3. Acute infectious diseases= all tend to cause the death of the

fetus and thus cause abortions. Fetal death in these cases is

believed to be due to the transmission of toxic material from mother

to child, as may occur also in such poisoning as phosphorus, lead

and illuminating gas.

=4. Mental or emotional= stress may be the cause of an abortion, but

less importance is attached to these factors to-day than formerly.

There is an occasional case, however, which can be explained on no

other grounds.

=5. Physical shocks=, such as falls, blows upon the abdomen,

jumping, tripping over carpets, jars, jolting or overexertion, may

be the exciting cause of an abortion where there is a marked

irritability of the uterine muscles. This factor is largely

influenced by individual stability, however, as a slight jar will

cause an abortion in one woman, and violent experiences will have no

effect upon another, at the same stage of pregnancy.

=Symptoms.= For purposes of differentiation in treatment, abortions are

usually divided into three groups and designated as threatened, complete

and incomplete, but the premonitory symptoms of all of the varieties are

the same. They are bleeding, with pain that is usually intermittent,

beginning in the small of the back and finally felt as cramps in the

lower part of the abdomen. Since menstruation is suspended during

pregnancy, it is a safe precaution to regard any bleeding during this

period, with or without pain, as a symptom of pending delivery.

=Prevention= of abortions is of course more satisfactory than remedial

treatment, and a nurse may be very helpful in this respect, by

explaining the underlying causes to the patients in her care, and

winning their cooperation in preventing a deplorable accident.

Preventive treatment really begins very early. In the chapter on

menstruation we referred to the importance of a young woman’s

ascertaining the cause of painful menses, in the interest of good

obstetrics, since inflammation of the uterine lining or a uterine

misplacement might be responsible not only for the dysmenorrhea, but if

neglected might, later, be factors in causing interrupted pregnancies.

The correction of such physical defects, then, no matter when they are

discovered, is an important step in preventing abortions.

A misplacement may be corrected, frequently, by means of a pessary,

though suspension is done in some cases; an inflamed lining, which

provides unsatisfactory lodgement for the ovum, may be removed by

curettage. The new lining which replaces the old one is sometimes

capable of receiving and holding the ovum.

There are also some more immediate preventive measures. A woman who is

pregnant for the first time, and who, therefore, does not know whether

or not she is likely to abort, should avoid such risks as fatigue,

sweeping, lifting or moving heavy objects, running a sewing machine by

foot, running, jumping, dancing, traveling or any action which might jar

or jolt her during the first sixteen or eighteen weeks of pregnancy.

On the other hand, there are many groundless beliefs concerning the

causes of abortions which the nurse may well dispel. Purgatives and

other drugs have much less effect in causing abortions under normal

conditions than is generally believed. But with a patient who has very

irritable uterine muscles, such a drug as quinine, for example, may act

as the last straw in producing an abortion which would almost certainly

have been brought on by some other slight stimulation had the drug not

been taken. Nor can reaching up, or sleeping with the arms over the

head, possibly separate the embryo from the uterine lining, yet many

women believe that they can.

In the case of an expectant mother who has had an abortion, even more

precautions than I have suggested will have to be taken, for she is in

greater danger of aborting than is a woman who has not had this

experience. It is of prime importance that she have the cause of her

previous abortion discovered, and if possible, corrected. In addition to

this, she should be particularly careful to observe precautionary

measures as she approaches the stage of her pregnancy at which the

previous abortion occurred. The accident is most likely to be repeated

at about the same time, or a little earlier, in each succeeding

pregnancy. The patient should remain quietly in bed for at least a week

before and after the time when an abortion is feared.

Complete rest and physical relaxation are such effective preventive

measures that patients with a tendency to have abortions, who have been

willing to stay in bed throughout practically the entire period of

gestation, have gone through pregnancy without interruption, and been

delivered of normal babies at term. As out-of-door exercise is clearly

impossible in such cases, it is imperative that the patient keep her

room particularly well-ventilated all of the time, and, under the

doctor’s direction, have massage or bed exercises.

Since abortion seems to be due, so often, to excessively irritable

uterine muscle fibres that respond to even slight stimulation, a patient

who is known to have difficulty in carrying a child to term is usually

advised to avoid the marital relation throughout pregnancy.

Some patients with defective uterine lining will have slight bleeding

for a long time, possibly throughout the entire period of pregnancy,

because a small area of the placenta has separated, leaving, however, a

sufficiently large attached area to nourish the fetus. Such women

should, of course, be under a doctor’s care and sedulously avoid all

shocks to the uterine musculature, for the separated area may very

easily be increased to such a size that the fetus will be unable to

secure adequate nourishment, and die as a result. And the mother’s life,

too, may be endangered by hemorrhage from the separated surfaces.

To sum up in a word, we may almost say that, after pregnancy has begun,

preventive treatment consists of rest and avoiding physical shocks,

particularly during the first sixteen or eighteen weeks and at the time

when menstruation would occur were the woman not pregnant.

=Treatment=, in the different degrees of abortion, employed by most

physicians, is usually along some such lines as the following:

=1. Threatened.= A threatened abortion is one in which there is some

loss of blood, associated with pain in the back and lower abdomen,

but without expulsion of the products of conception. The treatment,

as a rule, is absolute rest in bed and the administration of

powerful sedatives.

=2. Incomplete.= An incomplete abortion is one in which the fetus is

expelled but the placenta and membranes remain in the uterine

cavity. The treatment is removal of the retained tissues, followed

by the same care that is given during the normal puerperium. Prompt

action in completing the delivery is important because of the

hemorrhage that usually persists until the uterus is entirely

emptied of its contents. Since the pregnant uterus is very soft, the

retained membranes are more often removed manually than

instrumentally, for a curette may be very easily pushed through the

uterine wall, and peritonitis would be likely to follow.

=3. Complete.= A complete abortion, as the term suggests, is one in

which all the products of conception are expelled. The treatment and

care are exactly the same as are given after a normal delivery. This

point cannot be stressed too strongly, for it is because so many

women fail to appreciate the necessity for adequate post-partum

care, that abortions are so often followed by ill health and

invalidism.

Many doctors follow these various remedial measures with a search for

the cause of the abortion just past, in order that it may be corrected

if possible and recurrent abortions prevented.

=A missed abortion= occurs but rarely, and is one in which the embryo,

or fetus dies, and is retained within the uterine cavity for months, or

even years, sometimes without any unfavorable results to the mother. In

these cases, symptoms of abortion sometimes appear and then subside

without any part of the uterine contents being expelled. In other cases

there are no signs except that the abdomen stops growing. There are

cases on record in which the fetus has become mummified and others in

which it has been partly absorbed by the maternal organism.

In addition to abortions which occur spontaneously there are also

induced abortions, and these are designated as therapeutic or criminal,

according to the motive for the induction.

=Therapeutic abortions= are resorted to when the patient’s condition is

so grave that it is apparently necessary to empty the uterus in order to

save her life. Such a condition may exist, for example, when pregnancy

is complicated by pulmonary tuberculosis, heart disease, toxemia,

hemorrhage or some condition which is inherent to pregnancy. An abortion

induced under these circumstances is countenanced by law, as it is

performed to prevent the loss of life from disease; but an abortion is

not legal if brought on to save the woman from suicide, because of her

unwillingness to become a mother.

The Catholic Church, however, teaches that it is never permissible to

take the life of the child in order to save the life of the mother. It

teaches that, even according to natural law, the child is not an unjust

aggressor: and that both child and mother have an equal right to life.

There is apparently no reason why a therapeutic abortion should be

followed by ill health, for, since it is performed openly, it is done

under clean, and otherwise favorable conditions, and the patient is

given adequate after-care. It is only because the reverse conditions

frequently prevail: the unclean delivery and subsequent neglect which go

hand in hand with the secrecy of illegal performance that abortions are

followed so often by disaster.

As to the legal aspect of the matter, the laws relating to therapeutic

abortion vary in the different states. But they are fairly uniform in

their intent, and make quite clear the difference between this procedure

and the induction of abortion for any reason other than medical

necessity.

Dr. Slemons writes of the seriousness of criminal abortion in no

uncertain terms, in “The Prospective Mother.” “At Common Law” (an

inheritance from England) he tells us, “abortion is punishable as

_homicide_ when the woman dies or when the operation results fatally to

the infant, after it has been born alive. If performed for the purpose

of killing the child, the crime is _murder_; in the absence of such

intent, it is manslaughter. The woman who commits an abortion upon

herself is likewise guilty of the crime.”

PREMATURE LABOR is the termination of pregnancy after the seventh month,

but before term. Premature births are much less frequent than abortions

or miscarriages. They usually occur spontaneously, but are sometimes

induced for therapeutic purposes, or from criminal motives.

The premature baby’s chances of living are directly proportionate to the

length of its uterine life. This has already been stated, but will bear

repetition in view of the widely current fallacy that a seven-months’

baby is more likely to live than one born after eight months of

pregnancy. The facts are that as a rule, the nearer pregnancy approaches

term, the more likely is the baby to survive, provided it weighs four

pounds or more, and is forty centimeters or more in length. A smaller

baby than this has but a slender chance to live.

We ordinarily designate as premature any baby that weighs between 1500

and 2500 grams, or measures between thirty-six and forty-five

centimeters in length, and consider such a baby has a favorable outlook

if given special care. This special care of premature babies will be

described in connection with the care of the baby.

=Causes.= Syphilis was formerly thought to be a common cause of

abortion, but although this has been disproved by recent investigations,

the disease is still regarded as a frequent cause of spontaneous

premature labor. In fact, Dr. Williams considers syphilis the most

frequent single cause of premature births, and regards the birth of a

dead, macerated fetus, or a history of repeated premature labors, or

stillbirths, as strongly suggestive of syphilis.

“In my experience,” he says, “the recognition and treatment of this

disease is the most important matter in connection with the prophylaxis

of premature labor.... Some idea of the importance may be gained from

the fact that in a series of 334 premature labors, I found that syphilis

was the etiological factor in over 40 per cent., while toxemia, placenta

prævia and fetal deformity were concerned in 8.6 and 3.3 per cent.,

respectively. Sentex, who studied 485 cases in Pinard’s clinic arrived

at similar conclusions and found the underlying cause to be syphilis in

42.7 per cent., albuminuria in 10.8 per cent., and abnormalities of the

fetus in 11.1 per cent.”[3]

Other causes of premature births are the toxemias of pregnancy, chronic

nephritis, diabetes, pneumonia, typhoid fever, organic heart disease,

continuous overwork during the latter part of pregnancy, and such

poisoning as lead and illuminating gas, while of alcoholism, Dr.

Ballantyne says, “prematurity of birth is an undoubted result.”

Another important cause of premature births, of comparatively recent

recognition, is previous operation upon the cervix, particularly high

amputations; while placenta prævia and malformations of the fetus, or

monsters, are also reckoned with as causative factors. Hydramnios

sometimes brings on a premature labor by so distending the uterus as to

stimulate contractions.

Labor is sometimes induced prematurely when this procedure may be

expected to relieve an abnormality or complication which threatens the

life of the mother or baby, or both. Some of the indications for this

course are: seriously overtaxed heart or kidneys; a marked disproportion

between the size of the child’s head and the mother’s pelvis, or a fetus

that has been dead for two weeks or more. However, the reasons for it

and the methods employed in inducing labor will be discussed more at

length in the chapter on obstetric operations.

A therapeutic induction of premature labor, like a therapeutic abortion,

is not of itself usually considered any more serious for the mother than

a normal delivery, since it can be performed with care and cleanliness,

qualities not usually associated with the work of practitioners who are

willing to do criminal operations.

=Treatment.= The nursing care of the patient after a premature labor is

the same as that given after a normal delivery. Much invalidism would be

avoided if all women could be convinced of the importance of staying in

bed just as long, and having just as good care after a premature as

after a full-term labor. The difficulty of so convincing her is perhaps

due to the fact that the small, premature child is expelled more quickly

and less painfully than a baby at term and there is comparatively little

blood lost in the course of its birth.

ANTE-PARTUM HEMORRHAGE

[Illustration:

FIG. 44.—Diagram of centrally implanted placenta prævia.

]

Ante-partum hemorrhage, which is a hemorrhage occurring before delivery,

is another serious complication of pregnancy. During the early months,

hemorrhages are usually due to abortion, menstruation or lesions of the

cervix and are not severe as a rule. But during the last three months

hemorrhages are almost invariably due to placenta prævia or premature

separation of a normally implanted placenta, and are often profuse.

PLACENTA PRÆVIA is one of the most serious conditions met with in

obstetrics, the maternal mortality being about 40 per cent. and the baby

death rate about 66 per cent. The frequency with which it occurs is

variously estimated as from one in 250 cases to one in every 1000.

In order to understand what is happening to the patient in this

condition, we must go back to the question of the implantation of the

ovum. We learned that, as a rule, after the ovum entered the uterus it

attached itself to a point in the uterine lining high up on the anterior

or posterior wall. Unhappily, the position of this point of attachment

is a mere matter of chance, and the ovum sometimes, but not often, is

implanted so far down toward the cervix that as the placenta develops at

that site it partially or completely overlaps the internal os. It is the

extent to which the placenta grows over the cervical opening that

determines whether it is of the central, partial or marginal variety.

[Illustration:

FIG. 45.—Partial placenta prævia. Section of uterine wall and cervix

showing that part of the maternal surface of the placenta which

extends over the cervical opening and is exposed by dilation of the

internal os, with an escape of blood from the open vessels as a

result. Drawn by Max Brodel. (From “The Treatment of Placenta

Praevia,” by William B. Thompson, M.D.—Johns Hopkins Hospital

Bulletin, July, 1921.)

]

_A centrally implanted placenta prævia_ (Fig. 44) is one which entirely

covers the os; _a partial placenta prævia_ (Fig. 45), as the name

suggests, only partially covers the opening, while if it is implanted so

high up that only its margin overlaps the os, it is designated as

_marginal placenta prævia_. (Fig. 46.)

[Illustration:

FIG. 46.—Diagram of marginal placenta prævia.

]

Another classification groups all placenta prævia as complete or

incomplete, the latter comprising the partial and marginal varieties, as

well as the lateral which is so attached that it does not quite reach

the edge of the internal os. However, as these terms do not differ

widely and are clearly descriptive, the differences are of no great

moment to the nurse, as the treatment is practically the same and the

nurse’s duties quite the same for all varieties.

=Cause.= Not much is definitely known about the cause of placenta

prævia, but it is evident that multiparity is a factor, since the

condition is found about six times as frequently among women who have

borne children, as it is among those who are pregnant for the first

time. A diseased uterine lining is probably the fundamental cause, and

this may explain why the trouble is found more frequently among the

poorer classes, since such women as a class have less skilled medical

attention than those in better circumstance.

One theory is that an old endometritis results in a very unfertile soil

for the implantation of the ovum and as a result the ovum migrates to

other parts of the uterine cavity in its search for a more favorable

site, and comes to lodge near the lower segment.

=Symptoms.= The symptom of placenta prævia is hemorrhage, occurring

during the latter part of pregnancy or at the onset of labor. The cause

of the hemorrhage is the separation of that part of the placenta

covering the internal os, when the latter dilates, thus presenting an

exposed, bleeding surface. The hemorrhage is usually so profuse that

unless it is controlled, both mother and child may bleed to death.

=Treatment.= Unhappily there is no preventive treatment for placenta

prævia, beyond that which is included in treatment for endometritis, and

good care during the preceding puerperium.

[Illustration:

FIG. 47.—Position of Champetier de Ribes’ bag to stop hemorrhage, from

placenta prævia, by pressure.

]

Since the great danger in this complication is from hemorrhage the

doctor’s principal effort is directed toward its control. Infection and

shock are also feared but the first step is to stop the bleeding. A

common method is to stimulate the uterus to contract; that necessitates

the removal of its contents, or the induction of labor.

The separation of the placenta leaves open, bleeding vessels in the

uterine wall and placenta, which can only be closed by pressure, until

the uterus contracts on its own vessels. The doctor sometimes makes

pressure with tampons of gauze, by rupturing the membranes and bringing

down the presenting part of the child to press against the bleeding

surface, or by introducing a rubber bag into the cervix and pumping it

full of sterile water. (Fig. 47.) By means of its weight and downward

traction, this bag presses against the bleeding areas and thus checks

the hemorrhage. It also tends to dilate the cervix, after which the baby

is sometimes born spontaneously and sometimes delivered artificially.

PREMATURE SEPARATION OF A NORMALLY IMPLANTED PLACENTA. A placenta

prævia, as has been explained, is abnormally situated. But it sometimes

happens that a placenta that is normally placed will separate

prematurely, with hemorrhage as the inevitable result. Such a hemorrhage

is termed “accidental” to distinguish it from the unavoidable bleeding

caused by a placenta prævia. If the blood escapes from the vagina, the

hemorrhage is called “frank,” but if it is retained within the uterine

cavity it is called a “concealed” hemorrhage.

=Causes.= Endometritis is probably an underlying cause, though very

little is definitely known on the subject. Previous pregnancies are

believed to be a factor, as this accident occurs less often among women

who are pregnant for the first time than among those who have borne

children, and also as the frequency of the hemorrhages apparently

increases with the number of previous pregnancies. Nephritis is believed

to be a possible cause, as well as anemia, general ill-health, toxemia,

physical shocks, and frequently recurring pregnancies.

=Symptoms.= In a frank hemorrhage, the chief symptom is an escape of

blood from the vagina, occasionally accompanied by pain. A frank

accidental hemorrhage occurs once in about every two hundred cases,

according to Dr. Edgar’s estimate, but, although more frequent than

placenta prævia, it is much less serious.

A concealed accidental hemorrhage, on the other hand, is an extremely

grave complication for both mother and child, for according to

observations made by Dr. Goodell, the death rate is 51 per cent. among

mothers and 94 per cent. among babies.[4] The symptoms are acute anemia,

abdominal pain, a general state of shock, and usually an increased

enlargement of the uterus. The blood may be retained between the uterine

wall and the placenta or membranes, or its escape from the vagina may be

prevented by the child’s presenting part fitting tightly into the outlet

and acting as a plug.

=Treatment.= The treatment of a frank hemorrhage depends upon its

severity. If the bleeding is only moderate, labor is ordinarily allowed

to proceed normally and unassisted. If the bleeding is profuse, however,

the patient is usually delivered promptly.

The treatment for a concealed hemorrhage consists of emptying the uterus

speedily in order that the muscles may contract and stop the bleeding by

closing the uterine vessels; and of treating the accompanying shock

which may be almost, if not quite, as serious as the hemorrhage itself.

It is very disappointing to have to realize that there is very little

that a nurse may do, before the arrival of the doctor, for a patient who

is having an ante-partum hemorrhage. As has been explained, it is often

necessary to pack the cervix or introduce a bag, for the purpose of

stopping the bleeding by pressure, and of stimulating the uterine

contractions which will expel the child and empty the uterus. These

measures are surgical operations and quite evidently the nurse cannot

attempt to perform them. She can, however, put the patient to bed and

have her lie flat, without a pillow, and, partly for the mental effect

upon the patient, apply ice-bags or compresses to her abdomen. As

nervousness and excitement only tend to increase the bleeding, the nurse

has an excellent opportunity to try to soothe and quiet a frightened

woman, and convince her that she can help herself, in this emergency, by

quieting her mind and body.

Pending the doctor’s arrival, the nurse should have a large receptacle

of water, boiling, to sterilize the instruments and bags that he may

want to use; clean towels and sheets, a nail brush, hot water, soap, and

a basin of an antiseptic solution for his hands.

TOXEMIAS OF PREGNANCY

There is probably no group of complications which prove to be more

baffling to the obstetrician than the toxemias of pregnancy. Certainly

they are challenging the best efforts of many earnest investigators, for

it is known that the toxemias cause some of the gravest conditions that

arise during pregnancy, and they are suspected of being the underlying

cause of still others which are as yet unaccounted for.

Comparatively little is known of the origin of the toxemias, except that

they are due to pregnancy. But happily, a good deal is known about

preventing them, and also about relieving them, particularly in the

early stages; accordingly many mothers and babies are saved who

otherwise would perish.

The entire subject of the prevention and treatment of these disorders

will be somewhat simplified for the nurse if she will recall the general

question of the adaptations of the mother’s physiology during pregnancy.

She will then remember that there were certain alterations of function

which were necessary to keep the maternal organism normal, while it bore

the strain of supplying nourishment to the fetus from its own blood

stream, and received in turn the broken-down products of fetal activity.

If these adaptations are insufficient to meet the demands made upon the

maternal organism, a serious toxic condition may result.

To put the matter briefly, there is in the toxemias of pregnancy a

disturbance of the mother’s metabolism, involving the liver and kidneys,

and a resulting retention within her body of something which should be

excreted. The retention of this material, which may be of fetal or

maternal origin, or both, may give rise to symptoms which range anywhere

from slight headache or nausea to coma, convulsions and death.

Beyond these general facts, there seems to be deep obscurity concerning

the cause of this group of complications, of which _pernicious

vomiting_, _pre-eclamptic toxemia_ and _eclampsia_ are the most widely

and generally recognized.

While _nephritic toxemia_ and _acute yellow atrophy_ of the liver cannot

be designated, quite accurately, as toxemias due to pregnancy, they are

usually included in this group. This may be because they are toxemias

which have many features in common with those of pregnancy, as to

symptoms and treatment, and because of the frequency with which they

appear coincidently with pregnancy, although not always due primarily to

that state.

From the nurse’s standpoint, it will perhaps be as well to regard all of

the toxemias of pregnancy as manifestations of the same general

disturbance, which vary according to the stage of pregnancy at which

they appear, and which differ from each other chiefly in severity, or

degree, rather than in kind.

In all cases the patients need to have their toxicity lessened by

dilution, and this is accomplished by giving fluids, copiously, and by

increasing elimination by promoting the activity of the skin, kidneys

and bowels. And since the nervous system is irritated by the toxins,

sometimes slightly and sometimes profoundly, the patient must be

protected from outside irritation and stimulation. This means quiet; a

soft light, or even darkness in the room; gentle handling; and with

mildly toxic, conscious patients, a pleasant, reassuring and encouraging

manner. With those who are unconscious, each touch must be the lightest

and gentlest possible.

These are the main features of the nursing care: forcing fluids and

keeping the patient warm and quiet. They offer the nurse wide scope in

adjustment and adaptation to each patient, according to her immediate

condition and to the methods of the physician in charge. There is a

difference of opinion among doctors as to details of treatment, but the

fundamentals of the care are the same. In taking up, in turn, these

manifestations of disturbed metabolism during pregnancy, we find that

vomiting is the first to appear.

PERNICIOUS VOMITING OF PREGNANCY usually occurs during the first three

months. We learned in the preceding chapter that a milder form of the

malady, known as “morning sickness,” is present in about half of all

pregnancies. This mild type ordinarily consists of a feeling of nausea,

possibly accompanied by vomiting, immediately upon raising the head in

the morning, and a capricious appetite. It appears at about the fourth

or sixth week and subsides in the course of a few weeks, sometimes after

no more care than the nursing which was described, leaving the patient

none the worse as a result of the attack.

With some women, however, the distress does not disappear in this prompt

and satisfactory manner, in which case it is described as “pernicious

vomiting.” The nausea in the morning may then persist for hours; it may

occur later in the day, or even at night; it may come on during a meal

and consist of a single attack of vomiting, after which food is taken

and retained; or it may be so persistent that the patient will be unable

to retain anything taken by mouth at any time of the day or night. Such

a condition, is, of course, serious, and may terminate fatally. The

patient may become exhausted from lack of food or because of the toxic

condition which is responsible for the vomiting, or both.

There seem to be three possible classifications of pernicious vomiting:

(1) One of _reflex_ origin, (2) one of _neurotic_ origin, and (3) one

due to a _toxemia_, resulting from disturbed metabolism. Not all

physicians accept the possibility of all of these factors, however, for

while some recognize both toxemia and neuroses as causes, they question

the possibility of a reflex cause. Others believe that all nausea of

pregnancy, from the mildest to the most severe form, is of toxic origin,

while still others contend that even the severest pernicious vomiting is

always neurotic. However, as toxicity under any conditions is very

likely to give rise to nervous symptoms, and as a nervous, unstable

woman may be made very ill by a slight degree of toxicity, it may be

that both factors sometimes enter into the causation of this disorder.

=Reflex vomiting.= Those who subscribe to the theory of reflex vomiting

believe that it may result from the irritation caused by a retroverted

uterus, or occasionally by an ovarian cyst, an erosion on the cervix or

by adhesions.

The treatment for reflex vomiting, quite obviously, consists of

correcting the disturbing condition, whatever it may be, after which the

nausea usually subsides in a short time. The nurse should take care that

her patient resumes a regular diet very gradually, even after the cause

of the nausea has been removed, for the stomach has become irritable and

the vomiting habit, both mental and physical, though easily established,

is usually broken up with considerable difficulty. Breakfast in bed;

concentrated liquid foods or easily digested solids, particularly

carbohydrates; aerated waters; cold fruit juices and cracked ice are

easy to retain and tend to allay nausea.

=Neurotic vomiting.= Severe vomiting which is due to some kind of mental

stress or suffering, and commonly called “neurotic vomiting,” is not

always so easily relieved. In the opinion of many psychiatrists the

vomiting frequently constitutes a protection, or possibly a protest,

which the patient has developed subconsciously, because of some reason

for fearing, or not wanting, to become a mother.

It is difficult to outline the nursing care of such patients with any

degree of precision, as no two can be cared for in quite the same way.

While in some cases the patient is a selfish, overindulged woman who

objects to motherhood because of its inconveniences, in others, she is

tortured by fear of inability to go through her pregnancy successfully,

though sincerely wanting to; or she may be bewildered and overwhelmed by

the prospect of the dangers of childbirth and responsibilities of

motherhood, a truly pathetic figure whose distress may often be greatly

relieved by the nurse who has enough insight to grasp the situation. As

I have discussed this subject more at length in the chapter on mental

hygiene, I shall say only a word here, as a reminder that the nurse will

need all of the tact, resourcefulness, sympathy and understanding which

she is capable of offering, if she is to give real help to some of her

patients who suffer from neurotic vomiting.

In addition to the mental nursing, which will be necessary, the patient

also needs physical care, for though her trouble may be of emotional

origin, she is, nevertheless, physically ill. As a rule, the best

results are obtained by putting the patient to bed and separating her

from her family as completely as possible. A daily routine should be

adopted and rigidly observed, and the patient repeatedly assured that

the course being followed will end in recovery.

It is usually considered advisable not to offer food by mouth, in the

beginning, but instead to give nourishment, as well as large amounts of

saline and sugar solutions by enemata, during the first few days. One

routine is to give 500 cubic centimetres _very slowly_, every six hours

at first, gradually decreasing the treatments to one a day as the

patient improves. The rectum is irrigated with a simple enema, once

daily, immediately preceding one of the injections, consisting of an

ounce of dextrose or glucose and one dram of salt to a pint of water.

Small amounts of liquid nourishment are finally given by mouth, and

given frequently, the quantity being increased gradually as the patient

improves. Very light and easily digestible solid foods, chiefly

carbohydrates, are added by degrees, and in the end, five or six small

meals, rather than three full ones, are given in the course of the day.

In some cases the patient is induced to drink, daily, two or three

quarts of sugar solution (an ounce of lactose to a pint of water), and

to nibble at will on olives, walnuts, crisp crackers, or some such

articles of food, which are kept within reach on her bedside table.

These are usually retained, excepting in very severe cases, to the

patient’s great encouragement.

The duration and severity of the attacks vary widely. Some patients are

very ill and for a long time, even requiring an abortion before showing

signs of improvement, while others recover in a few days if wisely

managed. If a patient once suffers from neurotic vomiting, she is very

likely to have it in subsequent pregnancies, particularly if the

circumstances of her life remain unaltered.

=Toxemic vomiting= is regarded by some doctors as a very grave and very

rare complication of pregnancy, which is usually fatal; by others as

simply a severe form of the very common “morning sickness,” which they

believe is always toxic, no matter how mild; while still others, as

already stated, doubt the occurrence of such a condition as toxemic

vomiting of pregnancy. I mention these differences of opinion in order

that the nurse may be aware of their existence and be prepared to adjust

herself whole-heartedly to the different methods of treatment for which

they are responsible. For no matter what else may vary, the earnestness

and sincerity of the nurse’s attitude must be a veritable Gibralter of

reliability.

The chief =symptoms= of toxemic vomiting, in addition to persistent

vomiting, as described by those who recognize its occurrence, are

coffee-ground vomitus; a diminished amount of urine, possibly containing

albumen, acetone bodies and casts; coma and sometimes convulsions. The

disease may run its course swiftly and the patient die in a week or ten

days, or it may persist less acutely for weeks, in which case there is

extreme emaciation and prostration. In those cases which come to autopsy

there is a definite and characteristic, central necrosis of the liver

lobule.

The =treatment= and nursing care vary widely because so little is

definitely known about the cause, and because of the varieties of

theories concerning it which are held by different obstetricians. Some

believe that prompt emptying of the uterus is about the only course

which is effective, while others feel that because of the probable

toxicity of the patient it is advisable also to stimulate all of the

excretory organs. Accordingly, they give free purges, colonic

irrigations, hot packs and copious amounts of sugar and saline solution

by mouth, rectum, intravenously and by infusion.

Corpus luteum, too, is sometimes given hypodermically two or three times

weekly. Although this treatment is not in universal use or favor, some

patients seem to be given absolute relief by its administration.

A fairly typical method of treating toxemic vomiting, and of which the

nursing care forms a large part is somewhat as follows: When the

vomiting is only moderately severe, the patient is put to bed and

isolated from relatives and friends, because of her nervousness

resulting from the toxemia. She is given an abundance of very cold, 5

per cent. lactose solution by mouth in water or lemonade; from four to

six ounces being given every half hour if she is able to retain it. If

she is unable to take, by mouth, a total of about three litres of this

solution, in the course of twenty-four hours, she is sometimes given one

or two litres (of a 10 per cent. solution) by rectum by means of the

drip method. At least three hours are devoted to giving this amount of

fluid, the rectum being first washed out with a simple enema.

It is usually considered important to persist in giving small amounts of

practically any article of food that the patient fancies, in order to

encourage her in the belief that she can take nourishment and also to

accustom her stomach to receive and retain food. Olives and nuts are

particularly valuable for this purpose and are often kept on the

patient’s bedside table where she can reach them and nibble on them at

will. Ice cold fruits and fruit juices are useful, while strained apple

sauce, ice cold, is very valuable as a starting point from which a more

generous diet may be gradually developed. All foods should be very cold

except broths, which should be very hot. The dietary is gradually

increased to six small meals daily from which fats and proteids are

omitted.

In more severe cases, or if the patient does not improve, an injection

of 300 cubic centimetres of fresh 5 per cent. solution of glucose is

given under each breast daily, and sometimes a mild sweat-bath, given

with blankets and lasting twenty minutes. (See page 197 for sweat-bath.)

In very severe cases when the patient is unable to retain anything taken

by mouth; loses weight and strength; when possibly the urine decreases

in amount and contains acetone bodies and ammonia, the situation is

serious and the treatment is more drastic. All effort to give fluid by

mouth is abandoned and in addition to the sub-mammary injection of

glucose solution, a colonic irrigation of one and a half to two gallons

of sodium bicarbonate solution (from 2% to 5%) at 110° F., is given once

daily by the drip method. The daily hot pack is continued; a mustard

leaf is applied to the abdomen if necessary to relieve the pain and

nausea; glucose solution may be given intravenously and also a nutritive

enema, three times daily, consisting of a raw egg, four ounces of

peptonized milk and one-half ounce of whiskey.

The method employed at the Toronto General Hospital in treating patients

suffering from toxemic vomiting is outlined as follows by Dr. J. G.

Gallie: “The patient is given as much as she is able to drink. A

nutrient enema is given three or four times daily, consisting of six

ounces of a 10 per cent. solution of glucose in saline. Bromide and

chloral may have to be added to the last nutrient in the evening. A

simple enema is given each morning. Nutrients are discontinued when the

urine becomes free of acetone bodies. In more severe cases, where fluid

cannot be taken by mouth, it may be supplied interstitially or

intravenously, a 5 per cent. solution of glucose being used. When

vomiting ceases, and solid food can be taken, the feeding is begun very

carefully with small quantities of carbohydrates. Lactose is added where

possible to any fluid taken. Frequent small meals are then

instituted—six between 7 a.m. and 10.30 p.m., thus reducing to the

smallest space of time the period of starvation during the twenty-four

hours. Protein may be added to the diet when nausea is under control,

but fat should be left out for some time.”

Such a course of treatment, quite evidently, is designed to relieve a

toxic condition, in which increased elimination is important, and to

quiet an irritable nervous system.

As the patient with toxemic vomiting is often very uncomfortable because

of a bad taste and dryness of her mouth, some kind of a mouth wash which

she finds refreshing should be used frequently. And since a degree of

toxicity which is capable of producing such a condition as is described

above will almost inevitably produce nervous symptoms, as well, the

nurse’s attitude toward her patient must always be one of sympathy,

encouragement and optimism.

When the patient’s condition is so desperate that pregnancy is

terminated, with the hope of saving her life, ether or nitrous oxide

gas, or both, is used as an anesthetic rather than chloroform, which of

itself tends to produce a liver necrosis.

PRE-ECLAMPTIC TOXEMIA is the most common of all the toxemias of

pregnancy, occurring several times in every hundred pregnancies. It

develops more frequently among women who are pregnant for the first time

than among those who have borne children, and one attack usually confers

an immunity against a recurrence.

As pre-eclamptic toxemia usually responds to treatment, but if

neglected, frequently ends in the much more serious disease of

eclampsia, the imperative need of supervision and care during pregnancy

are once more borne in upon us.

=Symptoms.= Pre-eclamptic toxemia seldom appears before the second half

of pregnancy, usually not until after the sixth or seventh month, and

the symptoms vary widely in severity. They may range from headache and

nausea, so slight as to cause the patient little or no inconvenience, to

coma and death.

The patient may be entirely normal for six or seven months and then

notice that her rings and shoes are a little tight, because of the

slight swelling of her hands and feet. Puffiness of the eyelids may

appear, and other parts of the body may also be slightly swollen.

Headache, dizziness, lassitude, drowsiness, depression, apprehension,

nausea and vomiting are all symptoms, as also are high blood pressure

and a diminished amount of urine, containing albumen. The patient

frequently complains of visual disturbance, which may be only a slight

blurring, but in severe cases may amount to total blindness.

Other symptoms, when the condition is grave, are epigastric pain; rapid

pulse; extreme nervousness and excitement, which may amount almost to

insanity; or drowsiness, which grows deeper and deeper until the patient

sinks into a coma. Under such conditions, she may die without recovering

consciousness, but more frequently, eclampsia ensues. The child may

perish as a result of the toxemia and a dead, premature baby be born.

=Prevention= is of course, the most important aspect of the treatment

and is accomplished by means of the pre-natal care and supervision which

were described in the last chapter. In this connection must be mentioned

again the danger, during pregnancy, of overeating. It is more and more

frequently observed that toxemic seizures follow in the wake of a

single, large, heavy meal, such as one is so likely to take at

Thanksgiving or Christmas time. This is particularly true of patients

who have had nausea or who have even slightly disabled kidneys, which,

though able to meet the ordinary demands made by pregnancy, are

inadequate to cope with the sudden strain imposed by a large meal. In

such a case, toxic materials which should be excreted are retained

within the body, and the familiar symptoms of toxemia are the result.

Much the same condition is produced by the patient’s getting wet or

chilled. The excretory function of the skin is interfered with, under

such circumstances, and the kidneys are unable to do enough extra work

to make up for the skin’s failure, and again toxic material is retained,

instead of being excreted.

=Treatment and Nursing Care.= As might be expected, the details of

treatment and nursing care of a pre-eclamptic patient vary with

different doctors and with the severity of the attack. But the

essentials of treatment, the country over, may be summed up as rest and

elimination, coupled with close watching for unfavorable symptoms.

The surest way to have the patient really rest is to put her to bed,

even in mild cases, and recovery is so hastened, thereby, that she is

well paid for the temporary inconvenience.

Since it is widely believed that the metabolic disturbance, in toxemia,

is related to the nitrogenous part of the diet, the course usually

followed in this particular is a reduction of the nitrogen intake. This

is accomplished by putting the patient on a very low protein diet or a

milk diet, consisting of two quarts of milk daily. This amount of milk

provides adequate nourishment, for the time being, and also supplies a

large part of the fluid which is needed to promote elimination. In

addition to this, however, the patient is given one, or better still,

two quarts of water every day, and free saline purges.

Very frequently this treatment is all that is necessary. The blood

pressure falls in a few days, the albumen in the urine gradually

disappears, the patient completely recovers and in due time has a normal

labor.

But in more severe and less amenable cases it is necessary to increase

the eliminative treatment and give copious colonic irrigations; sweat

baths, in the form of hot packs or hot air baths, and even venesection

and saline infusions, in order to relieve the symptoms. Sometimes, even

these are not enough and the high blood pressure and albumen, which are

probably the most significant symptoms, will continue. If so, and the

patient grows worse, or if she simply fails to respond to the treatment,

the usual practice is to induce labor. A daily output of five grams of

albumen to a litre of urine, and a blood pressure of 200 millimetres are

usually regarded as insistent indications that pregnancy should be

terminated. Otherwise, eclampsia, always so dreaded, is practically sure

to follow and endanger the life of both mother and child.

It may be mentioned here that the normal blood pressure, during the

latter part of pregnancy, is about 120 millimetres. A gradual increase

to 130, or even 140 millimetres, may not be serious, but a sudden rise

or a pressure of 150 millimetres should be regarded with alarm, even

though all other symptoms be absent. The reason for this is that

eclampsia may, and sometimes does, occur with little or no warning

except the high, or suddenly increasing blood pressure.

ECLAMPSIA. Pre-eclamptic toxemia, as the name suggests, is a condition

that frequently precedes eclampsia, and the importance of the

prevention, early recognition and prompt treatment of this forerunner is

due to the seriousness of eclampsia which threatens to ensue. This

disease, which may be defined as a toxemia occurring before, during or

after labor, is one of the gravest complications which arise in

obstetrics. It is usually associated with both tonic and clonic

convulsions, unconsciousness and coma.

Patients who have a tendency to kidney trouble and to digestive

disturbances, such as so-called “biliousness,” are evidently likely to

have eclampsia; and in eclampsia there is a peripheral necrosis of the

liver which occurs in no other condition. These facts suggest that

possibly when metabolism is proceeding normally, the liver converts

certain material, whose retention within the body is inimical to health,

into a form which the kidneys can excrete without great effort; that if

the liver fails in this function, the kidneys are unable to stand the

increased strain put upon them, as is evidenced by casts and albumen

which appear in the urine, and the retained material gives rise to

toxemia. It is possible that disturbed functions of other glandular

organs, such as the thyroid, may play a part in causing eclampsia, but

this, too, is only conjecture.

The frequency with which the disease occurs has been variously estimated

at from one in 500 to one in 100 cases, apparently being more common in

first pregnancies than subsequent ones, but more serious when occurring

among women who have had children before. One attack is believed to

confer an immunity, or, as Dr. Chipman puts it, “the woman with

eclampsia vaccinates herself.” The average death rate from eclampsia is

from 20 to 35 per cent. of the mothers and about 50 per cent. of the

babies, except where the desired care can be given, either at home or in

a hospital, when the mortality is greatly reduced. These figures vary,

somewhat, according to the time of the onset, as the disease is usually

more fatal if the convulsions occur before or during labor, than

afterward.

Some authorities feel, however, that eclampsia is quite as fatal after,

as before, labor.

=Symptoms.= The symptoms, as a rule, are those of pre-eclamptic toxemia

which have persisted and grown more severe, accompanied by convulsions

and coma. The blood pressure may be from 150 to 250 millimetres and the

urine, in addition to showing many and varied casts, contains albumen,

which varies in amount from a few grams per litre to more than a hundred

in severe cases. In those cases which prove fatal and come to autopsy,

there is always found a characteristic, peripheral necrosis of the

liver, and since it is found in no other disease it definitely

establishes the diagnosis. It is true that this is of no help to the

poor woman who died, but it is of help to those investigators who are so

earnestly studying the disease with the hope of finding its cause and

cure.

Although there are frequently pre-eclamptic symptoms which have grown

worse, with or without treatment, it sometimes happens that the patient

has no warning discomfort and the first sign of the disease is a

convulsion; or a patient who has been treated for pre-eclamptic toxemia

may apparently recover, even to the extent of having the albumen

disappear from her urine, and suddenly have a convulsion.

Convulsions, which are both tonic and clonic in character, occur in

about 99.5 per cent. of all eclamptic cases and are very distressing to

watch. They are sometimes preceded by an aura, but often are so

unheralded that they may even occur while the patient is asleep. They

ordinarily begin with a twitching of the eyelids; the eyes are wide open

and staring and the pupils are first contracted and then dilated. The

twitching extends to the muscles about the nose and mouth, then to the

neck and arms, and so on until the entire body is convulsive. The

patient’s face is usually cyanotic and badly distorted, the mouth being

drawn to one side; she clenches her fists, rolls her head from side to

side and tosses violently about the bed. She is totally unconscious and

insensible to light, and during the seizure may not breathe beyond

giving one or two struggling gasps. Her head is frequently bent

backward, her neck forming a continuous curve with her stiffened, arched

back. Another distressing feature is the protruding tongue and the

frothy saliva, which is blood stained if the patient is not prevented

from biting her tongue by the introduction of some sort of a mouth gag

between her teeth.

Such is the typical eclamptic convulsion.

The attacks vary greatly in their intensity and duration. There may be

only a few twitches, lasting ten or fifteen seconds or violent

convulsions lasting as long as two minutes, their number and severity

increasing with the seriousness of the patient’s condition. In mild

cases there may be but one or two convulsions, particularly if the onset

is either late in labor or postpartum. But as a rule, there are several

convulsions; ten, twenty or thirty, and sometimes, though rarely, as

many as a hundred.

The patient always goes into a coma after a convulsion and this also

varies in length and profundity, her condition during the intervals

being very suggestive of the probable outcome of the disease. If the

attacks recur frequently, as they usually do in extreme cases, the

patient is likely to remain unconscious during the entire interval; but

she will usually awaken between attacks that are far apart, and this is

regarded as a hopeful sign. The respirations are labored and noisy as a

rule, and the pulse full and bounding, in which case the outlook is

good. The temperature is often normal, but may go as high as 104° F. or

105° F., dropping rapidly as the attacks subside. But a weak, rapid

pulse together with a high temperature, and above all, a persistently

high blood pressure, no matter what the other symptoms may be, are

always unfavorable.

Concerning the varied results of eclampsia, the opinion seems to be

growing that if it develops during late pregnancy, labor is likely to

set in and a premature child be born spontaneously; in some cases,

however, for reasons already given, labor is induced, while in others

the mother dies undelivered. The fetus may die, after which the

convulsions practically always cease and the infant is often born later

in a macerated state; or the patient may recover, go to term and give

birth to a normal, healthy baby.

When eclampsia occurs during labor the pains usually increase in force

and frequency, thus hastening delivery, after which the convulsions

usually cease. It will be noted that death or expulsion of the fetus is

in almost all cases followed by immediate cessation of the symptoms and

by ultimate recovery.

=Treatment and Nursing Care.= There is so little definite information

about the cause of eclampsia that there is quite naturally some

difference of opinion as to the best methods of curative treatment.

Unquestionably, prevention is of first importance and this is

accomplished through the watchfulness and care during the antenatal

period as described.

Dr. Edgar characterizes eclampsia as a preventable disease, and though

an occasional case will develop in spite of preventive treatment the

general results achieved tend to bear out his definition. For example,

in a series of 1200 maternity cases at Bellevue Hospital during 1920,

prenatal care was given to 900 women and not one case of eclampsia

occurred among them, while among the remaining 300 women who had not

been seen during pregnancy, there were ten eclamptics. It is but fair to

bear in mind that as some of these patients were taken into the hospital

because of their having eclampsia, the proportion is abnormally high.

The Henry Street Settlement reports through its maternity service that

there was but one case of eclampsia among 7600 women who were given

prenatal care by its nurses in 1920. These figures, contrasted with the

average of one case in about every 500 pregnancies, furnish astounding

evidence of what can be done through prenatal care in the prevention of

this one disease alone.

As to curative treatment, the variations of opinion are after all of

little consequence to the nurse, for there is almost entire unanimity

concerning the general principles, and it is these that shape the

nursing care. Broadly speaking, they comprise effort to dilute the toxic

material in the system, promote its elimination through the various

excretory channels and quiet the patient’s nervous excitability.

Since eclampsia occurs only in connection with pregnancy, and the

convulsions usually cease if the fetus dies or is born, one line of

reasoning is that the most effective way to treat the disease is to

terminate pregnancy. Formerly this was almost always done, and is still

practised by some obstetricians. Those who do not agree with this theory

contend that the eclamptic woman is a very ill woman whose nervous

system is so irritated that the slightest stimulation or irritation

works harm. In view of this they feel that manual or instrumental

dilation of the cervix, preparatory to delivering the child through that

channel, or delivery through an incision in either the abdominal wall or

cervix, constitutes a shock that outweighs the advantages of emptying

the uterus; therefore, that as a rule, less harm is done by

noninterference, quieting the patient and increasing her eliminative

functions, than by terminating pregnancy. This line of reasoning also

takes into consideration the fact that from 15 per cent. to 20 per cent.

of the cases of eclampsia are postpartum, indicating that convulsions

may occur even after the uterus has been emptied.

The growing tendency is to adopt a middle course and treat each

individual case according to the conditions and indications which it

presents. Thus the same doctor will hastily induce labor in a case where

the blood pressure and albumen remain alarmingly high, or increase, in

spite of all efforts to reduce them, and in another case will go to the

extreme of conservatism, doing nothing but quiet the patient with

morphia or chloral, or both, and stimulate all of her excretory organs

with abundant fluids.

But the nurse’s duties, and I may say her opportunities, for she is

privileged to do much, are virtually the same no matter which course is

followed, except, of course, the preparation for delivery, if this is

performed.

The nurse is concerned with helping to reduce the intake of nitrogenous

food, or proteids; diluting the toxines retained in the body; promoting

the activity of the kidneys, bowels, liver, lungs and skin; guarding the

patient against all avoidable stimulation from without, such as noise,

light, ungentle handling and undue resistance to the patient’s

convulsive movements; and protecting her from injuring herself by biting

her tongue, falling out of bed or striking the wall or head of the bed

during convulsions.

By striving to accomplish these general results for her eclamptic

patient the nurse will aid immeasurably in saving her life.

A milk diet is the means of reducing the nitrogen intake; or in some

cases even that small amount of proteid is deemed too much, and only

water is given until 24 to 48 hours after the convulsive seizures have

ceased. From three to five litres of these fluids should be given in the

course of twenty-four hours, in order to increase elimination by way of

both kidneys and skin, and it usually taxes the nurse’s patience and

ingenuity to give this amount, for the patient will seldom take large

quantities of fluids willingly, even when quite conscious. A surprising

amount of water may be given to the sleeping or unconscious patient by

dropping it into her mouth from the point of a teaspoon, taking care to

give it only at those moments when she is lying quite still. If the

nurse attempts to hold the restless patient’s head, or so much as places

her hand upon the chin to steady it in order to give water, the

irritation, though slight, may be enough to cause a return of the

tossing and struggling.