tartar to a pint of water), are frequently given because of their
diuretic and diaphoretic action; but whatever the fluid, it must be
given persistently, with greatest gentleness and with care that the
patient does not choke nor aspirate it into her lungs and thus possibly
cause pneumonia. Food even in liquid form is not given while the patient
is unconscious, because of this danger of aspiration and subsequent
pneumonia.
The bowels are stimulated to greater activity by powerful purges, such
as croton oil, in olive oil, dropped on the back of the tongue, or salts
or castor oil given by stomach tube.
Copious _colonic irrigations_, alternating with hot packs so that one or
the other is given every six, eight or twelve hours, according to the
seriousness of the case, are frequently given and with excellent
results. A colonic irrigation may be given by means of the Murphy drip
method or through a rectal tube so contrived that a two-way flow of
fluid is possible. Water, normal saline (2 drams of salt to a quart of
water), or a weak solution of sodium bicarbonate (an ounce of soda to a
quart of water), are all used for colonic irrigations, which are given
at a temperature of 110° F., very slowly, with the receptacle for the
solution placed so low that the flow is under very slight pressure. The
patient should lie on her left side, in a comfortable position and be
warmly covered. The tube should be introduced from 12 to 18 inches, and
the stop cock arranged so that it will take from twenty to thirty
minutes for each gallon of fluid to run in and out. About two gallons
are usually used for the first irrigation, the amount being increased
until five gallons are used each time. The beneficial effects of the
colonic irrigations are two-fold, for in addition to removing the toxic
material that may be in the colon and rectum, a good deal of fluid is
absorbed through the intestinal wall.
The function of the lungs may be promoted by using oxygen and by keeping
the air in the patient’s room fresh and constantly moving, but moving so
gently that there is no perceptible draft. The nurse must remember that
the skin also is an excretory organ whose function is being stimulated,
and this necessitates its being kept warm.
Some obstetricians feel that it is as important to increase the
excretions of the skin as of the kidneys, and that inability to induce
perspiration is an unfavorable sign. Others, who disagree on this point,
believe that the skin is of minor importance but that the bowels are of
equal consequence with the kidneys. However, the nurse will do no harm,
and will err on the safe side if she takes care to keep her patient warm
and constantly protects her from being chilled, that is from exposure or
changes in the temperature of her surroundings. A flannel nightgown or
dressing gown will help to this end, or if neither is available, at
least the patient’s chest and arms may be protected by warm bed jacket,
or sweater, put on backwards and fastened at the back of the neck. This
protection, together with a number of blankets, with or without hot
water bags between them, will often induce a slight but constant
perspiration, particularly if fluids by mouth are being forced at the
same time. This may be all of the stimulation that the skin needs, and
has the advantage of not greatly disturbing the patient, a point that
cannot be too constantly borne in mind.
[Illustration:
FIG. 48.—Patient in hot pack given with dry blankets and hot-water
bags. The blankets are turned back in this picture to show their
arrangement. (From photograph taken at Johns Hopkins Hospital.)
]
If something more is needed, the _hot dry pack_ is a widely used and
usually efficacious method of producing a sweat and can be given easily
in the patient’s home with no more equipment than the average family
possesses or can obtain. The articles needed are two rubber sheets or
two heavy quilts; four blankets; three, four or five hot water bags; an
ice cap or a basin with ice and two cloths for the patient’s head; a
pitcher of the fluid that she is taking, and a feeding cup, drinking
tube, small pitcher or a spoon with which to give it. One rubber sheet
(or one of the quilts), and two blankets should be slipped under the
patient, after the regular bedclothes have been loosened at the foot. If
the patient is having convulsions it is better to leave on her a warm
garment with sleeves to insure against her arms and chest being
uncovered, otherwise the nightgown may be removed.
The patient is covered with one blanket which is tucked between her legs
and around her body with her arms out, so that no two surfaces of the
skin come in contact. The blanket on which she lies is brought up about
her; another blanket should be laid over this and tucked in well about
the neck, shoulders and entire body, while the fourth blanket is next
wrapped around her from below. One long or two short hot water bottles
should be placed on each side of the patient and one at her feet, _all
being placed outside the four blankets_. The second rubber sheet, or
quilt, is thrown over the whole and the ice cap, or cold compresses
(changed every four or five minutes) placed on her forehead. (Fig. 48.)
A patient may usually be left in such a pack as this from half an hour
to an hour, but since any sweat bath is more or less depressing, she
must be watched constantly for evidence of exhaustion, such as a weak,
rapid, irregular pulse and increased weakness, or the sudden relaxation
of an active eclamptic patient.
In some instances the hot-water bags may be inadvisable, because of
supplying more heat than the condition of the patient warrants; but if
they are used, the nurse must remember how easily an unconscious or ill
person is burned. She must watch the bags, move them frequently and take
care that one of them does not slip under the patient. And while the
pack is in progress, an even greater effort than ever should be made to
force the fluids.
If the blankets are wrapped snugly about the patient, alternately from
below and above as described, they will frequently provide all of the
restraint that is necessary should she have a convulsion while in the
pack. The importance of protecting her against exposure and chilling
while in the pack cannot be too insistently stressed.
If I have seemed to dwell at surprising length upon rudimentary nursing
details, in this connection, it is because the patient’s life literally
depends upon the nurse’s conscientious and painstaking attention to
these same details. The doctor may study the case ever so earnestly and
order the treatment ever so wisely, but if every detail of that
treatment is not thoughtfully and skilfully carried out, it may do the
patient more harm than good. And on the other hand, I can think of no
circumstance that gives the nurse deeper gratification than the almost
miraculous improvement in an eclamptic patient, sometimes only
overnight, after she has taxed to the utmost all of her ingenuity to
make her ministrations effective.
Appliances for giving hot packs and hot-air baths are usually found in
all hospitals, and the nurse will use them as directed, which obviates
any necessity for describing them here. But in addition to correctly
adjusting and using the appliance itself, she must watch her patient for
evidence of exhaustion or shock; protect her from burns; keep cold
applications on her head and give her as much fluid as possible. And
when the hot pack is over, the patient must be taken from it gradually;
one blanket at a time, or the heat slowly reduced, and then the greatest
care taken that she is not chilled while being put into dry clothing,
for she must be kept warm and perspire slightly even after the sweat is
finished.
Restraint during convulsions should be as mild as possible, for
resistance only increases the patient’s excitement, and sustained effort
should be made to reduce it instead. To this end there are innumerable
details to be considered. Every act must be performed as quietly as
possible. The nurse must walk lightly and if her tread will be made
softer by wearing bedroom slippers, she should wear them. She should
consciously guard against kicking or striking the bed. All talking
should be in low tones; doors opened and closed quietly; papers should
not be rustled nor furniture scraped on the floor. The room should be as
dark as is feasible and the source of light screened from the patient’s
eyes.
She should be saved from biting her tongue by having placed between her
teeth something that will serve as a mouth gag and still not cut nor
bruise the mucous membranes. In a private home, one will find that a
cork answers admirably; or the handle of a wooden spoon well wrapped
with gauze or a clean handkerchief; or a small roll of bandage or clean
cloth tightly rolled. Another method is to take a fresh handkerchief, or
napkin, in the fingers by opposite corners, twist it slightly into a
roll and force it between the teeth and tie the two corners firmly
together at the back of the neck.
_Venesection._ The large intake of fluids tends to dilute and eliminate
the toxins which are giving so much trouble, but another very prompt and
efficacious measure is to withdraw from 500 cubic centimetres to 1000
cubic centimetres of blood by venesection, according to the condition of
the pulse. In preparing for a venesection the nurse will slip a small
rubber, covered with a towel, under the arm that is to be opened, and
scrub the inner surface of the elbow with soap and solutions according
to the wishes of the doctor in charge, and cover the cleaned area with a
dry sterile towel or one wet with a disinfecting solution. A sterile
towel should be slipped under the patient’s arm, one laid over the arm
above and one below the cleaned area so that the entire surrounding
field is protected by sterile towels.
For the puncture there will be needed a sterile canula, or infusion
needle, with a piece of rubber tubing attached; a sterile receptacle for
the blood, usually a 1000 cubic centimetre, graduated measuring-glass;
both dry and alcohol sponges or cotton pledgets; adhesive plaster, or a
bandage to hold in place the small dressing which is applied after the
needle is withdrawn; and a tourniquet for tight application to the upper
arm to impede the return of the venous blood and thus distend the large
vein to be seen near the surface of the inner curve of the arm. This
vein usually may be easily pierced, without incising the skin, the
canula pointed toward the hand to meet the blood stream, after which the
tourniquet is removed. Sometimes it is necessary to incise the skin in
order that the vein may be exposed and the needle inserted into it
directly. In this case the doctor will need, in addition to the articles
already mentioned, a scalpel, a pair of tissue forceps, three or four
artery clamps, a needle holder, skin needles and sutures.
A venesection is practically always followed by a drop in the blood
pressure and a marked improvement in the general condition.
_Infusions_, or subcutaneous injections of saline solutions, are also
frequently given to eclamptic patients with beneficial results. About
1000 cubic centimetres at 105° F. is introduced slowly into the tissues,
and the solution may be normal saline, consisting of two drams of common
salt to a litre of distilled water, filtered and sterilized; or possibly
one containing five grains each of sodium bicarbonate and sodium
chloride to the litre.
The articles necessary, in addition to the soap and solutions for
cleaning up the skin, are a small rubber to protect the bed; three or
four sterile towels; a flask of the solution at 105° F.; sterile
infusion bottle, or can, with rubber tubing fitted with a piece of glass
tubing at some point in its length, through which the flow of the
solution may be watched, a stopcock, and an infusion needle (I cannot
refrain from cautioning the nurse to be sure that the tubing does not
leak; is not collapsed and stuck together at any point along its length,
and that the needle is sharp, free from rust and contains a wire as
evidence of not being clogged); two hot water bottles about half full,
with air expelled; a pole or stand upon which to hang the bottle; a
package of gauze sponges, or squares, and narrow strips of adhesive.
The fluid is usually introduced between the breast tissues and
underlying muscles; the area to scrub up in preparation being just below
the breast, where the curve begins, and toward the axilla. The bottle
which contains the solution should be stoppered with sterile cotton, or,
if a can, covered with a sterile towel, and hung between the hot water
bottles, to keep the fluid warm, and held in place with a towel pinned
around them, top and bottom. (Fig. 49.)
If the nurse is to give the infusion, she should grasp the end of the
needle, to which the tubing is attached, with her right hand, pierce a
piece of sterile gauze; open the stop cock and allow the air and cold
fluid to escape, leaving a drop on the point of the needle; lift the
patient’s breast with her left hand and quickly plunge the needle in
just under it. The direction of the needle should be parallel to the
chest wall to insure its running below the breast tissue, and above, not
between the ribs. The needle, and the gauze through which it runs, may
be held in place by means of narrow strips of adhesive plaster. The stop
cock should be so adjusted that the warm fluid will flow into the
tissues very slowly, about an hour being required to introduce 1000
cubic centimetres. During this time the patient must be kept well
covered and the solution kept at about 105° F. as some of the heat is
lost in its course through the tubing. A hot water bag placed upon the
bed, over a coil of the tubing, is another means of maintaining the
desired temperature, but it must be watched and moved from time to time,
to guard against burning the patient. In hospitals where the infusion
apparatus is equipped with a heater, hot water bags are, of course not
needed, but they are of practical service in a patient’s home.
[Illustration:
FIG. 49.—Infusion being given under breast; needle held in place by
strips of adhesive and the solution kept warm by hot-water bottles
suspended on each side of the infusion bottle.
]
_Termination of pregnancy_ is resorted to much less frequently than
formerly, because it is believed that an eclamptic patient is
particularly susceptible to infection and also that the shock of an
induced labor is serious to so ill a woman.
The method of terminating pregnancy, when this is finally deemed
necessary, depends upon the condition of the cervix; the size of the
child; and upon the patient’s general condition. The method may be
simple induction of labor, by the introduction of a bougie, if haste is
not imperative; introduction of a bag; manual dilation of the cervix, if
it is soft and partly obliterated; vaginal hysterectomy, or even
cesarean section.
Chloroform is not used as an anesthetic, in eclampsia, nor to relieve
the labor pains nor control the convulsions because of its tendency to
increase the liver necrosis which is incidental to the disease.
Recovery is comparatively rapid, when it occurs. The blood pressure
drops to normal; the albumen and casts disappear from the urine and all
symptoms subside in from two to four weeks. (Chart 1.) And, happily,
since one attack confers an immunity, the patient who recovers from
eclampsia need not fear a recurrence of the disease.
NEPHRITIC TOXEMIA is a serious toxemia, sometimes complicating
pregnancy, and though it may occur at any time during the period of
gestation, it usually develops during the latter months. As a rule, it
is simply an exacerbation and accentuation of a previously existing,
chronic nephritis, of which the patient may, or may not, have been
aware; though in some instances the disability of the kidneys may arise
during pregnancy. In many cases, so far as the kidneys are concerned,
the patient is entirely normal in the non-pregnant state, and even
during pregnancy, up to a certain point; then her kidneys prove to be
unequal to the added metabolic strain of pregnancy, and signs of renal
insufficiency appear.
Such a patient will suffer from toxemia, with each recurring pregnancy,
the symptoms almost always appearing earlier, and with increased
severity, with each pregnancy, as the permanent damage to the kidneys is
increased by each successive attack.
[Illustration:
CHART 1.—Chart showing relatively rapid disappearance of albumen from
the urine and return of blood pressure to normal, after delivery in
eclampsia.
]
=Symptoms.= The symptoms in nephritic toxemia are practically the same
as those in chronic nephritis: lassitude, headache, visual disturbances,
edema, high blood pressure and casts and large amounts of albumen in the
urine. In some instances, the patient suffers such slight discomfort
that the increased blood pressure and urinary symptoms are the only
precursors of coma, and possibly convulsions which cannot be
distinguished from an eclamptic seizure.
As the patient may die in the coma, no matter how suddenly it develops,
the value of regular urinalyses and observations upon the blood
pressure, which are included in prenatal care, must once more be
mentioned.
In severe, chronic cases _infarcts_ (hemorrhagic or necrotic areas)
appear in the placenta. These may be extensive enough to interfere with
the nourishment of the fetus, which, being already weakened by the toxic
effects of the disease, is unable to survive. As a result, nephritic
toxemia is second only to syphilis in causing premature deaths. When the
child dies, the symptoms usually begin to subside in a week, or possibly
two, and the dead fetus is expelled.
=Treatment and Nursing Care.= The treatment and nursing care are
virtually the same as for pre-eclamptic toxemia; rest in bed, milk diet,
forced fluids, purges, and in addition, observations upon the intake and
output of fluids. The output of urine will not equal the amount of fluid
which the patient takes in, at first, but in those patients who improve,
the amount of urine gradually increases until it equals the amount of
fluid ingested. The edema and other symptoms improve, except the high
blood pressure and the albumen in the urine, which sometimes persist for
months. (Chart 2.)
If the patient has coma or convulsions, the treatment is the same as in
eclampsia.
A patient with inadequate kidneys who has never been able to carry a
child to term may sometimes achieve this coveted end by going to bed a
few weeks before the period in her pregnancy when the toxic symptoms
have usually appeared, taking only milk for food, drinking large amounts
of water, and keeping her bowels moving freely.
It is impossible to distinguish between eclampsia and nephritic toxemia
during an attack, but this is of no importance at the time, as the
treatment of the two diseases is the same.
[Illustration:
CHART 2.—Chart showing persistence of high blood pressure and of
albumen in the urine, after delivery, in _nephritic toxemia with
convulsions_.
]
But during the puerperium, the differential diagnosis may be made, for
in eclampsia the blood pressure falls rapidly to normal and the casts
and albumen disappear from the urine in from two to four weeks. In
nephritic toxemia, on the other hand, although the blood pressure falls
somewhat, and the albumen decreases in amount as the patient’s general
condition improves, by the end of the puerperium the blood pressure is
still elevated and casts and albumen are still present in the urine.
In eclamptic cases that come to autopsy, there is a typical, peripheral
necrosis of the liver, but in nephritic toxemia there is no liver
lesion.
ACUTE YELLOW ATROPHY OF THE LIVER is one of the grave but very rare
toxemias of pregnancy and though it may occur at any stage it usually
appears during the latter part of pregnancy or during the puerperium.
This complicating condition is not peculiar to pregnancy alone, although
from forty to sixty per cent. of the cases which occur are in pregnant
women.
The symptoms, which sometimes come on suddenly in a woman who previously
has been entirely well, may suggest phosphorus poisoning. They are
abdominal pain, headache, vomiting, and diarrhea followed in some cases
by coma and convulsions, and in others by violent delirium. With these
symptoms are jaundice and a diminished amount of urine, which contains
albumen, casts, and usually a good deal of blood. The picture is
practically that of pernicious vomiting plus jaundice and pain.
Little is known of the ultimate cause of the disease, but it produces
rapid atrophic and degenerative changes in the liver, and though mild
cases sometimes recover, the outcome is usually fatal. It was formerly
thought that the termination of pregnancy virtually cured the condition,
but the present belief is that delivery produces little or no effect.
The tendency now, therefore, is simply to employ the same kind of
eliminative treatment that is used in eclampsia.
Among the more serious complications of pregnancy, which are not due to
that condition, but which it is important to recognize and treat early,
may be included syphilis, heart lesions, pulmonary tuberculosis,
thyroidism, gonorrhea and pyelitis.
“SYPHILIS is one of the most important complications of pregnancy,” in
the opinion of Dr. Williams, “as it is the most important single cause
of fetal death.”
In support of this contention, Dr. Williams reports upon a series of
10,000 consecutive deliveries which took place under his observation,
and in which syphilis caused 26.4 per cent. of the deaths among 705
babies who died after the seventh month of pregnancy or during the first
two weeks after birth. Furthermore, nearly as many more babies who were
discharged alive, at the age of two weeks, died in a short time or gave
evidence of having syphilis later on in life.
Believing in the importance of diagnosing and treating this disease
during pregnancy, Dr. Williams subsequently made observations upon 4,000
cases in which Wassermann tests were given, and to which 421 women gave
positive reactions. In this series of 4,000 deliveries, 302 babies died
during the last two months of uterine life, or the first two weeks of
extra-uterine existence. The relative frequency of the various causes
which worked destruction in these 302 little lives is given by Dr.
Williams in the following table:—
Syphilis 104 cases 34.44%
Dystocia 46 cases 15.20%
Toxemia 35 cases 11.55%
Prematurity 32 cases 10.59%
Cause unknown 26 cases 8.61%
Placenta prævia and premature separation 16 cases 5.28%
Deformity 11 cases 3.64%
Eleven other causes 32 cases 10.69%
——— ———————
Total 302 100.00%
It will be seen from these figures that syphilis caused almost as many
deaths as the three causes, next in order, combined.
The effect upon the child’s chances for life, of treating the expectant
mother for syphilis, is suggested by comparing the results among the 421
syphilitic women who were not treated at all; those treated
insufficiently by receiving but two or three doses of salvarsan and no
after-treatment of mercury (because of the patient’s lack of cooperation
or because treatment was instituted too late in pregnancy); and those
treated satisfactorily, which meant the administration of from four to
six doses of salvarsan followed by mercurial treatment continued
sufficiently long to result in a Wassermann reaction that was negative,
and remained so.
Among those mothers who were not treated, 52 per cent. of the babies
were born dead or had syphilis; among those treated incompletely, 37 per
cent. and among those treated until cured, syphilis caused the death of
or was demonstrable in but 6.7 per cent. of the babies.[5]
The deductions to be made from these dramatic figures is, that although
syphilis seems to have about the same effect upon the pregnant, as the
non-pregnant woman, it constitutes a serious menace to infant life and
health.
Accordingly, it is very important that every pregnant woman be given the
Wassermann test as early as the third or fourth month, and any woman who
gives a positive reaction should be urged to submit to intensive
treatment until cured. Her compliance will apparently multiply by seven
or eight her expected baby’s chances for life.
HEART LESIONS sometimes present grave complications during pregnancy, or
at the time of labor, because the damaged or weakened heart is unable to
meet the greatly added strain put upon it at these times. Spontaneous,
premature labor sometimes results from serious heart trouble, while in
some cases labor is artificially induced to relieve the overworked organ
of the strain that is evidently exhausting it. Quite obviously it is an
important step toward the prevention of both these deplorable
occurrences to have the difficulty recognized early. Rest in bed and the
same kind of medical treatment that would ordinarily be given for a
poorly compensating heart will sometimes enable the disabled organ to
carry its load throughout pregnancy. But care is necessary.
PULMONARY TUBERCULOSIS is so common under all conditions that it is not
surprising to find it fairly often among pregnant women. Since the
treatment for this disease consists largely of effort to conserve the
patient’s forces and build up the bodily resistance, the drain which
pregnancy makes upon the system is likely to be inimical to the
tuberculous patient’s improvement. It is the general opinion, therefore,
that the tuberculous patient grows worse during pregnancy, and is still
further weakened by the ordeal of labor and the drain of nursing her
baby.
Some women with tuberculosis improve during the period of pregnancy, but
decline after delivery. The disease may advance rapidly in such cases
and the patient succumb very early.
There is great reluctance to terminate pregnancy in tuberculous
patients, except in extreme cases as a last resort, to save the mother’s
life, or when, after the child is viable, its chances for life would
seem to be better if it were brought into the world, because of the
mother’s possible death.
Certain it is that the care which is given to the non-pregnant
tuberculous person is needed to an even greater degree by the expectant
mother who is suffering from this disease. And under such care, it not
infrequently happens that the patient will go through pregnancy safely,
and if the care is continued after delivery, and her baby not allowed to
nurse, her ultimate recovery does not seem to be retarded by the
experience.
Tuberculosis is sometimes, though not frequently, transmitted from the
mother to the fetus; but babies born of these mothers are not likely to
be robust, particularly as they must be deprived of that bulwark of
early infancy—maternal nursing.
THYROIDISM in pregnancy has been, and still is, so widely discussed and
studied that the nurse will do well to at least take cognizance of that
fact, even though no definite conclusions seem to have been generally
accepted.
The toxemias of pregnancy are so shrouded in mystery, and knowledge of
the functions and inter-relations of the ductless glands is still so
meagre, though it is known that one, the ovary, is inevitably concerned
with pregnancy, that one is not surprised to find certain investigators
considering these two problems together. Nor is it surprising that
directly opposite views are held concerning the relation of thyroidism
to toxemia.
Since the nurse will sometimes care for toxemic patients who are treated
for thyroidism, either by means of gland therapy or operative procedure,
she should understand the rationale of such treatment when she meets it.
Dr. Williams says, for example, “A considerable amount of work has been
done in this direction, but the consensus of opinion is that
abnormalities of the thyroid secretion play no part in the causation of
eclampsia.”
On the other hand, it will be remembered that the thyroid gland is
usually somewhat enlarged during pregnancy, and in this connection Dr.
Edgar observes that “The normal enlargement of this organ in the gravida
has been wanting in certain cases of eclampsia.”
Dr. Edward P. Davis summarizes his opinions on the subject as follows:
“Hyper-thyroidism in pregnancy produces a toxic condition in the mother,
which exposes her to the danger of the toxemia of pregnancy and her
child to the dangers which accompany that condition. During pregnancy,
the patient has a rapid pulse, often with high tension, and attacks of
breathlessness and syncope, and intense nervousness. When uterine
contractions begin, the action of the heart becomes exceedingly rapid;
there is difficulty in breathing and the patient is brought into great
distress. It is often necessary to give prompt assistance in labor, and
this may require the performance of cesarean section. The child is
exposed to the risks of rapid delivery, although, if section be
performed, the risk to the child is reduced to the lowest point. When
the placenta is examined, it is found that certain changes have taken
place in its structure which interfere with the circulation of the blood
through the placenta, and may indirectly bring about the death of the
fetus. The child is also subject to the same toxic conditions which the
mother has had and may die from failure of the liver and kidneys or in
convalescence.
“A minute discussion of the subject would be occupied largely by the
question of exactly what are the poisons which cause this condition, and
this question has not yet been definitely answered.
“So far as neutralizing the results of excessive action of the thyroid,
it is best accomplished by rest, a diet from which meat and other heavy
proteins are excluded, regulation in the action of the bowels and the
avoidance of nervous excitement or undue exertion. If the action of the
heart is excessively disturbed, those drugs which control cardiac action
must be used. In extreme cases, morphine and atropine are given.”
PYELITIS is a fairly common, and sometimes a very painful and serious
complication arising during the latter half of pregnancy. It is an
inflammation of the pelvis of the kidney, most frequently the right,
caused by a damming back of urine, because of pressure of the enlarged
uterus on the ureter where it crosses the pelvic brim; and by infection,
which may travel up from the bladder or be conveyed by the lymph and
blood streams, frequently from the intestines. The colon bacillus is the
commonest offender, though the streptococcus, gonococcus or even the
tubercle bacillus may be the cause.
Frequently the patient will be entirely well, aside from a slight
irritability of the bladder causing frequent micturition, and suddenly
have paroxysms of acute pain in the region of the kidney, which may be
swollen and very painful on palpation. She will have fever and sometimes
chills and a catheterized specimen of urine will contain pus and
bacteria. The kidney may suddenly empty itself of pus after which the
pain and swelling will subside, only to recur when the pus accumulates
again.
The treatment is rest in bed, a bland diet and an abundance of milk and
water to drink. As the infection is often of intestinal origin, drugs
are usually given to prevent intestinal fermentation and keep the bowels
moving freely. Sometimes, though rarely, when the patient does not
improve under treatment, pregnancy is terminated to relieve the pressure
on the ureter and thus drain the diseased kidney by permitting an
unobstructed flow of urine.
The tendency of the disease is to subside spontaneously, but sometimes
it is necessary to incise and drain the kidney, or even to remove it;
while in others the infection is so virulent that the patient dies of
septicemia.
GONORRHEA during pregnancy may cause great discomfort in the shape of
irritation and itching of the vulva, or even excoriation of the mucous
membrane, and sometimes abscesses of the vulvovaginal glands.
Occasionally the infection reaches the decidua and causes an abortion.
But the chief danger in gonorrhea is that, after delivery, if the
disease has remained uncured, the organisms may travel up from the
vagina to the uterine cavity and tubes, and there set up an
inflammation, or possibly cause a general postpartum infection. The
greatest danger to the child is that its eyes may become infected during
the passage of the head through the birth canal. This is the reason for
the very great care that is taken of the eyes of the newborn, which will
be described in a later chapter.
It is very important, therefore, for the sake of both mother and child,
that gonorrhea be discovered early, for treatment started at this stage
is often attended by very gratifying results, as the disease may be
entirely cured before it is able to invade the uterus and tubes. This is
because the closure of the internal os, by the membranes, converts the
vagina and cervix into more or less of a cul-de-sac, to which the
infection is restricted. Being thus localized, it may often be
eradicated with relatively little trouble.
The yellow vaginal discharge, characteristic of gonorrhea, may become
profuse and purulent. It is removed by means of low, very gently given
douches. Tampons and vaginal suppositories are sometimes used, while
abscesses and abrasions are given appropriate surgical treatment.
The nurse must observe the strictest technique while caring for these
patients because of the danger of infecting herself and others with the
discharges. She should wear a gown and rubber gloves when giving douches
or dressing diseased vulva, and because of the possibility of
contamination by splashing fluids, she should hold her head well to one
side in addition to protecting her eyes with goggles. All utensils for
each patient should be isolated and they should also be washed and
boiled after each time that they are used.
“Lying-in is neither a disease nor an accident, and any fatality
attending it is not to be counted as so much per cent. of inevitable
loss. On the contrary, a death in child-bed is almost a subject for
an inquest. It is nothing short of a calamity which it is right that
we should know all about, to avoid it in future.”
FLORENCE NIGHTINGALE.
PART IV
THE BIRTH OF THE BABY
CHAPTER X. PRESENTATION AND POSITION OF THE FETUS. Breech, Head, Face,
and Vertex Presentations. Longitudinal and Transverse Presentations.
Position of Fetus. Time of Engagement. Methods of Ascertaining
Position and Presentation of Fetus. Abdominal Palpation. Vaginal
Examination. Rectal Examination. Auscultation of the Fetal Heart.
CHAPTER XI. SYMPTOMS, COURSE, AND MECHANISM OF NORMAL LABOR. Onset of
Labor. Three Stages of Labor.
CHAPTER XII. NURSE’S DUTIES DURING LABOR. General Principles of
Treatment and Nursing Care. Psychology of the Patient. Preparation
for Vaginal Examination or Delivery. Nurse’s Duties during First
Stage. Second Stage. Maintaining of Surgical Cleanliness. Immediate
Care of the Child. Resuscitation of New-born Child. Third Stage.
Immediate Aftercare of the Patient. Nurse’s Duties if the Doctor Is
Delayed. Prolapsed Cord. Post-partum Hemorrhage. Obstetrical
Anesthesia: Chloroform. Ether. Nitrous Oxide Gas Analgesia. Twilight
Sleep. Complete Anesthesia.
CHAPTER XIII. OBSTETRICAL OPERATIONS AND COMPLICATED LABORS.
Conditions Giving Rise to Operations. Preparation for Operation in
the Home. Perineal Lacerations. Episiotomy. Breech Extraction.
Version. The Use of Forceps. Symphysiotomy. Vaginal Hysterotomy.
Cesarean Section. Ruptured Uterus. Destructive Operations. Induced
Abortions and Premature Labors. Accouchement Forcé.
CHAPTER X
PRESENTATION AND POSITION OF THE FETUS
[Illustration:
FIG. 50.—Most frequent attitude of fetus in uterine cavity, at term.
]
Returning for a moment to the pregnant uterus at term, we find it to be
a thin-walled, muscular sac containing the mature fetus, attached by
means of the umbilical cord to the placenta and floating in the amniotic
fluid, which is contained within a sac formed by the amniotic and
chorionic membranes.
The average fetus at term is about 50 centimetres long, weighs about
3250 grams and is curved and folded upon itself into an ovoid mass,
occupying the smallest possible space. (Fig. 50.) Its most frequent
attitude is with the back arched; the head bent forward, with chin
resting upon chest; arms crossed upon chest below chin; thighs flexed
upon abdomen and knees bent.
[Illustration:
FIG. 51.—Illustrations from the first textbook on obstetrics,
Roesslin’s “Rosengarten,” 1513, which gives an amusing impression of
early ideas of the position of the fetus in utero.
]
With a few exceptions the long axis of the fetus is parallel to the long
axis of the mother, and most frequently the head is downward. It was
formerly believed that the child stood upright in the uterus until
toward the end of pregnancy and then somersaulted to the position it
occupied immediately before birth. (Fig. 51.) But it is now known that
though the fetus may move about and change its position during the early
part of pregnancy, it is not likely greatly to alter its relation to the
mother’s body during the tenth lunar month.
[Illustration:
FIG. 52.—Attitude of fetus in breech presentation.
]
It seems advisable to define here certain terms which are in common use
in discussing patients in labor, and which will be employed in the
following pages.
A _nullipara_ (0–para) is a woman who has not had children.
A _primigravida_ is a woman who is pregnant for the first time.
A _primipara_ (1–para) applies to a woman during her first labor and
until the beginning of her second labor.
_2–para_, _3–para_ and _4–para_ apply to women in succeeding labors
which correspond to the numerals used.
A _multipara_ is a woman who has had more than one child.
There is also a terminology, with abbreviations, which is fairly
generally used in this country and England to designate the position
which the child, about to be born, occupies in relation to its mother’s
body. A diagnosis of this position is, of course, absolutely necessary
to a skilful management of labor, and the nurse should understand the
meanings of the terms used, and also their distinctions and
subdivisions.
[Illustration:
FIG. 53.—Attitude of fetus in vertex presentation.
]
The _presentation of the fetus_ is the term which is employed to
indicate the part of the baby’s body which is at the brim of the
mother’s pelvis. Thus the part of the fetus which is lowermost is
designated as the _presenting part_ and gives the presentation its name.
If the breech is downward, therefore, it is a _breech_ presentation
(Fig. 52), and if the head is the lower pole it is termed a _head_, or
_cephalic_ presentation. (Fig. 53.) The head presentations are divided
into two main groups, which are designated, respectively, as _face_ and
_vertex_ presentations. For example, if the baby’s neck is so arched
that the chin rests upon the chest, the crown of its head, or the
vertex, is the part that is lowest in the birth canal and is the part
that will be seen first at the vaginal outlet. Therefore, this is called
a vertex, or occipital presentation. But if the neck is bent sharply
backward, the face becomes the presenting part and we have a face
presentation.
The breech, face and vertex presentations are sometimes referred to as
_longitudinal presentations_ since in these instances the long axes of
the bodies of mother and child are parallel. In _transverse
presentations_, however, the child lies across the uterus, with one side
or the other at the pelvic brim.
The transverse presentations are infrequent, occurring once in about 250
cases, and are regarded as abnormal because spontaneous delivery under
such circumstances is extremely rare. They are more likely to be seen,
when they do occur, among multiparæ and women who have contracted
pelves.
The longitudinal presentations, however, constitute something over 99
per cent. of all cases and are regarded as normal, since the child
occupying this relationship may be born spontaneously. In about 3 per
cent. of the longitudinal presentation the breech is the presenting part
and in about 97 per cent. it is the head. Of these, the vertex
presentation is the one most commonly seen and is the one in which the
child is most easily delivered. Face presentations are very rare,
occurring in only a fraction of 1 per cent. of all cases.
In addition to the child’s presentation, there is also its _position_,
which is an entirely different matter, for in each longitudinal
presentation the presenting part may occupy any one of six positions.
By _position_ is meant the relation of some arbitrarily chosen point on
the presenting part of the fetus, to the right or left side of the
mother, and to the front (anterior), side (transverse) or back
(posterior) segment of that side.
Taking these up in turn, we find, that in transverse presentations the
shoulder, _acromion_ process, is the point on the baby’s body which is
chosen, to give the four possible positions their names.
In breech presentations the sacrum is the arbitrarily chosen point.
In face presentations it is the chin, or _mentum_, while in vertex
presentations the occiput is the point chosen.
Presentation, then, describes the relation of the long axis of the
entire fetal body to the mother’s body, while position describes the
relation between the baby’s shoulder, sacrum, face or occiput to the
mother’s pelvis.
If the child is so placed in the uterus that the head is the presenting
part; the neck arched with chin on chest, and the occiput directed
toward the mother’s left side, and more to the front than to the side,
the presentation would be longitudinal, of the vertex variety, and the
position would be a left-occipito-anterior. The arbitrarily chosen point
on the child’s body (the occiput) would be directed toward the left,
anterior segment of the mother’s pelvis. This is the situation most
commonly seen and the description of this presentation and position are
abbreviated, by taking the first letter of each word, into L. O. A.
[Illustration:
FIG. 54.—Diagram showing the six possible positions in a vertex
presentation.
]
If the occiput were turned directly toward the mother’s left
side, neither to the front nor the back, we should have a
left-occipito-transverse, L. O. T., and if it were directed toward the
left posterior segment of the pelvis the position would be
left-occipito-posterior, or L. O. P. As there are three corresponding
positions on the right side, anterior, transverse and posterior, there
are six possible positions for the child to occupy in the vertex, or
occipital presentations, as follows:
Left-occipito-anterior, abbreviated to L.O.A.
Left-occipito-transverse, abbreviated to L.O.T.
Right-occipito-posterior, abbreviated to L.O.P.
Right-occipito-anterior, abbreviated to R.O.A.
Right-occipito-transverse, abbreviated to R.O.T.
Right-occipito-posterior, abbreviated to R.O.P. (Fig. 54.)
Similarly there are six face (Fig. 55) and six breech (Fig. 56)
presentations. Thus, if the chin (mentum) is resting in the left
anterior segment of the mother’s pelvis, the position would be
left-mento-anterior, or L. M. A. If the breech presents and the sacrum
is in that relation the position is left-sacro-anterior, or L. S. A.
[Illustration:
FIG. 55.—Diagram showing the six possible positions in a face
presentation.
]
In describing the transverse presentations, four words, instead of three
are used; thus, left-acromio-dorso-anterior, or L. A. D. A.
There are but four varieties of transverse presentations,
since the shoulder is either anterior or posterior: thus
left-acromio-dorso-anterior, left-acromio-dorso-posterior and the two
corresponding positions on the right side.
[Illustration:
FIG. 56.—Diagram showing the six possible positions in a breech
presentation.
]
During the last two to four weeks of pregnancy, particularly among the
primiparæ, the top of the fundus settles to the level which it reached
at about the eighth month, and the lower part of the abdomen becomes
more pendulous than formerly. The patient usually breathes much more
comfortably after this change in contour takes place, but, at the same
time, she may have cramps in her legs as a result of the increased
pressure; more difficulty in walking; frequent micturition and desire to
empty her bowels, while the vaginal discharge may be considerably
increased. It is at this time that the presenting part enters the
superior strait and is spoken of as being “engaged.”
The time at which engagement takes place depends upon three factors:
Whether the patient is a multipara or a primipara; the size and
normality of the pelvis; the size and position of the fetus. It is often
helpful to the obstetrician in planning for the delivery to know whether
or not the presenting part is engaged, particularly in primiparæ.
Although in primiparæ engagement usually occurs about four weeks before
labor begins, it does not normally take place in multiparæ until
immediately before labor. This difference is accounted for in the
increased tonicity of the uterine and abdominal muscles of primiparous
women. In certain abnormalities, or marked disproportion between the
diameters of the child’s head and mother’s pelvis, engagement may not
take place until labor is well advanced, or possibly not at all.
The presentation and position of the fetus are ascertained by means of
abdominal palpation, vaginal examination, rectal examination and
auscultation of the fetal heart.
Palpation of the child’s body through the mother’s abdominal wall is
possible under ordinary conditions, because the uterine and abdominal
muscles are so stretched and thinned that the various parts may be made
out through them. But it is sometimes difficult in hydramnios and is
practically impossible in very fat patients or in the case of a ruptured
uterus when the fetal outline is obscured by hemorrhage. This procedure
has been practiced only during comparatively recent years, and is
regarded by many obstetricians as one of the most important factors in
reducing the frequency of puerperal infections and thus in decreasing
maternal deaths. The explanation is that in general the dangers of
puerperal infection are believed to increase in direct proportion to the
number of times a patient is examined vaginally; and since it has been
known how to diagnose the child’s position by means of abdominal
palpation, the necessity for vaginal examinations is not so great and
they are accordingly made less frequently.
[Illustration:
FIG. 57.—First maneuver in abdominal palpation to discover position of
fetus.
]
Rectal examinations may also be regarded as a factor in preventing
infection, for, since much the same information may be obtained by means
of them as by vaginal examinations, after the onset of labor, they often
replace direct exploration of the easily infected birth canal.
Abdominal palpation, as usually practiced, consists of four maneuvers,
with the patient lying flat and squarely on her back with the abdomen
exposed. The nurse should bear in mind that successful palpation
requires even pressure. Cold hands applied to the abdomen or quick,
jabbing motions with the fingers will usually stimulate the muscles
lying beneath them to contract, thus somewhat obscuring the outline of
the child. Such palpation is also very uncomfortable for the patient;
but firm, even pressure, started gently, with warm hands, does not hurt.
[Illustration:
FIG. 58.—Second maneuver in abdominal palpation.
]
_First Maneuver._ The purpose of the first maneuver is to ascertain what
is in the fundus; this is usually either the head or the breech. The
nurse should stand facing the patient and gently apply the entire
tactile surface of the fingers of both hands to the upper part of the
abdomen, on opposite sides and somewhat curved about the fundus. (Fig.
57.) In this way the outline of the pole of the fetus which occupies the
fundus may be made out. If the head is uppermost, it will be felt as a
hard, round object which is movable or _ballottable_ between the two
hands, and if the breech, it will be felt as a softer, less movable,
less regularly shaped body.
[Illustration:
FIG. 59.—Third maneuver in abdominal palpation.
]
_Second Maneuver._ Having determined whether the head or the breech is
in the fundus, the next step is to locate the child’s back and the small
parts in their relation to the right and left sides of the mother. This
is accomplished by slipping the hands down to a slightly lower position
on the sides of the abdomen than they occupy in the first maneuver, and
making firm, even pressure with the entire palmar surface of both hands.
The back is felt as a smooth, hard surface under the palm and fingers of
one hand, and the small parts, or hands, feet and knees, as irregular
knobs or lumps, under the hand on the opposite side. (Fig. 58.)
[Illustration:
FIG. 60.—Fourth maneuver in abdominal palpation. (This series of
pictures is from photographs taken at Johns Hopkins Hospital.)
]
_Third Maneuver._ Unless the presenting part is engaged, the third
maneuver virtually amounts to a confirmation of the impression gained by
the first maneuver, by showing which pole is directed toward the pelvis.
The thumb and fingers of one hand are spread as widely apart as
possible, applied to the abdomen just above the symphysis and then
brought together to grasp the part of the fetus which lies between them.
If not engaged, the head will be felt as hard, round and movable, while
the breech will be less clearly defined. (Fig. 59.)
[Illustration:
FIG. 61.—Diagrams showing relation of nurse’s hands to fetus in the
four maneuvers of abdominal palpation.
]
_Fourth Maneuver._ The fourth maneuver is of particular value after the
presenting part has become engaged. The nurse faces the patient’s feet
in this position, and directs the first three fingers of each hand down
into the pelvis, on either side of the fetus, to ascertain whether it is
a face or vertex presentation, by discovering whether chin or occiput is
the higher cephalic prominence in the mother’s pelvis. (Fig. 60.) If it
is a vertex presentation, the neck will be flexed, with the chin on the
chest and consequently higher in the pelvis than the occiput. The
nurse’s fingers of one hand will accordingly come in contact with the
chin on the side opposite to the child’s back, before the fingers of the
other hand reach the occiput. If, however, it is a face presentation,
the neck will be bent sharply backward and the nurse’s fingers will feel
the occiput first, and on the same side as the baby’s back. This
maneuver tells, also, how far into the pelvis the presenting part has
descended.
[Illustration:
FIG. 62.—Diagram showing method of ascertaining position of fetus by
means of rectal examination. Examining finger palpates head through
recto-vaginal septum.
]
=Vaginal Examination.= The information obtained by vaginal examination,
before the cervix is dilated, is rather uncertain since the child’s
presenting part must be palpated through the fornix. But after complete,
or even partial dilatation, the exploring finger is able to feel the
sagittal suture and one fontanelle, in a vertex presentation, and
diagnose the position by discovering the direction of the suture and
whether it is the anterior or posterior fontanelle that is felt. The
anterior fontanelle, it will be remembered, is relatively large and
four-sided, while the posterior is small and more nearly triangular in
shape. In a face presentation, the features may be felt; in a breech the
examining finger can palpate the buttocks and genital crease.
Because of the possible danger of introducing infective material into
the birth canal, the tendency is to make fewer and fewer vaginal
examinations, and then only after the most painstaking preparation which
will be described presently. Needless to state, vaginal examinations are
not within the province of the nurse.
=Rectal Examinations.= More and more frequently rectal examinations are
being employed to obtain information about the child’s position, as the
examining finger is able to feel the surface of the presenting part
through the recto-vaginal septum, after the cervix is dilated, and there
is no danger of infecting the birth canal while so doing. For this
reason nurses are frequently taught to make rectal examinations, thereby
increasing the value of their assistance to the doctor in watching the
progress of labor. (Fig. 62.)
=Auscultation of the fetal heart= is valuable in confirming the
diagnosis of presentation and position which has been made by palpation.
In vertex and breech presentations the heartbeat is best heard through
the baby’s back and in face presentations it is transmitted through the
chest, which presents a convex surface in this case and fits into the
curve of the uterine wall. In anterior vertex presentations the heart is
heard a little to the side and below the umbilicus; in transverse,
further to the side, and in posterior, well toward the back.
CHAPTER XI
SYMPTOMS, COURSE AND MECHANISM OF NORMAL LABOR
Labor may be defined as the process by means of which the product of
conception is separated and expelled from the mother’s body. It
ordinarily occurs about 280 days from the beginning of the last
menstrual period. (See p. 93.)
The cause of labor is not known. Many theories have been advanced to
explain why the uterine contractions, which have occurred painlessly
throughout pregnancy, and without expulsive force, finally become
painful at the end of the tenth month and so changed in character as to
extrude the uterine contents; but as yet, none is wholly satisfactory
nor generally accepted. Nor is it known why some labors are premature
and some delayed.
The onset of labor is usually marked by the patient’s becoming conscious
of the uterine contractions through dragging pains which may be felt
first in the back and then in the lower part of the abdomen and the
thighs. At first the pains are feeble and infrequent, but they gradually
grow more severe and more frequent. Intestinal colic is sometimes
mistaken for labor pains, but when the paroxysms are rhythmical and the
uterus is felt, through the abdominal wall, to grow hard as the pain
increases and soft as it subsides, there can be no doubt but that the
patient is in labor. The first signs of labor may be a gush of amniotic
fluid, caused by the rupture of the membranes, or of blood, but these
are not typical.
For purposes of convenience, labor is usually described as consisting of
three periods or stages. The first stage begins with the onset of labor
and lasts until the cervix is completely dilated; the second stage
begins with the complete dilatation of the cervix and lasts until the
child is born; the third stage begins with the birth of the child and
lasts until the placenta is expelled.
The entire duration of labor may vary from a few moments, comprising a
few pains, to several days of severe and exhausting pain, but the
average length of the first labor is 18 hours and of subsequent labors
about 12 hours, divided respectively into the three periods as follows:
_1st stage._ _2nd stage._ _3rd stage._ _Total._
Primipara 16 hours 1¾ hours 15 minutes 18 hours.
Multipara 11 hours 45 minutes 15 minutes 12 hours.
The longer labor in primiparous women is due to the greater tone, and
thus the greater resistance offered by the muscles of the cervix and
perineum. Elderly primiparæ are likely to have longer labors than young
primiparæ.
=First Stage.= This is frequently called the stage of dilatation. During
this period the contractions of the uterine muscles make pressure upon
the amniotic sac of fluid, forcing it gradually down and into the cervix
as a water wedge, widening the internal os first, then the external os,
until the entire canal is fully dilated (thinned out); shortened to
about one-half inch in length and finally obliterated so that it is
uninterruptedly continuous with the lower uterine segment. (Figs. 63,
64, 65, 66.)
The first stage pains begin by being mild and occurring at intervals of
from 15 to 30 minutes, but they gradually increase in frequency and
intensity until at the end of 14 to 16 hours they are very severe and
recur every three or four minutes, each pain lasting about one minute.
The pains begin in the back, pass slowly forward to the abdomen and down
into the thighs.
The patient is entirely comfortable, as a rule, between pains and until
they become very frequent will usually feel able, in fact prefer, to be
up and about, but if she is on her feet when a contraction begins she
will usually seek relief by assuming a characteristic leaning position
(Fig. 67) or by sitting down, until the pain subsides. As dilatation
advances, the patient has an increasing, sometimes persistent, desire to
empty the bowels and bladder because of encroachment upon these two
organs by the descending head. She may vomit, also, when the cervix
becomes nearly or quite dilated.
[Illustration:
FIG. 63.
]
[Illustration:
FIG. 64.
]
[Illustration:
FIG. 65.
]
[Illustration:
FIG. 66.
]
FIGS. 63, 64, 65, AND 66 are diagrams showing stages of dilatation and
obliteration of cervix during labor.
In the course of this stretching process, the cervix sustains many tiny
lesions, from which blood oozes and tinges the vaginal discharge. This
blood-stained secretion is often called the “show” and usually appears
toward the end of the first stage.
[Illustration:
FIG. 67.—Characteristic position which patient often assumes during
pains in first stage.
]
As a rule, when the cervix is fully dilated the membranes rupture and
there is a sudden gush of that part of the fluid which was below the
fetus in the amniotic sac, but the rupture of the membranes does not
necessarily mark the end of the first stage. In some instances they
rupture before the cervix is fully dilated; in others, though not often,
before the patient goes into labor, thus producing what is known as a
“dry” labor.
The abdominal muscles do not contract very forcibly during the first
stage, the expulsive force in this period coming almost entirely from
the uterine contractions. The patient’s cries at this time are sharp and
complaining in contrast to the groans and grunts which accompany the
second stage.
Complete dilatation of the cervix marks the termination of the first
stage.
[Illustration:
FIG. 68.—Diagram indicating the rotation and pivoting of baby’s head
during birth.
]
=Second Stage.= The second stage is sometimes called the stage of
descent, or expulsion, of the fetus. The patient should and is usually
quite willing to be in bed throughout the second stage, during which she
should not be left alone. The pains are now regular, occurring at
intervals of about two minutes from the beginning of one to the
beginning of the pain following, and as the contractions last about one
minute and are excruciatingly painful, the patient has very little
respite from her suffering. Her face is flushed and she may perspire
freely.
The abdominal and respiratory muscles are brought into active use during
the second stage, contracting simultaneously with the uterine muscles
and increasing their expulsive force. These are apparently controlled by
the patient’s will at first, and she is able somewhat to increase their
power by taking a deep breath, closing her lips, bracing her feet,
pulling against something with her hands, straining with all her might
and “bearing down.” Finally, however, the whole bearing down process
becomes involuntary, is accompanied by intense pain and the deep
grunting sound, which is characteristic of the well-advanced second
stage. Under normal conditions, the child descends a little farther into
the pelvis with each contraction, and finally the presenting part begins
to distend the perineum and to separate the labia advancing at the
height of each pain and slipping back a little as it subsides.
[Illustration:
FIG. 69.—Anterior shoulder being slipped from under symphysis to
facilitate birth of posterior shoulder.
]
The baby descends into and through the mother’s pelvis by means of a
series of twisting and curving motions, accommodating the long axes of
its head to the long diameters of the pelvis. The head being somewhat
compressible and mouldable, because of imperfect ossification, is
capable of a good deal of accommodation to the mother’s pelvis.
The mechanism of labor, therefore, is virtually a series of adaptations
of the size, shape and mouldability of the baby’s head to the size and
shape of the mother’s pelvis. If the head passes through the inlet
satisfactorily, the rest of the labor will usually be accomplished with
comparative safety. But a marked disproportion between the diameters of
the head and pelvis may interfere with the engagement or descent of the
head and produce a serious complication.
[Illustration:
FIG. 70.—Delivery of posterior shoulder.
]
The long diameter of the head must first conform to one of the long
diameters of the inlet, usually oblique, and then turn so that the
length of the head is lying antero-posterior in conformity to the long
diameter of the outlet through which it next passes. As the head
descends and rotates it also describes an arc because the posterior wall
of the pelvis, consisting of the sacrum and coccyx, is about three times
as deep as the anterior wall formed by the symphysis. That part of the
baby’s head which passes down the posterior wall of the pelvis must
therefore travel three times as far in a given time as the part which
simply slips under the short symphysis pubis.
[Illustration:
FIG. 71.—Diagrams showing Duncan and Schultze mechanisms of placental
separation.
]
In a vertex presentation, left-occipito-anterior position, while the
occiput passes under the symphysis and appears at the distending vaginal
outlet, the face passes down the posterior wall and along the floor of
the pelvis. As pressure is exerted by the rapidly succeeding
contractions, the head pivots about the pubis, thus extending the neck
and pushing the face farther downward and forward. After emergence of
the back and top of the head below the symphysis, the forehead appears
over the posterior margin of the vagina, then the brow, eyes, nose,
mouth and chin in turn, and the entire head is born. (Fig. 68.) The
baby’s head then drops forward, in relation to its own body, with its
face toward the mother’s rectum and the occiput in front of the pubis,
but soon the occiput rotates toward the mother’s left side, resuming the
relation that it bore to the inner aspect of her pelvis before
expulsion. The undelivered shoulders are now antero-posterior, one under
the pubis and the other resting on the perineum. (Fig. 69.) The lower,
or posterior shoulder is born first (Fig. 70), followed quickly by the
anterior shoulder and the rest of the body, and the amniotic fluid which
was behind the child’s body. Thus is the second stage completed.
[Illustration:
FIG. 72.—Longitudinal section through uterus showing thinness of
uterine wall before expulsion of fetus, contrasting sharply with
thickened wall in Fig. 73. (From photograph of specimen, to which
twin placentæ are still adherent in upper segment, in the
obstetrical laboratory, Johns Hopkins Hospital.)
]
=Third Stage.= The third stage, sometimes termed the placental stage, is
that period following the birth of the child, during which the placenta
is delivered. For a few moments after the baby is born the tired mother
lies quietly and free from pain, as there is a temporary cessation of
the uterine contractions, and she often sleeps as a result of the
anesthetic given during the second stage.
[Illustration:
FIG. 73.—Longitudinal section through uterus, immediately after labor,
showing marked thickening of wall as a result of muscular
contraction. (From photograph of specimen in the obstetrical
laboratory, Johns Hopkins Hospital.)
]
The uterus has greatly decreased in size, the fundus now lying below the
umbilicus where it may be felt as a firm, solid mass. The uterine
contractions are resumed in the course of a few moments and as they
persist, the uterus grows smaller, thereby greatly decreasing the area
of placental attachment. As the placenta is non-contractile it cannot
accommodate itself to this decreased area of attachment, and so is
literally squeezed from its moorings. It is then gradually forced down
into the lower uterine segment where it may be located by the distension
of the abdominal wall which it produces just above the symphysis. After
the separation of the placenta is complete the uterus rises in the
abdominal cavity until the fundus is felt above the umbilicus. The
placenta, finally, may be completely expelled spontaneously, or
expressed by slight pressure made upon the fundus by the accoucheur.
The placental detachment may begin at the centre, the area of separation
spreading to the margin, or the detachment may start at the margin of
the placenta and extend toward the centre. Either is normal. These two
modes of placental separation are named the Schultze and the Duncan,
respectively, from the men who first described them. (Fig. 71.)
In the Schultze mechanism, which occurs most frequently, the separating
process begins at the centre of the placenta and the glistening fetal
surface appears at the vaginal outlet. In this case there is practically
no bleeding during the third stage as the inverted placenta blocks the
vagina and holds back the blood.
In Duncan’s mechanism the detachment begins at the margin, the placenta
rolls upon itself and presents at the outlet by its roughened maternal
surface and there is usually slight but continuous bleeding from the
time the separation begins. When the placenta is delivered, the
collapsed membranes trail after it like a tapering cord. A good deal of
blood is lost at the time of the placental expulsion and immediately
afterwards, but this profuse bleeding usually subsides in a few moments.
Although the loss of blood may be as much as 500 cubic centimetres
without its being regarded as serious, the average amount is about 350
cubic centimetres.
The patient has been through a severe ordeal and at the end of the third
stage of labor she is usually tired out and cold.
CHAPTER XII
THE NURSE’S DUTIES DURING LABOR
The extent of the nurse’s helpfulness during labor, both to the patient
and to the doctor, will depend very largely upon the intelligence with
which she grasps what is taking place and upon her own attitude, as an
individual, toward the patient and the miraculous event which
approaches. Important as is the preparation of the room and dressings,
this other factor is almost equally influential.
It will be wiser, therefore, for the nurse to try to picture the process
of labor in each instance, and to be guided by a few broad principles
that apply to all cases under all conditions, rather than to try to
memorize the details of her duties and of the desirable equipment and
preparation.
The process of labor we have just described.
As to the general principles: If there is any time in a nurse’s career
when she should give scrupulous attention to establishing and
maintaining asepsis, it is during labor, for the patient’s life may, and
often does depend upon it. If there is any time when she should be
watchful for developments and for symptoms of complications, it is
during labor, for again the patient’s life may depend upon this.
Her powers of adaptability to doctor, patient and surroundings may be
severely tried, for though they all may be infinitely varied, the nurse
must invariably be clear-headed and efficient and the adequacy of her
service must never fail.
The sympathetic insight, which should constantly underlie the work of
the obstetrical nurse, will be needed at this crucial time of labor in
the fullest and finest and completest sense. This is almost her test as
a nurse and as a womanly woman, for she needs to be both, supremely.
Perhaps she had better imagine for a moment what this occurrence, that
we baldly term labor, may mean to the patient and look at it as nearly
as possible from the standpoint of the patient herself. It is one of the
most stirring and momentous experiences of her life, particularly if the
expected baby is her first child. She is about to realize the sweetest
and tenderest of dreams—that of motherhood—cherished throughout nine
long months. She is also approaching a period of excruciating pain, and
knows it, with her eyes wide open to the possibility of not surviving
it; and an event so amazing in its mystery and wonder that to only the
most stolid can it fail to be a deeply emotional experience.
And so, the young woman, to whom we refer so impersonally as “the
patient,” is an intensely personal being at this time, experiencing a
number of the most poignant of the human emotions: awe, expectancy,
doubt, uncertainty, dread and in some cases fear amounting almost to
terror. And through it all her body is being racked and exhausted with
pain that grows harder and harder to bear.
It is known that the ravaging effects of pain, coupled with great
emotional stress, such as fear, worry, doubt, anger or apprehension,
upon the physical well-being of surgical patients, is such that death
itself may be caused by excessive fear and suffering. Accordingly, many
careful surgeons take elaborate precautions to tranquillize a patient
who is about to be operated upon, if for no other reason than to
increase his chance for recovery.
There can be no doubt that nervous and emotional disturbances are
detrimental to the physical well-being of the patient in labor, also,
and this fact alone is enough to warrant an effort to avert them. If the
nurse appreciates the significance of the emotional influence and shapes
her attitude and conduct accordingly, she will thereby help to increase
the ease and safety of the actual delivery. Just what that attitude
shall be, no one can say, for it must be developed, in each case, in
such a way as to win the confidence and meet the needs of that
particular patient.
But in all cases the nurse should impress her patient with her sincere
sympathy and appreciation of the fact that she, the patient, is going
through a difficult time. Through it all the nurse must be cheerful,
encouraging and optimistic; very gentle; very calm and reassuring in all
that she does in preparing for the delivery. She must steadily increase
the patient’s realization of the part which she herself must play in the
effort which is being made to carry the event through to a happy issue.
The occasion need not, should not, be a mournful one but it is often a
very sacred one to the patient, and the nurse should be dignified,
almost reverential in her bearing.
If the patient feels secure in the belief that her ordeal is not being
taken lightly; that it is being regarded seriously, as it merits, and
that every known precaution is being taken, and taken confidently, to
safeguard her and her baby’s welfare, her actual physical condition will
be favorably affected by the condition of mind thus produced. And her
patience and courage will often be strengthened if the nurse will
explain, from time to time, the cause of certain conditions that
normally arise, and which otherwise might give her alarm. It is the
mysterious events, the unexpected and unexplained that so often terrify.
This giving of comfort and strength to the variety of temperaments and
mentalities which the nurse meets among her patients will involve a very
sensitive adjustment of manner on her part, but it is one aspect of her
duty, none the less, and one which will give her great satisfaction.
FIRST STAGE
Happily, the onset of labor is usually gradual, as has been described,
and there is accordingly ample time during the first stage for
deliberate and unhurried preparation for the birth of the baby. The
character of the preparation and of the nurse’s assistance will vary
greatly according to the wishes of the attending doctor; the duration of
labor; the circumstances and condition of the patient, and whether she
is at home or in a hospital.
It is a fairly general routine, at present, both in hospitals and in the
home, to give the patient a soap-suds enema and a shower or sponge bath,
at the onset of labor; to braid her hair in two braids and dress her in
freshly laundered stockings and nightgown and a dressing gown. The enema
is given to empty the rectum of material which might be expelled during
labor and contaminate the field. For this reason, enemata are often
given until the fluid returns clear, virtually irrigating the rectum,
and are repeated every six or eight hours during the first stage. The
enema should be given to the patient in bed and expelled into a bed-pan,
as it is not wise for her to use the toilet after labor has begun.
Sometimes the vulva and perineal region are shaved and scrubbed at the
onset of labor, either before or immediately after the bath and enema.
But the time and sequence of the different steps in the preparation for
labor are governed entirely by the wishes of the individual doctor, to
which the nurse may very easily adjust herself.
The patient should be given a bed-pan and encouraged to void every four
hours. If she is unable to do so, and the bladder becomes distended, the
doctor will usually wish to have her catheterized, and with a rubber
catheter. This distension is not uncommon, and in extreme cases the
bladder may reach to the umbilicus. The nurse should therefore observe
the amount of urine which the patient voids and also watch the lower
abdomen for bladder distension, which may be observed easily, excepting
in very fat patients.
The seriousness of a distended bladder lies in the fact that it may
markedly retard labor, partly by interfering with the descent of the
baby’s head and partly through reflex inhibition of the uterine
contractions. The prevention of a distended bladder during labor,
therefore, is of considerable importance.
As the pains are infrequent and not severe at first, the patient will
usually prefer to be up and about, most of the time during the first
stage, when it occurs in the daytime, and many doctors think it
important that she should be. They feel that patients tend to stay in
bed too much during the first stage, since being on their feet would
really promote their comfort and also have a tendency to make the pains
more regular and efficient. But, on the other hand, the patient must be
cautioned against tiring herself, and should, therefore, lie down often
enough and long enough to avert fatigue. When labor begins at night, it
is well to advise the patient to stay in bed and to sleep as much as
possible until morning. Even though her sleep be disturbed and broken by
the labor pains, she will be much less tired in the morning than if she
had gotten up and had no sleep at all.
The patient should also be advised against trying to hasten labor by
bearing down during first stage pains, since the only result at this
time will be to waste her strength which will be needed later. This is
one of the points that the nurse will do well to explain; that no
voluntary effort on the patient’s part, during the first stage, will
advance labor and if she tires herself by making such efforts before the
second stage pains begin she will not be able to use them as effectively
as she would were she in a rested condition.
Bearing in mind the importance of conserving all of her forces, it is
usually advisable for a patient in labor to have no visitors,
particularly the type of person who would be likely to offer advice and
gratuitous information.
She should drink water freely and take some kind of light nourishment
about every four hours. As pain of any kind tends to retard digestion,
the diet during labor is usually restricted to fluids, such as broths,
weak tea or coffee and sometimes milk or cocoa; while occasionally
crackers and crisp toast are allowed. Whatever nourishment is given must
be very light because of the probability of the patient’s vomiting and
the possibility of her having to be given complete anesthesia before the
termination of labor.
The maternal temperature, pulse and respirations should be taken every
two or four hours and the fetal heart rate from every hour to every two
hours, according to the wishes of the doctor.
The time at which the nurse should call the doctor is the subject of
considerable discussion. Doctors never want to be called too late,
neither do they wish to be called unnecessarily early, though they
prefer to have the nurse err on that side, if at all. On general
principles the doctor should be notified as soon as the patient goes
into labor, in order that he may make his various plans with the pending
delivery in mind. But if the nurse remembers that in primiparæ the first
stage of labor usually lasts about sixteen hours and in multiparæ about
eleven hours, she will realize that if the pains begin between the hours
of eleven p.m. and seven a.m., and are of average character, mild and
infrequent, she is not warranted in disturbing the doctor’s much needed
sleep, unless he has explicitly requested her to do so. But under
average conditions he should be notified by seven o’clock in the morning
that the patient is in labor; at what hour the pains began; their
character and frequency at the time of the report; the patient’s
temperature, pulse and respirations and general condition and the fetal
heart rate.
During the early hours of the first stage the nurse should begin to
arrange the room and bed for delivery. She will need two, or preferably,
three tables, though the top of a bureau may be used in place of one
table. A washstand or the bathroom should be equipped for the doctor
with soap; two sterile brushes; nail scissors or clippers and file or
orange stick; hot water; alcohol and a solution of bichlorid 1–1000,
biniodid 1–5000, lysol 2 per cent. or any solution that he may wish;
sterile gloves and sterile vaseline or albolene to lubricate his hands.
In short, an equipment which will enable him to prepare his hands
exactly as he would for performing a major operation.
A large receptacle of water may be boiled, covered and set aside to
cool; a boiler or large kettle placed in readiness for boiling
instruments or other appliances that the doctor may bring; the room may
be given a final cleaning: floor wiped up, furniture and all small
articles wiped with a damp cloth; the unopened packages of dressings,
sterile douche pan, irrigation-bag and basins may be placed on the
tables, ready to be opened when needed, together with the other articles
which have been prepared.
In preparing the bed in a patient’s home, it is practically always
advisable to make it firm by slipping a board, or the leaves from a
dining-table, between the mattress and springs. The bed should be made
up with three freshly laundered sheets, the entire mattress being
protected by means of a rubber placed under the lower sheet; next a
rubber draw sheet, covered by one of muslin, while the top sheet, light
blanket and counterpane should be left free at the foot. A flat hair
pillow is better than one of feathers.
If the doctor wishes to make a vaginal examination, it devolves upon the
nurse to prepare the patient with the most scrupulous care, as it is by
means of vaginal examinations, made without careful preparation, that so
many parturient women are infected. In fact, even the most conscientious
preparation sometimes seems to be an inadequate safeguard, for infection
has been known to follow in its wake. For this reason, some
obstetricians prefer to make no vaginal examination during labor, when
previous inspection has indicated that the case is normal, depending
rather upon rectal examinations for guiding information.
The patient should be placed in bed, on a douche pan, with knees flexed
and well separated; gown tucked up under her arms; draped with a sheet
or the bedding folded down to her knees according to the extent of the
area to be prepared; and the articles needed for the preparation
arranged on a table at the bedside. The nurse should trim her nails,
scrub her hands with soap and hot water; shave the vulva, supra-pubic
region and inner surface of the thighs and rinse with sterile water. In
shaving the vulva, the strokes should be from above downward, greatest
care being taken not to allow hair, soap or water to enter the vaginal
opening. She should then scrub her hands vigorously for three minutes,
scrubbing about the nails with especial thoroughness. Some obstetricians
have the entire area from the umbilicus to the knees prepared as for an
operation, while others prepare only the supra-pubic region, inner
surface of the thighs and the vulva. The number and kind of solutions
which are used in this preparation also vary greatly, but in general the
shaving is followed by a thorough scrubbing, by clean hands, with green
soap and sterile water, then iodin, lysol or alcohol and bichlorid or
biniodid solution, according to the custom of the doctor. (Fig. 74.)
But the kind and number of the solutions are probably not so important
as the nurse’s technique. Throughout the entire course of the
preparation she must apply the principles of what she was taught about
the technique of preparing the skin for an operation and regard the
perineal region in the same light as she would the field which was being
prepared for a major operation; scrubbing from the centre toward the
periphery, always, in order not to carry infective material from an
unclean to a clean area, which in this case is the vaginal outlet.
[Illustration:
FIG. 74.—Bathing the vulva preparatory to vaginal examination or
delivery. (From photograph taken at Johns Hopkins Hospital.)
]
The supra-pubic region and abdomen are scrubbed across, back and forth,
working up from the symphysis; the strokes on the thighs are up and
down; in the groin, down toward the rectum, and away from the vagina,
_never toward it_, and fluids poured upon the vulval region must never
run into the vagina from over surrounding skin. A sponge or scrub ball
must be discarded after approaching the rectum, or stroking away from
the vagina in any direction. Some obstetricians instruct the nurse to
place a firm, sterile cotton pad or scrub ball between the labia,
against the vaginal opening while scrubbing and flushing the adjacent
areas, to preclude the possibility of introducing fluids. But with a
painstaking nurse this is scarcely necessary.
[Illustration:
FIG. 75.—Patient draped for vaginal examination; vulva covered with
sterile towel. (From photograph taken at Johns Hopkins Hospital.)
]
After the surrounding areas have been prepared, the labia are separated
and the inner surfaces scrubbed, first across, then from above downward,
and flushed by pouring the solution directly between the folds. After
the patient has been given this preparation, a dry sterile towel or pad
is placed over the vulva; the douche pan is removed, the back and hips
are dried, after which the patient is so draped with a clean sheet that
only the perineal region is exposed, and a sterile towel is slipped
under the buttocks. (Fig. 75.)
To summarize the preparation for vaginal examination or delivery:
1. Trim nails and scrub hands with soap and hot water.
2. Shave vulva.
3. Scrub and soak hands.
4. Scrub vulva, inner surface of thighs and lower abdomen with green
soap and sterile water, alcohol, 70%, and lastly bichloride
1–1000 or lysol 1% or 2%, using sterile sponges and _taking care
not to contaminate vulva from surrounding fields_.
5. Cover vulva with sterile towel or pad.
This may be taken as a description of a fairly typical method of
preparing a patient for vaginal examination or for delivery, which is
widely employed and with satisfactory results. But it is by no means the
only satisfactory procedure, for many other and different methods of
preparation also are followed by excellent results, as measured by the
patient’s temperature during the puerperium.
The details of preparation vary so greatly, even among different doctors
in the same hospital, that the nurse will simply have to bear in mind
the general principles of asepsis and antisepsis, and adjust herself to
the practices of the individual doctor. And she must remember that in
spite of the best planning, there will be emergencies and precipitate
labors, when the preparation will necessarily be modified, and sometimes
so curtailed that even the bath and enema are omitted.
But in all cases the nurse can, and must, bear in mind that on one point
there is virtually no difference of opinion among obstetricians of
to-day; and that is the imperative necessity of having everything
sterile that is brought to the perineal region or used in any way in
connection with the delivery, or as nearly sterile as is possible under
the circumstances.
By many doctors this is considered the most important factor, as to
surgical cleanliness, in the entire preparation. In their opinion the
local preparation of the patient may, with safety, be restricted to
clipping the pubic hairs (instead of shaving), and scrubbing the vulva
with only soap and water. But these doctors believe at the same time
that the patient is dangerously susceptible to infection which may be
conveyed to her from without, and accordingly they do not permit vaginal
examinations to be made during labor, and make the most exacting demands
concerning the maintenance of perfect surgical technique, by all who
assist with the delivery.
[Illustration:
FIG. 76.—Wrong and right methods of boiling gloves. Note that gloves
in basin at the left are partly above the surface of the water and
therefore will not be sterilized. Those in basin at the right are
kept below the surface by the weight of the towel and will be
sterilized by the boiling water.
]
In this connection, much depends upon the actual sterilization of the
rubber gloves, either by boiling or by steam under pressure; and the
method of putting on the gloves, in order that once having been
sterilized, they may be kept so. It is useless to attempt to sterilize
gloves by boiling, if they are thrown loosely into a kettle of water.
There will practically always be enough air in the fingers to keep at
least a part of the gloves out of the water, and consequently unaffected
by its heat. They should be put into a covered wire basket that will be
entirely submerged, or they may be wrapped in a towel, the weight of
which will carry them below the surface of the water (Fig. 76), and
insure their being completely covered while boiling, which should
continue for ten to fifteen minutes. The doctor will usually want boiled
gloves placed in a large basin of bichlorid solution, 1–1,000, or lysol
2 per cent., from which he may remove them after scrubbing his hands. If
dry gloves are used, there should be in readiness a sterile towel and
powder with which to dry and powder the hands before putting on the
gloves. (Fig. 77.)
[Illustration:
FIG. 77.—Powdering hands before putting on dry gloves. (From
photograph taken at the Brooklyn Hospital.)
]
Whether boiled or steamed, the cuffs of the gloves should first be
turned up toward the hand, to make it possible to put them on without
touching the glove fingers with ungloved hands. (Fig. 78.) For no matter
how long and carefully the hands are scrubbed and soaked, they cannot be
made absolutely sterile, and therefore, in relation to the gloves which
are sterile, the bare hands must always be regarded as unclean. Too much
thought and attention cannot be given to the sterilization and handling
of the gloves, for the patient’s very life may depend upon their aseptic
condition.
After the doctor has seen the patient, the nurse will make observations
and communicate with him in accordance with instructions which she must
make sure to obtain from him at that time. Many doctors wish to be with
a primipara continuously from the time the cervix is completely dilated,
and with multiparæ after it is half dilated. But that, of course, is a
matter which each doctor decides for himself. The nurse’s responsibility
is to learn his wishes.
[Illustration:
FIG. 78.—Successive steps in proper method of putting on sterile
gloves to avoid contaminating outside of gloves with bare fingers.
(From photographs taken at the Long Island College Hospital.)
]
_Watchfulness_, then, is of extreme importance; watching for symptoms of
complications or change in the patient’s condition, and watching the
progress of labor in order to keep the doctor fully informed about his
patient’s condition. Nurses are very frequently taught to make rectal
examinations for the sake of increasing the value of their assistance in
this respect.
Although unexpected symptoms do not, as a rule, develop suddenly during
the first stage, the nurse must be none the less vigilant for them. The
doctor should be notified if the pains suddenly grow either more or less
frequent, or more or less severe; if there is any bulging of the
perineum; if the membranes rupture; if there is any bleeding or a
prolapsed cord; if there is extreme restlessness or any evidence of
unusual distress; a rising temperature or pulse; a temperature of 100°
F. or a pulse of more than 100 or less than 60; a fetal heart rate of
more than 150 or less than 116, or any marked change of any kind in the
patient’s condition.
During the latter part of the first stage, and during the second stage,
the patient has an almost continuous desire to empty her bowels, because
of pressure made upon the rectum by the descending head. This is another
point which the nurse explain to her patient, in assuring her that
frequent attempts to use the bed-pan will give no relief.
The end of the first stage is reached when the cervix is fully dilated,
at which time the pains occur about every two minutes, are stronger and
more severe, and the patient begins to feel like bearing down. The
membranes frequently rupture at this point and the vaginal discharge is
blood tinged. The patient should remain in bed and not be left alone
from this time on.
To sum up the nurse’s duties during the first stage of labor, when the
patient is almost entirely in the nurse’s care:
1. She must be a sympathetic, encouraging friend to the patient.
2. She must help the patient to preserve her strength by giving her
light nourishment about every four hours; by advising her not to
bear down; not to exhaust herself by walking about too much but
to lie down when tired.
3. She must watch the progress of labor and watch for symptoms of
complications.
4. She must employ strictest aseptic and antiseptic methods.
5. She must prepare for the birth of the baby.
SECOND STAGE
The second stage is shorter, harder and more perilous than the first.
The uterine contractions are stronger; more frequent and more expulsive,
and the baby steadily curves and rotates its way down through the birth
canal.
With the onset of the second stage the nurse should complete the
preparations for the baby’s birth, bearing in mind that with a primipara
the baby probably will not come for an hour and a half or two hours, but
may come in half an hour or less if the patient is a multipara.
Everything which is to be used should be conveniently placed, but the
packages are not necessarily opened at this time.
In addition to the sterile dressings, basins, gloves, instruments and
various other articles which have been enumerated, the nurse must
remember that there should be for the baby a box or basket lined with a
blanket and containing one, or preferably two, hot-water bottles at 125°
F.; in hospitals, an adhesive strip for the baby’s name or a name
necklace; a binder of flannel or sterile gauze, according to the custom
of the doctor; sterile olive oil or albolene for the first oiling and
one or two tubs, in case the baby needs to be resuscitated.
There will be needed, also, a covered basin for the placenta; chloroform
and an inhaler; Wassermann tubes, for those doctors who make this test
as a routine; hypodermic syringe and needles, with pituitrin, ergotole
and drugs for stimulation which the doctor may specify. (Figs. 79, 80.)
In the meantime, the force and frequency of the pains should be noted,
and some doctors require a record of both the fetal and maternal pulse
rate every half hour, and notification if the baby’s is over 150 or
below 116, or the mother’s over 100 or below 60. Extreme restlessness,
distress, vaginal bleeding, prolapsed cord, a temperature of 100° F., or
any marked change must be communicated to the doctor immediately, if it
occurs before he has started for his patient.
The patient may complain of intense pain in her back and cramps in her
legs during the second stage. Pressure made by the nurse’s hand, or a
small pillow slipped under the small of the back will frequently relieve
the backache, while cramps in the legs may be relieved by straightening,
and slightly elevating the leg, and rubbing it while in that position.
As these pains are usually due to pressure they have no serious
significance and subside as soon as the child is born.
[Illustration:
FIG. 79.—Bed and simple equipment in readiness for normal delivery.
(From photograph taken at Johns Hopkins Hospital.)
]
_On table by bed_:
Sterile: cover.
towels, 6.
bag of sponges.
delivery pad.
pair of leggings.
delivery sheet.
doctor’s gown.
perineal pads.
cord ligatures.
_Lower shelf_: douche pan.
_Window sill_:
Baby box with hot-water bag
at 125° F., and blanket.
Chloroform dropper and inhaler.
Sterile albolene for baby.
Alcohol.
Baby band.
Wassermann tubes.
_Second table_:
Basin of instruments.
Basin of bichloride, 1–1,000 with pair
of gloves.
Sponge sticks in alcohol.
Hypo, tray: pituitary liquid.
ergotole.
syringe and needles.
alcohol.
pledgets.
_Lower shelf_: 2 tubs for resuscitating baby.
Covered placenta basin.
Dressing basin.
_Head of bed_:
Nightgown.
Sheet.
Stockings.
Towel.
The nurse may find herself in any one of three situations during the
second stage. The doctor may arrive in ample time to conduct the
delivery; he may be slightly delayed and the nurse endeavor to retard
labor, according to instructions; or the baby may be born, with or
without the expulsion of the placenta, before his arrival.
When the doctor arrives at the onset of, or during the second stage of
labor, the nurse acts solely under his direction, the nature of her
offices depending somewhat upon the condition and surroundings of the
patient, and whether or not the nurse is the only person at hand to give
assistance. In any case, the gloves, and instruments for repairing a
tear should be boiled and in readiness; the dressings and other articles
to be used are to be conveniently arranged upon the tables and opened at
the proper time.
[Illustration:
FIG. 80.—Instruments for normal delivery shown in boiling basin on
table in Fig. 79: Needle holder. Blunt hook. Blunt scissors. 2 small
Kelly clamps. Mouse tooth forceps. 4 towel clips. 2 large perineal
needles and 2 cervical needles in gauze sponge.
]
After having everything ready and at hand for the delivery, the nurse
may be called upon to clean up and act as an assistant, or to give the
anesthetic. If she cleans up, she should wear a sterile gown and gloves,
and if it is the doctor’s custom, a cap and mask as well, having
prepared her hands somewhat as follows:[6]
1. Scrub hands and arms with hot water and green soap for five
minutes, paying especial attention to the fingers and nails.
2. Clean and trim nails and scrub again for five minutes.
[Illustration:
FIG. 81.—Old prints illustrating early ideas of suitable methods of
making examinations and conducting deliveries, furnishing
interesting contrast with present-day methods. Concern seems to be
divided between the patient and the signs of the Zodiac in the
picture at the right.
]
3. Soak and scrub hands and forearms in alcohol, 70%, for two minutes.
4. Soak in bichloride solution, 1–1000, for five minutes.
5. Put on gloves out of second bichloride solution, avoiding contact
with fingers of ungloved hand. (See Fig. 78.)
[Illustration:
FIG. 82.—Patient draped with sterile towels, leggings, sheet and
delivery pad for delivery. (From photograph taken at Johns Hopkins
Hospital.)
]
The patient is given a final scrubbing with green soap and sterile water
and an antiseptic solution, by some one with clean hands, and is further
protected by means of sterile leggings, a sterile towel across the
abdomen and one covering the inner surface of each thigh, held in place
by sterile clips or safety pins. The lower half of the bed is covered
with a sterile sheet while a sterile delivery pad is slipped under the
patient’s hips. (Fig. 82.)
If the delivery is made with the patient lying on her side, the sterile
dressings are so arranged as to cover all but the perineal region after
she is placed in the desired position.
This brings up the question of the nurse’s obligation to protect her
patient from the embarrassment of unnecessary exposure at any time
during labor. The field which is prepared must be uncovered temporarily,
and while the patient is being draped for examination or delivery a
certain amount of exposure is unavoidable; but there are many little
ways in which the nurse may show her consideration for the patient in
this connection and the patient always appreciates the protection.
During the second stage, the preservation of asepsis, watching the
progress of labor and watching for unfavorable symptoms, are of even
greater importance than during the first stage. After the patient has
been prepared and draped with sterile dressings, neither they nor the
perineal region should be touched with anything unsterile.
If for any reason it has not been possible to sterilize sheets and
towels, or more are needed after the prepared supply has been exhausted,
the inner surfaces of towels and sheets that have been ironed either by
hand or machinery, and folded with the ironed surfaces inside without
being touched, may be regarded as practically sterile.
As the second stage advances, the patient may greatly aid the progress
of labor by voluntarily bearing down during pains, and the nurse in turn
may be called upon to help by encouraging her and explaining just what
she should do. At the beginning of a pain the patient should take a deep
breath, close her lips, brace her feet and strain with all her strength.
If she opens her mouth and cries out, she fails to use her pains to the
best advantage. The effect of this bearing down may be increased by
providing the patient with straps, attached to the foot of the bed, upon
which she may pull during the contractions, as she bears down. (Fig.
83.) Or, what is often a great comfort to her, she may pull upon the
nurse’s hands as the latter braces herself so as to offer strong
resistance. If the nurse can be spared from other duties to give this
kind of assistance, it is indeed a comfort to the patient, who appears
to derive from it both a moral and physical sense of being helped in her
struggle. It is also important to assure the patient, between pains,
that she is doing well, and that her efforts are advancing the baby, if
this is true; and if not, she may under ordinary conditions be urged to
make greater effort.
[Illustration:
FIG. 83.—Patient pulling on straps while bearing down during second
stage pains. (From photograph taken at Johns Hopkins Hospital.)
]
Before the head can be seen at the outlet or its advance noted by
perineal bulging, the stage of its descent is often ascertained by
palpating through the perineum, the fingers of a gloved hand pressing
upward, on one side of the vulva. (Fig. 84. See Figs. 85, 86, 87, and 88
for appearance, advance and birth of head during normal delivery.)
Immediately after the birth of the head, and before the birth of the
body, the nurse is frequently asked to wipe the baby’s mouth and eyes
and sometimes to drop nitrate of silver into the eyes. In such a case
she should wipe out the mouth very gently with a bit of sterile gauze,
wet with boric, wrapped about her little finger, reaching well back into
the throat; the eyes should be wiped from the nose outward, a separate
wipe being used for each eye. The purpose of these maneuvers, when they
are employed, is to favor respiration from the beginning by removing
mucus that might impede it and to remove possible infective material
from the lashes before it is spread to the conjunctivæ by the baby’s
winking. The silver solution is to destroy germs that may have gotten
into the eye.
[Illustration:
FIG. 84.—Palpating through the perineum to ascertain the stage of
descent of the baby’s head. (From photograph taken at Johns Hopkins
Hospital.)
]
As soon as the baby is completely born a sterile douche pan should be
slipped under the patient or a small sterile basin placed close to the
perineum, to receive the blood which escapes during the third stage.
This is partly to protect the bed, but chiefly that the blood may be
measured, as in no other way can it be ascertained how much the patient
loses. A loss of 600 cubic centimetres or more is regarded as a
hemorrhage.
[Illustration:
FIG. 85.—Baby’s head appearing at the vulva at the height of a pain.
(This and succeeding pictures of a normal delivery are from
photographs taken at Johns Hopkins Hospital.)
]
[Illustration:
FIG. 86.—Advance of the head indicated by stretching of the vulva and
perineum.
]
[Illustration:
FIG. 87.—Holding back the head at the height of a pain to prevent a
perineal tear.
]
[Illustration:
FIG. 88.—Birth of the head immediately followed by external rotation.
]
[Illustration:
FIG. 89.—Wiping mucus from baby’s mouth with gauze wrapped about
little finger.
]
=Immediate Care of the Child.= After the baby has been brought safely
into the world, it is of greatest possible importance to make sure that
it begins its separate existence by crying lustily, in order fully to
expand its lungs. This provides for oxygenation of its blood, which has
taken place, until now, through the placental circulation. In many cases
the baby cries satisfactorily without aid, but not infrequently must be
stimulated to do so. In all instances the first step is to clear the air
passages of the mucus lodged in the mouth and throat, by some one of the
many approved methods. One is by means of a piece of wet sterile gauze
wrapped about the little finger, and wiped gently about in the back part
of the baby’s mouth (Fig. 89), though many doctors object to this
procedure for fear of abrading the very delicate mucous membrane, no
matter how lightly it is done. They prefer to hold the baby by its feet,
with the head hanging down and the neck sharply curved backward, when by
gravity the mucus will drop out of the mouth; or, holding the baby by
the feet, to run the thumb and forefinger along the neck on either side
of the trachea, toward the mouth, and force out the mucus in that way.
If the baby does not cry well after the mucus is removed, it may usually
be stimulated to do so if held by the feet, head downward, and the back
gently rubbed (Fig. 90) or the face stroked or the buttocks spanked two
or three times. When holding the baby in this position the nurse should
slip one finger between the ankles and grasp them firmly.
[Illustration:
FIG. 90.—Stroking baby’s back to stimulate respirations.
]
After the baby has cried well it may be laid on the foot of its mother’s
bed. At this juncture it seems pertinent to stress two points which must
be remembered throughout the entire routine of the baby’s care, namely:
the importance of protecting it from infection and from being chilled.
As the baby lies on the mother’s bed, before the cord is cut, it finds
itself in a room which is many degrees cooler than the very warm habitat
from which it has just emerged; it is struggling to establish its
functions, which are suddenly deprived of the mother’s help, chief of
which at the moment are respiration and the circulation. Body warmth is
one of the most valuable aids in promoting an even circulation, and
accordingly the baby should be kept warm from the beginning. For this
purpose there should be a small sterile blanket, or piece of flannel, in
readiness to protect the little body as it lies on the bed, awaiting
further developments. The hands and feet of the newborn baby that lies
uncovered for even a quarter of an hour, or more, are nearly always
cold, and as this must be guarded against in an older, more securely
established baby, it cannot be desirable for the newly born.
[Illustration:
FIG. 91.—Showing two clamps on cord after pulsation has ceased.
]
[Illustration:
FIG. 92.—Wrong and right method of tying knot in cord ligature. A will
slip. B will not.
]
As soon as the cord ceases to pulsate, it is usually clamped with two
clamps about two inches apart (Fig. 91) and cut between the clamps. The
scissors should have blunt points, in order not to scratch or cut the
baby, who may be wriggling vigorously by this time. The cord is tied
tightly with a sterile cord ligature, in a square knot that will not
slip (Fig. 92), about an inch from the abdominal wall. It is considered
a safe precaution, after removing the clamp, to bend the cord back upon
itself and tie it a second time with the same ligature, as the danger of
hemorrhage from a loosely tied cord is serious when the baby is kept
sufficiently warm. The placental end of the cord is also tied, or it
remains clamped until the placenta is expelled, because of the
possibility of there being another child in the uterus and the danger of
its bleeding to death through the open cord.
Some doctors do not tie the cord, but crush the vessels with a clamp
which is left on the cord for about half an hour and then permanently
removed, but this should not be done by a nurse upon her own
responsibility.
Very often the person who performs the delivery removes the blood, mucus
and vernix from the baby’s body, as soon as the cord is tied, by
sponging it thoroughly with albolene or olive oil; wraps the cord stump
with a sterile, dry or alcohol sponge and applies the abdominal binder
while an assistant holds the baby by the feet, head down. It is also
very common simply to oil the baby with unsterile lard, oil or vaseline,
cover the cord with sterile gauze and leave the bath, cord-dressing and
binder to be attended to later.
If the delivery takes place in a hospital the baby must be marked
_before it is taken from the delivery room_, with adhesive plaster, upon
which its mother’s name is plainly printed, or with the name necklace,
now so frequently used.
The baby is once more wrapped in a warm blanket and placed, with a
hot-water bottle, at 125° F., in the basket or box, which was prepared
for it. Although the baby should be well covered, care must be taken to
leave the face fully exposed as a young baby is easily suffocated. It
was formerly customary to lay the new baby on its right side, but with
the present fuller knowledge of the fetal circulation and the changes
which take place after birth, this practice has been largely done away
with.
=Resuscitation of the Newborn Baby.= If the baby breathes feebly, or
even if it does not cry vigorously, the effort to stimulate the
respirations may have to be continued for an hour or more after the cord
is tied. In addition to the simple methods, previously described, which
are very commonly employed at the time of labor, such as stroking the
baby’s back or holding him by the feet and spanking him (Fig. 93), the
following measures are sometimes resorted to if the baby’s condition
demands it:
[Illustration:
FIG. 93.—Stimulating respirations by holding the baby head downward
and sharply spanking him. Note the method of grasping the baby’s
ankles with one finger between them to prevent his slipping from the
nurse’s hand.
]
One method is to hold the baby with its chest resting on the palm of one
hand, with head, legs and arms hanging forward, thus compressing the
chest wall and favoring expiration (Fig. 94), and then turning it over
on its back, in the other hand, in which position the head, legs and
arms hang backward, thus expanding the chest and favoring an inspiratory
movement. (See Fig. 95.) Alternate repetitions of these positions, about
twelve times a minute, will often stimulate the child to breathe
satisfactorily.
[Illustration:
FIG. 94. (See also Fig. 95.)
FIGS. 94 AND 95 show method of stimulating respirations by resting the
baby alternately on his chest and back on the nurse’s hands. (From
photographs taken at Bellevue Hospital.)
]
Another method is alternately to plunge the baby into tubs of hot and
cold water. But as there is doubt about the wisdom of chilling the
entire surface of the baby’s body, the cold plunge is forbidden by many
doctors, who, instead, dash a little cold water upon the face and chest,
while the body is immersed in water at about 110° F.
[Illustration:
FIG. 95.—Resuscitating the baby. (See also Fig. 94.)
]
A widely used and efficacious method is to hold the baby continuously in
a tub of water at about 110° F., and alternately extend and fold its
body, thus keeping it warm while stimulating inspiration and expiration.
(Figs. 96, 97.)
Direct insufflation may be employed while the baby is in the warm water,
by protecting its face with clean dry gauze and blowing directly into
its mouth at intervals corresponding to those of normal inspiration.
(Fig. 98.)
[Illustration:
FIG. 96. (See also Fig. 97.)
FIGS. 96 AND 97 show method of resuscitating the baby by alternately
extending and folding his body under warm water. (From photographs
taken at Johns Hopkins Hospital.)
]
Another procedure is to hold the baby by the shoulders, with its body
hanging down, thus expanding the chest, and then to toss it quickly
upwards, folding the legs upon the chest to compress it. This method is
objected to by many obstetricians on the ground that it both exhausts
and chills the baby.
[Illustration:
FIG. 97.—Resuscitating the baby. (See also Fig. 96.)
]
The outstanding requirements in resuscitating a baby are to stimulate
its respiratory movements, by alternately expanding and contracting the
chest; to promote its circulation by keeping it warm, and to avoid
exhausting the very frail little body. Gentle handling, therefore, is
important.
THIRD STAGE
After the birth of the baby, some doctors request the nurse to rest one
hand on the mother’s abdomen in order to feel the fundus as it rises
while expelling the placenta, and to keep him informed concerning its
consistency. Others regard this as a dangerous practice and forbid it.
As a rule, there is little bleeding until the placenta has separated. If
bleeding does occur, it is the practice of some doctors to have the
uterus gently massaged through the abdominal wall, to stimulate
contractions, while others consider this inadvisable.
[Illustration:
FIG. 98.—Stimulating respiration by means of direct insufflation, the
baby’s face being covered with clean gauze. (From photograph taken
at Johns Hopkins Hospital.)
]
After the placenta separates and descends into the lower uterine
segment, it produces a bulging just above the symphysis, while the
fundus may be felt as a firm, hard mass above the umbilicus. Since the
placenta is entirely separated from the uterus at this time, its
complete expulsion is usually aided, when it does not occur
spontaneously, by gentle pressure upon the fundus. The accoucheur holds
his hand just below the vaginal outlet, to receive the placenta (Fig.
99), which he turns over and over in his hands, thus twisting the
membranes, and gradually draws it away from the mother, the membranes
trailing after in the form of a tapering cord. (Fig. 100.) It is
important that the placenta and membranes be carefully examined to make
sure that they are intact, for if fragments of either are retained
within the uterus they will prevent its firm contraction and thus may be
a cause of post-partum hemorrhage. For this reason, only very gentle
pressure and traction are used in expressing the placenta and
withdrawing the membranes, for the use of force might leave small
particles adhering to the uterine lining, which would otherwise separate
with the rest, in due time, as a result of the uterine contractions.
[Illustration:
FIG. 99.—Delivery of the placenta.
]
Having been inspected, the placenta should be placed in a covered
receptacle to be disposed of as the doctor directs, as many physicians
make a routine laboratory examination of the placenta and wish to have
it kept for this purpose.
With the birth of the placenta comes a gush of blood, as the uterine
vessels, some of which are as large as a lead pencil at this time, are
left wide and gaping. The bleeding usually subsides very shortly,
however, as the blood vessels are closed by involuntary contraction of
the network of uterine muscle fibres in which they are enmeshed, and
which are sometimes referred to as “living ligatures.” If the bleeding
continues, these contractions should be stimulated by massage. This is
done by grasping the uterus through the abdominal wall firmly with one
hand and kneading vigorously. Rubbing the top of the fundus with the
fingers usually is not enough. The fundus should be grasped by the
entire hand; the thumb curved across the anterior surface and the
fingers, directed deep into the abdomen, behind it. (Fig. 101.)
Pituitrin or ergot, or both, are frequently given to further stimulate
contractions of the uterine muscles. Since the action of pituitrin is
quick, but evanescent, and the effect of ergot is slower and more
lasting, both a quick and lasting effect is obtained by giving them
together.
[Illustration:
FIG. 100.—Twisting the membranes while withdrawing them from uterus.
]
The expulsion of the placenta ends the third stage and completes the
process of labor.
[Illustration:
FIG. 101.—Grasping fundus through abdominal wall in giving massage to
stimulate uterine contractions.
]
=Immediate After-care of the Patient.= The patient should be bathed and
dried about the thighs and buttocks, the vulva being bathed with alcohol
or an antiseptic solution, and a sterile perineal pad applied. The
douche-pan, wet towels, delivery pad and draw sheet are replaced by a
dry draw-sheet and a towel or pad slipped under the patient’s hips,
while a fresh nightgown is put on if the one worn during labor is wet or
soiled. The perineal pad is very commonly held in place by a T. binder,
with which all nurses are familiar, but some doctors prefer an abdominal
binder to which a perineal strap is attached. This abdominal support may
be a straight swathe or a Scultetus bandage, varying with the wishes of
the doctor, and it may or may not be used in conjunction with a pad, so
applied as to make pressure over the fundus. Other doctors forbid the
application of any kind of a perineal dressing from the time of
delivery, but instead, have a large, sterile pad slipped under the
patient to receive the discharge.