The patient is usually tired and cold at_Obstetrical Nursing A Text-Book on the Nursing Care of the Expectant Mother, the Woman in Labor, the Young Mother and Her Baby

may even have a nervous chill. Although this chill is not serious, the

patient is none the less uncomfortable, and she should be warmly

covered, be given something hot to drink, and a hot-water bag placed at

her feet.

All possible effort must now be made to secure for her rest, quiet, and

an opportunity to sleep. Every one but the doctor and the nurse had

better be excluded from the room, which should be absolutely quiet,

somewhat darkened and well ventilated. In addition to this, the majority

of doctors now require that either they or the nurse shall stay with the

patient and keep one hand resting on the fundus for at least an hour

after delivery as a safeguard against post-partum hemorrhage. As long as

the fundus is felt through the abdominal wall as a firm, hard mass, its

irregularly arranged muscle fibres are contracted upon the blood

vessels, and will prevent an escape of blood. But if the fundus feels

soft and boggy, its muscles are relaxed, the constrictions are somewhat

released from the open vessels, and serious bleeding may occur unless

they are stimulated to contract again.

=If the Doctor Is Delayed.= It sometimes happens that labor progresses

with unexpected rapidity, or that the doctor is delayed in his arrival

and the nurse is accordingly confronted with the emergency of being

alone with the patient during part or all of the delivery.

When the baby is making such rapid descent that the nurse fears it may

be born before the doctor’s arrival, she may somewhat retard labor by

covering her hand with a folded, sterile towel, if she has not had time

enough to put on gloves, and hold back the head by pressing against the

perineum during pains, at the same time instructing the patient to open

her mouth, breathe deeply and try not to bear down. It is sometimes

easier for the patient not to bear down if she lies on her side.

If by mischance, or in spite of her efforts, the baby so far descends

that the brow appears before the doctor’s arrival, the nurse cannot

safely hold it back longer because of the danger of the baby becoming

asphyxiated. She should, up to this point, hold the head back during

pains in order that the perineum may be stretched slowly, with the hope

of preventing a tear. (See Fig. 87.) It is the sudden distension of the

perineum and expulsion of the baby’s head at the height of a pain that

frequently causes lacerations. If fecal matter is expressed during

pains, the field should be wiped, downward, with sterile sponges and

bathed with the antiseptic solution at hand.

After the brow is born, the nurse may gradually release the pressure and

allow the head to emerge, and remembering the position of the child and

the mechanism of its birth, assist Nature in its complete delivery.

After the head is born, it drops down toward the mother’s rectum, after

which external rotation, or restitution, takes place. (See Fig. 88.) A

finger should be slipped around the neck in search of coils of cord,

which, if felt, should be slipped over the baby’s head. Otherwise,

pressure upon the cord in that unnatural position might so interfere

with the circulation as to asphyxiate the baby.

The shoulders may be born spontaneously or the nurse may grasp the head

with both hands, curving the fingers of one hand under the baby’s chin,

and of the other, under the occiput, and make gentle, downward traction

(See Fig. 69.) in order to slip the anterior shoulder from under the

symphysis; and then pull gently upward, to deliver the lower or

posterior shoulder (see Fig. 70.), after which the rest of the body

follows easily.

This description of how a nurse may conduct a normal delivery by fairly

typical and generally approved methods is only intended to guide her in

an emergency, when there has been no understanding between her and the

doctor about what she should do in event of his absence; or when he has

authorized her to use her best judgment in safeguarding the lives of

mother and baby.

It is obviously of extreme importance for the nurse to ascertain

definitely the doctor’s wishes in this connection, as he sometimes will

be unwilling to have the nurse give any attention to either mother or

baby, even to tie the cord, before his arrival.

=Prolapsed Cord.= If the umbilical cord should prolapse at any time

during labor, in the absence of the doctor, or lacking instructions, the

nurse should elevate the patient’s hips, in order that gravity may

lessen the pressure on the cord as it lies between the presenting part

and the pelvic brim. Otherwise, the interference with the placental

circulation may result in asphyxiation of the baby. (Fig. 102.)

[Illustration:

FIG. 102.—Drawing showing how prolapsed cord may be pressed between

baby’s head and pelvic brim, thus cutting off placental circulation.

]

The elevated Sims position is often effective. Or, a straight chair may

be upturned and pushed under the mattress, from the foot toward the

head, in such a way that the patient will be lying on an incline which

slopes upward from the head of the bed toward the foot. Or the chair may

be placed in the same position on top of the mattress, with the top of

the chair-back under the patient’s shoulders. The chair should be padded

with pillows in order to minimize the patient’s discomfort as she lies

in this trying position.

=Post-partum Hemorrhage.= Should a post-partum hemorrhage occur, in the

absence of the doctor, the nurse should massage the fundus, unless she

has been instructed not to, and have some one elevate the foot of the

bed on blocks or the seat of a firm, straight chair. The use of ice bags

or cold compresses on the abdomen is sometimes helpful and some

physicians advise placing the baby at the mother’s breast immediately,

since the suckling stimulates the uterine muscles to contract.

In anticipation of a post-partum hemorrhage, the nurse must have a clear

understanding of the doctor’s wishes, particularly in regard to the

administration of pituitrin and ergot which are so widely and

efficaciously used to check post-partum bleeding.

ANESTHETICS

Those of us who are accustomed to seeing anesthetics used to relieve

patients of the worst of their pain, during labor, find it hard to

realize that until comparatively recent years women went through this

suffering without mitigation.

The use of anesthesia was introduced into obstetrical practice, in 1847,

by Sir James Y. Simpson of Scotland, who first used ether but later

adopted chloroform when he learned that it also had anesthetic

properties. Its use in America was subsequently introduced by Dr.

Channing of Boston.

In the early days, the idea of using anesthesia during labor was greeted

with a storm of protest, both from the clergy and the laity, because of

their belief that the relief of women in childbirth was contrary to the

teachings of the Bible, as set forth in God’s curse on Eve, when He

said, “In sorrow thou shalt bring forth children.”

There is to-day practical unanimity of opinion concerning the advantages

which are derived from the use of anesthesia when any operative

procedures are employed; but there is still some objection to its use in

spontaneous deliveries. This is partly on medical grounds because of the

possible ill effects of anesthetics and is partly a persistence of the

early religious protest. However, in the vast majority of cases, some

kind of an anesthetic, or analgesic, is administered to the woman in

labor because the advantages of its use are generally conceded.

[Illustration:

FIG. 103.—Method of giving chloroform for obstetrical anæsthesia.

]

The agents used are chloroform, ether and nitrous oxid gas, while what

is popularly called “twilight sleep” is produced, completely or in a

modified degree, by the hypodermic administration of scopolamin and

morphine.

=Chloroform.= Of these various drugs chloroform is apparently the

anesthetic most widely used in normal obstetrics. Its advantages are

that it is easy to give; quick in its action and is followed by little

or no nausea or other ill effects. For some reason, as yet not

explained, the woman in labor enjoys a certain amount of immunity

against chloroform poisoning, but this tolerance exists only during

labor as the puerperal woman is subject to the same dangers as any other

individual.

Chloroform is not usually administered until the patient is well along

in the second stage, or until the head may be felt through the perineum,

or is in sight. The patient’s face should be oiled and protected with a

towel or gauze folded across her brow, mouth and chin to prevent burns

that might follow the inadvertent dropping of chloroform on her face.

With the beginning of a pain, a few drops are poured on the inhaler

which is held about an inch from the face to give a free admixture of

air, and the patient is told to breathe in deeply. (Fig. 103.) The

inhaler is removed as soon as the pain subsides, but reapplied as soon

as another pain begins. The patient retains consciousness and is able to

talk under this degree of anesthesia, but her suffering is greatly

relieved. It has the advantage, also, of lessening the danger of

perineal tears, as the accoucheur has better control of the delivery

when the patient lies quietly than when she tosses violently about the

bed, and a tear resulting from the sudden delivery of the head at the

height of a pain may in this way be averted.

This light, intermittent anesthesia, now so widely used, is called

obstetrical anesthesia or anesthesia _à la reine_, after Queen Victoria,

upon whom it was first employed at the birth of her seventh child, in

1853.

When the perineum is distended to its maximum, obstetrical anesthesia is

not always sufficient, and complete anesthesia may be employed; but even

this requires very little chloroform. Under ordinary conditions, the

anesthesia is discontinued as soon as the child is born, for unless

there is an extensive tear, the patient is sufficiently anesthetized to

permit of a perineal repair and the delivery of the placenta.

Chloroform is not often given early in labor because of the general

belief that its free or prolonged use lessens the force and frequency of

uterine contractions, thus prolonging labor, and also may unfavorably

affect the child. But small doses seem to stimulate rather than retard

contractions, and by having her pain relieved, the patient is prompted

to make greater effort to use her abdominal muscles, an end greatly to

be desired.

If complete anesthesia is needed for more than a few moments, after the

child is born, ether usually replaces the chloroform, being considered

more satisfactory for prolonged anesthesia, but many obstetricians

prefer not to give it until after delivery because of its possible

effect upon the child.

[Illustration:

FIG. 104.—Giving ether for obstetrical anæsthesia. Ether is poured

into cone which is covered with nurse’s hand to prevent evaporation.

When the beginning of a contraction is felt by hand on abdomen, the

cone is placed about an inch from the patient’s face. (From

photograph taken at the Maternity Hospital, Cleveland.)

]

As chloroform poisoning is likely to produce degenerative changes in the

liver, and eclampsia also causes a liver necrosis, chloroform is not

used for an eclamptic patient.

[Illustration:

FIG. 105.—As pain increases and patient becomes accustomed to ether,

the cone is lowered and held close to her face until pain subsides.

Sufficient ether to control the next pain is then poured into cone.

(From photograph taken at the Maternity Hospital, Cleveland.)

]

=Ether=, also, is used widely in normal obstetrics and is almost always

preferred for continuous anesthesia, because of its being safer than

chloroform. Unlike chloroform, ether is sometimes given in the first

stage after the pains have become severe and frequent. About a dram of

ether is poured into the cone which is held just off the patient’s face

(Fig. 104.) until the beginning of a contraction, at which time it is

lowered and held close to her face (Fig. 105.) As the action of ether is

slower than chloroform, it should be poured into the cone in advance of

a pain, which the nurse anticipates by feeling the uterus begin to grow

hard under the hand which she keeps upon the patient’s abdomen. If the

ether is not poured into the cone until a pain begins, its anesthetic

effect may be lost because of the delay in its administration.

At the Cleveland Maternity Hospital, where ether is used during normal

labor, the nurses are taught to give it as has just been described, with

further instructions from Miss MacDonald, as follows: “A patient will

vaporize about one dram of ether per pain during the early first stage,

gradually vaporizing a greater amount until she will vaporize two or

three drams per pain near the end of the second stage. Should the

patient reach the excitement stage of ether before she is in the second

stage of labor, discontinue the ether for from five to fifteen minutes,

then give a lessened amount.

“Should it be necessary to control the descent of the presenting part,

light anesthesia may be given. This may be managed by putting about two

drams of ether in the cone at intervals frequent enough to sufficiently

retard the descent of the presenting part. This procedure almost

obliterates contractions. Lift the cone from the face for a few moments

at frequent intervals to admit air. Keep the ether vapor of such

concentration as avoids choking, coughing or vomiting. This may be done

by administering a small amount frequently, rather than a large amount

at longer intervals. When the desired stage is reached, try to keep the

patient at this degree of anesthesia by giving a few drams of anesthetic

at regular intervals.”

=Nitrous Oxid Gas Analgesia.= The effect of this drug is termed

analgesia rather than anesthesia, because the patient does not lose

consciousness but is unconscious of pain. From a medical standpoint it

is considered practically ideal for use in obstetrics. If given

skillfully it seems to have no bad effects upon the child; it tends to

stimulate, rather than diminish uterine contractions; it may be started,

with safety; as soon as the patient begins to suffer severely, and

continued for several hours if necessary.

Its disadvantages are that it is very expensive; it can be given safely

only by a skillful, trained person; the apparatus necessary for its

administration is expensive, heavy and difficult to transport. But when

these difficulties can be overcome, its use is attended with very

satisfactory results.

“=Twilight Sleep=,” so called, or _Dämmerschlaf_, as it is termed in

Germany, has been and still is discussed so widely, that the nurse

should know something of it, whether or not she aids in its

administration. It may be described as a state of amnesia, or

forgetfulness, produced by the hypodermic injection of morphin and

scopolamin. The patient, therefore, is conscious of pain at the time but

speedily forgets it.

This treatment was first used widely in Freiburg. Following an

enthusiastic report from there upon a large number of cases in which it

had been used, there was such a clamor for it by American women, that

its temporary use was practically forced upon obstetricians in this

country. It was given what appears to have been a fair trial, but its

continued use in this country has not been widespread. Those

obstetricians who object to its use describe its disadvantages as

follows: It cannot be used outside of a well-conducted hospital; it

requires the constant attendance of a well-trained obstetrician or

obstetrical nurse throughout the entire course of labor; it is suitable

for use in certain selected normal cases only; it prolongs the second

stage and increases the percentage of cases in which operative

interference is necessary; it has an asphyxiating effect upon the child

and increases the percentage of fetal deaths.

On the other hand, the use of scopolamin and morphin is a routine in

certain excellent maternity hospitals, and by many obstetricians of the

first rank, who maintain that with a nurse in attendance and the

observance of ordinary precautionary measures, the advantages far

outweigh the disadvantages of a modified “twilight sleep.” An anesthetic

is usually administered during the second stage, after the use of the

scopolamin-morphin treatment.

COMPLETE ANESTHESIA. If an emergency should arise and the nurse be

required to change from the light anesthesia _à la reine_, and to give

complete anesthesia, her responsibilities increase, for she must watch

carefully the patient’s pulse, respirations, color and pupils. The flat

pillow which is ordinarily left under the patient’s head during normal

labor, should be removed and the inhaler should be held closely over her

face with the nurse’s fingers so placed as to hold it in position and

also to hold the patient’s jaw forward and up. (Fig. 106.)

The ether should be dropped in clean drops, not poured, upon the

inhaler. The dripping should be steady, but slow at first, gradually

increased as the patient becomes accustomed to the fumes.

[Illustration:

FIG. 106.—Method of holding inhaler and supporting patient’s jaw in

giving ether for complete anesthesia. (From photograph taken at

Johns Hopkins Hospital.)

]

With the average, normal patient who is taking ether well the

_respirations_ become somewhat stertorous and more rapid, increasing to

possibly 36 or 40 per minute; the _pulse_ starts at a little above the

normal rate and increases to 116 or 120 and then drops to normal, which

is slightly below the rate at which it started; the _color_ is normal at

first and then may become crimson, or it may change very little; the

_pupils_ first dilate, and then contract almost to a pin point.

Unfavorable signs are: _respirations_ that are rapid and shallow, then

possibly slow, but still shallow; increasing _pulse_ rate, this being so

serious that the ether is usually stopped if the pulse approaches 140,

and stimulation is promptly given; _cyanosis_ which is slight at first

and then extreme, and dilated _pupils_.

It is obviously not wise nor possible to attempt, by means of a few

paragraphs and illustrations to teach a nurse so technical and important

a procedure as the administration of an anesthetic, but it is hoped that

these general suggestions may be helpful, particularly to the nurse who

is unexpectedly confronted by an emergency.

Under all conditions the nurse must remember that no matter what

anesthetic is given, nor by whom it is administered, she must guard

against the very prevalent tendency to talk freely while the patient is

going under, in the belief that she is unaware of what is going on about

her. Many patients suffer great mental distress because of hearing, or

partly hearing conversation not intended for their ears, which takes

place in their hearing while they are incompletely anesthetized.

CHAPTER XIII

OBSTETRICAL OPERATIONS AND COMPLICATED LABORS

Unhappily, not all labors run the smooth and uncomplicated course which

was described in the last chapter. Certain abnormalities sometimes arise

to complicate delivery, occasionally necessitating operative

interference or relief.

There is little that a nurse can do alone, in the presence of

complicated labor, but her preparations and assistance will be more

effective if she understands the purpose of the operations, and she will

better appreciate the gravity of certain symptoms, which she is required

to watch for and report, if she realizes the extreme seriousness of

their import.

The principal conditions which give rise to, or follow complications,

prevent spontaneous delivery or necessitate operations at the time of

labor are perineal lacerations; contracted or malformed pelves; marked

disproportion between the diameters of the child’s head and mother’s

pelvis; ruptured uterus; exhaustion of the mother; poor muscle tone or

certain chronic and acute diseases of the mother; death of the fetus;

prolapsed cord; certain presentations of the fetus in which spontaneous

delivery is doubtful or impossible.

The preparations for operations in hospitals are all so carefully

planned and systematized that in the presence of such emergencies the

nurse will merely have to carry out the customary routine, but in a

patient’s home she may have to exercise a good deal of originality in

attempting to meet the needs of the occasion and imitate hospital

provisions.

A satisfactory operating table may be fashioned in any one of a number

of ways. If the bed is high enough, it may sometimes be made fairly

satisfactory by slipping a board, such as a table leaf, under the

mattress to make it firm. The use of a kitchen table is time-honored,

but it is an unsafe practice unless the available table is very secure

and firm, which is usually not the case with present-day kitchen tables.

A flat-topped chest of drawers, with the casters removed, makes an

excellent operating table, for it is firm, a good height and about the

right size. Or an ordinary bureau may be pressed into service after

taking out the casters and removing the mirror by unscrewing its

supports. The front and sides of a bureau, or chest of drawers so used

should be protected from the damaging effects of fluids and solutions by

being covered with a bed-rubber or newspapers. A pad for the top of the

improvised operating table may be arranged by folding a blanket or quilt

to the proper size and folding over that the rubber draw-sheet and a

clean muslin sheet.

If the operation requires that the patient be held in the lithotomy

position (on her back with thighs and knees flexed and knees well

separated), and the doctor’s equipment does not include a strap to hold

the legs, one may be improvised from a sheet. It should be folded

diagonally, over and over, into a strip possibly a foot wide, passed

over one shoulder and the tapering ends used to tie around the legs,

above the knees, to hold them in the desired position. Bandages or tapes

are not always satisfactory, for the support is subject to a good deal

of strain, and narrow strips sometimes cut painfully into the legs and

shoulders. Certainly if tapes or bandages are used, cotton pads or

folded towels should be interposed between them and the patient’s skin.

In general, the nurse will prepare as for a normal delivery, in each

instance adding such details of equipment, or preparation as the

contemplated operation requires. Rigid asepsis must be observed

throughout the preparations and the operations. When large instruments

or appliances are to be used, a wash boiler is probably the safest thing

in which to boil them, for it is scarcely possible entirely to cover

them with water in a smaller receptacle; and they must be well covered

while boiling, or they will not be sterile.

=Perineal Lacerations.= A large proportion of women during the birth of

the first baby sustain some degree of perineal laceration, which may

amount to nothing more than a nick in the mucous membrane, or it may

extend entirely across the perineal body and tear through the rectal

sphincter. The causes of these tears are generally conceded to be

rigidity of the perineal muscles; disproportion between the size of the

child’s head and the vulval opening; a sudden expulsion of the child’s

head, before the perineum is fully distended, and certain abnormalities

in the mechanism of labor. Lacerations may, therefore, be prevented, or

limited, in many cases by holding back the baby’s head and allowing it

to dilate the perineum slowly. But in spite of the most skillful and

careful efforts, tears of some degree occur in most primiparæ, and

probably in half of all multiparæ. These injuries are usually described

as being of the first, second or third degree, according to their

extent.

=A first degree tear= is one that extends only through the mucous

membrane, usually at the margin of the perineum, without involving any

of the muscles.

=A second degree tear= is one that extends down into the perineal body

and may involve the levator ani, or even extend down to, but not through

the rectal sphincter. Such a tear usually extends upward on one or both

sides of the vagina making a triangular injury.

=A third degree tear= extends entirely across the perineal body and

through the rectal sphincter and sometimes up the anterior wall of the

rectum. This variety is often called a =complete tear=, in

contradistinction to those of first and second degree, which are

incomplete.

It is a fairly general custom to repair these lacerations at the time of

labor, no matter what their extent, the sutures being introduced but not

tied, during the third stage. The patient is usually sufficiently

anesthetized to permit of this, without further anesthesia, in all but

complete tears, and as there is usually but very slight bleeding before

the expulsion of the placenta, the field is comparatively clear and the

stitches are easily put into place. They are not tied, as a rule, until

after delivery of the placenta because of the strain which its expulsion

would put upon the fresh stitches. In all but very slight tears, the

doctor will usually want the patient turned across the bed, with her

hips brought to the edge, and her legs supported in the lithotomy

position. As the few instruments necessary for perineal repairs should

be boiled and placed in readiness before labor, there is usually no

further preparation for the nurse to make, and the perineal dressing,

after the stitches have been taken, is ordinarily the same as that

following a normal delivery. (See Fig. 80 for necessary instruments.)

Some physicians prefer not to repair perineal tears until some days

after labor, contending that the congestion of the soft parts

immediately after delivery is not favorable to a satisfactory union.

When the repair is made subsequently, therefore, the nurse prepares as

she would for any perineal operation, performed independently of labor.

Repairs are not often postponed for more than a few days, since long

delayed or neglected attention frequently gives rise to gynecological

disorders, such as descensus or prolapse of the uterus.

=Episiotomy.= Some obstetricians prefer to anticipate a perineal tear by

making an oblique incision, usually on one or both sides, extending

downward and outward from the margin of the vaginal outlet down into the

perineum. This operation is termed episiotomy, and the incision is

sutured after labor just as a tear would be. It is the belief of those

who perform this operation that the clean-cut incision heals more

satisfactorily than an irregular tear, and that by directing the

incision to the side, away from the median line, the integrity of the

rectal sphincter is preserved, even though the perineum tears beyond the

end of the incision, when distended during the birth of the head.

=Breech Extraction.= In some cases of breech presentation, particularly

among primiparæ, it is necessary to assist nature in the delivery of the

child in order to save its life. Complete anesthesia is usually

necessary at such times and the patient is preferably on a table or at

the edge of the bed in a lithotomy position.

In the majority of cases, no effort is made toward assistance until the

body is born as far as the umbilicus, partly because of the difficulty

of taking hold of the child securely before that time, and partly

because the perineum is not likely to be fully distended, in which case

a serious tear would probably result. But after the body has been

extruded as far as the umbilicus, it is usually considered imperative to

complete the delivery within eight minutes to save the child from

asphyxiation, due either to pressure on the cord between the head and

pelvic brim, or to premature separation of the placenta. The baby’s feet

or legs are grasped by a towel to prevent slipping, and downward

traction is made on the body until the tips of the scapulæ appear at the

outlet. During this procedure the nurse may be called upon to make

pressure on the uterus with the idea of keeping the baby’s head flexed

forward; preventing the arms from becoming extended upward above the

head and also to help in expelling the child.

After the scapulæ appear, the arm lying posteriorly is brought down over

the chest and delivered. The body is then rotated until the other arm

lies posteriorly and that is delivered. After delivery of the arms and

shoulders the head is usually delivered by what is known as Mauriceau’s

maneuver as follows: The accoucheur slips the index finger of one hand

into the vaginal outlet and into the child’s mouth, and supports the

body of the child upon his hand and forearm; two fingers of the other

hand are slipped around the back of the neck and curved forward like

hooks over the shoulders and strong downward traction is made by these

fingers; not by the one in the baby’s mouth. The occiput emerges from

beneath the symphysis, after which the body is lifted upward and the

chin, nose, forehead and entire head are born.

=Version.= By version is meant the turning of the child within the

uterus so that the part which was presenting at the superior strait is

replaced by another part, in order to hasten or facilitate delivery. It

is usually performed as the patient lies flat on her back, completely

anesthetized, and with great gentleness, for fear of rupturing the

uterus.

Common indications for a version are a transverse presentation; a

prolapsed cord, when the head has just begun to enter the superior

strait; and in some cases of placenta prævia. When the fetus is so

turned that the head becomes the presenting part, the procedure is

termed a _cephalic version_; if so turned that the breech presents, it

is termed a _podalic version_. The methods of accomplishing these ends

are described as _external version_, if the turning is done entirely

with the hands working through the abdominal wall; _internal version_ if

one entire hand is introduced into the uterine cavity, and _combined

version_ when one hand is outside on the abdomen and two fingers of the

other are introduced through the cervix into the uterus.

External cephalic version is often performed late in pregnancy, or early

in labor, in transverse and also in breech presentations, to secure a

vertex presentation because of the high fetal death rate in breech

extractions. Podalic version, or making the breech the presenting part,

is often performed in transverse presentations, in placenta prævia and

when the cord or extremities are prolapsed. Having converted the

presentation into a breech, the usual breech extraction is performed.

=Forceps= are instruments which are used to extract the child when

presenting by the head in certain conditions which endanger the life of

mother or child. The value of forceps in obstetrics can scarcely be

overestimated, as before their invention the only operative method of

delivering a live baby was by means of version and extraction, and in

these the fetal death rate was high. The obstetrical instruments in use

up to that time, therefore, were all for the destruction of the child in

utero.

Forceps were devised, and first used, in great secrecy, early in the

17th century, by a Dr. Chamberlen, in England, who jealously guarded all

information relating to his invention from every one but members of his

own family.

There were several doctors in the Chamberlen family who practiced

obstetrics and who used these forceps, but knowledge concerning the

nature of the instruments and methods of using them was not shared with

members of the medical profession outside of that family, until the

beginning of the 18th century. Since that time the use of forceps has

been widely extended and the original Chamberlen instruments have been

so modified and altered and improved by different obstetricians, that

there is now a bewildering number and variety in existence and in use.

Probably the most widely used are those which were devised by Dr.

Tarnier of France and Dr. Simpson of England, respectively. (Fig. 107.)

The Tarnier instrument is known as an axis traction forceps, and can be

used in all kinds of forceps operations, while Dr. Simpson’s are

suitable for use only in low forceps cases.

There are two groups of indications for the use of forceps; those

relating to the condition of the child and those relating to the mother.

[Illustration:

FIG. 107.—Two widely used forceps. A, Tarnier axis-traction forceps.

B, Simpson forceps.

]

Indications for their use in the interests of the child are symptoms of

asphyxia, and these are the passage of meconium, in head presentations,

and a change in the rate or rhythm of the fetal heartbeat. As pressure

on the abdomen of the fetus during labor, in breech presentations, is

very likely to express meconium, this is not of special significance in

these cases. But in head presentations, the escape of meconium suggests

paralysis of the rectal sphincter muscles, due to imperfect oxygenation,

which, in turn, is caused by interference with the placental circulation

by pressure on the cord or premature separation of the placenta.

Conditions which menace the life of the mother, and indicate the use of

forceps, are inadequate contractions of the uterine and abdominal

muscles; exhaustion, as indicated by an increase in the maternal pulse

rate or elevation of temperature, and in certain chronic and infectious

diseases, when the patient may be unable to stand the strain of the

second stage.

Forceps are usually employed when the head fails to make satisfactory

advancement after two hours of good, second-stage pains, or when it

remains in one place on the perineum for an hour, in spite of good,

second-stage pains.

[Illustration:

FIG. 108.—Patient in position and draped for forceps operation. (From

photograph taken at Johns Hopkins Hospital.)

]

Otherwise, there is danger of necrosis or sloughing of the soft parts as

a result of pressure, with a subsequent recto-vaginal or vesico-vaginal

fistula.

Among the acute conditions in which forceps are indicated are typhoid

fever; pneumonia; acute edema of the lungs, hemorrhage from premature

separation of the placenta; intra-partum infection and eclampsia, while

they are sometimes used in such chronic conditions as pulmonary

tuberculosis; various heart lesions, particularly when there is broken

compensation.

Before applying forceps the operator will usually wish to satisfy

himself that the following conditions exist: Complete dilatation of the

cervix, otherwise severe lacerations with hemorrhage may result; the

head must have entered the pelvis, otherwise an imperfect application of

the forceps may result in death of the fetus and serious injury to the

mother; the position of the child’s head must be known in order that the

forceps may be properly applied over the ears; the membranes must have

ruptured or the forceps may slip.

Forceps operations are usually designated as being high, mid or low,

depending upon the level to which the head has descended into the

pelvis. If the head is at the superior strait, a high forceps operation

is necessary; mid forceps if the head is half way down and on a level

with the ischial spines and low forceps when the head is on or just

above the perineum.

[Illustration:

FIG. 109.—Forceps sheet used in Fig. 108.

]

The application of low forceps is a simple operation and attended by

little danger to mother or child; mid forceps is more serious and high

forceps is very serious for the child and sometimes for the mother.

When forceps are applied, the patient must be at the edge of the bed or

preferably on a table, in the lithotomy position (Fig. 108), and

completely anesthetized. She should be shaved and scrubbed as for a

normal delivery, after which a sterile towel soaked in bichlorid 1–1,000

or lysol 2 per cent., is placed over the vulva and allowed to remain

until the operation is performed. She should be draped with sterile

leggings and towels, one of which is folded over the centre of a wide

strip of adhesive about twenty inches long, and hung curtain-like over

the rectum by strapping the free ends to the buttocks on each side,

while over all is placed a sheet with three openings; two slits for the

legs to pass through and one rectangle which exposes the field of

operation. (Figs. 109, 110.)

[Illustration:

FIG. 110.—Two types of easily made leggings suitable for use during

delivery or obstetrical operations.

]

=Pubiotomy=, or hebotomy, consists in sawing through the pubic bone on

one side of the symphysis with a string or Gigli saw. This operation is

performed in some cases of moderately contracted and funnel pelves,

through which the normal expulsive forces of labor are unable to force

the child. The separation of the bone allows it to gape, because of the

hingelike movement of the sacro-iliac joint, and thus the superior

strait is appreciably widened and the child may be delivered by high

forceps or version. As the bone heals by fibrous union, there is

sometimes permanent enlargement of the pelvis and there are seldom any

unsatisfactory after-effects, such as impairment of locomotion.

Pubiotomy is sometimes the operation decided upon when a patient is seen

for the first time after labor is well advanced, and a conservative

Cæsarean section is thought inadvisable because of the risk of

infection. But the operation is becoming more and more rare, for the

general practice of measuring the pelvis and supervising patients during

pregnancy discloses serious disproportions early enough to make a

Cæsarean section the elective operation.

=Symphysiotomy.= This operation is a cutting through the cartilage of

the symphysis pubis, instead of through the pubic bone, as in pubiotomy.

It was formerly performed for much the same reasons that pubiotomy is

now used, but has been practically abandoned since the development of

the latter operation. The reasons for giving it up were that the close

proximity of the bladder to the symphysis resulted in frequent injuries

to that organ, and as the cartilage of the symphysis does not heal as

well as the pubic bone, the patients frequently experienced difficulty

in walking and showed a tendency to tire more easily after the operation

than before it was performed.

=Vaginal Hysterotomy=, or vaginal Cæsarean section, as it is sometimes

called, consists of incising the cervix anteriorly and posteriorly,

delivering the child and placenta and suturing the wounds. It is

sometimes performed in cases which for some reason require immediate

delivery, as in severe cases of eclampsia. It is only possible when the

relation between the pelvis and the child’s head is such as to permit

the child to pass through the inlet. It is rarely done in primiparæ,

because rigidity of the outlet prevents proper exposure; or in multiparæ

at term as the incisions have to be extended so high to deliver a term

baby, that there is danger of tearing the lower uterine segment.

=Cæsarean Section= is the operation by means of which the child is

delivered through an incision in the abdominal and uterine walls. It is

believed by some that the operation was named for Julius Cæsar, who was

presumably delivered by this method, but this seems scarcely probable.

The operation was frequently fatal in those days and, moreover, as the

uterine wall was not sutured after the child was extracted, a woman was

not likely to have other children afterward even if she did live, and

Cæsar’s mother had several children after he was born. Another

explanation for the name is that during Cæsar’s reign a law was passed

which required that the abdomen be opened and the child extracted in

every case in which a woman died late in pregnancy, as one means of

increasing the population.

Thus it will be seen that the operation itself is very ancient, but as

performed to-day it embodies the most modern and scientific knowledge

and methods. The usual indications for it are cases of contracted or

deformed pelves; cases of tumors which block the birth canal or when

very speedy delivery is imperative as in some cases of eclampsia.

The anatomical indications for Cæsarean section are dependent upon the

degree and character of the pelvic contractions and upon the size and

mouldability of the child’s head in relation to the pelvis. This

explains why in two women with pelves of the same size and shape, one

will have a spontaneous delivery and one will require a section. The

former has a relatively small child which can pass through her pelvis;

while the second woman’s baby is too large, or the head not sufficiently

mouldable, to pass through hers.

This is one exemplification of the great importance of pelvimetry and of

constant watching during pregnancy, for the best results from Cæsarean

section are obtained when it is recognized that spontaneous delivery is

unlikely or impossible; the operation accordingly is performed at a time

which is deliberately selected by the obstetrician. The elected time is

often about two weeks before the expected date of confinement in order

that the baby may have the longest possible intra-uterine life and that

the operation may be performed before the patient goes into labor. In

these cases in which it is known that a section is to be performed

vaginal examinations are omitted after the pelvic measurements are

taken, in order to minimize the possibilities of infection, this being

one of the great risks of the operation.

Until recent years the operation was usually delayed until after the

patient had been vaginally examined, had been in labor long enough to be

exhausted and the only other courses open were high forceps or a

destructive operation upon the child. The results of the operation

undertaken under such circumstances were not good, and the maternal

deaths from infection were so frequent that the operation on the whole

was very hazardous. But improved surgical technique and extended

knowledge of the pelvis have so revolutionized Cæsarean section that it

is now successful in the majority of cases.

There are three main types of Cæsarean section: conservative, radical

and extraperitoneal.

The =conservative= operation consists of opening the abdomen in the

mid-line; incising the uterus; extracting the child and placenta, and

suturing both uterine and abdominal walls. This is the usual operation

when there is a choice, but because of the danger of infection, it is

ordinarily performed only before the onset of labor or in the early part

of the first stage, and many obstetricians are loath to undertake it

then if the patient has been examined vaginally, particularly if the

technique of the examination was open to question.

In the =radical= operation the abdomen and uterus are incised; the child

and placenta extracted and the uterus is amputated just above the

cervix. This operation is usually performed when labor is well advanced

and there is fear of infection.

In the =extraperitoneal= operation the incision in the abdomen is made

low down on one side, the peritoneum is not incised but is peeled back

from the bladder and lower part of the uterus. The uterus may thus be

opened and the child and placenta extracted, without entering the

peritoneal cavity, thereby greatly reducing the risk of infection, and

also without necessitating the removal of the uterus as a safeguard

against infection. This operation, also, is performed late in labor when

infection is feared, but is considered very difficult and therefore is

not common.

The nurse’s duties in connection with a Cæsarean section are the same as

those in any abdominal operation plus preparations for receiving and

reviving the baby.

=A Ruptured Uterus= is a splitting of the uterine wall at some point,

usually in the lower uterine segment, that has become thinned or

weakened and unable to stand the strain of further stretching incident

to uterine contractions, and is accompanied by an extrusion of all or a

part of the uterine contents into the abdominal cavity. The rupture of a

uterus during labor is a very rare accident, occurring but once in from

500 to 1,000 cases and usually only in prolonged labors, obstructed

labors or certain faulty presentations. It is also a very grave

accident, since the baby nearly always dies and sometimes the mother as

well.

The cause of a ruptured uterus may be found in scar tissue, following a

Cæsarean section or an injury; inherent defects in the tissues

comprising the uterine wall; contracted pelves; neglected transverse

presentations and the accident may occur during a version. It is usually

preceded by extreme tenderness in the lower uterine segment, the part

that is being abnormally stretched. The common symptoms, after the

rupture has occurred, are sudden and acute abdominal pain during a

contraction, which the patient describes as being unlike anything she

has ever felt and as though “something had given way” inside of her.

There is immediate and complete cessation of labor pains because the

torn uterus no longer contracts. Sooner or later the patient has

symptoms of shock because of the hemorrhage, which is usually internal,

though there may be vaginal bleeding as well. Her face becomes pale and

drawn and covered with perspiration; her pulse is weak and rapid; she

appears exhausted and collapsed and may complain of chilly sensations

and air hunger.

Abdominal palpation shows that the lower uterine segment is even more

sensitive than formerly and that the presenting part has slipped away

from the superior strait while at the side of the fetus the contracted

uterus, partly or entirely empty, may be felt as a hard mass. The

symptoms of shock may be delayed for some time when they will be

accompanied, as a rule, by abdominal distension, due to hemorrhage, and

a slight elevation of temperature.

The prevention of this disaster lies in performing version and prompt

extraction in transverse presentations, as soon as the cervix is

dilated, and in interference if the presenting part does not engage

after an hour of strong, second-stage pains.

The treatment of a ruptured uterus is influenced by many factors.

Possibly the most frequent course followed is to open the abdominal

cavity and repair or remove the uterus, after extracting the fetus and

placenta, according to existing conditions and the judgment of the

operator. Sometimes the fetus is removed through the vagina and the

uterus repaired through that channel.

=Destructive Operations= have as their purpose the crushing or

dismembering of the child in utero so that it may pass through the

pelvis. In the early days such operations were resorted to fairly often

in the presence of conditions that threatened the mother’s life and

which apparently could not be met in any other way. They are performed

less and less frequently to-day because of the success attending the

performance of Cæsarean section, version, pubiotomy and forceps

operations. They are never sanctioned by the Catholic Church in cases

where the child is alive.

=Induced Abortions and Premature Labors.= As was explained in the

chapter on complications and accidents of pregnancy, it is sometimes

deemed advisable, or necessary to terminate pregnancy by artificial

means, in the interests of the mother or child or both.

The procedures are termed _induced abortion_, _induced premature labor_

and _accouchement forcé_. The effects of these operations, _per se_,

when skillfully performed, for therapeutic purposes, are not usually

considered more serious for the mother than a normal delivery, since

they can be performed with deliberate care and cleanliness and can be

followed by adequate aftercare. When the reverse conditions prevail, as

in criminal abortions, the patient’s subsequent suffering or ill health

are more likely to be due to the poor obstetrics and unclean work which

is characteristic of practitioners who are willing to do illegal

operations, than to the termination of pregnancy itself. It is important

that the nurse fully appreciate this and be as scrupulously careful in

her preparations for, and assistance with these operations as for a

major operation or a normal delivery.

=Induced abortion= applies to the termination of pregnancy before the

child is viable, or before the end of the twenty-eighth week, and is

performed solely in the interests of the mother, as the fetus is always

lost. It is resorted to in those cases where the mother is suffering

from some condition, which may or may not be inherent to pregnancy,

which threatens her life or health but which it is believed may be cured

or arrested if uncomplicated by pregnancy. Such conditions may be

toxemic vomiting; nephritis, particularly with evidences of increasing

renal insufficiency; bleeding, due to an incomplete abortion; a dead

fetus; infection following an attempt at criminal abortion. Contracted

pelves and pulmonary tuberculosis are sometimes taken as indications for

inducing abortions, but with the development and improvement of

obstetrical operations, more and more women are able to go nearly, or

quite, to term and be delivered of live babies; while increasing medical

knowledge concerning the care of patients with tuberculosis, and also

with some heart lesions, is applied so successfully during the prenatal

period that some pregnancies which formerly would have been terminated,

are now allowed to continue, and with happy results.

The methods of induction depend upon the stage to which pregnancy has

advanced and also upon the importance of haste. In the very early

stages, one method is for the operator to dilate the cervix with a

dilator; insert one finger into the cervix and up into the uterus and

separate the placenta from its uterine attachment, while making pressure

on the uterus from above with the other hand on the abdomen. Another

method is to introduce a gauze pack into the cervix, packing it and the

vagina firmly and leaving the packing for twenty-four hours. When it is

removed the ovum frequently follows. Sometimes the membranes are

ruptured, after which the amniotic fluid drains off and the ovum is

expelled; or vaginal hysterotomy is sometimes performed when the

patient’s condition is such that haste is imperative. The termination of

pregnancy before viability is never sanctioned by the Catholic Church,

because of the almost certain loss of the child.

=Induction of premature labor.= This procedure is the termination of

pregnancy after the twenty-eighth week, or after the child is viable,

and may be performed to save either the mother or the child or both,

from conditions which would evidently work destruction if allowed to

persist. The indications for inducing labor prematurely may be a

seriously overtaxed heart or kidneys; pulmonary tuberculosis;

preëclamptic toxemia or nephritic toxemia; chorea, neuritis; pyelitis;

placenta prævia; a fetus that has been dead for two weeks, with no signs

of labor; in some cases of nephritis when the fetus during previous

pregnancies has died, and it is believed that the child may be saved by

inducing labor before the stage in pregnancy at which the others

perished.

Labor is sometimes induced when the mother’s pelvis is normal, but the

child has grown as large as is safe in anticipation of a spontaneous

labor, and particularly if the expected date of confinement has passed.

[Illustration:

FIG. 111.—Rubber bougie used in inducing labor.

]

A common method of inducing labor when haste is not important, is to

introduce one or more bougies (Fig. 111) through the cervix into the

uterine cavity between the membranes and the uterine wall. The presence

of the bougies will often stimulate the uterine contractions and bring

on labor, with expulsion of the fetus, in from six to twenty-four hours.

[Illustration:

FIG. 112.—Champetier de Ribes’ bag.

]

More speedy results are obtained by the use of rubber bags, which may be

collapsed before introduction and expanded afterward by filling them

with sterile salt solution. There is a great variety of bags for this

purpose, two of which that are frequently used are the Champetier de

Ribes (Fig. 112) and the Voorhees bags. (Fig. 113.) They come in

graduated sizes, the largest holding about 500 cubic centimetres.

[Illustration:

FIG. 113.—Voorhees’ bag, collapsed.

]

[Illustration:

FIG. 114.—Rubber bag rolled and held in forceps for introduction into

uterus.

]

[Illustration:

FIG. 115.—Syringe for introducing sterile water into bag after its

insertion into the uterus.

]

The operation is performed with the patient in the dorsal position. The

cervix is drawn down into sight, with forceps, and if intact, is

slightly dilated. The bag is rolled tightly, held in suitable forceps

(Fig. 114), and after being well lubricated is introduced through the

slightly dilated cervix into the lower uterine segment, and pumped full

of sterile salt solution. The solution is first measured in order to be

sure that the bag is filled to its desired capacity, and is then

introduced by means of a syringe, (Fig. 115), through the rubber tubing

which is attached to the lower end of the bag, and which is then closed

off by the stop cock, to prevent escape of the fluid. It is very

important that the solution be sterile in view of the possibility of any

rubber bag rupturing, particularly when pressed upon by the contracting

uterus. (See Fig. 47 for position of bag after introduction into

uterus.)

The presence of this bag stimulates uterine contractions, the cervix

dilates, the bag is expelled and in some instances the child is

delivered spontaneously and in others by means of forceps. The effect of

this bag in producing labor may be hastened by tying a weight to the end

of the tubing and allowing it to hang over the side of the bed. This

traction and pressure help to dilate the cervix and seem to increase the

irritation of the uterine muscles, thus increasing the force of their

contractions.

=Accouchement forcé= is a speedy, forced delivery requiring the forcible

widening of an intact, or partly dilated cervix, manually, or

instrumentally. It is sometimes performed when existing conditions

require extreme haste, as in certain heart lesions; eclampsia; concealed

or accidental hemorrhage or in any condition which suddenly arises to

threaten the life of the patient or her expected baby. But as the shock

of this operation is great and the condition which threatens the patient

can usually be better relieved by means of some one of the operations

already described, it is less and less frequently performed.

THE MIRACLE[7]

Elizabeth Newport Hepburn

The wind blows down the street,

A shutter bangs somewhere,

While twilight falls as softly as

A woman’s flowing hair.

Within a quiet room,

Adventurers at rest,

A mother holds her newborn son,

Safe, now, upon her breast!

For out of Night and Pain,

The womb of mystery,

Is sprung this miracle of Life

That she can touch and see.

No seer’s prophetic dream,

No star in all the skies

Burns with a lustre half so bright

As happy mother eyes.

No quester for the Grail,

No searcher for the Truth,

Counts more than those who bear and rear

And love and nurture Youth!

Within her curving arm,

All safe and warm he lies,

The heir of all that Man has won

Down countless centuries!

PART V

THE YOUNG MOTHER

CHAPTER XIV. THE PUERPERIUM. Physiology. Involution. After-pains.

Lochia. Loss of Weight. Menstruation. Lactation. Abdominal Wall.

Digestive Tract. Temperature. Pulse. Skin. Urine.

CHAPTER XV. ROUTINE NURSING CARE DURING THE PUERPERIUM. Complications

to be Guarded against. General Treatment of the Patient. Nursing

Care. Position in Bed. Sitting up. The Daily Bath. Diet. The Bowels.

The Bladder. Catheterization. Temperature, Pulse, and Respiration.

Care of the Perineum. Care of the Breasts. Lactation. Stripping.

Abdominal Binders and Bed Exercises.

CHAPTER XVI. THE NURSING MOTHER. Normal Routine. The Establishment of

Breast Feeding. The Mother’s Frame of Mind and State of Nutrition.

Method of Nursing. The Nursing Schedule. Personal Hygiene of the

Nursing Mother. Diet. Bowels. Rest and Exercise. Recreation.

Weaning. Drying up the Breasts.

CHAPTER XVII. NUTRITION OF THE MOTHER AND HER BABY. Importance of

Adequate Nutrition in First Weeks of Life. Necessary Elements of an

Adequate Dietary. “Vitamines.” Danger of Deficiency Diseases. Danger

of Conditions Approaching Recognizable Disease. The Deficiency

Diseases. Scurvy. Infantile Scurvy. Corrective Diet. Beriberi.

Xerophthalmia. Pellagra. Rickets. Corrective Diet. Application of

Principles of Nutrition to the Diet of the Nursing Mother.

CHAPTER XVIII. COMPLICATIONS OF THE PUERPERIUM. Postpartum Hemorrhage.

Causes, Treatment and Nursing Care. Puerperal Infection. History of

Disease. Prevention. Symptoms, Treatment and Nursing Care.

Phlegmasia alba dolens, or “Milk leg.” Puerperal Mania.

CHAPTER XIV

THE PHYSIOLOGY OF THE PUERPERIUM

The puerperium[8] is ordinarily regarded as comprising the five or six

weeks immediately following delivery. During this period the mother’s

body undergoes various changes which restore it very nearly to its

pre-pregnant state, leaving the patient in a normal, healthy condition.

The most important of these changes are involution of the uterus, loss

of weight and improvement in tone of the abdominal and perineal muscles.

The alterations which produce this restoration are normal physiological

processes, but mismanagement or lack of care while they are taking place

may result in serious complications; these may be immediate or remote,

such as hemorrhage and infection or chronic invalidism.

Recognition of these dangers, and the possibility of preventing them, is

responsible for the present custom of obstetricians to watch over their

patients during the puerperium. This is in sharp contrast to the old

practice of the doctor’s visiting the puerperal woman only when there

was a complication so apparent that he was summoned.

The precautions and the care which the doctor takes of his patient after

delivery involve intelligent and watchful nursing. In order to give this

the nurse must understand something of the normal physiology of the

puerperium, just as she did in pregnancy and labor. Otherwise she may

not be able to distinguish evidences of normal changes from symptoms of

complications.

=Involution.= Considerable attention is centred in the remarkable

atrophic changes that take place in the uterus during the puerperium,

for it is upon their being normal that the patient’s recovery and future

well-being so largely depend. Immediately after delivery the uterus

weighs about two pounds; is from seven to eight inches high; about five

inches across and four inches thick. The top of the fundus may be felt

above the umbilicus, and the inner surface, where the placenta was

attached, is raw and bleeding. At the end of six or eight weeks the

uterus has descended into the pelvic cavity and resumed approximately

its original position and size, and its former weight of two ounces; a

new lining has developed from the few glands which have not been cast

off in the discharges.

This rapid diminution in the size of the uterus is termed involution and

is accomplished by means of a process of self-digestion or _autolysis_.

The protein material in the uterine walls is broken down into simpler

components which are absorbed and eventually cast off largely through

the urine. This change and absorption of uterine tissues is similar to

the resolution that takes place in a consolidated lung in pneumonia.

Since satisfactory involution is necessary to the patient’s future

health, its progress should be watched with deep concern and interest,

and all possible effort made to promote it; firm consistency of the

uterus and a steady descent into the pelvis and normal lochia being the

chief evidences of satisfactory involution. There is evidently a close

relation between the functions of the breasts and of the uterus during

the puerperium, and as a rule involution accordingly progresses more

normally in women who nurse their babies than in those who do not.

The so-called “after-pains” are also affected by nursing, being more

severe as a rule when the baby is at the breast than at other times.

These pains are caused by the alternate contractions and relaxations of

the uterine muscles and are more common in multiparæ, than in primiparæ,

because the muscles of the former have somewhat less tone than the

latter and therefore tend to relax, and then contract, whereas the

better muscle tone of the primipara tends to keep the uterus steadily

contracted.

These after pains usually subside after the first twenty-four hours,

though they may persist for three or four days. They may amount to

little more than discomfort, but not infrequently are so severe as to

require the administration of sedatives. Persistent after pains may be

due to retained clots.

The cervix, vagina and perineum which have become stretched and swollen

during labor, gradually regain their tone during the puerperium, and the

stretched uterine ligaments become shorter as they recover their tone,

finally regaining their former state. Until the ligaments and the pelvic

floor and abdominal wall are restored to normal tonicity the uterus is

not adequately supported and therefore may be easily displaced.

=The lochia= consists of the uterine and vaginal secretions and the

blood and uterine lining which are cast off during the puerperium.

During the first three or four days this discharge is bright red,

consisting almost entirely of blood, and is termed the _lochia rubra_.

As the color gradually fades and becomes brownish it is called the

_lochia serosa_. After about the tenth day, if involution is normal, the

discharge is whitish or yellowish and is designated as the _lochia

alba_. The total amount of the lochial discharge has been variously

estimated at from one to three pints, being more profuse in multiparæ

than primiparæ, and in women who do not nurse their babies. Under normal

conditions the discharge is profuse at first, gradually diminishing

until it entirely disappears by the end of the puerperium. There may be

small amounts of blood retained during the first day or two and expelled

later as clots, without any serious significance, and there may be a

pinkish discharge after the patient gets up for the first time, but if

the lochia is persistently blood-tinged it may be taken as an indication

that the uterus is not involuting as it should.

The normal characteristic odor is flat and stale. A foul odor, no odor

at all or a marked decrease in the amount of the discharge is suggestive

of infection.

=Loss of Weight.= One of the striking changes during the puerperium is

the loss in weight, due largely to three factors: the elimination of

fluids from the edematous tissues; the decrease in the size of the

uterus and the escape of vaginal and uterine secretions, termed the

lochia. The smaller amount of food taken during the first few days

post-partum also may be a factor.

This loss in weight is extremely variable, fat women naturally losing

more than thin women and those who nurse their babies losing more than

those who do not.

Dr. Edgar estimates that the loss through the lochia amounts to

something over three pounds, and the loss through fluids from the

tissues, from nine to ten pounds. According to Dr. Slemons, the loss in

fluids equals about 1/10th of the patient’s weight at the beginning of

the puerperium, while all agree that the uterus decreases about two

pounds in weight. All told, then, the patient may normally lose from

twelve to fifteen pounds during the puerperium. This loss may be

somewhat controlled, however, by a suitable diet, and under most

conditions the patient should return to not less than her pre-pregnant

weight by the end of the sixth or eighth week.

=Menstruation.= Although in the ideal course of events, the mother does

not menstruate while nursing her baby, that is, for eight to ten months,

Dr. Slemons estimates that about one-third of all nursing mothers begin

to menstruate about two months after delivery, while according to Dr.

Edgar one-half of those who do not nurse their babies begin to

menstruate in six weeks after delivery.

Menstruation is more likely to return early in primiparæ than in

multiparæ. Patients sometimes wonder whether this early discharge is

menstrual or lochial, and though they can not tell, a physician can

easily decide by examination, and it is important that he be given the

opportunity to do so. A nursing mother may menstruate once and then not

again for several months or a year; or she may menstruate regularly and

nurse her baby satisfactorily at the same time, though menstruation is

usually regarded as unfavorable to lactation.

=Lactation.= During the first two or three days after the baby is born,

the breasts secrete a small amount of yellowish fluid called colostrum,

which differs from milk chiefly in that it contains less fat and more

salts and serum-albumen than milk and in the fact that it coagulates

upon boiling. About the third day after delivery, the meagre amount of

colostrum is replaced by milk and as it increases rapidly in amount, the

breasts usually become tense and swollen at this juncture, and sometimes

very painful; but this turgidity usually subsides after a day or two.

The function of the breasts, that of secreting milk, is definitely

stimulated by the baby’s suckling and will not continue for more than a

few days without this stimulation, a fact to be remembered if it is

desirable for any reason to dry up the breasts.

The ideal condition is for the breasts to secrete a quantity and quality

of milk which will adequately nourish the baby for eight or ten months.

The reverse of this condition is sometimes found in very young or in

elderly women, or in very fat or frail, undernourished women.

Ovulation is usually suspended during lactation, but a mother may become

pregnant a few weeks after delivery even while nursing her baby, though

the quality of her milk is likely to be unfavorably affected by the

pregnancy. But, as has been explained, the return of menstruation does

not necessarily exert as unfavorable an influence upon lactation as was

formerly believed.

=Abdominal Wall.= The abdominal wall is usually overstretched during

pregnancy, and immediately after labor when the tension is removed, the

skin lies in folds and the entire wall is soft and flabby. The normal

and desirable course is for the muscles gradually to regain their tone;

for the excess of fat to be absorbed and the walls to approach their

original state in the course of a few weeks. The striæ usually remain,

and the muscles sometimes fail to regain their tone, as for example when

pregnancies follow each other in rapid succession or when there has been

excessive distension. In such cases there is likely to be the pendulous

abdomen so often seen in multiparæ, and a diastasis, or separation of

the rectus muscles.

=Digestive Tract.= During the first day or two after delivery the mother

may have very little appetite but she is usually very thirsty. She will

almost inevitably be constipated, because of the loss of intra-abdominal

pressure; the sluggishness of the intestines acquired during pregnancy;

her recumbent position, lack of exercise and the fact that she is taking

relatively less food than usual and that her bowels were freely

evacuated at the onset of labor.

=Temperature.= The temperature often rises to about 99° F. immediately

after labor but it should drop to normal in a few hours and practically

remain so. For various causes, some of which are unexplained, the

temperature will not infrequently be slightly above normal at times

during the first few days of the puerperium, without the patient’s

seeming to suffer any ill effects. But the fairly general agreement

among obstetricians seems to be that a temperature of 100.4° F. is the

upper limit of normality and that infection is to be suspected if it

reaches that point and remains there for twenty-four hours.

=Pulse.= The normal pulse rate is usually slower during the puerperium,

being about 60 or 70 beats to the minute, and is referred to as

puerperal _bradycardia_. It is thought that this is due to the absolute

rest in bed and the decreased strain upon the heart after the birth of

the baby.

=Skin.= There is usually profuse perspiration during the first few days,

while the elimination of fluids is most active, but it gradually

subsides and becomes normal by the end of a week. The perspiration

sometimes has a strong odor and there is not infrequently an appreciable

amount of desquamation.

=Urine.= Many patients find it difficult, even impossible, to void urine

during the first several hours after delivery because of the removal of

intra-abdominal pressure; the recumbent position and the swelling and

bruised state of the tissues about the urethra. The bladder is likely to

be less sensitive than usual and the patient will be able to retain an

abnormally large amount of urine for several hours without discomfort,

or desire to void.

The output of urine during the first few days is greater than normal,

and there is also a considerable increase in the amount of nitrogen

excreted, beginning two or three days after delivery. This is evidently

derived from the broken down proteins in the uterine wall, and the

excess gradually subsides as involution progresses, and disappears by

the time the uterus descends into the pelvis.

When one considers the severe ordeal that the young mother has just

passed through, her recovery and return to a normal state are

surprisingly rapid, when she is given good care.

CHAPTER XV

NURSING CARE DURING THE NORMAL PUERPERIUM

In general, the nursing care during the puerperium is much the same as

that which is given to a surgical patient, with special attention to the

breasts and perineum and a sustained effort to prevent complications and

restore the mother to a normal state of health in due time.

As the nurse doubtless realizes by this time, the principal

complications to guard against during the puerperium are hemorrhage from

the still raw area, where the placenta was attached to the inner surface

of the uterus; infection of the birth canal; breast abscesses;

displacement of the uterus and subinvolution, or failure of the uterus

to return to its normal size and condition in the usual length of time.

In addition to guarding against these definite complications, the nurse

must help to save her patient from the less tangible, but perhaps

equally injurious effects of fatigue of mind and body. As many young

mothers are in a more or less unstable, excitable condition after the

baby’s birth, the beneficial effect of promoting a tranquil and

contented state of mind can scarcely be overestimated.

The doctor may be ever so tactful and cheering and sustaining, but his

contacts with the patient are short and infrequent as compared with the

nurse’s constant companionship. She can, therefore, by her attitude,

manner and conduct practically create or destroy the atmosphere that is

necessary to her patient’s welfare.

In order to give the best and most helpful service the nurse must try

from the very beginning to understand her patient as an individual and

adapt herself to the patient’s temperament. Some women are rested and

soothed by being talked with, read to, diverted and amused in one way or

another, during most of the time, and will grow nervous and depressed if

left to their own devices. Others, who have greater resources within

themselves are happier and better off when left to themselves a good

deal, and given an opportunity to think things over. Some women are much

subdued as the consciousness of their motherhood grows upon them, and

they feel a kind of awe and wonder about this baby that they begin to

realize is their own. It is a big experience, this one of motherhood,

full of promise and responsibilities, and the young mother herself very

often wants to think it out. She will enjoy talking when she wants to

talk, but may be irritated and exhausted by a nurse who tries to

entertain her all of the time.

For this reason, the most conscientious and painstaking nurse imaginable

may destroy her usefulness, by adopting the wrong attitude toward her

patient during this period of enforced intimacy. Some women want, and

even need to be indulged and petted; but, on the other hand, a certain

type of reserved and dignified woman is affronted by such attention or

by the easy air of familiarity that another courts; one patient is

exhausted by the unvarying punctuality and precision of a conscientious,

but unadaptable nurse, while that very punctuality and precision is

satisfying and restful to another.

It is not a simple matter to sound the depths of a patient’s

personality, for they are all complex and each one is peculiar to

herself. That fact must not be overlooked for each patient is an

entirely new and different problem and not like any other that the nurse

has had before. But the nurse who is sincere and sympathetic and who

earnestly tries to put herself in her patient’s place and see things

from her standpoint, will, by virtue of that very attitude, accomplish

much toward sensing the patient’s temperament and establishing

harmonious relations. Moreover, the patient, herself, will all

unconsciously make something of an adjustment to the nurse when she

feels the nurse’s sincerity and her eagerness to be of service.

One factor in shaping the young mother’s state of mind, which the nurse

must take into account is that the entire scheme and purpose of her

patient’s life have been changed. She has been plunged very suddenly

into a wholly new condition and her reaction to this change will depend

upon her temperament, disposition and habits of adjustment.

She has spent nine months looking forward to an event that has been

consummated; she has spent nine months in a state of more or less

apprehension and suspense that have been abruptly ended, and we know

that it is quite natural for any one to experience a letting down, or

something akin to collapse, when long-continued uncertainty is ended,

even though it ends happily.

And as recovery progresses the patient becomes aware, perhaps only

vaguely, of another change which is not always a welcome one. For nine

months she has been the centre of interest in her immediate circle; she

has been the object of unremitting concern and solicitude, and much as

she and her family may have tried to keep her life normal, she and her

needs have constantly been given the first consideration. The very

mystery of the child developing within her has created an attitude of

respect, almost of reverence, which was never her portion before. In

every way she has been shielded, protected and cared for, and all eyes,

including her own, have steadily looked forward to the event for which

this care has been preparing her—her ordeal of childbirth and the coming

of her baby.

And now her ordeal is over. Her baby is here. Every one may be said to

be breathing easily at last and they are no longer apprehensive and

absorbingly interested in her. As a result the young mother will soon

become simply one of the family and the community, and will cease to be

the centre of reverential interest and solicitude.

It is scarcely human to welcome such a change in one’s state, and though

in all probability very few mothers are conscious of resenting it, very

many actually do. And for this reason very many unwittingly cling to a

rôle of semi-invalidism. It is entirely unconscious on their part and it

is also very human and natural.

To aid in the process of bracing up such a young woman to resume her

former life and to meet the demands which it imposes; or to protect

another patient of the eager, buoyant type from exposing herself too

early to the onslaughts made by everyday life, is far from being a

simple task, and to meet it no one rule can be laid down. There are all

of the variations and degrees between the timid or self-indulgent woman,

who must be encouraged and spurred on, and the too active, ambitious

patient, who must be steadied and held back for a time.

But here, again, this is simply a part of the nurse’s duty; one aspect

which makes nursing the gratifying service that it is.

Fortunately the majority of young mothers are happy and normal in their

outlook and may be kept so by the exercise of an average amount of tact

and amiability on the part of the nurse. The actual physical care of the

patient during the puerperium is a fairly simple matter for the well

trained nurse. She will find, however, that in hospitals, private

practice and public-health work alike there will be wide differences in

the treatment given by different doctors, during this period, just as

there were during pregnancy and labor, and she will have to carry out

the prescribed directions enthusiastically and loyally no matter how

they vary from those of the doctors who helped in her training.

The details of the care will be indicated by the individual doctor, but

the general, underlying principles—cleanliness, watchfulness,

adaptability and sympathetic understanding will apply to the nursing of

all patients. The most notable differences of opinion relate to the care

of the breasts, the perineum and the use of abdominal binders, the

accepted routine for the general nursing of average, normal cases being

fairly uniform the country over.

NURSING CARE

As has been stated, the general nursing care of the puerperal patient is

much the same as that given to any surgical patient, with such

adaptations as are indicated by the condition and needs of the young

mother.

=Position in Bed.= The question of the patient’s position in bed is

probably the first one that presents itself to the nurse after that

first hour when the patient must be kept flat on her back and the fundus

closely watched. She should continue to lie quietly on her back for a

few hours, with only a small pillow under her head, as moving about may

cause hemorrhage. Some doctors permit the patient to turn from side to

side at will after a few hours of quiet, while others do not allow this

for two or three days particularly if the patient has perineal stitches,

unless her knees are tightly bound together. Their reason for this

precaution is fear that the stitches may be torn out if the thighs are

separated and also that air may gain access to the uterine vessels,

through the relaxed and gaping birth canal, and produce air embolism. It

is a routine in some hospitals to keep the head of the patient’s bed

elevated during the first week, to promote drainage, but as a rule it is

in the usual position.

[Illustration:

FIG. 116.—Height of fundus on each of the first ten days after

delivery.

]

Quite commonly the patient is encouraged to lie first on one side and

then on the other, after she begins to move about in bed unassisted, and

then face downward at intervals, in order to change the position of the

uterus and thus tend to prevent backward displacement.

In many hospitals, it is part of the daily routine to measure and record

the height of the fundus (Fig. 116) above the symphysis, in addition to

noting the character, amount and odor of the lochia, in order to judge

if involution is progressing normally. A uterus that does not remain

firm and does not steadily shrink in size and descend into the pelvis is

not involuting properly, and the usual remedy is more rest and a longer

stay in bed, with an icecap over the fundus.

=Sitting Up.= Except when there are perineal stitches or the temperature

has been elevated at some time following delivery, the patient is

ordinarily allowed to sit up in bed about the sixth or eighth day. If

the lochia is normal, the uterus firm and in the proper position in the

abdomen and her general condition satisfactory, she is allowed to sit up

in a chair for a little while about the ninth or tenth day. Some

patients are able to sit up for an hour the first time without being

tired, but it is often better for them to sit up for a few moments

morning and afternoon on the first day, than for a longer time at one

stretch. The patient is usually allowed to sit up an hour longer on each

successive day and to walk a few steps on the third or fourth day after

getting up.

A patient with stitches does not usually sit up in bed until the ninth

or tenth day, when the stitches are removed, sitting up in a chair for

an hour, two or three days later. If she has had fever, the time at

which she may sit up will of necessity depend upon her condition.

The return to normal life must be very gradual and this also must be

regulated by the patient’s general condition and her recuperative

powers. A pinkish or red discharge or backache should be taken as

warnings against standing or walking or working. The possible

consequences of ignoring these warnings and being up and about too soon,

may be displacement, even prolapse of the uterus; hemorrhage, from

dislodgment of clots in the uterine vessels; metritis or endometritis.

It is not a good plan, as a rule, for the patient to go up and down

stairs until the baby is about four weeks old, nor wholly to resume her

normal activities within six or eight weeks after delivery.

In addition to this sustained, general care, it is a customary

preventive measure for the doctor to make a thorough pelvic examination

from four to six weeks after delivery. A slight abnormality, if detected

at this time may usually be corrected with little difficulty, but if

allowed to persist may result in chronic invalidism or necessitate an

operation. If the uterus is not properly involuted, for example, or the

perineum is found to be flabby, more rest in bed is indicated; while a

uterine displacement, which seems to be present in about a third of all

cases, usually may be corrected by the adjustment of a pessary.

The time of sitting up, of getting up and of walking about varies so

with the individual, therefore, that it is not possible to describe a

definite routine, for some patients recover slowly and would be injured

by getting up and about at a period which would be entirely safe and

normal for the majority. It must be determined in each case by the

condition of the uterus, the appearance and amount of the lochia and the

patient’s general condition.

Quite evidently, then, much ill health and many gynecological operations

may be prevented by caution, prudence and good care during the first few

days and weeks after the baby’s birth, while the patient returns to a

normal mode of living.

=The Daily Bath.= During the first week or two the patient’s skin must

aid in excreting fluids from the edematous tissues throughout the body

and broken down products from the involuting uterus. Therefore she

should have a bath of warm water and soap every day, to remove material

already on the surface and stimulate the skin to further activity, and

an alcohol rub at night, if possible. It is important for the nurse to

remember, while bathing her patient, that she is perspiring freely and

therefore may be easily chilled if not well protected.

It is often a good plan to have the patient, without stitches, begin to

bathe herself in bed, after the third or fourth day, for the sake of the

exercise, and also the encouragement that it offers. When all is going

well, tub-bathing is usually resumed by the third or fourth week.

=Diet.= Opinions as to diet vary slightly with different doctors and in

different hospitals, but in general, a patient in good condition is

given liquid food during the first twelve to twenty-four hours after

delivery; then a soft diet for a day or two, a nourishing, light diet

being resumed by the third or fourth day, or after the bowels have moved

freely.

The patient will usually have little appetite, at first, and will have

to be tempted by small amounts of invitingly served food. The factors

which the nurse must bear in mind when arranging the patient’s dietary

are the general nutrition of the mother; the desirability of minimizing

her loss of weight during the puerperium; increasing her strength and,

particularly, of promoting the function of her breasts, in order to

produce milk of a quality and quantity adequate to nourish the baby.

The best producer of such milk is a diet consisting largely of milk,

eggs, leafy vegetables and fresh fruits, taken with an appetite that is

made keen by constant fresh air. The nurse will do well to convince her

patient of this, in addition to bearing it in mind herself, and to place

little reliance on so-called milk producing foods.

The young mother’s dietary may well be made up from the groups of foods

that are suitable for the expectant mother. (See Chapter VI). At this

time, as during pregnancy, she must avoid all food which may produce any

form of indigestion, but for the baby’s sake, now, as well as her own.

While it is not generally believed, to-day, that there are many, if any

articles of diet which in themselves affect the mother’s milk

unfavorably, it is generally conceded that a derangement of her

digestion may, and usually does, have a deleterious effect upon her

milk, and therefore upon the baby.

The old, and widespread, belief that certain substances from such highly

flavored vegetables as onions, cabbage, turnips and garlic are excreted

through the milk, to the baby’s detriment, is not given general credence

to-day. On the other hand, it is known, however, that certain protective

substances in certain foods are excreted through the milk, to the baby’s

distinct advantage, and it is therefore, important that the mother’s

diet should regularly contain those articles of food which contain them.

These foods are milk; egg yolk; glandular organs, such as sweet-breads,

kidneys and liver; the green salads, such as lettuce, romaine, endive

and cress and the citrus fruits, or oranges, grapefruit and lemons.

These are called “protective foods” because they protect the body

against the so-called deficiency diseases known as scurvy, beri-beri,

xerophthalmia, which with rickets and pellagra are discussed in the

chapter on Nutrition. It is possible for a baby who nurses at the breast

of a woman whose diet is poor in protective foods, to be so

insufficiently nourished, in some particular, as to be on the border

line of one of these diseases, or even to develop the disease itself.

This is one reason for the statement that the nursing mother must “eat

for two.”

Certain drugs are excreted through the milk and may affect the baby in

the same way as though they were administered directly, for example:

salicylic acid, potassium iodid, lead, mercury, iron, arsenic, atropine,

chloral, alcohol and opium.[9]

In addition to her food the nursing mother should have an abundance of

water to drink, and to facilitate this it is a good plan to keep a

pitcher or thermos bottle of water on the bedside table, and replenish

it regularly, every four hours.

In general, the young mother should have light, nourishing, easily

digestible food, with little, if any meat; an abundance of cereals,

creamed dishes, creamed soups, eggs, salads and the fresh fruits and

vegetables which ordinarily agree with her; at least a quart of milk,

daily, in addition to that which is used in preparing her meals, and an

abundance of water to drink.

=The Bowels.= The puerperal patient is almost always constipated, and

needs assistance in regaining regularity in the movements of her bowels.

The routine use of cathartics and enemata varies, but it is very common

to give an enema on the second morning after delivery or castor oil or

Rochelle salts, followed by an enema if necessary. After this, a mild

cathartic or a low enema is given often enough to produce a daily

movement when this is not accomplished by means of the diet.

Some doctors, however, prefer that the bowels shall not move for four or

five days after delivery, believing that this delay reduces the danger

of infection from the intestinal contents, which are swarming with

organisms, particularly the colon bacillus.

In cases of third degree tears, catharsis is practically always delayed

for four to six days in order that the torn edges of the rectal

sphincter may become well united before being strained by a bowel

movement. In these cases an enema of six or eight ounces of warm olive

oil is often given and the patient encouraged to retain it over night,

in order to soften the contents of the rectum and lessen the strain and

irritation of evacuation.

=The Bladder.= The question of helping the patient to void after

delivery is one of extreme importance, because she will almost certainly

have difficulty in emptying her bladder, and yet catheterization is not

to be resorted to unless absolutely necessary. As a rule the patient

should be encouraged to try to void from four to eight hours after

delivery. If she is unable to do so at first there are several aids

which the nurse should employ before admitting the patient’s inability

to empty her bladder. Inducing her to drink copious amounts of hot

fluids is the first step. Very often she will then void if placed upon a

bedpan containing water hot enough to give off steam, and more warm,

sterile water is poured directly upon the urethral outlet; or hot and

cold sterile water may be dashed, alternately, upon the meatus.

The sound of running water is often helpful as well as the application

of hot stupes over the supra-pubic region. When everything else fails,

success frequently follows the application of a partly filled hot-water

bottle over the bladder, held in place by a tight binder, particularly

if the patient rests upon a pan of steaming water at the same time.

The danger of infecting the bladder, by carrying lochia into it upon the

catheter, is so great that some doctors choose what they regard as the

lesser of two evils, and allow the patient to be assisted to the sitting

position, if she has not a serious tear. Not infrequently the patient’s

inability to void is due to the fact that she is unaccustomed to using a

bedpan, and would have difficulty in using one under any conditions, but

is able to void while sitting up. As the danger of infection is greater

two or three days after delivery than at first, because of the beginning

decomposition of the lochia, it is very evidently important to help the

patient to establish the habit of voiding from the beginning, for if she

is catheterized once there is great likelihood that she will need to

have it continued for some days.

If the first attempts are unsuccessful, therefore, but the patient

thinks that she may be able to void later, if the efforts are repeated,

catheterization is sometimes delayed for as long as sixteen to eighteen

hours after delivery in the hope that it may be avoided altogether.

When the most persistent and painstaking efforts fail, and

catheterization is necessary, the nurse must remember the extreme

gravity of her responsibility and preserve asepsis throughout the

procedure. Although there is extreme danger of infection, it can be

prevented as a rule, and its occurrence is therefore regarded as almost

inexcusable.

In preparing for catheterization, the nurse should drape the patient as

for a vaginal examination, making sure that she is warmly covered, and

place her on a sterile douche- or bedpan. If it is done at night she

should place the light in a position at once safe and advantageous. She

should have at hand on a tray: sterile forceps; cotton pledgets; two

glass catheters (in case one should be broken or become contaminated); a

disinfecting solution such as bichlorid, 1–4,000 or lysol 1 per cent.; a

sterile receptacle in which to receive the urine; sterile towels and a

dressing basin or paper bag for the used pledgets.

The preparation of the nurse’s hands, at this point, varies in different

hospitals, but always the greatest care is taken to bring nothing

unsterile in contact with the vulva and meatus.

According to one method, the nurse scrubs her hands for three minutes

and prepares the patient as for a vaginal examination, removes the

douche pan and places a sterile towel over the vulva. She then scrubs

and soaks her hands as described in Chapter XII, puts on sterile gloves,

places a sterile towel over the patient’s abdomen and slips one under

her hips. She should then separate the labia with the gloved fingers of

the left hand, drawing the fingers upward a little to make the meatus

more prominent. The inner surface of the labia is then bathed with

pledgets soaked with the disinfecting solution, with downward strokes,

each pledget being used but once. Five or six pledgets should be used,

one after the other, to sponge the meatus, each pledget being placed

squarely against the orifice, without touching the adjacent tissues, and

given a slight, downward twisting motion and discarded. The bowl may

then be placed in position to receive the urine, and the catheter picked

up with the fingers, by its open end. The rounded end must be carefully

inspected to insure against using one that is cracked or broken, after

which it is slowly and gently introduced into the urethra for two or

three inches. If the urine does not flow freely the catheter may be

slightly withdrawn and light pressure made upon the bladder.

Before removing the catheter the nurse must locate the fundus and assure

herself that it is in a proper position. If it is pushed up or to one

side she will know that the bladder is still distended, and that more

urine must be withdrawn. After the bladder has been emptied the nurse

should place one finger over the open end of the catheter and remove it

slowly.

Another method of catheterization differs from the one just described,

in the preparation of the nurse’s hands. In this instance she simply

washes her hands well with soap and hot water and wears neither gloves

nor finger cots.

She bathes the vulva with pledgets and an antiseptic solution, using

forceps, and then separates the labia with two dry pledgets, one each

under forefinger and thumb of the left hand, and proceeds as above. It

will be observed that the nurse avoids touching the inner surface of the

labia or the meatus with anything but sterile pledgets and the sterile

catheter. The advantage of this procedure is that it is accomplished

quickly and with the minimum of disturbance to the patient.

A distended bladder may so easily occur unless the patient is carefully

observed during the puerperium that the nurse should charge herself to

watch for this complication. She should give the patient a bedpan every

four hours, note the contour of the abdomen and measure the urine during

the first week, remembering that the patient should void considerably

more than the average amount, both because of the amount of milk and

water that she is taking, and the fluid which she is eliminating from

her tissues. The importance of measuring the urine lies in the fact that

though the patient may void fairly regularly she may not empty her

bladder, and thus enough urine may accumulate to distend it.

=The temperature, pulse and respirations= are usually taken and recorded

every four hours for the first five or six days and then two or three

times daily, if normal. If the temperature is above normal at any time,

the nurse should take it every two hours until it becomes normal and

notify the doctor immediately if it goes as high as 100.4° F., or if the

pulse reaches 100.

=Care of the Perineum.= The best way of caring for the perineum, during

the first week or ten days after delivery, is a moot question, and the

nurse may find herself sorely perplexed by the widely divergent

instructions of different doctors who have excellent results, unless she

goes back of the details themselves and recognizes their purpose. She

will then see that there is entire agreement about the importance of

protecting the patient against infection, at this time, when infection

may so easily occur. And so far as the nurse is concerned, this means

cleanliness as to methods and appliances, when making perineal

dressings, and extreme precaution against conveying infection to her

patient. The minimum requisites for this are that the bedpan shall be

sterilized, by steam or boiling, at least once a day, and well scrubbed

and scalded after each time that it is used, and that the nurse shall at

least scrub her hands with soap and hot water before making each

perineal dressing, and apply only sterile pads.

After the perineum is bathed, immediately following delivery, the usual

practice is to apply a sterile pad, after which a fresh one is applied

as often as necessary at first, every four hours during the first week

and subsequently every eight hours. When the dressing is changed, and

after each voiding and defecation, the perineum is bathed with sterile

pledgets and some such antiseptic solution as bichlorid 1–2,000 or lysol

½ per cent. or 1 per cent. (Figs. 117 and 118.) The soiled pad must

always be removed from above downward and the bathing also directed

toward the rectum, each pledget being used for one stroke only. The

rectum is bathed last, a fresh sterile pad applied and the patient’s

hips and back thoroughly dried.

The nurse may be required to scrub and soak her hands, wear sterile

gloves and hold the pledgets in forceps when bathing the perineum, the

object of such precautions being, quite clearly, to avoid infecting the

patient from without, for the inner surface of the uterus is still

regarded as an open wound.

[Illustration:

FIG. 117.—Preparation and draping of patient for post-partum dressing.

Note rack of equipment on table; bag of dry, sterile pledgets at

head of bed; paper bag on floor for used pledgets. The nurse has

scrubbed her hands. (From photograph taken at The Manhattan

Maternity Hospital.)

]

Some obstetricians believe that the perineal pad is a menace, since it

slips and moves about, and thus may transfer infective material from the

anus to the vagina. Accordingly, they forbid the use of all perineal

dressings and instead have large, sterile, absorbent pads slipped under

the patient’s hips to receive the lochia, the pads being changed as

often as necessary. This is the practice at the Brooklyn Hospital, for

example, where the nurse bathes the vulva with lysol 1 per cent.,

placing the patient on a sterile bedpan, using sterile forceps and

cotton swabs and wearing sterile gloves while making the dressing.

Another method is to place the patient on a sterile bedpan, remove the

pad and with gloved hands pour from a sterile pitcher a warm antiseptic

solution over the groin and outside of the vulva; then to separate the

labia and pour the solution between them, in some instances pressing a

dry, sterile pledgets to the vaginal orifice during the irrigation.

[Illustration:

FIG. 118.—Equipment, in rack, used at The Manhattan Maternity Hospital

in bathing perineum. A, pitcher of lysol, 1%. B, basin of pledgets

in lysol. C, sponge-sticks in alcohol.

]

When the urine is being measured, as it frequently is during the first

week, the solution which is used for irrigating the vulva should be

measured beforehand and the contents of the bedpan measured after the

dressing, in order that the amount of urine passed, if any, may be

ascertained.

Another method of bathing the perineum, that employed at Johns Hopkins

Hospital, is simply to bathe the perineum with soap and warm water,

without separating the labia, using a clean wash cloth and afterwards

applying a sterile pad, the pads being changed every four hours, or

oftener if necessary. The theory upon which this procedure is based is

that the steady outward flow of the lochia constantly carries material,

infective and otherwise, away from the generative tract, and that if

nothing is introduced between the labia or into the vagina the patient

will not be infected.

In caring for the perineum, the nurse must remember also the real danger

of the patient infecting herself with her own fingers and should caution

her against taking this risk. The patient should be told that if she

feels uncomfortable, or thinks she is bleeding, she must lie quietly and

summon a nurse, but on no account to try to find out for herself what is

wrong. There is little doubt that cases of severe infection have been

caused by the introduction of organisms into the vagina by means of the

patient’s own fingers, after the most scrupulous precautions had been

taken by doctors and nurses to avoid that very disaster.

In most instances the care of the perineum is the same whether or not

there are stitches, and in any case the method employed will be

specified by the doctor. The nurse’s responsibility is to appreciate the

object of the care, whatever form it may take, and bring intelligence to

bear in giving it.

When there are perineal stitches, it is a wise and harmless precaution

to fasten a towel or bandage about the patient’s knees for a few days,

to prevent her pulling apart the uniting edges of the tear as she moves

about in bed.

=Douches.= In connection with perineal dressings, it may be well to

caution the nurse against giving douches without explicit orders.

Douches are seldom given early in the puerperium, for fear of carrying

infective material up into the uterus, except occasionally in cases of

hemorrhage, in which case they are given by the doctor.

Sometimes, however, a low vaginal douche is given daily for some time

after the patient gets up, with the idea of increasing her comfort and

promoting involution. About two quarts of some weak antiseptic solution

at 110° F. is given with the nozzle introduced just within the vaginal

outlet, and the container of the solution placed only slightly above the

level of the patient’s hips, in order that the stream may be very

gentle.

[Illustration:

FIG. 119.—Sterile gauze held in place over nipples by means of

adhesive strips and tapes. (From photograph taken at Bellevue

Hospital.)

]

=The Care of the Breasts.= There is a wide difference of opinion about

the proper care of the breasts, also, but here again, although the

details vary, the ultimate objects of the care are always the same,

namely: to facilitate the baby’s nursing, promote the mother’s comfort

and prevent breast abscesses. These ends are usually accomplished by

keeping the nipples clean and intact and by giving support and rest to

heavy, painful breasts.

The patient who has cared for her nipples during the latter part of

pregnancy will usually have little or no trouble with them during the

period of lactation, if the care is continued. But this attention is

imperative.

It is very generally customary to have the nipples bathed before and

after each nursing with a saturated solution of boracic acid, in either

water or alcohol, using sterile pledgets and forceps, and to keep them

clean between nursings by applying sterile gauze. This gauze may be held

in place by means of a breast binder or by tapes tied through the ends

of narrow strips of adhesive plaster, four being applied to each breast.

(Fig. 119.) Strips of adhesive plaster about five inches long are folded

over at one end, two adhesive surfaces being in contact for about an

inch. Through a hole in the folded end a narrow tape or bobbin is tied

and the strips applied to the breast, beginning at the margin of the

areola and extending outward. The free ends of the tapes are tied over

squares of sterile gauze, between nursings, and untied to expose the

nipple at nursing time.

Lead shields are sometimes used to protect the healthy nipple and not

infrequently are applied to cracked nipples, being held in place by

means of a breast binder. The secretion of milk which escapes into the

shield is acted upon by the metal and the result is a lead wash which

continuously bathes the nipple. The shields should be scrubbed with

sapolio and boiled once daily.

Another method, and one widely employed, is to anoint the nipple after

nursing with sterile albolene or a paste of sterile bismuth and castor

oil, and apply squares of sterile paraffin paper. These bits of paper

are pressed into place and held for a moment by the nurse’s hand, the

warmth of which softens and moulds them to the breast after which they

remain in place. In some instances the bismuth and castor oil paste is

wiped off, with a sterile pledget, before nursing and in others it is

not.

In some hospitals, neither gauze nor paper is used, the nipples being

protected by putting sterile night-gowns on the patients.

The purpose of all of these methods is to keep the nipples clean, and

here again the patient must be cautioned against infecting herself. No

amount of care on the nurse’s part will protect the patient if she

touches her nipples with her fingers.

The nurse will appreciate the reason for all of this painstaking care if

she calls to mind the fact that the breast tissues are highly vascular

and excessively active at this time and therefore very susceptible to

infection, and also that the baby’s suckling is often very vigorous and

accompanied by a good deal of chewing and gnawing of the nipples. Unless

the nipples have been toughened, and sometimes even when they have, the

skin becomes abraded or cracked as a result of the baby’s suckling, thus

creating a portal of entry for infecting organisms, in addition to the

milk ducts which lead back into the breast tissues. Unless the nipples

are kept clean, constantly, they may become infected by organisms from

the baby’s mouth or on the patient’s hands, bedding or gown with a

breast abscess as a result. The important thing, then, is to keep the

nipples clean and not allow anything unsterile, excepting the baby’s

mouth, to come in contact with them at any time.

[Illustration:

FIG. 120.—Protecting cracked nipples by having the baby nurse through

a shield. (From photograph taken at Johns Hopkins Hospital.)

]

It is sometimes the practice to swab the baby’s mouth with boric soaked

cotton or gauze before each nursing, but many doctors hold that this is

injurious to the delicate mucous lining of the baby’s mouth. The

opinions for and against this routine seem to be about equally

prevalent.

[Illustration:

FIG. 121.—Nipple shield used in Fig. 120.

]

If the nipples become painful or cracked, one can easily understand that

continued suckling would only aggravate the condition and increase the

danger of infection. But the baby must nurse, if possible, and so in the

majority of cases a nipple shield is used (Figs. 120–121) as a

protection, and after nursing the fissures or abraded areas are painted

with bismuth and castor oil paste; compound tincture of benzoin; balsam

of Peru; argyrol, silver nitrate or sometimes only alcohol. The

application is made with sterile swabs prepared by twisting a wisp of

cotton about the end of a toothpick. If the crack or abrasion is

extensive enough to cause bleeding, even nursing through a shield is

sometimes, but not necessarily discontinued, while the other treatment

is the same as for a nipple that does not bleed.

Sound, uninjured nipples, then, are to be kept clean and protected from

infection and those which are abraded or cracked are to be kept clean

and also protected against further injury.

=Lactation.= About the third or fourth day after delivery, when milk

replaces colostrum, the breasts become swollen, engorged and often very

painful, and not infrequently, a hard, sensitive lump or “cake” may be

felt. The growing tendency, now, is merely to support these heavy

breasts by means of a binder which has straps passing over the

shoulders, in order to hold them up without making pressure (Fig. 122)

and to apply ice caps or hot compresses to the painful areas. It used to

be customary to massage and pump caked breasts, to apply pressure and

various kinds of lotions or ointments. Though one, or all of these

measures are still employed, in some cases, the general practice is to

avoid manipulating the breasts but to empty them regularly by the baby’s

nursing; support them and allow Nature to make an adjustment between the

amount secreted and the amount withdrawn.

[Illustration:

FIG. 122.—A simple method of supporting heavy breasts by means of

three folded towels; one fastened about the waist, one over each

shoulder, crossing front and back.

]

Free purging is sometimes employed and the amount of fluids reduced

until the engorgement and discomfort subside. This happy issue is

practically always reached if the baby nurses regularly and

satisfactorily, as there is a spontaneous adjustment between the amount

secreted by the mother and that withdrawn by the baby. But as abscesses

may follow in the wake of caked breasts, particularly if the nipples are

sore, it is of great importance that the nurse watch closely for the

first evidence of painful lumps. The prompt application of a supporting

bandage and ice bags (Fig. 123) or hot compresses will, in the majority

of cases, give speedy and complete relief. So widely is this believed

that many doctors regard the care of the breasts, including the

prevention of breast abscesses, as a nursing question, entirely, and

conversely are likely to regard the occurrence of a breast abscess as an

evidence of careless nursing.

[Illustration:

FIG. 123.—Ice caps held in place on painful breasts by straight binder

with darts pinned in under breasts and supported by shoulder straps

of muslin bandage.

]

Certain it is that breast abscesses are almost never seen where the

nurses have this sense of responsibility, and habitually watch the

breasts closely and promptly use support and either heat or cold when

the breasts become heavy and sensitive.

There are innumerable bandages and methods for supporting heavy breasts,

any one of which is efficacious so long as it meets the two chief

requirements: to lift the breasts, suspending their weight from the

shoulders, and, while fitting snugly below to avoid making pressure at

any point, particularly over the nipples. One of the most satisfactory

and widely used supports is the Y-bandage, (Figs. 124, 125, 126),

another, the Indian binder (Fig. 127.)

[Illustration:

FIG. 124.—Modified Richardson “Y” binder made of two strips of soft

muslin, full width of material and 44 inches long, folded into

strips of same width as distance from margin of patient’s breast to

outer part of areola. One strip is folded in the middle at right

angles and pinned to one end of the other strip as indicated. (Figs.

124, 125, 126, with captions, are from The Maternity Hospital,

Cleveland, by courtesy of Miss Calvin MacDonald.)

]

The nurse must on no account massage or pump engorged breasts on her own

responsibility, for there is a good deal of evidence to show that any

such manipulation tends to increase the amount of the secretion and this

in turn increases the engorgement and pain. It is possible, too, that

massage may bruise the breasts and thus make them more susceptible to

infection.

=Mastitis.= When infection occurs, the swollen, painful breasts may grow

hot and red, the patient may complain of chilliness and have a slight

fever, with or without there being an abscess. Even then the general

treatment is most frequently found to consist of support; ice or heat;

catharsis and restricted fluids, though in some cases the breasts are

pumped and nursing is discontinued.

[Illustration:

FIG. 125.—Bandage in Fig. 124 applied. The long arm of binder is

placed under patient’s shoulders, one end of the Y being brought

around the top of the breasts and the other around the lower part,

toward the nurse, crossed at right angles under the arm and pinned

to long arm of bandage as indicated in Fig. 126. The nipples are

covered with sterile gauze and the upper and lower parts of the Y

fastened with a safety pin between the breasts. The remaining length

of the long arm is brought across the breasts and fastened with a

safety-pin to the opposite side. When the baby nurses this pin is

removed as well as the one between the breasts. The entire binder

should be snug and held in place by means of shoulder straps, pinned

front and back.

]

When the inflammation so far progresses as to require that the breast be

opened and drained, the subsequent nursing care will be outlined by the

doctor to meet the needs of each case. It is a painful operation and

often a serious one, for the destruction of breast tissue may be

extensive enough to render the breasts valueless as milk-producing

organs. The healing is slow and altogether the occurrence is a most

lamentable one.

[Illustration:

FIG. 126.—Y bandage in Fig. 125 seen from the opposite side.

]

The nurse’s part in preventing this complication is cleanliness and

gentleness in her attentions; unremitting watchfulness; immediate

application of a suspensory bandage and either heat or cold, upon the

first sign of engorgement and prompt reporting to the doctor.

[Illustration:

FIG. 127.—Indian Binder used at The Montreal Maternity Hospital for

supporting heavy breasts. The tapering ends tie in a knot in front.

]

If the patient’s nipples have not been toughened during pregnancy or if

flat or retracted nipples have not been satisfactorily brought out, it

may be necessary for the nurse to employ the treatment to these ends

which were described in the chapter on pre-natal care. In the meantime

the baby may have to nurse through a shield until the nipple is brought

out prominently enough for him to grasp it well.

=Stripping.= Sometimes in cases of depressed nipples, which the baby

cannot grasp, or when the baby is too feeble, to nurse at the breast,

milk is withdrawn from the breast by means of so-called “stripping.” The

nurse should scrub her hands thoroughly with hot water and soap and dry

them on a sterile towel before beginning. The breast is grasped by

placing the thumb and forefinger of the right hand on the areola on

opposite sides of the nipple but well below it. The nipple is then

raised from the breast by a quick, lifting and rolling motion of the

thumb and finger, accompanied by slight pressure. A sterile medicine

glass should be held in position to receive the milk which spurts from

the nipple, but the glass should not touch the breast. (Fig. 128.)

[Illustration:

FIG. 128.—Position of thumb and finger below nipple on areola, in

stripping breasts. (From photograph taken at The Long Island College

Hospital.)

]

There is a knack about stripping and it requires practice, but those

doctors who advocate it feel that it empties the breast, when this is

necessary, with less disturbance than that caused by pumping, and as the

milk is projected directly from the nipple into the sterile glass,

without any of it running over the nipple or breast as may happen in

pumping, it has the additional advantage of always being sterile.

Extreme gentleness must be used; the openings of the milk ducts must not

be touched by the fingers, and the thumb and finger must not press

deeply enough to reach the glandular tissue itself. If done properly

stripping neither stimulates nor bruises the breast tissue nor does it

cause the patient even temporary discomfort.

=Abdominal Binders and Bed Exercises.= There is considerable difference

of opinion about the advantage of using abdominal binders upon the

puerperal patient while she is in bed, and the nurse will accordingly

care for the patients of some doctors who use them and for those of

others who do not.

The application of a moderately snug binder for the first day or two is

a fairly common practice, for multiparæ, particularly, are often made

very uncomfortable by the sudden release of tension on their flabby

abdominal walls; a discomfort which a binder will relieve. And during

the first few days after the patient gets up and walks about, she is

sometimes given great comfort by a binder that is put on as she lies on

her back, and is adjusted snugly about her hips and the lower part of

her abdomen.

But the continued use of a binder after the first day or two, while the

patient is still in bed, is not as general as it formerly was. Many

women ask for binders in the belief that they help to “get the figure

back” to its original outline, and some doctors feel that the use of the

binder is helpful in restoring the tone to the abdominal muscles, which

amounts to about the same thing. Both the straight swathe and the

Scultetus binder are used for this purpose and they are put on in the

usual manner; snugly and with even pressure, but not tight enough to

bind.

Those doctors who disapprove of the binder believe that it interferes

with involution and, by making pressure, tends to push the uterus back

and cause a retro-position, in addition to retarding instead of

promoting a return of normal tone to the abdominal muscles.

Accordingly, they instruct their patients to take exercises, instead of

wearing binders, and they have these exercises started while the patient

is still in bed. Their adoption, and the rate at which they are

increased, are entirely dependent upon the individual patient’s

condition, for they must never be continued to the point of fatigue.

There are, therefore, no definite rules laid down, concerning these

exercises, beyond a description of the positions and movements

themselves, and their sequence.

Those which are taught to the patients at the Long Island College

Hospital are so simple, and evidently productive of such happy results

that they offer excellent examples of this form of treatment. They are,

of course, taken only by the doctor’s order, but the nurse’s intelligent

supervision increases their effectiveness.

[Illustration:

FIG. 129.

Figs. 129 to 135, inclusive, are bed exercises taken during the

puerperium.

For description see text. (From photographs taken at The Long

Island College Hospital.)

]

The general purpose of these exercises is to strengthen the abdominal

muscles, thus helping to prevent a large, pendulous abdomen; to increase

the patient’s general strength and tone, just as exercise benefits the

average person; to promote involution; to prevent retro-version and in a

measure, increase intestinal tone and thus relieve constipation. To

accomplish these much to be desired ends the exercises must be taken

with moderation and judgment; started slowly; increased very gradually

and constantly adapted to the strength of the individual patient.

Otherwise they may do more harm than good. In the average, uncomplicated

case in which the patient is doing well, she usually starts the

chin-to-chest exercise from twelve to twenty-four hours after delivery.

She should lie flat on her back and raise her head until her chin rests

upon her chest. (Fig. 129.) If she rests her hand upon her abdomen, she

will feel for herself that the abdominal muscles contract, and

accordingly will be disposed to continue the exercises with more

interest and confidence than she otherwise might. The movement is

repeated twenty-five times, morning and evening, every day, and

continued as long as the patient is in bed.

[Illustration:

FIG. 130.

]

[Illustration:

FIG. 131.

]

The familiar, deep-breathing exercise is ordinarily started on the third

or fourth day. The patient should lie flat, with her arms at her sides,

then extend them straight out from the shoulders (Fig. 130), raise them

above her head (Fig. 131) and return them to the original position. This

is repeated ten times morning and evening, daily, as long as the patient

is in bed.

[Illustration:

FIG. 132.

]

The one-leg-flexion exercises are not done by patients with perineal

stitches, but in other cases they are usually started about the fifth

day. The thigh is flexed sharply on the abdomen and leg on thigh (Fig.

132), then extended and lowered to the bed. This is repeated ten times,

with each leg, morning and evening for one, or possibly two days.

The next exercise replaces the one-leg-flexion and is started after the

latter has been done for one or two days, according to the strength of

the patient, and it in turn is continued for only one or two days. Both

thighs are sharply flexed on abdomen and legs on thighs (Fig. 133), then

extended and lowered but not far enough for the heels to rest upon the

bed before being flexed again. This is repeated ten times morning and

evening.

[Illustration:

FIG. 133.

]

[Illustration:

FIG. 134.

]

Next is the exercise for which the leg-flexion exercises prepare the

patient, and which are discontinued when this one is adopted. It is

started, as a rule, about the seventh day, or three or four days before

the patient gets up. Both legs are slowly lifted to a position at right

angles to the body (Fig. 134) and slowly lowered, but not far enough for

the heels to touch the bed (Fig. 135), and the movement repeated. As

this exercise requires a good deal of effort, it must be taken up very

gradually, as follows: The legs should be raised on the first day, once

in the morning and twice in the evening; second day, three times in the

morning and four times in the evening; third day, five times in the

morning and six times in the evening and so on, if the patient is not

fatigued, until the exercise is repeated ten times each morning and

evening. It is continued for several months.

[Illustration:

FIG. 135.

]

The knee chest position (Fig. 136) is intended to counteract the

tendency toward retroversion, from which so many women suffer after

childbirth. It is usually started about the seventh day and the patient

begins by remaining in that position for a moment or two, gradually

lengthening the time to about five minutes each morning and evening for

about two months.

[Illustration:

FIG. 136.—Knee chest position.

]

[Illustration:

FIG. 137.—Walking on all fours. (From a photograph taken at the Long

Island College Hospital.)

]

Walking on all fours is violent exercise and has to be taken up very

gradually. Some patients are able to attempt it on the first day out of

bed, if they have been taking the other exercises, but as a rule it is

not started until the second or third day. The patient’s clothes should

be free from all constrictions; the knees should be held stiff and

straight with the feet widely separated, to allow a rush of air into the

vagina, and the entire palmar surface of the hands should rest flat on

the floor. (Fig. 137.) The patient should start by taking only a few

steps each morning and evening, gradually lengthening the walk to five

minutes twice daily and continuing it for about two months.

It is believed that as the patient walks in this position the uterus and

rectum rub against each other producing something the same result as

would be obtained by massage. The effect of the exercise is to promote

involution and diminish the tendency toward constipation and

retroversion, apparently preventing malposition entirely in a large

percentage of cases. Though not widely used, its beneficial effects are

unquestioned by those doctors who employ it.

Obstetrical Nursing A Text-Book on the Nursing Care of the Expectant Mother, the Woman in Labor, the Young Mother and Her Baby · 第 11 / 15 章

The patient is usually tired and cold at the conclusion of labor, and