PREPARATIONS FOR LABOR AND THE NORMAL COURSE OF LABOR
=The Nurse.=—Scientific obstetric nursing is a specialty that enlists
the interest of exceptional women only.
It demands a high sense of duty, a strong physique, broad training,
unusual judgment, and rare tact. The nurse must be professionally
aseptic and personally clean. She should keep herself free from odors,
and bathe at least three times a week. The presence of pus anywhere on
her body disqualifies her _at once_, and she should report off duty.
The compensation should always be somewhat higher than for other work,
because there are two patients to be cared for.
An obstetric nurse should specialize in her work, and not take
infectious cases. Unhappily the haphazard character of the onset of
labor presents a difficulty. The patient frequently can not afford to
have the nurse for a long time in advance of labor, and the nurse whose
income is limited by the number of her cases can not afford to be idle.
Hence, it is better for two nurses to work in alternation with one
another, so that one is always available in an emergency.
Both doctor and nurse should visit the lying-in room before labor
begins, and plan its rearrangement. At least a week before the expected
confinement, the chamber selected should be thoroughly cleaned and the
woodwork wiped off. Curtains, draperies and bric-a-brac and all useless
furniture should be removed. Carpets must be taken up, or at time of
confinement, well protected. Rugs can be easily managed. A chair, a bed,
and the various tables for instruments and solutions are all that are
required.
The nurse usually is called to the case first, and upon her falls the
responsibility of the diagnosis and the burden of the preparation. As
soon as she arrives and satisfies herself that the patient is really in
labor, she puts the final touches to the room. In her own mind she goes
over all possible emergencies and prepares to meet them.
The following supplies should be in the house for the labor:
3 hand basins, 10 inches in diameter.
3 hand brushes.
1 two-quart douche bag.
15 yards nonsterile gauze.
2 lb. each of cotton batting and absorbent cotton for making bed
pads.
2 pieces of rubber sheeting 1 by 2 yards.
5–yd. jar of borated gauze.
4 oz. lysol (or ziratol).
100 c.c. of Squibb’s chloroform.
2 oz. green soap.
2 oz. solid albolene.
8 oz. alcohol.
½ oz. ergotol.
½ oz. bismuth subnitrate and ½ oz. boric acid powder mixed.
1 nail file.
=Nurse’s outfit consists of the following:= Nail file, surgical
scissors, catheter (silver is best), hypodermic syringe with tablets of
morphine, strychnine, and digitalis; two fever thermometers, one for
mouth and one for rectum; a pair of tissue forceps and a razor.
Some time before the labor, the nurse should call on the patient and
establish a working acquaintance. It adds greatly to her authority and
to the patient’s confidence in her. Her advice will be sought on a
multitude of subjects, partly real and partly to try her out.
[Illustration: Fig. 31.—Abdominal binder with crosspiece to hold vulvar
pads.]
[Illustration: Fig. 32.—T-binder, used in all cases after the fifth day
post partum.]
=Sterilizing= may be done in a hospital, or, if this is not feasible,
the nurse should go to the house two or three weeks before the expected
labor and sterilize in an Arnold or Rochester sterilizer the following
articles:
½ doz. sheets.
3 doz. towels.
2 pillow slips.
3 abdominal binders of unbleached cotton, 16 in. wide and 36 in.
long, folded and hemmed.
4 T bandages.
3 breast binders.
2 jacket parts of pajama suits.
3 pairs of long white stockings.
3 packages of vulvar dressings (see Preparation of Supplies, p.
326).
2 obstetric pads 1 by 36 by 36 inches.
1 pillow slip full of cotton pledgets for sponges.
1 jar applicators (cotton twisted about toothpicks).
1 jar of gauze pledgets for perineorrhaphy and cord dressings.
Everything must be neatly wrapped and labeled.
[Illustration: Fig. 33.—Breast binder.]
[Illustration: Fig. 34.—Baby’s dress with winged sleeves.]
=Infant’s Outfit.=—
12 plain slips 27 inches long of dimity or nainsook (with winged
sleeves).
3 long sleeve shirts, silk and wool (size No. 2).
6 pinning blankets, made of outing flannel, if it is a winter
baby.
3 bands, 6 by 18 inches, clip or notch edges, do not hem.
3 petticoats, flannel bottoms and muslin waists, without sleeves
and with small button on shoulders.
3 outing flannel wrappers.
6 plain, soft muslin dresses.
3 (Arnold) knitted night gowns, light weight.
4 doz. light weight cotton diapers, 20 x 40 inches. Bird’s-eye
linen is the best. Wash and dry these in the air before using.
4 soft towels (linen preferred).
2 quilted pads.
4 soft wash cloths.
4 wool wrapping blankets.
1 pair scales that weigh ounces and fractions thereof.
4 oz. of olive oil or benzoated lard.
4 oz. of alcohol (95 per cent).
¼ lb. boric acid crystals.
½ lb. absorbent cotton.
1 cake of castile soap.
2 oz. solid albolene.
½ oz. subnitrate of bismuth powder and ½ oz. of powdered boric
acid mixed.
1 bed pan.
2 basins, holding 2 quarts each.
1 papier mache, rubber, or enamel ware bathtub.
=Anæsthetics.=—Excessive pain is destructive and disintegrating to the
vital forces. Many a woman who has passed through a particularly severe
labor remembers her experience with a horror that forever precludes its
repetition.
This is the day of relative painlessness in labor, and all the world is
striving to make childbirth easier and less lethal. No woman, unless she
herself requests it, should be permitted to go through the agony of
labor without an anæsthetic, judiciously selected and carefully
administered.
Pain-deadening agents are numerous and inexpensive, and it is only a
matter of experience and judgment to choose a method that will reduce
the suffering of childbirth to a minimum. The second and first stages of
labor, in the order named, demand the most in the way of relief.
A prolonged first stage with nagging, violent and apparently useless
pains may devitalize the patient more than short, but acute pains of the
second stage. In the first stage, under proper selection of cases and
experienced supervision, “Twilight Sleep” will be successful in seventy
to eighty per cent of the cases.
By success, is meant that the patient is relatively free from pain. When
the drugs do not relieve pain, the case is a failure (fifteen per cent),
although in no case, when properly given, is the mother or child
endangered. Morphine solution ⅙ gr. and scopolamine hydrobromid 1/200
gr. to 1/150 gr. is the customary dosage for the first injection.
Another injection of 1/200 gr. is given in a half or three-quarters of
an hour. The room is darkened, talking is forbidden, and the family
exiled. The patient gets red in the face and very thirsty, the pulse is
rapid but full. She answers questions very slowly and drowsily, awakes
for her contraction but goes right off to sleep again. In this condition
she is kept through bi-hourly repetitions of the scopolamine until the
delivery. It is this half waking and half sleeping condition that
suggested the name of “Twilight Sleep.”
Morphine and scopolamine will relieve the pains of the first stage
without greatly protracting the labor. The same drugs may and probably
will prolong the duration of the second stage. The first dose should be
given as soon as the patient is well started in labor.
“Twilight Sleep” is at present a hospital procedure, and the technic so
exacting as to weary the attendants greatly. It can not be employed
until the woman has definitely gone into labor and is at least three
hours away from delivery. It is not serviceable where the pains are weak
and shallow; and it must be used with wise circumspection, if at all, in
the presence of complications.
For the second stage, there is a choice of three drugs: gas, chloroform,
and ether. Like twilight sleep each is open to some objection, but each
may be of the greatest assistance if used under appropriate indications
and conditions.
Gas has one advantage, in that it in no way interferes with the pain
activities; and Lynch and Davis have shown that with a proper admixture
of oxygen, it may be given with comparative safety for the two or three
hours which may mark a normal second stage. To administer it a competent
machine for mixing the gas is necessary. It should not be given to
patients who have bad hearts, high blood pressure, or toxæmia. Neither
is it a satisfactory anæsthetic when the head delivers, for the mother
being less relaxed and more rigid, the legs and muscle action are harder
to control and unnecessary perineal lacerations are liable to occur. The
patient is instructed to take several deep breaths just as the uterine
contraction comes on and the gas bags supply about 75 per cent nitrous
oxide and 25 per cent oxygen. As the pain passes off the oxygen is
increased and the nitrous oxide diminished until the mind is again
clear.
To save the perineum and better to control the patient, when the head is
about to pass the vulva, it is wiser to abandon the gas for chloroform
or ether.
Obstetrical operations, such as forceps and version, require ether or
chloroform, and not gas. The dangers vary with the anæsthetic chosen, as
well as the amount and the method of administration. Ether affects the
respiration, chloroform attacks the heart. Ether must not be given near
an open flame. Chloroform is not explosive but is decomposed by fire
into an irritating gas. Chloroform must be diluted with 90 per cent of
air, hence the mask must be open, or the napkin held free from the face,
so that plenty of air can enter. Ether and chloroform, when given “_a la
reine_;” i. e., a few drops on the mask at the beginning of each pain
and increased up to the acme, is relatively free from danger. They have
the additional advantage that the sleep may be instantly deepened if
operation is required. Chloroform, it is now believed, predisposes
mildly to post partum hæmorrhage. Davis has shown that neither ether,
gas, nor chloroform affects the child injuriously if the administration
is intermittent and not too greatly prolonged.
To summarize: Morphine and scopolamine combined is a first stage
analgesic, which has too much value to be neglected.
Gas, if an apparatus is to be had, may work well for the greater part of
the second stage, while for operations, or for the period of expulsion,
during which the head passes the perineum, chloroform and ether give
bests results. Moreover, chloroform “_a la reine_” may be given safely
and efficiently by a competent nurse and in many instances _must_ be
given by the nurse, if at all.
When the perineum bulges, or the head becomes visible at the vulva, the
nurse should anoint the lips, cheeks and tip of the nose with cold cream
or olive oil, to avoid burning the skin, and lay two or three
thicknesses of handkerchief or gauze over the nose (an inhaler is best).
An abundance of room must be left underneath and at the sides of the
mask for air to enter.
At the beginning of the pain a few drops of chloroform are poured on the
cloth and the patient instructed to breathe vigorously. The cloth is
removed as soon as the pain ceases and when the next contraction comes
on, the process is repeated. As the head passes the perineum, the
chloroform should be pushed to complete anæsthesia, both to save
suffering and to give the doctor full control of the perineum. When the
nurse gives the anæsthetic, she should watch the doctor for his signal
to increase the vapor or remove the mask.
_Summary._—Cover the eyes with a wet towel and anoint the face with
cream or oil before using chloroform. Remove false teeth, if present.
Obstetric degree—a few drops on mask at beginning of each pain.
Surgical degree—complete anæsthesia.
Watch pulse and respiration.
A nurse should never leave a patient who has had an anæsthetic until she
is conscious. Vomiting is especially dangerous.
=Normal Labor.=—Labor is the process by which a fœtus of viable age is
expelled from the uterus.
By normal labor is meant a case where the fœtus presents by the vertex
and terminates naturally without artificial aid, or complications. It
varies greatly in severity, duration and danger to mother and child. A
first labor is more prolonged and difficult than later confinements. A
woman in her first delivery is called a primipara, in subsequent cases,
a multipara.
The _date_ at which labor comes on is difficult to determine accurately.
The average duration of pregnancy is from 275 to 280 days, forty weeks,
or ten lunar months, but conception does not occur necessarily at the
time of coitus, nor is it possible to know with any certainty when it
does occur.
Labor may occur two weeks earlier than calculated, with benefit to the
mother, and no harm to the child; but if the woman goes over time, the
child becomes much larger and the labor harder and more dangerous to
both.
=Causes of Labor.=—Why labor should occur at all is not known. Many
theories have been advanced, none of which is entirely satisfactory.
Some of the best known are the growing irritability of the uterus
accompanied by an increase in the frequency and strength of the
intermittent uterine contractions or increasing distention of the
uterus. Thus it is believed that when the uterus is distended up to a
certain point, it will try to relieve itself like the bladder, or a
baby’s stomach. It may be that any one of the following factors, or all
of them acting together, are influential.
Dilatation of the cervix by the presenting part.
Increasing distention of the lower half of the uterus with pressure on
neighboring nerve structures.
The circulation of fœtal products of metabolism (toxins) acting on the
nerve centers.
The menstrual periodicity.
Heredity and habit.
Physical and emotional causes.
The onset of labor probably is not purely accidental, and yet it is so
inconstant in appearance and so indifferently early or late, that it has
every appearance of being an affair of chance. The time when labor will
come on is highly speculative in general, but the phenomenon is preceded
by certain definite symptoms:
The lightening.
False pains.
Show.
Rupture of membranes.
The pains.
_Lightening._—About two weeks before labor, especially in a primipara,
the uterus and the head sometimes descend into the pelvis. The body of
the child falls forward and the abdomen protrudes, the stomach is
flatter, the patient breathes easier and feels, as she says, “lighter.”
But walking is more difficult, the bladder is stimulated to frequent
evacuations and the rectum is compressed.
This occurrence is a premonitory sign of labor, and also favorable
inasmuch as it demonstrates that this particular head is not too large
to pass this particular pelvis.
_False pains_ may appear, especially in multiparas, from two to four
weeks before labor. In some of these cases the pains may be due to gas
or indigestion and respond to hot applications and enemas, or there may
be definite uterine contractions, as shown by the hardness of that organ
during a pain, but the phenomena are irregular and therefore not typical
of labor pains.
Usually they pass off in a few hours, but if the patient is nervous, the
doctor or nurse may be called needlessly. The patient, therefore, should
be instructed to have the pains timed by the watch for half an hour or
an hour. If they are regular during this period, the physician should be
notified. Upon his arrival, an internal examination will reveal the true
character of the disturbance by the condition of the cervix and os.
_The show_ is a discharge of thick, white mucus, slightly stained with
blood. This is the mucus plug which occludes the cervix during pregnancy
and when the os begins to dilate, the mass is released and passes out.
Labor usually comes on vigorously within twelve hours.
_The membranes_ may rupture before labor begins and much fluid escape.
The advantage of the dilating bag of water and lubricating qualities of
the liquor amnii are thus lost. Such a labor is called a “dry birth” and
is frequently slow, exhausting, and extremely painful.
_The pains_ are the subjective manifestations of the powers of labor.
The forces concerned are uterine and abdominal muscles, principally
assisted by those of the back, legs, and arms. Their constricting action
on the nerve fibers in the walls of the uterus is the cause of the pains
in the first stage. The onset may be violent and go on to a quick
delivery, but generally the inception is more insidious.
The _irregular_, _painless_ contractions, (of Braxton Hicks) that were
mentioned on an earlier page, gradually at term change their character
and become _regular_ and _painful_.
At first they may be slight and vague, lasting only half a minute and
separated by intervals of ten or fifteen minutes and scarcely attract
the patient’s attention. They are felt chiefly in the abdomen.
More or less rapidly they increase in frequency, severity and duration.
They last from a minute to a minute and a half and come every three
minutes. The whole uterus hardens and its outline is clearly defined
during the contraction; it relaxes and becomes soft in the interval. The
woman is now in labor. The pains become grinding and the patient feels
that she is not accomplishing anything, yet under the influence of these
contractions the cervix is effaced and the os is dilated.
=The Course of Labor.=—Labor is divided for convenience into three
stages as follows:
The _first stage_, from the beginning of pains until the complete
dilatation of the os.
The _second stage_, from the complete dilatation of the os to the
delivery of the child.
The _third stage_, from the delivery of the child to the expulsion of
the placenta.
The _first stage_ is the stage of dilatation.
Usually at term, the cervix is columnar and unshortened, the canal
intact, and closed at both ends, as shown in Fig. 36.
In multiparas the outer opening will usually admit the tip of the
finger.
As labor proceeds, the cervix is _effaced_, the os slowly dilates, and
the bag of waters forms.
_The Bag of Waters._—When the cervix is effaced and only the os remains,
the lower end of the egg with its fluid restrained by the membranes,
bulges forward into the canal. The fœtal head, or breech presses into
the pelvis, and the fluid in the membranes, compressed between the
presenting part above and the cervix below, is called the bag of waters.
When the contraction comes on the longitudinal muscular fibers of the
uterus are drawn upward and the bag of waters becomes tense and pushes
farther and farther down into the opening; and by its even and universal
pressure, mechanically and slowly increases the size of the opening
which the muscular traction is pulling apart. At the same time, the
fluid around the child prevents, for a time, direct and injurious
compression on the body. When no definite cervical projection can be
felt, and when the teat-like protrusion of the cervix has disappeared,
the cervix is said to be effaced.
[Illustration: Fig. 35.—The bag of waters begins to act on the cervix.
(Eden.)]
The os now begins to stretch and widen, the bag of waters becomes more
and more evident, vomiting occurs, and at last, when the os has expanded
to a diameter of four inches (ten centimeters), the membrane can
withstand the pressure no longer. It ruptures, a certain amount of fluid
escapes, the presenting part comes down against the opening, and like a
valve, prevents the outflow of the waters from above.
[Illustration: Fig. 36.—The effect of the pains. The cervix before labor
begins. (Bumm.)]
[Illustration: Fig. 37.—The effect of the pains. The cervix begins to be
“effaced.” (Bumm.)]
[Illustration: Fig. 38.—The effect of the pains. The cervix is effaced,
and the dilatation of the os begins. (Bumm.)]
[Illustration: Fig. 39.—The effect of the pains. The cervix is effaced,
and the os continues to dilate. (Bumm.)]
Sometimes the labor may be preceded by some hours (two or three), or
days (two or three), even weeks (two or three), by the rupture of the
membrane, and sometimes when the structure is thick and tough, the
rupture may be delayed until well into the second stage, or even until
the child is born. In the latter case, the head comes out, covered with
membrane. In the old days, this was called being “born with a caul.” It
was supposed to be a lucky omen, but it was lucky only that the babe
escaped suffocation. The membrane should be torn open quickly.
The duration of this stage is variable. It is much longer in primiparas
than multiparas. It averages sixteen hours in the former, and eight
hours in the latter. Vomiting during this stage is quite common, but the
pulse and temperature remain normal. The first stage of labor is usually
under the entire control of the nurse. It is her responsibility.
With complete dilatation of the os, the _second stage_, or stage of
expulsion, begins, whether the membranes rupture or not. The presenting
part, usually the head, passes from the cervix into the vagina. The
vagina in turn gradually dilates from above downward until uterus,
cervix and vagina form a single, wide channel of the same diameter. The
child is driven forward by the uterine contractions, strongly reinforced
by the abdominal muscles, which the patient uses vigorously. The onset
of each pain is accompanied by a deep inspiration, followed by straining
or bearing down with the abdominal muscles as in a highly exaggerated
bowel movement. The patient holds her breath, braces her feet, fastens
her hands on bed or attendant, and uses all the trunk muscles in the
effort. The face becomes congested, the pulse quickened, she perspires
some, and groans deeply during the contraction. The pain is extreme and
is due partly to the stretching of the vagina and vulva and partly to
the distention of deeper sensitive structures.
When the head reaches the pelvic floor, the first change observed in the
external genitals is the stretching (bulging) of the perineal body.
Next, the anus becomes turgid, dilates slightly, the anterior wall
becomes visible, and the hairy scalp of the child appears at the vulva.
The actual expulsion of the head in a primipara is accomplished by a
series of prolonged and severe contractions, accompanied by violent
straining.
[Illustration: Fig. 40.—The cervix is effaced, and the os dilated. The
second stage begins. (Eden.)]
[Illustration: Fig. 41.—Child in second stage of labor with bag of
waters unruptured and presenting at the vulva. (Braune, from Barbour.)]
A short pause ensues, followed in two or three minutes by a return of
the pains, which expel first the shoulders and then the trunk. As the
body escapes it is followed by a rush of blood-stained liquor amnii.
This is the fluid that has been pent up in the uterus by the obstructing
body of the child. The second stage lasts about two hours in a primipara
and from fifteen minutes to one hour in a multipara.
_The third stage_ is the delivery of the after-birth. The after-birth
sometimes called the secundines, consists of placenta, umbilical cord,
and membranes.
[Illustration: Fig. 42.—The head passing over the perineum. (Bumm.)]
After the expulsion of the fœtus, the uterus undergoes a sudden
diminution in size. It is about as large as the child’s head, and the
fundus lies near the level of the umbilicus. The contractions still
persist feebly, but they are practically painless, and the patient is
greatly relieved, possibly sleeping.
In from ten to thirty minutes, the uterus becomes smaller, harder, more
globular in shape and more movable. The patient brings the voluntary
muscles of the abdomen strongly into action again. The nurse presents a
sterile basin and the physician sustains and slowly twists the membranes
free from their final attachment and out of the uterus. When the
placenta passes the vulva, a moderate sized blood clot follows it.
[Illustration: Fig. 43.—Normal expulsion of the placenta like an
inverted umbrella according to Schultze. (Williams.)]
The uterus is now much smaller, and hard and firm in consistency, but
for some hours the contractions are intermittent, and while this
continues, there is risk of hæmorrhage.
_General Effects._—The mother’s pulse is quickened during the
contraction. The fœtal heart beats more slowly and feebly during a
contraction, but quickly recovers in the interval.
The amount of blood lost during labor averages from ten to sixteen
ounces. The temperature may be elevated one or two degrees in a woman of
moderate physique, while one with a fragile body may present the signs
and symptoms of surgical shock. The chill, pallor, cold limbs and body,
rapid and feeble pulse with subnormal temperature, suggest to the nurse
at once the proper _treatment_. Heat, to all parts of the body, warm
covers and hot milk or coffee. If hæmorrhage is present and the uterus
relaxed, the nurse should immediately inject pituitrin (15 ♏︎) into the
deltoid muscle and notify her attending physician.