THE CARE OF THE PATIENT DURING NORMAL LABOR
Every case of labor must be conducted with the most scrupulous attention
to surgical cleanliness on the part of the patient, doctor and nurse.
Puerperal infection in most cases is due to the introduction of
disease-producing microbes into the wounded genital canal. To be sure,
the successful enforcement of surgical cleanliness is attained only in
good hospitals, but it can be approximated in a private house if the
patient insists upon delivery at home.
A nurse or doctor who is clean of person, is most apt to have an
“aseptic conscience.” The possession of such a conscience may entail
financial sacrifices, but it has many compensations. Neither the nurse
nor the doctor is doing justice to the patient, nor to the profession,
who indiscriminately takes pus cases, contagious diseases, and
confinements. The public will soon learn that such a nurse and such a
doctor are unsafe attendants.
How may the nurse know that the patient is in labor? This is the final
assumption that must be confirmed or refuted when the nurse is called to
her case. It is ascertained partly by the history and partly by the
conditions found.
Thus, the patient may report the passage of a piece of blood-stained
mucus, and the nurse will observe that the contractions of the uterus
are regular, rhythmical and painful. She will observe that when the
patient complains of pain, the uterus gets hard. She will also observe
the definite regularity of the contractions by timing them.
Under such conditions, the doctor should be called at once if the
symptoms develop between 7 A. M. and 11 P. M. If the pains begin in the
night, say from 11 P. M. to 7 A. M., the doctor need not be called
unless he has requested it, or, unless in the judgment of the nurse or
the anxiety of the patient, it is desirable for him to see her.
[Illustration: Fig. 51.—Points of greatest intensity of fœtal heart
tones. _V_, vertex presentations; _B_, breech presentations. (Eden.)]
When the doctor is notified he will want to know, and the well trained
nurse will be able to inform him, when the pains began, their strength,
duration and frequency. He will want to know whether or not the
membranes have ruptured. Many doctors also require, and a well trained
nurse who specializes in obstetrics should be able to say by external
examination, whether the head seems high or low, as well as the position
and frequency of the fœtal heart tones.
In the hospital the following rules for summoning the resident physician
may be found useful:
1. For multipara, when pains are regular and five minutes apart.
2. For primipara, when pains are regular and two minutes apart, or
when head is visible if pains are less frequent.
3. If a precipitate is imminent, delivery must be delayed until
arrival of attending man by—
(a) Turning patient on side with legs straight;
(b) Instructing patient to breathe deeply or to cry out with mouth
wide open; then
(c) Place sterile towel over vulva, and at time of pain prevent
expulsion by compressing the head by means of locking the hands
over a towel on the vulva.
It is possible thus to delay delivery two hours, or until the doctor
arrives. _Do not permit a precipitate._
After the nurse has completed her preliminary observation, she starts
her history, notes the character of the pains, the pulse, temperature
and respiration. All unusual phenomena should be recorded; and after the
visit of her attending man, his examination, if any, and the conditions
found, are put down. Then she prepares the patient and sets up the room
for the delivery.
=Preparation.=—As soon as the patient is known to be in labor, the
bowels are thoroughly cleansed with a soapsuds enema. A toilet jar
should be used and not the water closet. The bladder must be emptied at
the time of preparation and at frequent intervals throughout the labor.
As soon as the bowels and bladder are emptied, the patient is given a
bath and thoroughly soaped. The shower is preferred lest the water,
contaminated by bacteria from the skin and external genitals, should
enter and pollute the vagina.
[Illustration: Fig. 52.—Handling forceps, kept sterile in a jar of
alcohol.]
The hair should be braided in two braids. The vulva and perineum are
shaved. No patient will object to this when its importance as a feature
of protection against blood poisoning is explained to her.
Scrub thighs, hips, and abdomen as far as the navel with soap and warm
water, then sterile water, followed by a 2 per cent solution of lysol.
Care must be taken to remove the smegma and dried secretions from the
folds of the vulva. Put on a fresh pad, a clean gown, and long
stockings. A loose wrapper over all permits the patient to move about.
(See Chapter XXIII.)
Guests are forbidden, and the immediate family is kept at a distance—if
possible.
An air of buoyancy, composure, and competence should prevail in the sick
room, and the patient should be cheered and encouraged in every possible
way.
During the first stage, the patient may be up and about, as this diverts
the mind. She may assist in the arrangement of the room which should
always be the best room in the house. It should be well warmed and close
to the bathroom. All unnecessary furniture and hangings should be
removed, as previously described. After the room has been put in order,
the bed is made.
=Making the Bed.=—Put mattress pad over mattress and cover with rubber
sheet or oil cloth, and spread a sheet over all. Then a smaller rubber
sheet is put on, extending from under the pillows to a couple of feet
from the foot. A plain muslin sheet goes over the rubber, then the
delivery pad.
When the bed is ready, a small table or stand should be placed near the
head, on which is put the anæsthetic, the mask and the oil or cold
cream. The patient may be lightly covered with a sheet or a sheet and
blanket.
During the first stage, light and easily digested food and drinks may be
served, either cold or hot, as the patient prefers.
When the doctor arrives he may want to examine the patient either
externally or internally, or both. So a sheet is thrown across the lower
part of the body and the night-dress pulled up as far as the breasts.
=For the external examination= the doctor washes his hands in warm water
and green soap and scrubs with the nail brush for five minutes. This
period should be prolonged to fifteen minutes, if, by any mischance, the
hands have been in contact with pus or infectious material. It is
extremely difficult to get them even approximately clean after such an
experience.
[Illustration: Fig. 53.—Palpation. What is in the pelvis? (Eden.)]
He now palpates the abdomen, notes the location of the head and back,
finds and counts the heart tones, measures the pelvis and child,
estimates the descent of the head and the character of the pains.
[Illustration: Fig. 54.—Palpation. What is in the fundus? (Eden.)]
If he thinks an internal examination is necessary, he will now return to
the bathroom, pare and clean his nails, scrub hands and arms to elbows
for ten minutes in running water with green soap and a sterile brush,
soak the hands in lysol solution 0.5 per cent for five minutes.
Bichloride of mercury solutions have no place in obstetrics. They ruin
instruments and hands, and are valueless for asepsis since the mercury
unites with the albumin of the mucoid discharges and forms an albuminate
of mercury, which is inert. The bichloride solutions also are
nonlubricating, harsh and astringent, as well as poisonous, as soon as
the mucoid protection has been removed. When the doctor takes his hands
from the lysol solution, they should be wiped on a sterile towel. A
sterile gown is put on, if possible. If it is not available, he should
be careful not to touch anything that may destroy or contaminate his
preparation. The hands are powdered and sterile rubber gloves pulled on
(one will do.).
[Illustration: Fig. 55.—Palpation. Where is the back? Where are the
small parts? (Eden.)]
The nurse, meanwhile, has wrapped the legs of the patient in the ends of
a sterile sheet, the bulk of which covers the abdomen. The knees are
spread apart. The vulva cleansed with pledgets of cotton soaked in lysol
solution. One or two pledgets are used on either side of the vulva and
the same number for cleansing the introitus.
The fingers are now introduced.
The internal examination may be conveniently postponed until the waters
break, or it may be omitted altogether if the heart tones of the child
remain good, the labor progressive, and the head continually advances
into the pelvis, as determined by the external examination. The great
advantage of an internal examination at this time is the diagnosis of
the degree of dilatation and the assurance that the cord has not been
washed down into the vagina by the rush of fluid.
If the first stage is prolonged, the nurse should try to get the patient
to rest, and she should herself snatch a few moments of repose if
possible.
[Illustration: Fig. 56.—Patient draped for internal examination.
(Williams.)]
The condition of the os and the character of the pains may make the
doctor feel safe in leaving the house, but his whereabouts and telephone
number should be ascertained and the exact time of his return.
=Second Stage.=—During this stage, the patient should go to bed and the
doctor should remain nearby. The nurse may observe the vulva at
intervals and note bulging, if present, or she may press a finger
against the soft parts outside the labia and see if the hard resistant
head has come into the outlet.
The pains are severe and all accessory muscles are called into action.
Partial anæsthesia should be maintained in most cases, which should
merge into complete narcosis as the head passes the vulva. The nurse may
have to administer this.
When this stage begins, or is well under way, the patient should be
prepared. A _sterile pad_ should be placed under her, then a _sterile
bed pan_. The nurse having prepared her hands and arms as previously
directed for the doctor, scrubs abdomen, legs, and vulva with green soap
and warm water, followed by lysol solution 0.5 per cent and a rinsing
with sterile water. The cleansing of the patient should take about ten
minutes. Cover with a sterile towel and put on the sterile linen.
If in the hospital, the drums have been packed for sterilization so that
when they are opened each article will appear in the order of its need:
_No. 1._ (Beginning at the bottom.) A receiving blanket, which has
a ticket, marked with the weight of the blanket, attached to
it.
1 abdominal binder with pad holder attached.
1 pillow slip folded half way back.
1 gown for patient.
2 surgeon’s gowns.
3 sheets.
1 pair surgical stockings folded half way.
1 surgeon’s gown for nurse.
_No. 2_ contains cotton pledgets.
_No. 3_ contains strips of gauze and combination pads.
=Application of Sterile Linen—Normal Case.=—Sterile linen is to be
applied as follows, by a clean nurse;
1. Lay sheet across foot of bed and half way up.
2. Put surgical stocking on one foot and draw sheet up for foot to
rest upon.
3. Second foot as above.
4. Lay sterile sheet across bed under patient, letting ends hang.
5. Lay sterile sheet over abdomen of patient.
In many hospitals the sterile stockings and protective sheet are all
made in one piece, which greatly simplifies the application of the
linen.
As soon as the second stage begins, the packet containing the
perineorrhaphy and cord set, carefully sterilized, is brought out and
placed in convenient reach of the doctor.
This set contains—
8 in. forceps.
2 scissors curved on the flat.
1 dissecting forceps.
1 duck bill speculum.
1 needle holder.
1 metal catheter.
8 gauze sponges.
1 medicine dropper.
1 cord clamp, or
2 cord tapes.
2 case numbers, attached.
12 needles, 4 round, 4 half-curved cervix needles, and 4 skin
needles.
This is the stage of expulsion and the patient may want to pull or push
on something to aid the straining effort. Unless the nurse needs time to
set up the room or to get the doctor, this tendency may be encouraged.
A sterile sheet may be attached to the foot of the bed and the ends
(corners) given into the patient’s hands as a knot or loop to pull on,
or she may push upward against the head of the bed. Under no
circumstances must she be permitted to touch or contaminate the clean
linen in her movements, either consciously or unconsciously. The hands
should be restrained, if necessary, to avoid this.
The face may be sponged and a cold towel laid across the eyes. Rubbing
of the back and legs will bring great comfort, and cramps of the limbs
may be removed by straightening the legs and rubbing the muscles
underneath. Everything is now ready for the delivery. If the husband
insists upon being in the room, he should take off his coat and vest and
wear a gown, or if the labor is in the home, drop a clean night robe
over his clothes.
The prepared room will show at close hand-reach, the basins of
solutions, the pledgets of cotton, tape or clamp for cord, scissors,
nitrate of silver solution (1 per cent) for the eyes, with dropper, the
sterile douche can in readiness for hæmorrhage and a large reserve of
supplies. Whatever anæsthetic has been chosen for the second stage, is
now administered. Throughout this stage, the heart tones of the child
must be watched, as well as those of the mother, for intra-partum death
may occur at any moment.
A second examination may be desirable now to confirm the diagnosis and
to secure an estimate of the advance. As a rule, the examinations should
be as few as possible on account of the danger of infection.
This is the period of greatest responsibility for the doctor whose duty
it is to watch and, if necessary, to restrain the advance of the head in
order to protect the perineum from rupture.
This may be done at times most successfully, or in the case of too few
assistants, most desirably, by _delivery on the side_. To secure this,
as the head becomes more and more visible, the woman is turned upon her
left side; a pillow rolled tightly and pinned in a sterile covering is
placed between the knees, and a sheet flung across the body.
[Illustration: Fig. 57.—Delivery in side position. The hands should be
gloved and the upper leg raised on a hard cushion or pillow. (American
Text Book.)]
The hips must be brought to the edge of the bed while the chest and head
are pulled over to the other edge of the bed, leaving the legs just
enough space to double up along the side of the bed parallel with its
long axis.
The doctor may now sit on the edge of the bed, or on a high stool at the
back of the patient and facing the buttocks. This is a most convenient
and easily managed position.
As the head is born, the fæcal matter, blood and discharges must be
sponged away, and the field kept clean, with the whole perineum visible.
Always sponge from vagina toward rectum and throw away the sponge.
Should the hand touch nonsterile things or septic material, like fæces,
the glove must be changed. The _hands must be kept surgically clean_.
It is a part of the nurse’s duty tactfully to warn the doctor when such
a thing occurs, as it may happen accidentally while his attention is
concentrated elsewhere, and a conscientious man will be grateful for the
information. As the head passes the perineum the anæsthesia should be
deepened.
As soon as the head is born and the first respiration established (see
Asphyxia, p. 278), the cord is cut and clamped. There is rarely any
necessity for haste in this maneuver. The eyes are treated, and if in a
hospital, a numbered tape is tied about the wrist and a tape with a
corresponding number about the mother’s wrist.
The baby is now placed in the receiving blanket on its right side, with
artificial warmth at its back and feet. The head must be lower than the
body so any retained mucus can drain out of nose and mouth. Meanwhile,
the doctor (or nurse) keeps a hand on the fundus of the uterus to watch
its contraction, see that it does not balloon up, and massage it
occasionally if necessary while he awaits the onset of the third stage.
=Third Stage.=—The patient is turned upon her back as soon as the child
is delivered. The pulse and face must be watched for signs of
hæmorrhage. While waiting for the placenta, the perineum is examined to
note the degree of laceration, if any. To do this, the vulva must be
spread apart with clean fingers so as to bring the posterior wall into
view, and the discharge is sponged away with cotton pledgets taken from
the lysol solution and squeezed dry.
The patient may now have the saturated dressings removed and clean, dry
ones substituted. The new pads catch the oozing blood and give an
estimate of its amount.
At this time, if desirable, the perineum can be repaired. The woman is
partly unconscious, the tissues numbed, and the needle hurts much less
than it will later. Nevertheless, anæsthesia may be required.
In a period varying from a few minutes to an hour, the hand on the
uterus will note a hardening, the mass will become smaller, more
globular, and rise slightly in the abdomen. A gush of blood appears at
the vulva and usually the placenta follows. If it does not, or if
hæmorrhage or the condition of the mother requires it earlier, the
uterus may be compressed (see Credé expression) and the placenta
constrained to deliver.
The nurse holds a sterile basin for its reception. As the mass drops
into the pan, the membranes drag after and it should be gently twisted,
or the loose portions drawn upon until the end slips out. The placenta
is set aside for examination, and ergot or pituitrin may be given to
enforce the uterine contraction. The process of expulsion is generally
assisted by a strong voluntary contraction of the abdominal muscles.
After a short rest, the blood is washed off the genitals, clean linen
and clean pads applied, and the abdominal binder or girdle is put on to
hold the pads. Warm blankets are thrown over the patient and within an
hour, a glass of hot milk is administered.
The legs should be kept together, and in case of hæmorrhage, the feet
crossed.
The placenta is now inspected and not only its completeness or
incompleteness noted, but anomalies of every kind should be looked for.
IMMEDIATELY AFTER LABOR
Perineorrhaphy must be done if required.
A lacerated cervix is _not_ to be repaired at this time, except in case
of hæmorrhage, for the tissues are greatly swollen, and if sutures are
put in tight enough to allow for sufficient shrinkage, they will cut
through; while if not tight, they will be useless in twenty-four hours.
=Care of Mother=.—
1. Cleanse genitals with lysol solution 0.5 per cent from above
downward.
2. Put on sterile pad, with pad holder and binder.
3. Wash face and hands.
4. Take temperature, pulse, and respiration.
5. Glass of hot milk.
6. Keep on back four hours. Watch uterus for hæmorrhage and keep firm
by occasional massage.
7. Put tape with case number on arm.
=Care of Child=.—
1. Clamp for the cord.
2. Place on right side with head lower than breech.
3. Keep warm and watch for cord hæmorrhage.
4. Treat eyes with silver nitrate solution 1 per cent, or argyrol
solution, 15 per cent. Do not neutralize the 1 per cent silver
nitrate solution.
5. Put tape with case number corresponding to mother’s on arm.
To preserve the perineum from rupture is an important duty, and in a
definite percentage of cases, unsuccessful. Nevertheless, it is a duty,
which, in the absence of the doctor, may fall upon the nurse. How shall
she meet it?
The greatest danger to the perineum comes from a too rapid advance of
the head; hence, the nurse retards the delivery by putting the woman on
her side where she can not bear down so successfully, and instructs her
to cry out with her pains. She may also delay the labor by holding the
head back with a clean pad until the vulva stretches to its fullest
capacity.
The rules which the doctor follows in protecting the perineum as the
head advances, may be thus summarized.
1. Deliver the patient on her side.
2. Maintain flexion of head.
3. Delay extension of the head.
4. Give chloroform to retard delivery and to prevent precipitate
delivery.
5. Deliver between pains, if possible, by Ritgen’s maneuver
(modified).
6. Do episiotomy, if necessary.
=Perineorrhaphy.=—Lacerations of the perineum occur in about 30 per cent
of all primiparas and in from 10 to 15 per cent of multiparas. They
occur when the child is large or too rapidly delivered, and when the
orifice is small or the tissues inelastic.
For convenience, the lacerations of the perineum are divided for
description into three degrees.
The _first degree_ involves only the fourchette and a small portion of
the mucosa. It is rarely more than one-half an inch in depth and
requires no attention except cleanliness by the nurse.
The _second degree_ may tear a variable distance into the perineal body,
sometimes so deeply as to expose the sphincter ani. It is usually on one
side, but may appear on both sides, and be accompanied by prolongations
into the vagina.
The _third degree_ passes through the sphincter and sometimes well up
the rectal wall. This is also called a complete tear.
The lacerations of the perineum which require sutures should be attended
to _at once_ unless the patient’s condition is critical. In such cases
the repair may wait from twelve to twenty-four hours.
For this operation the nurse will assemble and boil for fifteen minutes:
2 pairs of scissors.
2 tissue forceps, one with teeth and one without.
1 bull-dog forceps.
3 artery forceps.
6 needles, 3 full and 3 half-curved.
1 dressing forceps.
1 needle holder.
Suture material of catgut and silkworm gut should be ready in sterile
containers. The catgut should be the twenty-day chromicized, No. 3 and
4. Even then the strands are quickly absorbed when the lochial
secretions flow over them.
Silkworm gut is better, but hard to remove from the vagina; hence it is
customary to use catgut inside the vagina and silkworm gut for the
sutures outside.
The nurse renews the supplies of gauze and cotton sponges. Hot solutions
are prepared, and the patient brought into a position on table or
_across the bed_ so that the best light may be had. The legs may be held
by the husband or nurse, or both. If help is inadequate, a sheet sling
can be utilized. This is made by twisting the sheet from corner to
corner and passing it rope-like over the shoulders, and back of the
neck. Then each end is tied above the patient’s knee on either side as
the legs are flexed in an exaggerated lithotomy position.
The sutures are now introduced and tied loosely from below upward and
from within outward. If tied too tightly, they will cut through. The
success of the operation depends on two things: the care with which the
levator ani, if torn, is found and restored; and the scrupulous
cleanliness obtained by the nurse in her after-care. If the stitches
become sore, a few drops of sterile glycerine should be applied with an
applicator.
[Illustration: Fig. 58.—Sheet twisted into a sling. The patient lies on
the unrolled portion. The rolled cords bearing against the shoulders are
tied to the legs below the knees. See Fig. 102. (American Text Book.)]
If catgut is used inside the vagina, the counting of the stitches is
gratuitous, since they absorb without removal. If silkworm gut is used,
the number of sutures must be recorded, lest one be overlooked in
removal.
Binding the legs together after repair is not required, but the sutures
must be given aseptic care after each bowel movement, each urination,
and when the pads are changed, if they have become contaminated. The
sutures are removed on the tenth day.
[Illustration: Fig. 59.—Repair of perineum. Sutures in place.
(Hammerschlag.)]
After _complete tears_, the bowels are kept constipated for two or three
days, and then moved with a high enema of sweet oil, followed by castor
oil by mouth. After the bowel movement, the nurse should wash out the
rectum with normal saline solution. The nurse must look carefully at the
stitches every time the pad is changed and note if the swelling is
increasing or diminishing, if there is irritation or tenderness, or if
they are cutting out through the tissues.
The external sutures are usually left long and tied together in a knot,
to prevent the ends from sticking into the patient. If she complains of
this, the ends may be wrapped in sterile gauze. During the progress of
the case the nurse must watch for and report any sign of fluid passing
from bowel through the vagina.
The perineorrhaphy being completed, the woman is permitted to rest
though the nurse will make frequent examinations of pulse and
respiration. She will note the look of the face and the hardness of the
uterus. The pad should be watched and the amount of blood discharged,
duly estimated. If the flow does not diminish or if the uterus should
balloon up, the doctor should be notified and the nurse meanwhile should
give a dram of ergot (fluid extract) by mouth or an ampoule of aseptic
ergot hypodermically.
The doctor should remain within call of the patient for at least an hour
after delivery.
In the hospital the following rules may be used as a concise guide for
the conduct of the third stage:
CONDUCT OF THIRD STAGE.
Keep patient on back and keep a hand on fundus. Note amount of blood
lost, its character, its flow, and whether steady or in gushes.
The placenta should detach itself normally in thirty minutes.
After thirty minutes, expulsion may be assisted by—
(1) Early expression.
(a) Massage, rub and knead the uterus, until it hardens under the
hand.
(b) Seize contracted uterus by fundus with full hand, fingers
behind and thumb in front.
(c) Push slowly but firmly toward the pelvic outlet.
(2) Credé expression.
Same maneuver as above, except that the fundus is compressed
between thumb and fingers while the downward movement is
progressing.
Conditions for Credé expression:
(a) Uterus must be contracted.
(b) Uterus must be in median line.
(c) Bladder must be empty.
If not successful, wait ten minutes and then repeat maneuver. _Never_
make traction on the cord. _Never_ use ergot until uterus is
empty.
If placenta does not come away within an hour, manual removal must be
considered. In case of hæmorrhage, it must be removed at once.
Carefully inspect placenta and be sure it is complete. (See Post
Partum Hæmorrhage, p. 232.)
When the patient is put to bed, the bloody sheets and towels are put
to soak in cold water, and after several rinsings, may be sent to
the laundry. Drapings stained with fæcal matter must be cleansed
separately.