THE NORMAL PUERPERIUM
The puerperium is the name given to the period succeeding the birth of
the child as far as the time of the complete restoration of the
genitals. It may last from six to ten weeks, or even longer if
complicated.
When the labor is completed, the most urgent desire of the patient is
for rest. She is thoroughly exhausted in nerves and body. A post partum
chill may appear,—a slight shiver that may last a quarter of an hour.
Since the pulse and temperature remain unaffected, this phenomenon may
be regarded merely as a sign of prostration or nervous revulsion.
In the course of the first three days, the _temperature_ may rise to
100° F. in a case entirely normal. It has no pathological significance
unless persistent or increasing. The temperature should be taken night
and morning, and in complicated cases every four hours. All temperatures
over 100° F., after the initial rise and descent just described, must be
regarded as septic.
The _pulse_ does not rise with the temperature of the first three days,
but remains firm or even falls a little. When the pulse rises and the
temperature sinks, it means hæmorrhage.
The _urine_ is usually increased for the first few days and then returns
to the normal for that patient. The labor affects the patient like a
surgical operation.
The _digestion_ is disturbed. The appetite is gone, and the stomach must
be treated gently until its tone is restored. The body in repose is less
urgent in its demands for food. Liquids in abundance form the staple
diet for the first two days. For the next three days, semisolids may be
added, and after the milk is well established, a general diet is
desirable; but so long as the mother nurses her child, the liquids must
preponderate in most cases.
[Illustration: Fig. 60.—The progress of involution on the various days
of the puerperium. (von Winchkel, from Knapp.)]
Meanwhile, certain changes are taking place in the pelvis that are
highly important.
=Involution= is the process undergone by the uterus in returning to its
normal nonpregnant state. This shrinkage can be followed abdominally and
is registered by the nurse in the number of finger-breadths or
centimeters above the symphysis pubis.
Edgar gives the rate of shrinkage as follows:
After delivery, 5.92 in. long, or 15.8 cm.
2nd day, 4.63 in. long, or 11.30 cm.
3rd day, 4.37 in. long, or 11.10 cm.
6th day, 3.42 in. long, or 8.48 cm.
8th day, 2.55 in. long, or 6.40 cm.
10th day, 2.22 in. long, or 5.60 cm.
The rate of involution not only varies greatly with different women, but
varies much after the different labors of the same woman.
Ordinarily at the end of the first week the fundus should lie midway
between the navel and the pubes, and should shrink rapidly thereafter.
The necessity for watching the rate of involution is imperative for a
number of reasons. If involution is slow, or stops, it may indicate
fatigue of the muscle from multiparity or over-distention (twins,
hydramnios, etc.) or it may follow a post partum hæmorrhage.
Subinvolution may also indicate infection, the retention of clots, or
pieces of placenta. It happens also when the woman gets up too soon or
does not nurse her child and thereby delays the restoration of her
waistline, as well as diminishes her resistance to disease.
=The binder= is objectionable to some doctors on the ground that it
favors retroversion of the uterus during involution.
This would be a plausible theory when the uterus is high, if it were not
that the vertebræ of the patient and the pelvic brim keeps the uterus
from being pushed out of its place and after the uterus descends into
the pelvis the gentle pressure of the binder evenly distributed over the
abdomen can not affect it appreciably. Furthermore, the uterus in
involution shows a persistent tendency toward anteflexion and
anteversion.
The binder is merely a girdle put on just tight enough to hold in place
the bandage that supports the perineal pads and to allow the patient
more easily to grow accustomed to the sudden change in intraabdominal
pressure which the delivery of the child creates. However, if the doctor
objects to a binder, it may be left off with safety.
=The Lochia.=—When the placenta is delivered, the uterus normally closes
down and all gross hæmorrhages cease; but for the next two weeks or
possibly longer, a vaginal discharge continues. For the first few days
it is hæmorrhagic in character and it is called lochia rubra, and
consists mostly of fluid blood with occasional small clots. By the
fourth day, usually it has become brown and thinner. It is now called
lochia serosa. By the tenth day, it is yellowish-white, and is called
lochia alba.
The lochia is the wastage from the shrinking uterus, and is made up of
red blood corpuscles, epithelial cells, leucocytes, and pieces of
broken-down deciduæ. The entire lining of the uterus is loosened,
discharged and a new one formed during the puerperium. The lochia is
regularly infected by bacteria in the vagina. If involution is slow, the
lochial discharge may be prolonged.
=The After-Pains.=—The puerperium is not infrequently accompanied by
painful contractions of the uterus called after-pains. These are more
common in multiparas and serve a useful purpose in maintaining a
definite contraction of the uterus.
If the pains are at all severe, they are a suggestive symptom of the
retention of blood clots, a fragment of placenta, or of membrane. This,
of course, will occur either in a primipara or multipara. In all cases
the after-pains must be differentiated from gas and from the pains of
pelvic inflammation.
Gas pains can be relieved by hot spiced drinks, asafœtida and the high
rectal tube.
=Subinvolution= is treated by the administration of fluid extract of
ergot, in twenty to twenty-five drop doses, three or four times daily.
This will bring about the discharge of the irritating fragment or clot,
and the nurse can aid the process by gently massaging the uterus several
times daily or by giving a hot vaginal douche. Codeine may be used for
after-pains if absolutely necessary.
=Diet in Normal Cases.=—There is no restriction on the kind of food the
patient may take, so long as she can digest it cleanly and without gas.
Acids or alkalies, cold or hot, rich or otherwise, fruits, meats or
vegetables, all go to the formation of good milk if properly digested.
The old idea that acids should not be eaten is fallacious. There is more
acid in the stomach normally, than could be added in a meal made up
entirely of citrus fruits. At the same time, the heavy foods should be
avoided on account of the serious demand on the liver and kidneys in the
absence of exercise.
On the other hand, if the breasts are engorged, the fluids must be
reduced to a minimum, and a relatively dry diet enforced.
The patient loses about one-ninth of her previous body weight in the
course of labor and the puerperium.
=The breasts= are made ready for lactation twelve hours after delivery
by cleansing with sterile green soap and warm water and bathing in 50
per cent alcohol. Next, the nipple is attended to, and the infant is put
to the breast.
The nipple is prepared by cleansing it with an applicator soaked in
fresh boric acid solution, and after nursing, the same process is
repeated. This is routine, whether the mother is in bed or walking
about. In the latter case, the mother must be taught to care for her own
breasts.
The child is put to the breast every three hours and given six feedings
a day. This leaves a six hour interval at night, which is very necessary
for the mother’s rest and for the child. If the babe is feeble, seven or
eight feedings in the twenty-four hours may be required for the first
two weeks.
At first the breast only secretes a thick, yellowish secretion called
colostrum, of which the child gets from a drachm to an ounce. It is a
mild laxative.
The irritation of the nipple by the child’s mouth is begun as early as
possible in order to stimulate the breasts to secrete milk and the
uterus to contract, and thus aid involution and the preservation of the
maternal figure.
The milk usually “comes in” on the third day and is accompanied by a
sense of distention and moderate pains in the breasts. The glands may be
hot, hard and swollen, but normally there is no rise of temperature with
the inflow of the milk, except with nervous women who stand pain badly.
There is no such thing as milk fever. If fever appears at this time, an
infection must be suspected.
The engorgement of the glands may become so great that the nipples are
drawn in and nothing is left for the child to grasp. If the engorgement
becomes too painful, fluids are removed from the diet list, and saline
cathartics administered, while ice packs are applied to both breasts.
Heat should never be used _except_ for the purpose of hastening
suppuration.
This engorgement, or so-called “caking” of the breasts is not due to the
milk, but to the infiltration of the connective tissue around the glands
with serum and blood which stimulate the glands to secrete. The
distention usually disappears in twenty-four or forty-eight hours,
especially if the child is sturdy. Massage of the breasts only increases
their activity and tends to make the trouble worse.
The weight of the glands may be considerable and require the application
of a light supporting breast binder. Pillows under them will also give
relief at times.
In putting the child to breast, the mother should lie on the side with
the arm raised and the child is dropped into the hollow thus created,
facing the mother (see Fig. 113). In this position the nipple will most
easily and conveniently slip into the child’s mouth. The child should
nurse fifteen or twenty minutes and then be removed. The toilet of the
nipple is made by cleansing with boric solution as previously described,
and then placing not gauze but a piece of aseptic cotton cloth over it,
after which the binder is readjusted. (See Breast Covers, p. 326.)
=The menstrual flow= ceases during lactation as a rule, but not
invariably. The flow returns in from four to six weeks after delivery,
if the child is not nursing, and about the same time after lactation
ceases. There is a popular idea that conception can not occur during
lactation, and many women injuriously prolong lactation in the hope of
avoiding another child. The theory is fallacious and conception during
lactation is not uncommon.
=The Bowels.=—A lying-in woman is regularly constipated. Lack of
exercise, a nutritious diet, but one with a minimum of wastage, together
with relaxed abdominal walls, contribute to a condition that is
primarily due to changes in intraabdominal pressure, which follow the
delivery. For weeks the intestines have been under pressure and
irritation by the growing uterus, and when this is suddenly removed the
intestines become sluggish.
On the morning of the second day the patient should receive an ounce of
castor oil. This dose, suspended in black coffee, beer, orange juice, or
sherry wine can be taken by nearly everyone. In from four to six hours a
normal saline, or soapsuds enema is given. The enema may be repeated
daily, or if this is objectionable to the patient, the castor oil or
Russian oil, may be given as a routine. Saline cathartics should not be
used unless there is an oversupply of milk.
There is sometimes a good deal of gas following labor, which can be
removed by the 1–2–3 enema (see Enema, p. 335). In giving enemas, the
nurse must use great care to avoid touching or infecting an injured
perineum.
Many women secrete less gas and are agreeably influenced mentally by a
five grain pill of asafœtida taken thrice daily.
=Urination.=—One of the commonest difficulties after labor concerns
micturition.
Owing to the swollen and bruised condition of the urethra and the nerves
supplying the neck of the bladder, the usual stimuli do not act and the
woman, conscious of a painful distention, is unable to pass water. The
helplessness is increased by her position in bed.
The nurse must make every effort to have the bladder emptied naturally.
The process is aided by letting the water run from the faucet into the
toilet basin, by using hot applications to bladder or vulva, by allowing
warm, sterile water to run down over the vulva and perineum, by an
enema, by putting smelling salts to the nose, by using slight pressure
over the bladder, or by having the patient sit up on the bedpan.
If these measures fail and moral suasion is fruitless, the bladder must
be catheterized at the end of twelve hours. The two dangers of
catheterization are injury to mucous membrane, and infection. Many cases
of cystitis have resulted from an unclean catheter or the improper use
of a sterile instrument.
To catheterize a patient, she is first given aseptic care during which
particular attention is paid to the meatus. This should be cleansed with
an applicator dipped in a solution of boric acid. Next, the nurse
prepares her hands by scrubbing ten minutes in hot running water with
sterile nail brush and green soap. The catheter either of soft rubber or
glass, is boiled for fifteen minutes and passed, not by touch, but by
sight, and the flow is received in a clean basin and the amount
recorded. As soon as the urine ceases to flow freely, the tip of the
index finger is placed tightly over the end of the catheter and the
instrument is gently withdrawn. The finger is placed over the end of the
catheter not only to avoid the dripping of urine as it is removed, but
especially to prevent the disagreeable sensations produced by the inrush
of air.
Usually one catheterization is sufficient, and every time the bladder
fills, the nurse must take the time and trouble to make the patient
urinate spontaneously, if possible, for some women form a catheter
habit, from which it is difficult to break them. After natural urination
and after catheterization, the aseptic care should be repeated.
=The Genitals.=—The vulvar pads should be changed as often as they are
soiled. Four a day is an average number, and six or eight in the first
three days is not unusual. Every time the pad is changed, the nurse
should give aseptic care, and extra attention whenever the bowels and
bladder are emptied.
The dried secretions should be washed off with sterile sponges, wiping
always toward the rectum and throwing away the sponge. Smegma collects
in the folds of the labia and about the clitoris. This should be
carefully sponged away. If it becomes dry and hard, oil or albolene will
soften it and facilitate its removal. Plenty of soap and warm water
should be used, then with a pitcher or douche point, the whole area is
irrigated with a solution of lysol 1 per cent. Especial care is given to
the stitches if any are present. No traction must be made on the ends of
the sutures, and if unusual soreness is complained of, the doctor should
inspect them at his next visit.
The nurse should be careful not to get lochia on her hands as the
discharge contains germs which she may carry to herself, to the baby, or
to the patient’s breasts or eyes.
Painful swelling of the vulva, or edema of the rectal protrusion may be
relieved by hot boric dressings or by ice bags to the anus.
=The vaginal douche= is rarely employed at present except under specific
indications.
If the involution is slow, it is safer to use ergot by mouth, rather
than the hot vaginal douche, as sometimes recommended. The douche is a
frequent source of infection, as well as a useless procedure.
Nevertheless, a dainty woman gets much comfort mentally, as well as
physically, if she is kept clean and free from odors; hence if the
lochial discharge becomes offensive on the fifth day or sixth day, as
sometimes happens, a single hot vaginal douche may be permitted. A
1:5000 solution of potassium permanganate, or a teaspoonful of
formaldehyde to a quart of water, or a chinosol solution 1:1000 may be
used.
=Rest.=—Since the patient will be in bed from eight days to two weeks in
normal cases, she must be made as happy and comfortable as possible, and
nothing contributes so much to her satisfaction as a cheerful, competent
nurse. Her mind is at ease about herself and her child, and the
companionship of the nurse can be made one of the pleasantest
recollections of her illness.
Any patient who is at all reasonable can be managed by a tactful nurse
without the consciousness of being opposed or directed. Gossip, hospital
stories, criticism of other cases, other nurses, or of doctors should be
avoided. The patient is deeply interested in her own case, and the
private troubles of the nurse do not concern her nor enlist her
attention for more than a few polite but unpleasant moments.
The nerves of the patient are highly sensitized, and therefore she
should sleep as much as possible at night, and take an additional nap in
the afternoon. Only the members of the family should be allowed to see
the patient the first week, and they but for a short time. It takes the
strength of the patient unnecessarily to see guests even though they be
close friends. Importunate visitors may be pacified frequently by a view
of the baby. The patient must be spared all household responsibilities,
and if necessary, the nurse must take charge. Tact must be used to avoid
being dictatorial, either to family or servants. If anything unusual
arises, the nurse must show no surprise, annoyance, or bewilderment.
Everything is attended to quietly, firmly, and without friction.
=Getting Up.=—It is a tradition that the woman is lazy who does not get
out of bed by the ninth day.
There are three factors to be considered, the progressive involution of
the uterus, the strength of the patient, and the presence of stitches.
Involution may be complete on the fifth day, but the prostration from
the labor may make the woman indifferent to arising. She may be strong
enough to rise on the third day, but the uterus is large and heavy, and
the erect position will put an unnecessary strain on the supports which
may retard involution and cause displacement or disease later. Also, it
is not desirable for a woman to sit up until her perineum is well on the
road to restoration.
In general, the woman should not get up until the uterus has gone down
into the pelvis and is nonpalpable. If this is the case on the fifth day
and she feels strong, she may get up. If she is not strong, time will be
saved by staying in bed until her vigor returns, whether it is ten days
or twenty.
Getting up may be followed by a return of the bloody discharge. This may
come from subinvolution, from a relaxed and flabby uterus, from a
cervical tear, or from change in posture.
If there has been a retroversion before pregnancy, lying prone with an
occasional knee chest position for a few moments will aid. Massage and
passive exercises while in bed will aid the patient to recover and to
maintain her strength. Even after she is up and about, she should lie
down frequently during the day and always when nursing the babe, until
she feels quite normal again.
For the hospital the following standing orders may be followed:
=Standing Orders—Puerperium=
_Breasts:_
1. Prepare for lactation 12 hours after delivery.
(a) Clean breasts and nipples with soapy water and green soap.
(b) Sponge with sterile water.
(c) Sponge with boric solution.
(d) Sterile compresses over nipples and adjust binder.
2. Babe to breast immediately after breast preparation.
3. Every morning apply fresh compresses over nipples and oftener,
if necessary.
4. Cleanse nipples with boric solution (use applicator) before and
after each nursing.
To dry up milk:
Restrict fluids; give saline cathartics; apply ice bags to
breasts, as needed; for pain give codeine solution ¼ to ½
gr. hypodermically, if necessary.
_Do not massage, do not bind, do not pump. Let breasts alone._
When breast is inflamed:
Apply ice bags constantly until pain subsides and temperature
goes down. Watch for signs of suppuration.
_Genitals:_
1. S.S. enema each morning, followed by aseptic care.
Cleanse from above downward—1 per cent solution of lysol and
cotton pledgets.
1 pledget for each side.
1 pledget for center.
1 pledget for rectum (last).
External douche of sterile water.
Dry sterile pad.
2. Aseptic care following all bowel movements and urination.
_Routine:_
1. Record pulse and temperature twice a day, unless otherwise
ordered.
2. Bladder must be emptied in twelve hours. If all persuasive
means fail (may sit up in bed), catheterize.
3. Make daily records of conditions of uterus (firmness and
height), breasts and nipples.
4. No vaginal douche unless ordered.
5. Diet: liquid two days; semisolid two days; then general.
6. Watch for hæmorrhage.
7. Keep uterus firm by occasional massage.
8. All cases to have castor oil, 1 ounce within thirty-six hours
after delivery (before noon).
9. Woman may get up as soon as uterus can not be felt above pubes,
if there is no contraindication.
The history sheet should be kept accurately and should show every
incident in the course of the lying-in period.
The condition of the bowels, bladder, and lochia, the temperature, pulse
and respiration and the height of the fundus above the symphysis from
day to day must be set down in finger-breadths or centimeters.
For the hospital, the following system will be found useful in
establishing a routine.
=Nurse’s Record=
_First Stage._
1. When pains began.
2. Frequency and duration of pains.
3. Character vaginal discharge.
4. Time membranes ruptured.
(a) Artificial.
(b) Spontaneous.
_Second Stage._
1. Time second stage began and ended.
2. Anæsthetic.
3. Mode of delivery.
4. Who delivered.
5. Sex of child.
(a) Living.
(b) Dead.
6. Perineum.
(a) Condition.
(b) Repair.
_Third Stage._
1. Method.
(a) Spontaneous.
(b) Early expression.
(c) Credé expression.
(d) Manual removal.
2. Placenta delivery.
(a) Time.
(b) Size.
(c) Complete or incomplete.
(d) Length of cord.
3. Note.
(a) Hæmorrhage.
(b) Quantity.
(c) Color.
(d) Clots.
General condition—was case number put on mother and child?
Other treatments.
Medications.
Condition of uterus.
Temperature, pulse and respiration before leaving delivery room.
Signed ..........................
(Nurse’s Name.)