MINOR OPERATIONS
=Aseptic Care.=—Place patient on a clean bed pan. It need not be
sterile. Drape with a sheet and arrange it so the fold may be easily
raised by nurse’s elbow. Have sterile basin with cotton pledgets to be
filled with solution of lysol 1 per cent. Lysol must be put in basin
first and the water added. Take to bedside. Nurse scrubs her hands ten
minutes with a sterile brush, hot water, and green soap. Use no towel,
no gloves. Keep hands wet and clean. Cleanse vulva with wet pledgets
from above downward. Apply sterile pad.
=Sterile Specimen.=—To get a sterile specimen of urine without catheter,
give aseptic care, tampon vagina with large pledget of sterile cotton.
Have patient urinate in a sterile basin. Remove tampon.
=Sterile Specimen from Child.=—Take a glass test tube and thrust its
round end through a hole in a square piece of adhesive plaster. Push it
down until the plaster is caught and stopped by the enlarged rim at the
mouth of the tube, with adhesive side of plaster on same side as opening
of tube. Fasten the tube over the male penis or female vulva by applying
the plaster to the surrounding skin. Leave until full.
=Aseptic Douche.=—Boil douche point and basin. Leave point in sterile
basin. Fill douche can with sterile water, temperature 104° to 110° F.
Put clean bedpan under patient who is draped with a sheet. Have at hand
a sterile basin containing solution of lysol 0.5 per cent, or boric acid
5 per cent in which cotton pledgets are immersed. Scrub the hands as for
aseptic care. Cleanse the vulva with cotton pledgets, washing always
toward the anus, and use each pledget but once. Adjust the douche point
and introduce it just inside the labia. The douche can should be only a
trifle higher than the pelvis. When can is empty, apply a sterile pad.
[Illustration: Fig. 86.—Apparatus for getting a sterile specimen of
urine from an infant.]
If the douche is to be used as a deodorant after the fifth day of the
puerperium, either of the following solutions may be employed: Potassium
permanganate, 1:5000; formaldehyde 1 dram to quart, or chinosol 1:1000.
=The vaginal douche= may be used in cases of gonorrhœal infection in
pregnancy during the last weeks, in the hope of avoiding infection of
the child’s eyes.
It is given like the aseptic douche (q. v.) with potassium permanganate
1:5000, or chinosol 1:1000. It should be hot (112° to 120° F.), and be
begun not long before term, so that in case labor comes on, the danger
to the child will be minimized. The reservoir must not be too high, nor
the douche point inserted much beyond the labia. The woman should be on
her back and the douche point should be rubber or glass.
=Removal of Sutures.=—On, or about, the tenth day the removal of sutures
is required.
The nurse will sterilize by boiling, 1 pair of long-handled,
sharp-pointed scissors, 1 pair of tissue forceps, and if the sutures
extend far into the vagina, a vaginal retractor.
A basin of lysol solution (1 per cent) with cotton sponges, a sterile
towel to lay the instruments on, a dish to receive the soiled dressings,
sutures and discarded sponges, completes the arrangement.
The patient is now draped with sheets as for examination. The doctor
prepares his hands as for operation. The nurse holds the limbs of the
patient in lithotomy position and the operation is begun.
=Uterine Tampon.=—Packing the uterus is mostly employed for hæmorrhage
after labor. The patient, therefore, has been prepared and only fresh
sponging with lysol solution is required.
The _instruments_ are, 1 vaginal retractor, 1 pair of dressing forceps,
1 vulsellum forceps and a jar of gauze, four to six inches wide and ten
or twelve feet long. Always use a single continuous strip. A very large
quantity is necessary to fill the uterine cavity. Any sterile gauze may
be used, but weak iodoform is satisfactory.
[Illustration: Fig. 87.—Tampon of the uterus. (Hammerschlag.)]
The vagina is held open with retractors, the cervix seized with a
tenaculum and pulled down, the end of the gauze strip is then carried
into the uterus as far as the fundus, the dressing forceps withdrawn and
a new length carried in until the cavity is packed tightly from the
fundus clear to the os.
Care must be taken that the strip of gauze is not contaminated by
vaginal contact during the introduction. A pad and binder are now
applied. If no instruments are at hand, or there is not time to
sterilize, then the nurse can grasp the fundus through the abdominal
wall with her hand and push the cervix down to the vulva where the gauze
can be pushed in by the doctor’s fingers, if necessary.
The tampon acts as a hæmostatic through its direct mechanical pressure,
and dynamically by stimulating the uterus to contract. It should be
removed in from twelve to twenty-four hours.
[Illustration: Fig. 88.—Tampon of vagina. (American Text Book.)]
=To tampon the vagina= the woman lies on her back across the bed, with
her feet on the knees of the doctor, who sits facing her. A sterile
retractor holds back the posterior wall of the vagina.
With a pair of dressing forceps the doctor seizes the pledgets of cotton
or gauze out of the lysol solution and carries them one by one as far as
they will go, in various directions around the cervix. One is pushed
forwards toward the bladder, the next back toward the rectum, the next
in the middle, and so on until no more can be introduced. A pad and
binder are applied tightly.
=The uterine douche= is sometimes employed for hæmorrhage. The field of
operation and the doctor’s hands are prepared as usual. The nurse cools
the boiled douche water down to 120° F. and if ordered, adds 2 drams of
sterile salt to each quart.
The _instruments_ are a vaginal retractor, a long uterine douche point,
and one vulsellum forceps.
The cervix is seized and brought down, the long douche point connected
with the tube from the reservoir is carried to the fundus and the water
started. Care must be used that the return flow is free and
unobstructed.
This method is most satisfactory in uterine hæmorrhage after the uterus
has been entirely emptied. It stimulates a prolonged and profound
uterine contraction.
=Intravenous Injections.=—The vein in the front of the elbow is usually
chosen. (Median basilic or median cephalic.) A rubber bandage or
tourniquet is wound tightly about the middle of the upper arm to make
the veins stand out prominently. The surface of the skin should be
sterilized for operation by scrubbing with green soap and hot water and
rinsing with 50 per cent alcohol, followed by 1:2000 solution of
bichloride, or by the application of tincture of iodine.
The hypodermic needle is then introduced after expulsion of all the
contained air and the piston is drawn up until the blood enters. This
assures the operator that the needle has entered the vein. The bandage
is now loosened and the solution of the drug is introduced very slowly.
Intravenous infusion or transfusion is given in the same way. The fluid
(normal saline?) must be running from the needle as it is introduced.
=Hypodermoclysis= is the introduction of normal saline solution, under
the skin, or under the breasts. The solution may be transfused also into
a vein.
By this operation, the quantity of fluid in the vessels is greatly
increased and a circulatory stimulant is provided. Normal saline also
promotes diuresis and aids in the removal of wastage.
The principal dangers arise from too great rapidity or too large a
quantity of the flow.
The skin should be sterilized at the point of attack by a coating of
tincture of iodine.
The _instruments_ required are, a bath thermometer, a douche can
(fountain syringe) with long tubes and an aspirating needle. A
hypodermic needle will do, but the reservoir must be well elevated since
the caliber is so small. Ordinarily the reservoir need be held only two
or three feet above the point of discharge. The water should be flowing
through the needle when it enters the tissues. If the fluid is to be
introduced under the skin, the best place is in the loose region between
the hips and the ribs in front. If under the mammary gland, the needle
must go _below_ and under the gland from the outside edge, not into the
gland. If into a vein, such additional instruments will be needed as a
rat-toothed tissue forceps, a pair of sharp-pointed scissors, a knife
and some fine catgut. From four to sixteen ounces of fluid may be used
at a temperature varying from 105° to 110° F.
The openings where the needles entered are closed by cotton and
collodion.
=Curettage of uterus= is done for abortion or puerperal sepsis when
foreign fragments are left in the uterus. The room is prepared as for
delivery.
The instruments are:
1 vaginal retractor.
1 vulsellum forceps.
1 long uterine douche point.
2 dull curettes.
2 sharp curettes of different sizes, together with gauze for
packing the uterus.
Rubber gloves should be worn both by nurse and physician as much for
personal protection as for the patient’s safety. In many cases of
incomplete abortion or of puerperal sepsis the endometrium is more
satisfactorily curetted with the gloved fingers.
=Abortion= may be indicated in many of the early complications of
pregnancy, such as hyperemesis, nephritis, uncompensated heart lesions,
tuberculosis, insanity, hydramnios, incarcerated retroversions of the
uterus and the presence of hæmorrhage. These cases require the operation
to be undertaken and finished by the doctor, but other conditions
develop wherein, without volition on the part of the patient or doctor,
the abortion begins. Some may be saved, but at times the attempt is
futile.
If the emptying of the uterus seems inevitable, the function of the
physician is to see that the process is finished as quickly and cleanly
as possible.
This may be done in the early stages by packing the cervix and vagina
with iodoform gauze and administering ergot in twenty-five drop doses
thrice daily.
In case of dangerous hæmorrhage from spontaneous abortion, the vagina
can be tamponed with cotton pledgets or gauze by a clean nurse while
awaiting the arrival of the doctor.
When the uterus has partially emptied itself and the retained fragments
prevent the complete contraction and allow of serious bleeding, or if
the fragments are septic, then their removal is required. This is done
by the finger or curette.
The preparation of rooms, patient and doctor are the same whether the
operation is for therapeutic or incomplete abortion. These have been
described.
The instruments are:
1 pair dressing forceps.
2 vaginal retractors.
artery forceps.
2 curettes of different sizes.
2 vulsellum forceps.
1 long uterine douche point.
1 pair Goodell dilators.
1 douche can.
[Illustration: Fig. 89.—Pean forceps.]
=The induction of labor= at or near term is done for pelvic contraction,
maternal disease, for danger threatening mother or child, or to avoid
the birth of a post-mature child. A variety of methods may be employed,
but the Vorhees bag is best.
_Technic._—Assemble, and sterilize by boiling twenty minutes, a Vorhees
bag No. 3 or 4, Simon speculum or vaginal retractor, 1 pair long Pean
forceps, 2 pairs vulsellum forceps, 1 dressing forceps, 2 pairs
compression forceps, 1 Goodell dilator, 1 tenaculum forceps, Davidson
hand bulb syringe with glass tubes and rubber connections for the bag.
Patient, prepared as for delivery, is placed upon the table in
exaggerated lithotomy position. Stirrups will serve.
The vagina is retracted, a smear made from cervix, and the mucous
membrane wiped clean with pledgets of gauze on forceps.
Anæsthesia is only occasionally necessary even in primiparas.
[Illustration: Fig. 90.—_A_, Hand bulb syringe; _B_ and _C_, Vorhees
bags; _D_, Bag rolled and grasped by Pean forceps ready for
introduction.]
Before using, the apparatus must be tested by forcibly filling the bag
with sterile solution.
One lip and sometimes both are seized by vulsellum forceps and brought
down. Usually, even in primiparas, the os is sufficiently patulous to
admit the bag—if not, dilate.
[Illustration: Fig. 91.—Vorhees bag in place.]
The bag, emptied of residual air and fluid, is rolled up into a compact
mass like a cigarette, seized with Pean forceps so that the tips extend
just to the end of the bag. Turn the concavity of forceps toward
patient’s left leg and introduce. As the bag enters turn the mass to the
left—a quarter turn—so that when operation is completed the forceps
curve faces upward. Release the lock on forceps. Connect the tube of the
bag with syringe tube and force the solution slowly into bag. Pean
forceps may be removed as bag fills. Remove vulsellum. Tie tube of bag
with tape when bag is full—disconnect syringe. Put sterile pad on either
side of tube.
If pains do not start within an hour, or if compression is desired as in
placenta prævia or a more rapid dilatation, then a weight of one or two
pounds is attached by a tape to the protruding tube and passed over the
foot of the bed.
=Digital dilatation of cervix= may be indicated in cases of rigid os or
where prolonged labor or some danger to mother or child requires the
hastening of the delivery.
No instruments are needed, but a complete anæsthetic is necessary.
Thorough asepsis must be observed. The patient’s genitals and the
doctor’s hands are prepared as described for labor, and rubber gloves
are imperative.
The gloved hands and the vagina and vulva are well rinsed with lysol
solution 1 per cent. The operation must be done carefully, patiently and
gently, lest the cervix be lacerated.
The hand is introduced into the vagina, and first the thumb and index
finger are introduced into the os and separated as widely as possible,
then the second finger and so on, until the dilatation is complete.
(Hirst’s method.)
Another method is the introduction of the tips of both index fingers,
back to back. Force exerted will dilate the canal so second fingers may
also be inserted. Then patiently and gently the rigid ring of the os is
overcome. (Edgar’s method.)
=Episiotomy.=—This is a clean incision of the vulva, which is done to
avoid an apparently inevitable and ragged tear of the perineum.
The _instruments_ required are either a blunt tipped knife or a pair of
blunt scissors.
The operation may be done on one or both sides depending on the amount
of room required. The incision begins at a point just above the lower
third of the vulvar outlet when distended by the head, and passes
obliquely downward and outward. This severs unimportant tissues only,
instead of allowing the valuable perineal body to suffer. It makes a
clean wound that heals readily, instead of a ragged tear through bruised
tissue. The cut is high enough to be free from the constant bath in
infectious lochia, which troubles the healing of the usual perineal
laceration.
[Illustration: Fig. 92.—Episiotomy. (Hammerschlag.)]
=Rectal Infusion (Drop Method).=—A douche bag containing normal saline
solution is hung near the bed and kept warm with an electric pad, a hot
flatiron, or by a hot water bag on either side. The tube ends in a
catheter which is inserted into the rectum. The tube is clamped so that
only a drop of solution can escape each second.
=Wet packs= are both sedative and antipyretic and may be employed for a
local or a general effect.
For bronchitis the pack may be applied to the chest only as follows: The
child (or adult) is stripped in a warm room (75° F.) and the chest
swathed front and back with a thick towel wrung out of hot water
(temperature 105° to 110° F.) Over this a woolen shirt may be drawn or a
blanket wrapped, and the patient put to bed. After six or eight hours,
the dressing is removed in a warm room, a hot bath administered, and the
body well rubbed with alcohol, and dried. The treatment may be repeated
if necessary. Do not burn the patient by applications too hot.
The general pack is most serviceable in reducing temperature and
producing a diaphoresis to relieve the kidney and cleanse the system, as
in eclampsia. For this purpose the entire body, naked, is rolled in a
sheet wrung out of hot water and then put between heavy blankets in bed.
The pulse should be taken frequently and the temperature recorded at
intervals. A cool application to the head is very soothing.
The patient sweats profusely and hot drinks may be given to promote a
more abundant diaphoresis. Usually the patient drops off to sleep as the
fever subsides. Twenty to forty minutes is the average duration of such
a treatment.
When the pack is removed, the patient is wrapped at once, without
drying, in warm blankets, and left for an hour or so.