THE ABNORMAL PUERPERIUM
The practice of obstetrics has many features that are very gratifying to
the nurse and physician.
Instead of a surgical operation, which has come unexpectedly and
undesired; a disaster in which some part of the body is removed or
altered by means of a procedure associated with extreme pain, mental
tribulation and large expense, a much-wished for addition is brought to
the family, with pain, to be sure, but a pain that is soon forgotten in
the general joy. This is the normal condition that causes the nurse and
the doctor to rejoice that such a delightful specialty has been chosen.
Then comes a case in which the labor may be complicated by some dreadful
anomaly, or the puerperium burdened or disordered by some unwelcome
invasion that tortures the souls of the family and may cost the life of
the mother, or child, or both.
At such a time the nurse and the doctor feel the full weight of their
responsibility, and after a series of anxious days and sleepless nights,
they wonder why they did not choose gardening or a clerical position for
their life work.
The disorders of the puerperium are many and various, but naturally the
breasts and the pelvic organs are most frequently affected.
=The breasts= of the human female are not reservoirs of milk like the
cow’s, but a pair of highly sensitive organs that functionate and
produce only as the demand is made. It follows that when the milk comes
in, the breasts become engorged and all the neighboring structures are
involved in the new process. However, it is not milk that is overfilling
the breasts, but serum, lymph and venous blood, which congest the
tissues surrounding the glands and produce a hard painful mass.
The breasts become heavy, hot, and painful; supernumerary glands in the
axillæ enlarge, but there is no fever. There is but little more reason
for a fever when the mammary gland begins to functionate than when the
lungs fill for the first time except in the case of nervous patients who
bear discomfort badly.
If fever appears simultaneously with the milk, the cause must be sought
in some atrium of infection, possibly in the breasts, but usually
elsewhere. There is no such thing as “milk fever.” The enlarged glands,
the tense mottled skin on which blue veins run visibly here and there,
the nipple, flattened and drawn into the swelling, so that the child can
not grasp it with the mouth, all produce a sense of disorder that ought
to be associated with fever—but is not. This is the “caked breast” of
the laity, and if let alone, the hyperæmia subsides and the function
remains. The temperature in possibly two cases out of five may rise to
100° F. for twenty-four hours, but it promptly subsides. These
temperatures generally occur in neurotic women.
If the breasts are irritated by binders, breast pumps, or massage,—like
the blacksmith’s arm, with exercise—the trouble, if not increased, is at
least much slower in disappearing.
It is reported that the young virgins of some African tribes nurse the
babies in the family, the breasts being stimulated to produce milk
largely by massage.
If the condition of the breasts becomes too painful, the liquids by
mouth are reduced to the last degree, saline cathartics are given until
frequent watery stools result, one or more ice bags are applied to each
breast and codeine sulphate may be given at night. The child nurses
every four hours only. Williams was the first to show that no tight
binder is necessary, but only a supporting bandage. The tight binder is
a cruel and useless barbarism that has been abandoned by progressive
physicians. No massage is allowed; no pumps; no irritation whatever, and
in twenty-four hours the trouble has disappeared. Hot dressings to the
breast are equally archaic. They should _never_ be applied to any breast
unless it is desired to hasten suppuration.
If the child dies, or for any reason can not nurse (inverted nipple,
cleft palate, harelip) and it becomes necessary to dry up the milk, the
treatment for “caked breast” is continued. After twenty-four hours the
breasts are comfortable and rarely give trouble again.
_Cracks, Fissures and Abrasions of the Nipple._—The care of the nipples
should be inaugurated about six weeks before labor, as elsewhere
described:
The nipple must be inspected and its possibilities determined, early in
pregnancy, if possible, for many varieties of badly shaped and
ill-developed nipples exist which may make nursing difficult or
impossible.
Imperfect nipples especially are predisposed to fissure and crack, and
will require extreme care on the part of the nurse. She should inspect
them before and after each nursing and sedulously use cleanliness and
asepsis in her management. In normal and tranquil as well as in neurotic
women, the nipple may become so sore as absolutely to preclude nursing,
and this entails much additional work on the nurse and mother, as well
as considerable peril for the child. The condition usually begins as a
fissure or crack, and is accompanied by much pain. It is serious,
furthermore, in another aspect since all breaks in the surface of the
nipple are avenues of infection that may result in mastitis. The child
may produce fissures or abrasions by rubbing the nipple with his mouth,
by pulling too hard, or by the habit of holding it in his mouth and
macerating it with his gums when he has finished nursing.
[Illustration: Fig. 108.—Examples of imperfect nipples. (American Text
Book.)]
The child must not be left at the breast after he has nursed, but the
nipple should be gently removed from the child’s mouth by passing one
finger in beside the nipple. Fissures and abrasions usually occur within
ten days if at all. Abrasions or erosions are due to the wearing away of
the epithelial covering of the nipple in patches more or less extensive.
Thin-skinned blonde women suffer more than those with dark, dense oily
skins.
A _fissure_ is a distinct separation of tissue that goes deeply into the
underlying substance.
A _crack_ is a long abrasion which may deepen into a fissure.
Both fissure and crack may affect the top, the side of the apex, or the
base of the nipple. They may be either longitudinal or circular. The
entire nipple must be kept under observation and the instant a raw
surface is detected, _treatment_ must begin.
[Illustration: Fig. 109.—A standard nipple shield. (American Text
Book.)]
Compound tincture of benzoin, liberally applied, is a favorite and
successful remedy. Our routine is to apply a paste made of equal parts
of castor oil and subnitrate of bismuth. This is put on after the child
nurses, and must be removed carefully before the next nursing. Sometimes
the child’s stools become black and constipated and the trouble may be
traced to imperfect removal of the bismuth preparation.
Whatever medication is used, the nipple must be protected from injurious
friction by the clothing. This is best done by the hat-shaped lead
nipple shield, which is placed over the nipple and held in place by a
light binder. The shield should be boiled before use.
To protect the nipple during nursing, a glass shield may be used for a
day or so, but not long enough for the babe to get accustomed to it,
else he will form a habit hard to break. This shield must be taken apart
after use, washed and kept in saturated solution of boric acid until the
next nursing.
If all these measures fail, the fissure must be touched with a nitrate
of silver stick once, or have a 2 per cent solution of nitrate of silver
applied night and morning. It may be necessary to take the child from
the breast for a day or so, in which case he nurses the other breast and
the side with the bad nipple is pumped.
The care of the nipple is highly important since the apprehension and
the actual pain of each nursing may prevent sleep, destroy the appetite,
and diminish the milk. If begun early, most fissures will heal in
twenty-four to forty-eight hours.
=Mastitis.=—From three to five per cent of lying-in women have mastitis
in the European clinics, but the records in America show a much smaller
number.
The disease occurs most frequently in blondes and in primiparas. It is
most apt to appear during the first two weeks, when the congestion
accompanying the new mammary function produces a stasis that favors the
growth of germs, which may enter through the abrasion or fissures of the
nipple produced by zealous activity of the child’s gums. But it may also
occur when the child’s first teeth come and the nipple is again exposed
to injury. At times it is impossible to find a plausible excuse for its
occurrence.
Mastitis is usually described in three forms: The (a) parenchymatous or
glandular type, which affects the substance of the gland or the
enveloping connective tissue; in (b) subcutaneous mastitis the
connective tissue beneath the skin is attacked; and in (c) the
sub-glandular variety, the infection finds a lodging between the gland
and the chest wall.
Mastitis is always due to the presence of microorganisms which in many
cases gain access to the gland through fissures or abrasions by means of
the lymphatics. In other instances the germs may be in the blood and a
local stasis may encourage the infection. Still again, they seem to
enter through the normal nipple openings.
_Symptoms._—The parenchymatous inflammation begins with a chill, and the
temperature promptly rises to 102° to 105° F. The pulse is high. The
patient complains of headache and thirst. Examination reveals hard,
tender nodules in some part of the gland. The skin may or may not be
reddened.
If the trouble has begun in the connective tissue, the skin will be
diffusely reddened, the nodule ill-defined, the temperature will rise
gradually and the chill may be absent.
_Treatment._—The breast is put at rest. No tight binder is applied, no
breast pump, no massage. No heat is allowable.
Ice bags surround the gland night and day. The liquids by mouth are
restricted and saline cathartics given. Codeine may be administered for
pain. Usually the symptoms subside without suppuration in from one to
two days.
Should the inflammation persist for more than two or three days, in most
cases the tissue will break down and form a _mammary abscess_. When it
is evident that suppuration has begun, heat may be applied to the gland
and the process accelerated. The abscess may be superficial or deep and
will be diagnosed by a bogginess in a circumscribed area or by
fluctuation. The abscess must be opened as soon as possible.
The nurse sterilizes a bistoury and a pair of long artery forceps. Lysol
solution and cotton sponges are made and sterile gauze for packing. The
hands are surgically prepared and rubber gloves worn. If an anæsthetic
is required, gas may be used, or chloroform. The incision is made
radially from the nipple so as to minimize the injury to the milk ducts.
A gauze drain may be required for a few days.
In the _after-care_, the nurse must be scrupulously clean and not convey
contagion from the breast to the woman’s genitals, to the child’s eyes,
navel or vagina, nor to her own person.
=Excess of milk= is rare, but may be observed for a short time after the
glands fill. It seldom requires treatment, but saline cathartics,
restriction of fluids, and putting the child on a four-hour schedule
will reduce it. Pads may be worn if it runs away freely.
=Scarcity of milk= is only too common. There may be enough at first and
the quantity gradually diminish, or it may be deficient from the very
beginning.
The faulty secretion may be due to the age of the mother, to disease
(anæmia), to bad nutrition, or to overwork. It may follow a premature
child. Compression of the breasts by corsets or tight dresses may
prevent development. The amount of gland tissue is very important. Many
women have large, fat breasts, but a small glandular development. Mental
conditions, such as fright, worry, and anxiety, will diminish the flow
of milk or stop it altogether.
_Symptoms._—The child is fretful, goes to sleep after nursing but soon
wakes up, or may nurse awhile, and then finding it useless, will cry and
refuse the nipple. He loses weight and when weighed before and after
feeding, the scales scarcely vary. No secretion or very little can be
squeezed from the breasts. The child may be given a bottle after which
he goes to sleep.
_Treatment._—When the gland tissue is defective, no treatment can
succeed.
The appetite must be improved by bitter tonics and the mind relieved of
its anxieties, if possible. Change of scenery may help. The fluids must
be increased, milk, cocoa, chocolate and gruel must be pushed, and such
vegetables added as corn and beets. Oyster stews, clams, lobsters, and
crabs will help. The diet must be full and nutritious with especial
stress on those foods that raise the blood pressure. Malt drinks or
champagne may avail in some cases. Exercise in moderation is desirable.
Artificial stimulation of the breast sometimes succeeds. Massage will
irritate the glands, increase the congestion, and promote functional
activity; or a Bier vacuum apparatus may be put over the gland several
times a day and the air pumped out. The breast should be kept distended
for fifteen to twenty minutes. There is difficulty in this country in
getting glass bells of sufficient size.
=Galactorrhœa= is the name applied to an abundant secretion of milk poor
in quality toward the end of a long lactation or after the child is
weaned. The symptoms are an almost constant flow of milk with resultant
anæmia.
_Treatment._—Elix. of iron, quinine and strychnine with compression of
the gland. A dry diet and the avoidance of all irritation of the breasts
will aid.
To “dry up the milk,” follow the treatment for “caked breast.”
[Illustration: Fig. 110.—A standard breast pump. (American Text Book.)]
=Quality of the milk= may be such that the child will not take it or, if
taken, it fails to nourish. In some cases this is due to overlong, or to
irregular, periods between feedings; for when the nursing interval is
too short, the milk becomes too rich, when too long, it becomes thinner
and less nutritious.
Fright, anxiety or anger may change the character of the milk so that
colic, vomiting, and diarrhœa and indigestion are produced in the child.
A wet nurse becomes homesick and the milk dries up. It may become
extremely indigestible, as shown in cases where a wet nurse quarrels
with her husband and her foster child develops green stools. If the
mother’s milk does not agree, the child may be put on feedings for
twenty-four or forty-eight hours, while the milk, pumped from the
breast, is sent to a laboratory for analysis. If a return to the breast
is unsatisfactory, artificial feedings or a wet nurse must be supplied.
=Removal of the child from the breast= may be required for a variety of
reasons. Thus, the mother’s addiction to alcohol or opium is good ground
for taking away the child. Arsenic, bromides and iodides of potassium,
saline cathartics, salicylates, alcohol, opium and belladonna must be
given to the mother with great caution during lactation, for they pass
over into the milk.
Acute diseases, such as erysipelas, pneumonia, diphtheria, typhoid,
malaria, pronounced puerperal sepsis or persistently high fever from any
cause, usually dries up the milk; while cardiac lesions, unless well
compensated, chronic anæmia and tuberculosis, obviously demand the
removal of the child for the sake of both. Sometimes a new conception,
especially when the milk becomes poor in the last half of gestation,
compels the mother to wean her babe.
A syphilitic woman may nurse her own child, provided her condition is
good and the child also is syphilitic.
Theoretically, the return of menstruation in no way affects the nursing
child, unless the blood is lost to the point of anæmia. Yet cases do
occur in which the child has indigestion, colic and bad stools, as well
as loses weight, when the mother is menstruating.
The quality of the milk is sometimes altered, but only for a day or so,
and the child should continue at the breast unless some definite
indication for removal arises.
=Weaning= ordinarily is completed by the ninth month, but the child
should never be carried beyond the twelfth month on account of changes
in the character of the milk.
When a child is weaned, the substitution of an artificial food may be
made gradually,—a bottle a day, two bottles a day, etc., until, in a
couple of weeks, the breasts are at rest.
The excessive prolongation of lactation is shown upon the mother by
impairment of the health. The patient is pale, weak, anæmic, fretful,
and thin. Headaches, dizziness, loss of appetite, and constant fatigue
will be complained of.
The _treatment_ is to remove the child at once and put the mother on
stimulating drugs and foods. A change of air and scenery, if possible,
will be highly beneficial.
=The wet nurse= is always a tribulation, which must be endured until the
child can be put on artificial food. She should have a Wassermann test
before entering upon her duties. Syphilis, tuberculosis, and gonorrhœa
must be guarded against. She must be kept like the family cow, in a
placid frame of mind, fed on nutritious food that is not too rich, and
exercised enough to keep the blood circulating.
Light housework and duties that take her out of doors part of the time
are advisable. Her moral character can only be assured through those who
have known her. If she brings her own child with her, she will need
watching to provide for an equable distribution of the milk. The first
few days is never a criterion of a wet nurse’s effectiveness. Change of
food and surroundings may interfere with her usefulness.
=Gas= may complicate the puerperium after Cæsarean section, and even
after normal labor. A rectal tube of soft rubber may be passed as high
as possible into the bowel and left for some time, or enemas of S. S.,
turpentine, asafœtida, or milk and molasses may be given. By mouth
calomel or mag. cit. is valuable.
=Headache= in the puerperium should be watched carefully, and the cause
discovered. Pain in the head may be a habit with the patient, or it may
be a symptom of some complication either present or developing, such as
toxæmia, eclampsia, or acute yellow atrophy of the liver. In general, it
is due to milder conditions like exhaustion, too many visitors,
excitement, nerves, or insomnia.
=After-pains.=—Sometimes patients are greatly annoyed by after-pains.
The pain may be due to a clot retained in the uterus or possibly a
stimulation of the uterus when the child goes to breast. Gentle massage
of uterus, or ergot, quinine, or codeine may be required to bring about
the expulsion of the clot or to control the pain. A reasonable degree of
after-pain is of favorable significance. (See p. 154.)