Foundation in Nursing 
 Kducatlon 
 
OBSTETRICAL NURSING 
 
A Companion Book 
 
 GETTING READY TO BE A MOTHER 
 
 A LITTLE BOOK OF INFORMATION AND 
 ADVICE FOR THE YOUNG WOMAN 
 LOOKING FORWARD TO MOTHERHOOD 
 
 BY 
 CAROLYN CONANT VAN BLARCOM, R.N. 
 
 WITH AN INTRODUCTION BY 
 
 J. CLIFTON EDGAR, M.D. 
 
 AND 
 
 FREDERICK W. RICE, M.D. 
 
 Many obstetricians require their patients 
 to read this book 
 
 "If every expectant mother followed the simple practical 
 advice which this book offers, the rate of injury and death 
 among our mothers and babies would be materially lessened." 
 — From the Introduction by Doctors Edgar and Rice. 
 
 76 Illustrations Price $1.50 
 
THE CAEESS 
 From the painting by Qari Melchen 
 
I hold you close: and I could cry 
 Because you seem so new and dear; 
 And such a helpless warder I 
 To keep your candle burning clear: 
 
 The curious candle of your breath, 
 Body 's and spirit 's throbbing breath. 
 
 Fanny Stearns Gifford. 
 
OBSTETRICAL 
 NURSING 
 
 A TEXT-BOOK ON THE NURSING CARE OF 
 THE EXPECTANT MOTHER, THE WOMAN IN 
 LABOR, THE YOUNG MOTHER AND HER BABY 
 
 BY 
 CAROLYN CONANT VAN BLARCOM, R.N, 
 
 Formerly, assistant superintendent and instructor in obstetrical nursinq 
 
 and the care of infants and children at the johns hopkins 
 
 hospital training school for nurses 
 
 Author of 
 "The Midwife in England" 
 
 WITH 200 ILLUSTRATIONS AND 8 CHARTS 
 
 THE MACMILLAN COMPANY 
 1926 
 
 All rights reserved 
 
V2> 
 
 .C ., // .r „ •-- 'J^<f 'l^-^ ^A/^^(.t-^lAj^(n/[ 
 
 COPTRIGHT, 1922, 
 
 By the MACMILLAN COMPANY. 
 
 Set up and electrotyped. Published May, 1922. Reprinted 
 September, 1922; January, May, 1923; January, September, 
 October, 1924; April, September, 1925; March ; October, 1926. 
 
 PRINTED IN THE UNITED STATES OF AMERICA BY 
 THE BERWICK & SMITH CO. 
 
THIS BOOK IS DEDICATED 
 
 TO THE 
 
 SPIRIT OF HELPFULNESS 
 
 WHICH HAS MADE ITS PREPARATION 
 POSSIBLE WITH THE HOPE THAT IT 
 MAY BE OF HELP TO THOSE NURSES 
 WHO TAKE YOUNG MOTHERS AND BABIES 
 INTO THEIR CARE. 
 
 (S2SSG1 
 
PEEFACE 
 
 In writing this book on obstetrical nursing I have been in- 
 fluenced by certain steadily deepening impressions which have 
 been received in the course of my contact with maternity work 
 in this country, Canada and England during the past twenty 
 years. It has been borne in upon me, in the first place, that 
 very often there is something akin to bewilderment among those 
 nurses who have been trained to care for patients according 
 to the teachings of one group of obstetricians and who later find 
 themselves nursing the patients jdJ other doctors who hold dif- 
 ferent, or even opposite views. JAnd not infrequently I have 
 found in the nurses a degree of loyalty to their training which 
 made them sceptical, or even intolerant, of nursing methods 
 which differed from those which they had been taught. 1 
 
 I have become convinced, therefore, that a book on oijstetrical 
 nursing which would be helpful to and widen the outlook of all 
 nurses, no matter where nor by whom trained, must of necessity 
 describe the underlying principles of obstetrical nursing and 
 offer a survey of the nursing methods which are employed in 
 maternity wards and hospitals of recognized excellence and in 
 the practice of acknowledged authorities upon obstetrics. 
 
 This is, I am aware, a unique attitude, fori the present text 
 books on obstetrics for nurses reflect, in each instance, the wishes 
 of one doctor, almost entirely, or advocate the methods employed 
 in one hospital.! /My experience in teaching obstetrical nursing 
 makes me feel that a parallel description of dissimilar nursing 
 procedures serves to broaden the nurse's attitude toward her 
 work and her grasp of the entire subject, both because she be- 
 comes aware of the fact that methods, other than those with 
 which she is familiar, are employed in hospitals of high standing 
 and because she appreciates the fact that these unfamiliar 
 methods may be as efficacious as those in which she has become 
 expert. ) 
 
xii PREFACE 
 
 Accordingly I have devoted the better part of the past year 
 and a half to a study of the scope and methods of the present 
 training in maternity nursing in several hospitals, in this coun- 
 try and Canada, in which the obstetrical work is of a conspicu- 
 ously high character, and have presented a composite of this 
 teaching in the succeeding pages. 
 
 But that there might not be apparent inconsistencies in the 
 different methods of maternity care described, I have given an 
 explanation of the purposes and general principles of the care, 
 including nursing, which the nurse is likely to find is given to 
 all obstetrical patients, the country over. 
 
 For the sake of simplicity and clarity I have divided the 
 book into seven parts, following an introduction Avhich describes 
 the requisites and opportunities of obstetrical nursing and the 
 importance of the nurse's own attitude toward her work and her 
 patient. The first two parts, dealing with the normal anatomy 
 and physiology of the female generative tract and the develop- 
 ment of the fetus, are designed to supply the nurse with enough 
 technical information to make her ministrations intelligent and 
 effective. In this respect, I have doubtless given less than some 
 nurses will wish and possibly more than others will think neces- 
 sary, but I have given about the average amount of instruction 
 that is found satisfactory in the training schools of high stand- 
 ing. Four of the succeeding parts are devoted respectively to a 
 description of the nurse's duties during pregnancy, labor, the 
 puerperium and early infancy. In each of these I have explained, 
 first, the normal physiological processes which take place ; then, 
 the nurse's duties under average conditions and finally, her 
 responsibilities in the event of complications or abnormalities. A 
 separate part is devoted to a description of the organized care 
 and instruction of the maternity patient, by public health nurses, 
 both before and after delivery, which have proved to be satis- 
 factory. 
 
 While describing various hospital procedures, I have deemed 
 it of practical importance to explain, in each instance, how 
 similar results might be obtained, with improvised appliances, in 
 a patient's home whether in a city or a rural community. In 
 
PREFACE xiii 
 
 short, I have endeavored to make clear the essentials of obstet- 
 rical nursing without regard to the status or location of the 
 patient. 
 
 Since the patient's state of nutrition and her frame of mind 
 are of vital importance throughout pregnancy, labor and the 
 puerperium, I have not only dwelt upon them in all descriptions 
 of the nurse's duties during these periods but have devoted an 
 entire chapter to a simple explanation of the principles of each 
 of these two important subjects. 
 
 My varied contact with obstetrical nurses has convinced me 
 that those nurses who appreciate the never ending wonder and 
 beauty of this miracle of the beginning of a new life, derive 
 peculiar satisfaction from the care of the maternity patient. 
 At the same time, in many hospitals, even where the patients are 
 given the most conscientious care, the nurses are often so nearly 
 overwhelmed by the long, irregular hours and the insistent de- 
 mands of routine duties, that they do not grasp the significance 
 of the event in which they are participants. Accordingly, I 
 have made a sustained effort throughout the following pages 
 to give the young nurse something of a feeling of reverence for 
 this great mystery of birth. 
 
 In the course of my survey of the present training in ob- 
 stetrical nursing, I have met the warmest generosity on the part 
 of the obstetrical and nursing staffs in all of the hospitals which 
 I have visited. Accordingly, I find it very difficult to find ade- 
 quate expression for my sense of gratitude to the doctors and 
 nurses of the Montreal Maternity Hospital; the Burnside Ob- 
 stetrical Department of the Toronto General Hospital; The 
 Hospital of the University of Pennsylvania ; Bellevue Hospital ; 
 The Long Island College Hospital; The Brooklyn Hospital; 
 The Cleveland Maternity Hospital and to Dr. J. Whitridge 
 Williams and Miss Elsie Lawler for making available the entire 
 resources of the wards, clinics, laboratories and class and lecture 
 rooms at Johns Hopkins Hospital, 
 
 I wish to offer an expression of deepest possible appreciation 
 to Dr. John W. Harris for the generosity with which he has 
 given of his time, thought and wide experience in an effort to 
 
xiv PREFACE 
 
 provide accurate and practical information, and to set a high 
 standard of work and ideals for those nurses who would be 
 influenced by this book. Having taught and lectured to nurses, 
 as well as medical students, for years, Dr. Harris is in a posi- 
 tion to give counsel and criticism of peculiar value to a book 
 on obstetrical nursing and he has given these throughout the 
 entire preparation of this book. 
 
 Because of their concern with any effort to better the state 
 of mothers and babies, I have been given suggestions, assistance 
 and inspiration with the most selfless generosity by The Rev- 
 erend Father John J. Burke ; Dr. J. Clifton Edgar ; Dr. Frederic 
 W. Rice; Dr. J. P. Crozer Griffith; Dr. Caroline F. J. Rickards; 
 Dr. Esther Loring Richards; Dr. E. V. McCollum; Miss Nina 
 Simmonds. and Dr. John R. Eraser. Among the many nurses 
 with whom I have conferred, I have met a characteristic spirit 
 of helpfulness which has expressed itself in their eager readi- 
 ness to pass on to other nurses the beneflts of their own training 
 and experience. Those to whom I am especially indebted, for 
 aid and suggestions, are Miss Calvin MacDonald; Mrs. Bessie 
 Amerman Haasis ; Miss Robina Stewart ; Miss Caroline V. Bar- 
 rett; Miss Katherine de Long; Miss Jean Gunn; Miss Mary E. 
 Robinson ; Miss Sara Cooper ; Miss Laura F. Keesey ; Miss Chelly 
 Wasserberg; Miss Kate Madden; Mrs. Minnie S. Brown; Miss 
 Anne Stevens; Miss Madge Allison and Miss Katherine Tucker. 
 
 To Mrs. Elizabeth Porter Wyckoff I am under heavy obliga- 
 tion for most discriminating editorial assistance and for her far- 
 sighted criticisms toward increasing the clarity of the text. And 
 I feel sure that the tender little poem on the miracle of mother- 
 hood, which Mrs. Elizabeth Newport Hepburn wrote expressly 
 for this book, will be as warmly appreciated by my readers as 
 it is by me. 
 
 I wish to express my deep gratitude to Mr. Max Brodel for 
 his invaluable counsel and guidance in planning and assembling 
 the illustrations to elucidate the text. And I am very grateful to 
 Mr, Gari Melchers for the spirit which I believe is infused into 
 this book through the reproduction of two of his lovely 
 paintings of a mother and baby, and to Mr. Russell Drake for 
 
PREFACE XV 
 
 his valuable drawings. I wish further to thank Mr. J. Norris 
 Myers, of The Maemillan Company, for unfailing courtesy and 
 helpfulness in facilitating all matters relating to the publication 
 of this book. 
 
 For statistical information I am indebted to Dr. Louis I. 
 Dublin and for authority in offering the scientific background 
 of the teaching I have drawn from "The Practice of Obstetrics" 
 by J. Clifton Edgar; "Obstetrics" by J. Whitridge Williams; 
 "The Diseases of Infants and Children" by J. P. Crozer Grif- 
 fith and "The Prospective Mother" by J. Morris Slemons. 
 
 Carolyn Conant Van Blarcom. 
 New York City, 149 East 40th Street 
 
TABLE OF CONTENTS 
 
 fAQZ 
 
 Preface ...... :a 
 
 Intewduction 3 
 
 PART I. 
 ANATOMY AND PHYSIOLOGY 
 
 CHAPTER 
 
 I. Anatomy of thk Female Pelvis and Geneeattve Organs 19 
 II. Physiology 45 
 
 PAET n. 
 
 THE DEVELOPMENT OF THE BABY 
 
 III. Development of the Ovum, Embryo, Fetus, Placenta, 
 
 Cord and Membranes 61 
 
 IV. Physiology op the Fetus 84 
 
 V. Signs, Symptoms, and Physiology of Pregnancy ... S3 
 
 PART III. 
 
 THE EXPECTANT MOTHER 
 
 VI. Prenatal Care Ill 
 
 VII. Mental Hygiene of the Expectant Mother .... 145 
 
 VIII. Preparation op Room, Dressings, and Equipment for 
 
 Home Delivery 155 
 
 IX. Complications and Accidents op Pregnancy .... 164 
 
 PART TV. 
 THE BIRTH OF THE BABY 
 
 X. Presentation and Position of the Fetus 217 
 
 XI. Symptoms, Course, and Mechanism op Normal Labor . 232 
 
 XII. Nurse's Duties During Labor 243 
 
 XIII. Obstetrical Operations and Complicated Labors . . 295 
 
xviii TABLE OF CONTENTS 
 
 CHAPTEB VASI 
 
 PART V. 
 
 THE YOUNG MOTHER 
 
 XIV. Physiology of the Puerperium 317 
 
 XV. Nursing Care During the Normal Puerperium . . . 323 
 
 XVI. The Nursing Mother 357 
 
 XVII. Nutrition of the Mother and Her Baby 368 
 
 XVIII. Complications of the Puerperium 391 
 
 PART VI. 
 THE MATERNITY PATIENT IN THE COMMUNITY 
 
 XIX. Organized Prenatal Work 405 
 
 XX, Care of the Mother and Baby by Visiting Nurses . .407 
 
 PART VII. 
 THE CARE OfF THE BABY 
 
 XXI. Characteristics and Development of the Average New- 
 born Baby 451 
 
 XXII. Nursing Care of the Average New-born Baby .... 461 
 
 XXIII. Common Disorders and Abnormalities of Early Infancy sig 
 
 XXIV. A Final Word 544 
 
LIST OF ILLUSTRATIONS AND CHARTS 
 
 ILLUSTRATIONS 
 Anatomy and Physiologt. 
 
 FIO. PAGE 
 
 1 a. Normal female pelvis 21 
 
 b. Normal male pelvis 21 
 
 2. Diagram of pelvic inlet seen from above 22 
 
 3. Diagram of pelvic outlet seen from below 23 
 
 4. Sagittal section of the pelvis 24 
 
 5. Twa types of pelvimeters 25 
 
 6. Diagram showing method of measuring distance between crests, 
 
 spines and trochanters 26 
 
 7. Diagram showing method of measuring Baudelocque 's diameter 27 
 
 8. Diagram showing method of estimating true conjugate ... 28 
 
 9. Diagram showing method of measuring intertuberous diameter . 29 
 
 10. Anterior view of external and internal female generative organs 31 
 
 11. Diagrams of sections of virgin and multiparous uteri ... 32 
 
 12. Sagittal section of female generative tract 35 
 
 13. Diagram of external female genitalia 39 
 
 14. Sagittal section of breast 42 
 
 15. Front view of breast 43 
 
 16. Diagram of human ovum 47 
 
 Development of the Baby 
 
 17. Diagram of human spermatozoa 61 
 
 18. Diagram of segmenting rabbit's ovum 65 
 
 19. Ovum about 13 days old embedded in the decidua ... 66 
 
 20. Diagram of developing fetus, cord, membranes and placenta in 
 
 utero 69 
 
 21. Diagram of structure of placenta 71 
 
 22. Photograph of placental vessels 72 
 
 23. Maternal surface of the placenta 74 
 
 24. Fetal surface of the placenta 75 
 
 25. Embryo about 5.5 cm. long in amniotic sac 77 
 
 26. Outlines of fetus at different stages 78 
 
 27. Full term fetus in utero 81 
 
XX 
 
 LIST OF ILLUSTRATIONS AND CHARTS 
 
 PIG. 
 
 28. 
 
 PAGE 
 
 85 
 
 Diagram of fetal circulation 
 
 29. Diagram of circulation after birth 87 
 
 30. Side and top view of fetal skull ....... 90 
 
 The Expectant Mother. 
 
 31. Height of fundus at different stages of pregnancy ... 94 
 
 32. Contour of abdomen at ninth month 95 
 
 33. Contour of abdomen at tenth month 95 
 
 34. Front view of home-made abdominal binder 123 
 
 35. Side view of same 123 
 
 36. Back view of same 123 
 
 37. Abdominal binder used in above 124 
 
 38. Front view of home-made stocking supporters .... 124 
 
 39. Back view of same 124 
 
 40. Patient in right-angled position to relieve varicose veins . . 138 
 
 41. Elevated Sims position 139 
 
 42. Gloves, ready for dry sterilization 160 
 
 43. Delivery pad of newspapers and old muslin 161 
 
 44. Diagram of centrally implanted placenta prsevia .... 174 
 
 45. Partial placenta praevia 175 
 
 46. Diagram of marginal placenta prsevia 176 
 
 47. Champetier de Eibes' bag inserted in uterus 177 
 
 48. Patient in hot pack given with dry blankets 197 
 
 49. Method of giving infusion 202 
 
 The Birth of the Baby. 
 
 50. Attitude of fetus in uterus at term 
 
 51. Illustration from first text-book on obstetrics 
 
 52. Attitude of fetus in breach presentation 
 
 53. Attitude of fetus in vertex presentation 
 
 54. Diagram of six positions in a vertex presentation 
 
 55. Diagram of six positions in a face presentation 
 
 56. Diagram of six positions in a breech presentation 
 
 57. First maneuver in abdominal palpation 
 
 58. Second maneuver in abdominal palpation 
 
 59. Third maneuver in abdominal palpation . 
 
 60. Fourth maneuver in abdominal palpation 
 
 61. Diagrams showing positions of nurse 's hands in four 
 
 of abdominal palpation .... 
 
 62. Ascertaining position of fetus by rectal examination 
 
 maneuvers 
 
 217 
 218 
 219 
 22C 
 222 
 223 
 223 
 225 
 226 
 227 
 228 
 
 229 
 236 
 
LIST OF ILLUSTRATIONS AND CHARTS 
 
 XXI 
 
 rra. 
 
 63-64-65-66. Diagrams showing stages of dilatation and oblitera- 
 tion of cervix 
 
 67. Characteristic position of patient during first stage pains . 
 
 68. Diagram indicating rotation and pivoting of head during birth 
 69. 
 70. 
 71. 
 
 Anterior shoulder being slipped from under symphysis 
 
 Birth of posterior shoulder 
 
 Diagrams of Duncan and Schultze mechanisms of placentaf 
 separation 
 
 72. Section showing thinness of uterine wall before birth of fetus 
 
 73. Section showing thickness of uterine wall immediately after labor 
 
 74. Preparing patient for vaginal examination or delivery 
 
 75. Patient draped for vaginal examination 
 
 76. Wrong and right methods of boiling gloves 
 
 77. Powdering hands before putting on dry gloves 
 
 78. Successive steps in proper method of putting on gloves 
 
 79. Bed and simple equipment ready for normal delivery . 
 
 80. Instruments shown in Fig. 79 ... . 
 
 81. Old prints showing early methods of delivery 
 
 82. Patient draped with sterile dressings for delivery 
 
 83. Patient pulling on straps while bearing down during second stage 
 
 84. Palpating baby's head through perineum 
 
 85. Baby's head appearing at vulva 
 
 86. Head farther advanced .... 
 
 87. Holding back head at the height of a pain 
 
 88. External rotation following birth of head 
 
 89. Wiping mucus from baby's mouth . 
 
 90. Stroking baby's back to stimulate respirations 
 
 91. Two clamps on cord after pulsation has ceased 
 
 92. Wrong and right method in tying knot in cord ligature 
 
 93. Stimulating baby 's respirations 
 
 94-95. Stimulating baby's respirations 275, 
 
 96-97. Eesuscitating baby by holding under warm water . . 277, 
 
 98. Eesuscitation by means of direct insufflation 
 
 99. Delivery of the placenta 
 
 100. Twisting membranes while withdrawing placenta 
 
 101. Massaging fundus through abdominal wall 
 
 102. Showing prolapsed cord between head and pelvic brim 
 
 103. Giving chloroform for obstetrical anaesthesia 
 104-105. Giving ether for obstetrical anaesthesia .... 289, 
 106. Giving ether for complete anaesthesia 
 
 PAGE 
 
 234 
 235 
 236 
 237 
 238 
 
 239 
 240 
 241 
 250 
 251 
 253 
 254 
 255 
 258 
 260 
 261 
 262 
 264 
 265 
 266 
 267 
 268 
 269 
 270 
 271 
 272 
 272 
 274 
 276 
 278 
 279 
 280 
 281 
 282 
 285 
 287 
 290 
 293 
 
xxii LIST OF ILLUSTRATIONS AND CHARTS 
 
 FIO. PAGB 
 
 107. a. Tarnier forceps, b. Simpson forceps 301 
 
 108. Patient in position and draped for forceps operation . . . 302 
 
 109. Forceps sheet used in Fig. 108 303 
 
 110. Two types of leggings for obstetrical use 304 
 
 111. Eubber bougie 311 
 
 112. Champetier de Eibes' bag 311 
 
 113. Voorhees' bag 312 
 
 114. Bag held in forceps for introduction into uterus . . . 312 
 
 115. Syringe for filling above bags after insertion .... 312 
 
 The Young Mother. 
 
 116. Height of fundus on each of first ten days after delivery . 327 
 
 117. Patient draped for postpartum dressing 336 
 
 118. Equipment in rack used in Fig. 117 337 
 
 119. Method of covering nipples with sterile gauze .... 339 
 
 120. Baby nursing through a nipple shield 341 
 
 121. Nipple shield used in Fig. 120 342 
 
 122. Supporting heavy breasts by means of folded towels . . . 343 
 
 123. Ice caps applied to engorged breasts 344 
 
 124. Y binder before application 345 
 
 125. Y binder applied 346 
 
 126. The same seen from the other side 347 
 
 127. Indian binder . 347 
 
 128. Method of stripping 348 
 
 129. 130, 131, 132, 133, 134, 135. Bed exercises taken during the 
 
 puerperium 350 to 353 
 
 136. Knee-chest position 354 
 
 137. Exercising by walking on all fours 354 
 
 138. Position of mother and baby for nursing in bed .... 359 
 
 139. The Nursing Mother (from a painting by Gari Melchers) . 361 
 
 140. Baby partially blind as a result of a faulty diet . . . 378 
 
 141. Eachitic and normal babies of the same age .... 381 
 
 142. Chest walls of normal and rachitic rats of the same age . . 383 
 
 143. Interior of specimens in Fig. 142 384 
 
 The Maternity Patient in the Communitt. 
 
 144. Baby's bed improvised from a market basket .... 415 
 
 145. Layette recommended to expectant mothers by Maternity Centre 
 
 Association *^6 
 
 146. Breast tray recommended to expectant mothers by Maternity 
 
 Centre Association *17 
 
LIST OF ILLUSTRATIONS AND CHARTS xxiii 
 
 FIG. PAGE 
 
 147. Baby's toilet tray recommended to expectant mothers by Ma- 
 
 ternity Centre Association . . . . . . . . 417 
 
 The Baby. 
 
 148. Diagram of first teeth 456 
 
 149. Umbilical cord immediately after birth 457 
 
 150. The same four days later 457 
 
 151. Umbilicus immediately after separation of cord .... 458 
 
 152. Well healed umbilicus 458 
 
 153. Nursery at Mahattan Maternity Hospital 465 
 
 154. Bathing the baby 467 
 
 155. Preparation for circumcision 468 
 
 156. Baby draped with sterile sheet, in above 469 
 
 157. Cord dressed with dry sterile gauze 470 
 
 158. Abdominal binder applied over cord dressing .... 471 
 
 159. Satisfactory baby clothes 473 
 
 160. Diagonally folded diaper applied 474 
 
 161. Longitudinally folded diaper applied 474 
 
 162. Sutton poncho to protect baby for outdoor sleeping . . . 479 
 
 163. Training the baby to use a chamber 481 
 
 164. Stiff cuffs to prevent thumb sucking 483 
 
 165. Hammer cap to prevent ruminating 484 
 
 166. Ruminating cap applied 485 
 
 167. Proper method of carrying baby 487 
 
 168. Preparing the baby's milk 493 
 
 169. Giving the baby his bottle 496 
 
 170. Holding baby upright after feeding 497 
 
 171. Dr. Griffith's table of fat percentages 500 
 
 172. Reverse side of above card 501 
 
 173. Baby in a basket ready to travel 507 
 
 174. Quilted robe with hood for the premature baby .... 509 
 
 175. Premature baby in lined basket, being fed with Boston feeder 510 
 
 176. Bed for premature baby improvised from small clothes basket 511 
 
 177. Putting the baby in a wet pack 521 
 
 178. Baby in wet pack 522 
 
 179. Diagrams showing successive steps in giving the baby a pack 522 
 
 180. Baby wrapped in blanket preparatory to gavage . . . 523 
 
 181. Gavage 524 
 
 182. Obtaining a fresh specimen of urine from the baby . . . 526 
 
 183. Obtaining a 24-hour specimen of urine from the baby . . 527 
 
xxiv LIST OF ILLUSTRATIONS AND CHARTS 
 
 riG- PAGE 
 
 184. Band to hold baby's legs while obtaining specimens of urine . 527 
 
 185. Belt used to hold tube for specimen 528 
 
 186. Giving the baby an enema 530 
 
 187. Irrigating the eye with a blunt nozzle 536 
 
 188. Method of holding baby for treating gonorrhoeal ophthalmia . 537 
 
 CHAETS. 
 
 NO. 
 
 1. Showing drop in blood pressure and albumen, after delivery, 
 
 in eclampsia 204 
 
 2. Showing persistence of high blood pressure and albumen in the 
 
 urine, after delivery, in nephritic toxaemia with convulsions "06 
 
 3. Showing temperature curve in streptococcus infection . . . 397 
 
 4. Showing temperature curve in gonorrhoeal infection . . . 398 
 
 5. Showing normal weekly gain in weight during first year of life 454 
 
 6. Showing normal daily gain in weight during first two weeks . 520 
 
 7. Showing loss of weight in inanition fever contrasted with No. 6 520 
 
 8. Showing rise in temperature in inanition fever .... 520 
 
OBSTETRICAL NURSING 
 
''Can there be any higher work than this? 
 Can any woman wish for a more womanly work?" 
 
 Florence Nightingale 
 
INTRODUCTION 
 
 The avowed purpose of care given to the maternity patient 
 to-day is to minimize the discomforts and perils of her preg- 
 nancy, labor, and the pnerperium, and so safeguard her and her 
 baby that both will emerge from the lying-in period in a satis- 
 factory condition and with a bright prospect of having perma- 
 nently good health. 
 
 The striking difference between obstetrics as practiced to-day, 
 and that of former times, is that it now lays as much stress upon 
 the future health of the mother and baby as it does upon their 
 immediate safety. 
 
 Happily, the present-day obstetrician, who assumes the care 
 of an expectant mother, does so with confidence and optimism 
 because of the available knowledge upon which he may draw 
 for her benefit. Progress in the various branches of medicine 
 and nursing is steadily pointing the way toAvard greater and 
 more effective safeguards for the maternity patient and her 
 baby. 
 
 The value of these safeguards is attested to by the satisfactory- 
 results of the care which is given to the patients in well con- 
 ducted hospitals or in their homes by careful physicians; by 
 various out-patient departments and nursing organizations to 
 patients within their reach. These results are in the form of a 
 large proportion of mothers and babies who are well and continue 
 to be well. 
 
 That is one view of the matter. Looking at it from another 
 aspect, we discover that more than seven women still lose their 
 lives for each 1,000 births that occur in this country, the actual 
 number varying in different localities. Childbirth is still sec- 
 ond to tuberculosis as a cause of death among women between 
 fifteen and forty-five years of age, and in spite of the proved 
 value of care in making maternity a safe adventure, the larger 
 
 3 
 
4 INTRODUCTION 
 
 proportion of these women die from infection or toxaemia which 
 are almost entirely preventable. 
 
 The incredible fact in this connection is that, while there has 
 been a decline in the deaths from such other controllable condi- 
 tions as typhoid fever and some of the infectious diseases of 
 childhood, there has been an actual increase in deaths from 
 preventable causes associated with child-bearing. 
 
 Dr. Dublin estimates that throughout the United States as a 
 whole, during 1920, the total number of deaths due to child- 
 birth was about 20,000. 
 
 In addition to the high death rate among mothers the mor- 
 tality among babies is even greater. Dr. Dublin estimates that 
 out of every 1,000 babies born during 1920, about 85 died before 
 they were a year old, or about 200,000 in the course of the year, 
 and that the large majority of these died from congenital causes, 
 from infection or nutritional disturbances. Another 100,000 
 babies perish, yearly, through still births. As all of these con- 
 ditions are preventable to a greater or lesser degree, we have to 
 acknowledge that many babies die whom we know how to save. 
 There is sound reason, therefore, for the belief that proper 
 care would save the lives of about two-thirds of the mothers and 
 half of the babies who now die and half of the babies who are 
 born dead. 
 
 And let it be remembered that conditions which destroy life, 
 also destroy or greatly impair health and resistance to disease. 
 Although we may count the number of mothers and babies who 
 fail to survive the too severe test to which they are put during 
 crucial periods in the lives of both, we cannot count, nor even 
 approximately estimate, the number of those who escape death 
 only to be imprisoned in frail, deformed, or diseased bodies. 
 Therein lies much of the tragedy which follows in the wake of 
 neglect — the lifelong handicaps, suffering, and inefficiency that 
 need not have been. 
 
 This lack of care is not due to limitations in medical knowl- 
 edge, for the efficacy of known methods is being constantly 
 demonstrated. And our instant and generous response, the 
 country over, to appeals for help in relieving various forms of 
 need and disaster does not suggest a national cold-bloodedness, 
 
INTRODUCTION 5 
 
 or even indifference, to needless suffering. But still a legion of 
 mothers and babies die each year from lack of care, and almost 
 at our very thresholds. 
 
 Perhaps the root of the difficulty lies in the fact that child- 
 birth, as well as the attendant suffering and death, are so fa- 
 miliar that they are regarded as being normal incidents in the 
 ordinary course of affairs. 
 
 One of the most dramatic of all human events, the birth of a 
 new being, is accepted casually, almost without concern, because 
 it is so frequent — so commonplace. 
 
 Moreover, we are all accustomed to hearing stressed the fact 
 that child-bearing is not a disease, but is a normal physiological 
 function. 
 
 Not so generally, however, do we hear emphasis made upon 
 the equally important facts that there is extreme danger of infec- 
 tion while these physiological functions are in progress, and 
 that they subject the entire organism to such a strain that there 
 results a dangerously narrow margin between health and disease. 
 
 Accordingly, too much is expected, or taken for granted, 
 from the provisions which Nature has made to promote these 
 functions, and not enough assistance is given to protect the 
 mother, while they are in course, or to help the immature baby 
 in adjusting himself to the greatest change which he makes dur- 
 ing the entire span of his existence. 
 
 When the time comes, and it seems to be approaching, that 
 pregnancy, labor, the puerperium and infancy are regarded as 
 crucial periods in the life history, demanding all the preventives 
 and safeguards that all branches of medicine and nursing can 
 offer, these periods will cease to be so enormously destructive of 
 life and health. 
 
 We cannot build a strong race with sickly and maimed 
 mothers and babies, and we can scarcely have other than sickly 
 and maimed mothers and babies without care. 
 
 Apparently, then, our national health is in a large measure 
 dependent upon good obstetrics and good obstetrics includes 
 good nursing. 
 
 Good nursing implies more than the giving of bed baths and 
 medicines, boiling instruments and serving meals. It is more 
 
6 INTRODUCTION 
 
 than going on duty at a certain time, carrying out orders for a 
 certain number of hours and going off duty again. It implies 
 care and consideration of the patient as a human being and 
 a determination to nurse her well and happily, no matter 
 what this demands. 
 
 In carrying on her work, the maternity nurse may be called 
 upon to aid in prenatal supervision and instruction; to pre- 
 pare for and assist with a delivery, or to give either exclusive 
 or visiting nursing care to a young mother and her baby. These 
 patients may be in a hospital or at home and the home may 
 be of any kind from a palace to a hut or a tenement. The 
 patients may be in a city, a small town, or a rural community, 
 and in the care of doctors whose methods vary widely. 
 
 But in spite of the diversity of conditions and the fact 
 that no two will be quite alike, the general need of all of 
 these patients will be the same. 
 
 Their need is care, which includes cleanliness in order to 
 prevent infection ; suitable food ; fresh air and exercise ; regular 
 and sufficient rest and sleep ; an equable body temperature ; 
 early treatment of complications and correction of physical de- 
 fects. In short, each patient needs to be watched; needs clean 
 care and to practice the approved principles of personal hygiene 
 from the beginning of pregnancy. This without regard to 
 race, color, creed, occupation, status, or location. It means 
 all maternity patients and their babies the country over. 
 
 There was a time when the obstetrician first saw his patient 
 in labor or shortly beforehand, and when the care of the baby 
 began at birth or soon afterward. 
 
 We know what this tardy attention Las cost in human lives 
 and suffering. 
 
 We know, too, that among the mothers, abortion, miscar- 
 riages, toxaemias, difficult or impossible labors may be largely 
 prevented through prenatal care; while among babies, the 
 enormously high death rate, during the first month of life 
 from causes which begin to operate before birth, convinces us 
 that we must begin to take care of the baby nine months before 
 he is born, if he is to have the greatest benefits of present 
 available knowledge. Such early care reduces still births and 
 injury during labor; it reduces premature births, which is im- 
 
INTRODUCTION 7 
 
 portant, because the nearer tlie baby goes to term the better 
 his chance of survival and of good liealth, and prenatal care 
 also increases the prospects of satisfactory breast feeding. 
 
 Although we knoAV that the ideal is to have all maternity 
 patients supervised and instructed entirely by a physician 
 from the beginning of pregnancy and then delivered in a well 
 conducted hospital, it is scarcely probable that this ideal will 
 ever be realized. There will always be patients who cannot 
 afford to employ a doctor for so long a period ; there will always 
 be communities in which hospital provisions do not exist or are 
 inadequate. There will alwaj's be expectant mothers whom it 
 would be unwise to remove from home, excepting under press- 
 ing conditions, because of the influence exerted by their mere 
 presence in keeping the family group intact. And so on, 
 through a number of deterring conditions which Avill probably 
 never cease to exist, and which will keep the patient at home. 
 
 Since patients who are supervised during pregnancy and 
 delivered in hospitals usually recover, the high rate of death 
 and injury, in this country, is to be found among women who 
 are unsupervised before labor and subsequently delivered at 
 home. Accordingly, if this widespread injury is to be reduced, 
 the essentials of the care which is found to be efficacious must 
 be made available for all patients throughout the length and 
 breadth of the land. 
 
 Prenatal care, clean deliveries, and intelligent motherhood 
 will go far toward solving the problem of a high maternal and 
 infant death rate, and these require not widespread care, alone, 
 but widespread teaching as well — impressing upon women and 
 their families the importance of care and precautions in con- 
 nection with childbirth. Important as it is for men to study 
 and inform themselves in regard to the problems of finance 
 and cattle raising, for example, it is still more important for 
 both men and women to .study and a])pi'eciate the i)roblcms of 
 expectant and actual motherhood. 
 
 It is in this teaching that the nurse may be immeasurably 
 helpful, in fact is indispensable, for the carrying of approved 
 care into the home and the general teaching of personal hygiene 
 are inextricably bound up with nursing. 
 
 M 
 
8 INTRODUCTION 
 
 The details of the care and teaching of patients are, of 
 course, specified by a doctor or a medical board, but the effec- 
 tiveness of the planning, whether for one or several patients, is 
 very largely dependent upon the nurse's intelligence, interest 
 and conscientiousness, and her ability to teach. 
 
 This is borne out by the almost uniform recommendations, 
 made by official bodies, for provisions looking toward the re- 
 duction of maternal and infant deaths including as they do the 
 following : 
 
 1. The employment of public health nurses. (To give home 
 care or instruction or both.) 
 
 2. The establishment of prenatal clinics and baby health cen- 
 ters. (In both of these the nurse aids in supervising and 
 teaching the mother how to take care of herself and her 
 baby.) 
 
 3. Trained attendance during labor. (The nurse aids greatly 
 in preparing for and assisting with clean deliveries.) 
 
 4. Improved and increased hospital facilities. (There cannot 
 be good hospital work without good nursing.) 
 
 5. Prompt and accurate registration of births. (Here, too, 
 the nurse may be helpful by always making sure that the 
 birth has been reported.) 
 
 Here is no light task nor mean privilege which is set before 
 the nurse and in order to meet them fitly she must be prepared. 
 The indispensable requisites for nursing and teaching the ma- 
 ternity patient, whether at home or in a hospital, are training, 
 an exacting conscience, and genuine concern for her patient as 
 an individual. 
 
 A certain amount of scientific knowledge is necessary, in this 
 as in any other field, to give the nurse an intelligent background 
 and a kind of definiteness and stability to her work. She should 
 be trained in the essentials of general nursing, of surgical nurs- 
 ing and operating room technique, and in the care of babies. 
 She must of necessity know something of the anatomy and 
 physiology of the female generative organs; the physiological 
 adjustments during pregnancy; the development of the baby 
 within the uterus; the normal process, or mechanism, of labor, 
 and the changes which ordinarily take place during the puer- 
 
INTRODUCTION 9 
 
 perium. Such information will make clear to her the reasons 
 for the care which she gives to her patient, and accordingly her 
 care will be more intelligent. And she will be better able to 
 recognize the difference between evidences of normal physiolog- 
 ical changes and the symptoms of complications. 
 
 Two of the newer branches of medicine — nutrition and men- 
 tal hygiene or psychiatry — have a more and more apparent 
 relation to the safety and welfare of the maternity patient, and 
 accordingly are of moment to the maternity nurse. For, it 
 must be remembered, it is the purpose of obstetricians to-day to 
 establish future health for their patients as well as immediate 
 safety. The nurse should endeavor to help with all that the 
 doctor attempts to do toward these ends, and in order to help 
 she must understand. 
 
 The maternity nurse can scarcely be expected to specialize 
 in nutrition or in psychiatry, but she may give to her patients 
 the practical benefits of many valuable discoveries in these fields. 
 She may not be able to remember, for example, all of the sources 
 and purposes of lime in the diet, nor of each of the protective 
 substances, often referred to as vitamines, but any nurse can 
 remember and be guided by the fact that her patient will not 
 be satisfactorily nourished either before or after the birth of 
 the baby unless she has a varied diet containing milk, eggs, and 
 green vegetables. She also can explain to her patients that 
 faulty dietaries are responsible for the tradition that each child 
 costs the mother a tooth, as well as the fact there may be under- 
 nourishment even among babies who are fed at the breast, if 
 the mother's diet is inadequate. 
 
 And though the mass of nurses cannot be expected to grasp 
 all of the intricacies of psychiatry, they may without exception 
 apply one of its most important principles by adopting a warm 
 and sympathetic attitude toward their patients and by this 
 means win their trust and confidence. The restfulness of this; 
 the relaxation and general state of mind that this will engender 
 in a large proportion of patients will exert a definitely beneficial 
 effect upon the physical well-being of the expectant mother, the 
 woman in labor and the nursing mother. 
 
 These simple applications of important scientific discoveries 
 
10 INTRODUCTION 
 
 that relate to the everyday life of her patient — these are things 
 for the maternity nurse to bear in mind. She is nursing a 
 human being who is passing through crucial periods and any- 
 thing that affects her as a human being affects her as a patient. 
 
 Apparently, then, the work of the obstetrical nurse neces- 
 sitates a training in general nursing and its various branches, 
 in addition to obstetrics, for there seems to be no aspect of nurs- 
 ing which may not, under some condition, have its place in the 
 care of the mother or her baby. All of this training, however, will 
 prepare her for effective work only if she herself has a spirit of 
 eagerness and enthusiasm. But if she has these and even a 
 little training, she may do much. 
 
 Accordingly, let the nurse who has been prepared by a 
 general and special training, and who wants to be of the greatest 
 possible service to the maternity patient start by appreciating a 
 few general principles which will be absolutely indispensable 
 to the success of her work. They may be expressed somewhat 
 as follows : 
 
 1. Cleanliness — under all conditions, to protect both mother 
 
 and baby from infection. 
 
 2. Watchfulness — for early symptoms of complications in either 
 
 mother or baby. 
 
 3. Adaptability — to the patient, the doctor, and the surround- 
 
 ings. 
 
 4. Sympathy — for every mental and physical stress which the 
 
 patient may suffer. 
 If the nurse convinces herself of the import of these requirements 
 and is exacting of herself in giving them broad interpretation, 
 she cannot but nurse her patients well. 
 
 She will appreciate the invariable need for cleanliness and 
 watchfulness if she will hark back to the fact that our mothers 
 and babies die in distressingly large numbers from infections, 
 toxaemias, and nutritional disturbances, all of which are usually 
 amenable to preventive or early treatment. 
 
 In order to be always clean, always watchful, and always 
 ready to execute, both in letter and spirit, the orders of doctors 
 whose methods of treatment will differ, the nurse will need 
 to be very adaptable. She will need to keep a clear head 
 
INTRODUCTION 11 
 
 and an open mind and to remember always the ends that are 
 being striven for : the immediate saf etj' and the future well- 
 being of the mother and the baby. And she may rest assured 
 that, no mattei* how they vary as to details, all doctors want 
 all of their patients to be given clean care ; watched for symptoms 
 of complications; and given good general nursing. 
 
 Considering the need for cleanliness in a very broad and 
 practical sense, the nurse will realize that the test of her ability 
 to protect her maternity patients from infection is not what 
 she is able to do in a hospital where there is every facility for 
 clean work. It is not the ability to maintain asepsis in a tiled 
 operating room that counts, where she is aided by sterilizers, 
 basins, and solutions of various kinds and colors, a wealth of 
 ingenious appliances and a corps of co-workers. It is the 
 understanding and imagination which will enable her, perhaps 
 single-handed, to carry the principles of such work into a 
 patient's home; to do clean work, from the standpoint of avoid- 
 ing infection, in a mountain hut or a city tenement where 
 everything is dirty. 
 
 The nurse will do well to begin to develop her powers of 
 adaptability while she is still in training. She may greatly 
 increase the value of her hospital experience by trying always 
 to understand the purpose of the care which she is giving and 
 trying at the same time to imagine how, in an average home, 
 she would accomplish the results of this or that procedure which 
 is made easy of execution in the hospital by special equipment. 
 She should never lose sight of the fact that she is not being 
 trained solely to conform to any one hospital routine or to 
 become expert in only one method of nursing care. She is 
 being prepared to go out and give nursing care to any young 
 woman and her baby who need it, no matter Avhere or how they 
 are situated or by what methods they are treated. 
 
 If conditions are such that the doctor's orders and the 
 patient's requirements seem impossible of fulfillment, then the 
 nurse must attempt the impossible and attempt it with con- 
 fidence of success. 
 
 It is clear that the nurse must cultivate adaptability and 
 resourcefulness if she is to give good care to all her patients 
 
12 INTRODUCTION 
 
 under all conditions. But even the most efficient and intelli- 
 gent work will not be wholly satisfactory unless it is infused 
 with a spirit of sympathy for the woman as an individual. 
 
 The thing that counts in this connection is what the nurse, 
 herself, means to the woman who is facing a very important 
 and mysterious event, who, after every known aid has been 
 given, must still go through a great deal alone, both mentally 
 and physically. It is not helpful to a woman in such a situa- 
 tion to be told that women have borne children since the dawn 
 of Creation and that they all have had pain; that she will 
 have to go through with it, as they have, and that the less 
 fuss she makes about it the better. But it does help her to 
 have the nurse say that she has been with so many women in 
 labor that she knows they suffer intensely, and because she 
 knows it so well she wants to do all that lies in her power to 
 give even a little relief. The nurse may never know just how 
 she has helped and reassured ; how a pain was made a little easier 
 to bear, not only by the hand slipped under an aching back, but 
 also by the sympathy that the act conveyed. But she may be 
 sure that she has helped. 
 
 In such a connection, the nurse must guard against the 
 mistake of dividing her patients into well defined groups : those 
 who are poor and those who are more favored. If she un- 
 failingly looks for the human being beyond the patient she 
 will find some of the most sensitive and appreciative of women 
 among the simplest and poorest and they will be warmly re- 
 sponsive to a thoughtful, considerate attitude. And at the same 
 time, the patient in comfortable circumstances who seems to be 
 surrounded by all that one could desire, is often pathetically 
 lonely and isolated. She, too, will be appreciative of encourage- 
 ment and an attitude of concern for her comfort. 
 
 Suffering and anxiety make no class distinctions and have 
 a very leveling effect, for prince and pauper, alike, need sym- 
 pathy when afflicted. 
 
 From the standpoint of the nurse herself, there might be 
 discouragement in this description of what is expected of 
 her, and what are her opportunities in this work of caring for 
 mothers and babies, if she did not go straight to tlie heart of 
 
INTRODUCTION 13 
 
 the matter and see that all that is needed, after all, is good 
 nursing. She must realize, of course, that good nursing neces- 
 sitates training and a spirit of such eager service that she will 
 do for her patient all that lies in her perhaps limited power, 
 and then try to learn of still more that she may offer. And 
 she may rest assured that the value of her work will be quite 
 as dependent upon such a spirit as upon her training. 
 
 Obstetrical nursing may be defined, with accuracy, as the 
 nursing care of an obstetrical patient, but its true significance is 
 limited only by the nurse's ability, resourcefulness, and vision. 
 And the more spirituality which pervades this work the more 
 effective will be tlie nurse's skilled ministrations and the more 
 satisfying will it all be to her. 
 
 This aspect of maternity nursing — what it means to the 
 nurse herself — should be given full recognition, for although 
 the demands which are made upon her are exacting, she will 
 find more than compensating interest and gratification in her 
 work. 
 
 It provides a channel of expression for some of her most 
 elemental and deeply rooted impulses. The desire to create 
 exists within most of us, and surely the nurse tastes of the 
 joys of creation when she watches the beautiful baby body 
 grow and develop under her care. And she has a consciousness 
 of patriotic service, too, for while helping to secure the im- 
 mediate safety and future health of the baby citizen she is 
 helping to build a strong race. 
 
 But this work goes still further and offers even more than 
 these. 
 
 The average nurse has a deep maternal instinct. She may 
 not be conscious of it as such, but it is this instinct which 
 prompts her to select nursing from the wide range of occupa- 
 tions and professions which are open to her. And it is entirely 
 natural that she should derive great satisfaction from this 
 vicarious motherhood — this giving of her knowledge and skill 
 in service to the woman with a baby in her arms. 
 
 The opportunities for self-expression which are open to the 
 nurse who gives this form of service make us wonder if she 
 should not be included in the enviable group of those others 
 
14 INTRODUCTION 
 
 whose life work is an expression of themselves — the poets and 
 painters; the architects, musicians, and sculptors — those who 
 create and build because of an urge within them. Surely, the 
 spirit and the results of the work of the nurse who thus gives of 
 herself may be ranged with the efforts of those others whose 
 work is an expression of tiiemselves. 
 
"The body is the crowning marvel in the world of miracles 
 in which we live. Fearfully and wonderfully made, it claims our 
 respect not only because God fashioned it, but because He fash- 
 ioned it so well — because it is a thing of beauty, a perfection of 
 mechanism. ' ' 
 
 The Splendor of the Human Body — Bishop Beent. 
 
PART I 
 ANATOMY AND PHYSIOLOGY 
 
 CHAPTER I. ANATOMY OF THE FEMALE PELVIS AND GENERA- 
 TIVE ORGANS. Normal Female Pelvis. Pelvimetry. Female 
 Organs of Reproduction. Internal Genitalia. Uterus. Fallopian 
 Tubes. Ovaries. Vagina. Bladder. Rectum. External Genitalia. 
 Mens Veneris. Labia Majora. Labia Minora. Vestibule. Vaginal 
 Opening. Fossa Navicularis. Bartholin Glands. Perineum. Breasts. 
 
 CHAPTER II. PHYSIOLOGY, Puberty. Ovulation. Menstruation. 
 Modifications of Menstruation. Menopause. 
 
CHAPTER I 
 
 ANATOMY OP THE FEMALE PELVIS AND 
 GENERATIVE ORGANS 
 
 NORMAL FEMALE PELVIS 
 
 The present broad knowledge of the anatomy of tlie female 
 pelvis has resulted in an enormous reduction in death and in- 
 jury amonp: obstetrical patients and tlieir babies. 
 
 This knowledge of the pelvic anatomy, relatinpj as it does, to 
 both normal and malformed pelves, has made possible a system 
 of taking measurements, termed pelvimetry, which gives the 
 obstetrician a fair idea of the size and shape of his ])atient's pel- 
 vis. Such information, coupled with observations upon the size 
 of the child's head, gives a foundation upon which to base some 
 expectation of the ease or difficulty with which the approaching 
 delivery is likely to be accomplished. 
 
 Since each patient's pelvic measurements are considered 
 from the standpoint of tlieir comparison with normal dimensions, 
 it is manifestly important that the obstetrical nurse have a clear 
 idea of the structure of the normal female pelvis, and also of 
 its commonest variations. 
 
 Viewed in its entirety, the pelvis is an irregularly constructed, 
 two-storied, bony cavity, or canal, situated below and support- 
 ing the movable parts of the spinal column, and resting upon 
 the femora or thigh bones. (Fig. 1, A. and B.). 
 
 Four bones enter into the construction of the pelvis : the two 
 hip bones or ossa innominata, on the sides and in front with the 
 sacrum and coccyx behind. 
 
 The innominate bones (ossa innominata), symmetrical!}^ 
 placed on each side, are broad, flaring and scoop-shaped. Each 
 bone consists of three main parts, which are separate bones in 
 early life, but firmly welded together in adults : the ilium, ischium. 
 and pubis. The ilia are the broad, thin, plate-like sections above, 
 
 19 
 
20 OBSTETRICAL NURSING 
 
 their upper, anterior prominences, which may be felt as the hips, 
 are the anterior superior spinous processes used in making pelvic 
 measurements. The margins extending backward from these 
 points are termed the iliac crests. 
 
 The ischii are below and it is upon their projections, known 
 as the tuberosities, that the body rests when in the sitting posi- 
 tion, and which also serve as landmarks in pelvimetry. The 
 pubes form the front of the pelvic wall, the anterior rami uniting 
 in the median line by means of heavy cartilage and forming the 
 symphysis pubis. 
 
 The sacrum and coccyx behind are really the termination of 
 the spinal column, the sacrum consisting, usually, of five rudi- 
 mentary vertebrae which have fused into one bone. It some- 
 times consists of four bones, sometimes six, but more often of 
 five. The sacrum completes the pelvic girdle behind by uniting 
 on each side with the ossa innominata by means of strong car- 
 tilages, thus forming the sacro-iliac joints. The spinal column 
 rests upon the upper surface of the sacrum. The coccyx, a little 
 wedge-shaped, tail-like appendage, which ordinarily has but 
 slight obstetrical importance, extends in a downward curve from 
 the lower margin of the sacrum, to which it has a cartilaginous 
 attachment, the sacro-coccygeal joint. This joint between the 
 sacrum and coccyx is much more movable in the female than in 
 the male pelvis. 
 
 We find, therefore, that although the pelvis constitutes a 
 rigid, bony, ringlike structure, there are four joints: the sym- 
 physis pubis, the sacro-coccygeal, and the two sacroiliac articu- 
 lations. As the cartilages in these joints become somewhat sof- 
 tened and thickened during pregnancy, because of the increased 
 blood supply, they all permit of a certain, though limited amount 
 of motion at the time of labor. This provision is of consider- 
 able obstetrical importance, since the sacro-coccygeal joint al- 
 lows the child's head to push back the forward-protruding coc- 
 cyx, as it passes down the birth canal, thus removing what other- 
 wise might be a serious obstruction. And when, as is some- 
 times necessary, because of a constricted inlet, the pubic bone 
 is cut through (the operation known as pubiotomy), the hinge- 
 like motion of the sacro-iliac joint permits of an appreciable 
 
ANATOMY 
 
 21 
 
 A. Normal female Pelvis. 
 
 B. Normal male Pelvis. 
 
 FlQ. 1. — Normal Pelves. Note the broad, shallow, light construction of the 
 female pelvis- A. as coiiipareJ with the more massive male pelvis, B. 
 
22 
 
 OBSTETRICAL NURSING 
 
 spreading of the two hip bones and a consequent widening of 
 the birth canal. 
 
 The pelvic cavity as a whole is divided into the true and 
 false pelves by a constriction of the entire structure known as 
 the brim or inlet. The inlet is not round, its antero-posterior 
 diameter being shortened by the sacro-vertehral joint which 
 protrudes forward and gives the opening something of a blunt, 
 heart-shaped outline. (Fig. 2.) 
 
 As the pelvis occupies an oblique position in the body, the 
 plane of this brim is not horizontal, but slopes up and back from 
 
 Fig. 2. — Diagram of the pelvic inlet, seen from above, with most important 
 
 diameters. 
 
 the symphysis-pubis to the promontory of the sacrum. Being 
 swung upon the heads of the femora, the relation of the pelvis 
 to the entire body differs in the sitting and standing positions. 
 When a woman stands upright, her pelvis is so markedly oblique 
 in its position that she would tip backward but for strong ten- 
 dons attached to the pelvis and running down the front of the 
 thighs. Added strain upon these tendons during pregnancy 
 may account for some of the apparently undue fatigue experi- 
 enced by the expectant mother. 
 
 The shallow, expanded portion of the pelvis above the brim 
 
ANATOMY 
 
 23 
 
 is the large, or false pelvis, its walls being formed by the sacrum 
 behind, the fan-like flares of the ilia on each side, with the in- 
 completeness of the bony wall in front made up by abdominal' 
 muscles. 
 
 The false pelvis ordinarily serves simply as a support for the 
 abdominal viscera, which do not occupy the true pelvis unless 
 forced down by some such pressure as that caused by tight, or 
 poorly fitting corsets. The false pelvis is of little obstetrical im- 
 portance, its function during pregnancy being to support the 
 enlarged uterus, while at the time of labor it acts as a funnel 
 to direct the child's body into the true pelvis below. 
 
 Fig. 3. — Diagram of pelvic outlet, seen from below, with most important 
 
 diameters. 
 
 The true pelvis, on the other hand, is of greatest possible ob- 
 stetrical importance since the child must pass through its nar- 
 row passage during birth. It lies below and somewhat behind 
 the inlet; is an irregularly shaped, bottomless basin, and con- 
 tains the generative organs, rectum and bladder. Its bony walls 
 are more complete than those of the false pelvis, and are formed 
 by the sacrum, coccyx and innominate bones. Its lower margin 
 constitutes the outlet, or inferior strait, and l)eing longer in its 
 antero-posterior dimension than in its transverse measurement, 
 its long axis is at right angles to the long axis of the inlet. (Fig. 
 3.) A baby's head, accordingly, must twist or rotate in making 
 its descent through this bony canal, for the long diameter of the 
 head must first conform to one of the long diameters of the in- 
 let, either transverse or oblique, and then turn so that the length 
 
24 OBSTETRICAL NURSING 
 
 of the head is lying antero-posteriorly, in conformity to the long 
 diameter of the outlet, through which it next passes. 
 
 The posterior wall of the pelvis, consisting of the sacrum 
 and coccyx, forms a vertical curve and is about three times as 
 deep as the anterior wall formed by the narrow symphysis 
 pubis. The structure as a whole, therefore, curves upon itself, 
 
 Fig. 4. — Diagram of sagittal section of the pelvis showing curve of the 
 bony canal, with most important diameters. 
 
 resembling a bent tube with its concavity directed forward. 
 (Fig. 4.) 
 
 Thus it becomes apparent that the structure of the pelvis 
 requires the child 's head, not only to rotate in its passage through 
 the birth canal, but also to describe an arc, since the part of the 
 head which passes down the posterior wall travels farther in a 
 given time than the" part which passes under the pubis. 
 
 This twisting and curving of the bii'tli canal must be appre- 
 ciated in order to understand the mechanism of labor. 
 
ANATOMY 
 
 25 
 
 In considering the question of pelvimetry, we find that there 
 are both external and internal measurements to be taken, all 
 for the purpose of estimating as accurately as possible the short- 
 est diameter of the inlet through which the baby must pass. 
 (Fig. 5.) 
 
 According to a common system of mensuration, the first ex- 
 ternal measurement is the inter-spinous, the distance between 
 the anterior-superior spines, those bony points which are upper- 
 
 FiG. 5. — Two types of pelvimeters frequently used in taking measurementa 
 of the pelvic inlet and outlet. 
 
 most as the patient lies on her back. This distance is normally 
 26 centimetres. (Fig. 6.) 
 
 The second measurement is the inter-crestal, or the distance 
 between the iliac crests, and is normally 28 centimetres. 
 
 Baudelocque's diameter is the third measurement and is 
 taken with the patient lying on her side. (Fig. 7.) It is the dis- 
 tance from the top of the symphysis to a depression just below 
 the last lumbar vertebra. This depression is easily located as it 
 also marks the upper angle of a space just above the buttocks, 
 which in normal pelves is quadrilateral. In malformed pelves 
 this quadrangle may be so misshapen as to become almost a 
 triangle with the apex directed either up or down. This dimen- 
 
26 
 
 OBSTETRICAL NURSING 
 
 sion is sometimes called the external conjugate and ordinarily 
 measures 21 centimetres. 
 
 The fourth measurement is the distance between the great 
 trochanters, or heads of the femora, and normally is 32 centi- 
 metres. 
 
 All of these measurements, which after all are only approxi- 
 mate, relate to the top of the pelvis and are valuable in that they 
 
 ^ spl-nes 
 
 Fig. 6.- 
 
 Vockanjers 
 
 -Diagram showing method of measuring distances between iliac 
 crests and spines and the trochanters. 
 
 help in estimating the dimensions of the inlet, which are the im- 
 portant ones, and obviously cannot be measured on a Ha^c woman. 
 The inlet has four measurements of obstetrical importance: 
 the antero-posterior, or true conjugate, which is the distance 
 from the top of the symphysis pubis to the prominence of the 
 sacrum, and is normally 11 centimetres; the transverse diameter, 
 which is at right angles to the true conjugate and is the greatest 
 width of the inlet, measuring from a point on one side of the 
 brim to the corresponding point on the other, is normally 13.5 
 centimetres, and the two diagonal measurements, known respec- 
 
ANATOMY 
 
 27 
 
 tively as the right and left oblique diameters, which are nor- 
 mally 12.75 centimetres. 
 
 Although it is very important to the expectant mother that 
 all of these dimensions be of normal length, the length of the true 
 conjugate, or conjugata vera, is of the gravest importance of all 
 because it is the shortest diameter through which the child's head 
 must i)ass. If it is shorter than normal, the ('lianncl may be too 
 constricted for the full-term l)al)y's head to pass through com- 
 
 udeloc^ue'a 
 dlomeler gicm. 
 
 Fig. 7. — Diagram showing method of measuring Baudelocque 's diameter. 
 
 fortably, thus making a spontaneous delivery extremely difficult, 
 or even impossible. 
 
 The length of the all important, true conjugate is estimated 
 by introducing the first two fingers of one hand into the vagina 
 until the tip of the second finger touches the promontory of the 
 sacrum. (Fig. 8.) The point at which the inner margin of 
 the sjTuphysis then rests upon the forefinger is measured, thus 
 giving the length of the diagonal conjugate. This normally 
 measures 12.5 centimetres or more, and is estimated as being 1.5 
 centimetres longer than the true conjugate. 
 
28 
 
 OBSTETRICAL NURSING 
 
 The most important measurement of the outlet is the inter- 
 tuberous diameter, the distance between the tuberosities of the 
 ischii. This is the shortest diameter through which the child 
 must pass in the inferior strait, and normally measures some- 
 thing more than 8 centimetres, usually about 11 centimetres. 
 (Fig. 9.) 
 
 It is possible, by studying such measurements as these, made 
 upon an expectant mother, and comparing them with dimensions 
 which have been accepted as normal, to form a reasonably ac- 
 curate estimate of the size and shape of her pelvis. 
 
 ^^_7rue conjugate 
 
 Fig. 8. — Diagram showing method of estimating the true conjugate by 
 measuring the length of the diagonal conjugate. 
 
 A delivery may be, and frequently is, accomplished through 
 a pelvis which is not entirely normal in size or shape. But the 
 obstetrician of to-day is closely observant of the patient whose 
 pelvic measurements depart from the normal by more than the 
 accepted margin of safety, and he plans for labor in accordance 
 with the indications in each case. 
 
 Disproportion between the measurements of the mother's 
 pelvis and the size of the child 's head must be considered in this 
 connection. A small pelvis may permit of the spontaneous de- 
 livery of a small child, but be too narrow for the passage of a 
 
ANATOMY 
 
 29 
 
 full-sized baby, while a woman with a normal pelvis may have 
 an extremely diffii'ult labor because of an unusually large child. 
 The size and shape of the pelvis is found to vary among dif- 
 ferent races and in different individuals. And the size and con- 
 tour of the inlet may be so altered by rickets, lack of proper 
 exercise during early life, or by growths upon the pelvic bones, 
 as to seriously interfere with normal labor. 
 
 Fig. 9. — Diagram showing method of measuring the inter-tuberous diameter. 
 
 The various kinds of malformed pelves may be loosely clas- 
 sified as generally contracted or small ; flat ; simple funnel ; gen- 
 erally contracted funnel ; and the rachitic pelves, both flat and 
 generally contracted. There may be a contracted inlet, or a con- 
 tracted outlet, or both may occur in the same pelvis.* 
 
 * In the generally contracted pelves, all of the external measurements 
 are shorter than normal, the diagonal conjugate being 11.5 cm., or less. In 
 simple flat pelves, on the other hand, the external measurements are normal, 
 but the diagonal conjugate is 11 cm., or less. 
 
 If the distance between the tuher-ischii is only 8 cm., or less, the patient 
 
30 OBSTETRICAL NURSING 
 
 Rachitic pelves are common among negroes and not alto- 
 gether rare among white women. 
 
 The normal male pelvis is deep, narrow, rough and massive 
 as compared with the female structure (see Fig. 1.), and the 
 angle of the pubic arch, formed by the two pubic bones, is deeper 
 and more acute in the male than in the female skeleton. 
 
 The normal female pelvis, on the other hand, is light, broad, 
 shallow, smooth and large, giving evidence of the infinite wis- 
 dom and skill that entered into constructing it for the high pur- 
 pose it was designed to serve. 
 
 FEMALE ORGANS OF REPRODUCTION 
 
 The female organs of reproduction are divided into two 
 groups, the internal and the external genitals. With them are 
 usually considered certain other structures: the ureters, Mad- 
 der, urethra, rectum and the perineum, because of their close 
 proximity (Fig. 10.) ; and the breasts, because of their func- 
 tional relation to the reproductive organs. 
 
 Internal Genitalia. The internal organs of generation are 
 contained in the true pelvic cavity and comprise the uterus and 
 vagina in the centre, an ovary and Fallopian tube on each side, 
 together with their various ligaments, membranes, nerves and 
 blood vessels and a certain amount of frt and connective tissue. 
 
 The uterus is the largest of these organs. In its nonpregnant 
 
 has some kind of a funnel pelvis; simple, if the inlet measurements are 
 normal, but if they also are shortened, the pelvis is described as a generally 
 contracted funnel. 
 
 The rachitic pelves present certain characteristic features, one being 
 less difference between the inter-spinous and inter-crestal measurements 
 than is found in a normal pelvis. Another, that the distance between the 
 tuber-ischii is always of normal length and may even be greater than 
 normal. The peculiar deformity of the sacrum, however, is the most 
 characteristic abnormality of the rachitic pelves. The concavity from above 
 downward is markedly increased, in some cases almost forming an angle, 
 while the horizontal concavity is nearly or quite obliterated. The com- 
 monest type of a rachitic pelvis is one in which all of the inlet measure- 
 ments are shortened, the inter-tuberous distance normal, and the sacrum 
 characteristically deformed. This is called the generally contracted, rachitic 
 pelvis. In the flat rachitic pelvis all of the inlet measurements are 
 normal, except the diagonal conjugate, which may be shortened to 11 cm., 
 or less, and the sacrum presents the deformity described above. 
 
ANATOMY 
 
 31 
 
 state, it is a hollow, flattened,. pear-shaped organ about three 
 inches long, one and a quarter inches wide, at its broadest poipt, 
 three-quarters of an inch tliick and weighing about two ounces. 
 
 Fig. 10. — Anterior view of female tfeuerative tract, showing both ex- 
 ternal and internal organs. Drawn by Max Brodel. (Used by permission 
 of A. J. Nystrom & Co., Chicago.) 
 
 Ordinarily it is a firm, liard mass, consisting of irregularly 
 disposed, involuntary (unstriped or plain) muscle fibres and 
 "onnective tissue, nerves and blood vessels. The arrangement 
 
32 
 
 OBSTETRICAL NURSING 
 
 of the utorine muscle fibres is unique, for they run up and down, 
 around and crisscross, forming a veritable network. This strange 
 arrangement of the fibres is favorable to the growth of the uter- 
 ine musclature during pregnancy, and a factor in preventing 
 hemorrhage after delivery. 
 
 The abundant blood supply to the uterus merits a word. It 
 is derived from the uterine arteries, arising from the internal 
 iliacs, and the ovarian artery from the aorta. The arteries from 
 the two sides of the uterus are united by a branch where the 
 neck and body of this organ meet, thus forming an encircling 
 
 Lateral secUon 
 of virgin uterus 
 
 Lateral section 
 of multlparous uterus 
 
 Antero- posterior section 
 
 Fig. 11. — Diagrams of sections of virgin and multiparous uteri 
 
 artery. A deep cervical tear during labor may break this vessel 
 and a profuse hemorrhage occur as a result. 
 
 The uterus is covered, front and back, by a fold of the peri- 
 toneum, except the lower part of the anterior wall where the 
 peritoneum is reflected up over the bladder. It is lined with a 
 thick, velvety, highly vascular mucous membrane, the endome- 
 trium, the surface of which is covered by ciliated, columnar 
 epithelium. Embedded in the endometrium are numerous mu- 
 cous glands which dip down into the underlying, muscular wall. 
 
 The uterus as a whole is comprised of three parts : the fundus, 
 that firm, rounded, head-like part above; the body, or middle 
 portion, and the cervix, or neck, below. It is in the body and cer- 
 vix that we find the long, narrow uterine cavity, divided by a 
 constriction into two parts. The cavity of the body is little 
 more than a vertical slit, being so flattened from before backward 
 
ANATOMY 33 
 
 that the anterior and posterior surfaces are nearly if not quite 
 in apposition. It is somewhat triangular in sliape with an open- 
 ing at each angle. (Fig. 11.) The h)wer of tliese openings leads 
 into the cavity of the cervix through a constriction termed the 
 internal os, while at the cornua, or two upper angles, are the 
 openings into the Fallopian tubes. 
 
 The cavity of the cervix is spindle-shaped, being expanded 
 between its two constricted openings, the internal os above and 
 the external os below, which opens into the vagina. The exter- 
 nal OS in the virgin is a small round hole but has a ragged outline 
 in women who have borne children. 
 
 This oblong, muscular body, the uterus, is suspended ob- 
 liquely in the centre of the pelvic cavity by means of ligaments. 
 In its normal position the entire organ is slightly curved forward, 
 or ante-flexed, the fundus being directed upward and forward 
 and the cervix pointing down and back. This position is affected 
 by a distended bladder or rectum, and also by postural changes 
 in the body as a whole. The cervix protrudes into the anterior 
 wall of the vagina for about one-half inch and almost at right 
 angles, since the vagina slopes down and forward to the outlet. 
 
 The upper part of the uterus is held in position by means of 
 ligaments, the lower part being imbedded in fat and connective 
 tissue between the bladder and rectum. This more or less ot a 
 floating position makes possible the enormous increase in size 
 and upward push or extension of the uterus during pregnancy. 
 The pregnant uterus becomes soft and elastic as it grows. At 
 term it is about a foot long, eight to ten inches wide, and reaches 
 up into the epigastric region. This growth is due in part to the 
 development of new muscle fibres and in part to a growth of the 
 fibres already existing in the uterine wall. 
 
 After labor the uterus returns almost, but never entirely, to 
 its former size, shape and general condition. 
 
 The Fallopian tubes are two tortuous, muscular tubes, four 
 or five inches long, extending laterally in an upward curve, from 
 the cornua of the uterus and within the folds of the upper mar- 
 gin of the broad ligament, by which they are covered. At their 
 juncture with the uterus, the diameter of these tubes is so small 
 as to admit of the introduction of only a fine bristle, but they 
 
34 OBSTETRICAL NURSING 
 
 gradually increase in size toward their termination in wide 
 trumpet-shaped orifices, which open directly into the peritoneal 
 cavity. Finger-like projections called fimbrice, fringe the mar- 
 gins of these openings. 
 
 The mucous lining of the tubes is covered with ciliated epithe- 
 lium and is continuous with that of the uterus. At the fimbriated 
 extremities of the tubes this lining merges into the peritoneum, 
 the serous lining of the abdominal cavity. 
 
 Just here it will be well to say a word about the peritoneum 
 because of the possibility of its becoming infected during labor 
 and the lying-in period, and the very grave consequences of such 
 infection. It is a delicate, highly vascular, serous membrane 
 which both lines the abdominal cavity and covers the abdominal 
 and pelvic organs, which press into its outer surface and are 
 covered much as one 's fingers would be covered by pushing them 
 into the outer surface of a child 's toy balloon. The continuity of 
 this membrane is broken only where it is entered by the Fallopian 
 tubes. 
 
 The ovary, the sex gland of the female, is a small, tough duet- 
 less gland, about an inch long and three-quarters of an inch wide, 
 or about the size and shape of an almond. It is greyish pink in 
 color and presents a more or less irregular, dimpled surface. An 
 ovary is suspended on either side of the uterus, in the posterior 
 fold of the broad ligament, by which it is partly covered. Its 
 outer end is usually attached to the longest of the fimbriated 
 extremities of the Fallopian tube, the fimhria ovarica, which has 
 the form of a shallow gutter, or groove. The inner end of the 
 ovary is attached to the ovarian ligament, which in turn is at- 
 tached to the uterus below and behind the tubal entrance. 
 
 The ovary consists of two parts, the central part or medulla, 
 composed of connective tissue, nerves, blood and lymph ves- 
 sels, and the cortex, in which are embedded the vesicular Graa- 
 fian follicles containing the ova. At birth each ovary contains 
 upwards of 50,000 of these ova, which are the germ cells con- 
 cerned with reproduction and the process of menstruation. 
 
 These ovarian glands perform two vital functions, for in 
 addition to their prime function of producing and maturing the 
 germinal cell of the female, they provide an internal secretion 
 
ANATOMY 
 
 35 
 
 which exercises an immeasurably important, though imperfectly 
 understood, influence upon the general well-being of the entire 
 organism. 
 
 The vagina is an elastic, muscular sheath or tube, about four 
 
 Fig. 12. — Sagittal section of female generative tract. Drawn by Max 
 Brodel. (Used by permission of A. J. Nystrom & Co., Chicago.) 
 
 inches long, lying behind the bladder and urethra and in front of 
 the rectum. It leads interiorly up and backward from the vulva 
 to the cervix, which it encases for about half an inch. The space 
 between the outer surface of the cervix that extends into the 
 vagina, and the surrounding vaginal walls, is called the formx. 
 
36 OBSTETRICAL NURSING 
 
 For convenience of description, this is divided into four sections 
 or f ornices : the anterior, posterior and lateral f ornices. 
 
 Between the posterior fornix and the rectum a fold of the 
 peritoneum drops down and forms a blind pouch known as 
 Douglas' cul-de-sac. At this point the delicate peritoneum is 
 separated from the vagina by only a thin, easily punctured, mus- 
 cular wall. This is a fact of grave surgical significance, for un- 
 less instruments and nozzles introduced into the vagina are very 
 gently and skillfully directed, they may easily pierce this thin 
 partition. Septic material may thus gain entrance to the peri- 
 toneal cavity and peritonitis result. 
 
 The bore of the vaginal canal ordinarily permits of the intro- 
 duction of one or two fingers. It is somewhat flattened from be- 
 fore backward, and on cross section resembles the letter H. Dur- 
 ing labor this canal becomes enormously dilated, being then four 
 or five inches in diameter, and permits the passage of the full 
 term child. 
 
 The vagina is lined with a thick, heavy, mucous membrane 
 which normally lies in transverse folds or corrugations called 
 rugce. These folds are obliterated and the lining stretched into 
 a smooth surface as the canal dilates during labor. 
 
 Attention must be drawn to the fact that the vagina, cervix, 
 uterus and tubes form a continuous canal from the vulva to the 
 easily infected peritoneum, a fact which makes absolute surgical 
 cleanliness in obstetrics virtually a matter of life or death to 
 the patient. 
 
 This muscular tube is lined throughout its entire length with 
 mucous membrane, which, though continuous, changes some- 
 what in character along its course. The epithelial cells of the 
 lining of the tubes and body of the uterus have hair-like projec- 
 tions, ciliae, which maintain a constant waving motion from 
 above downward. The effect of this sweeping current is to carry 
 down toward the outlet any object or secretion which may be 
 upon the surface of the lining of the tubes or uterine cavity. 
 The unfertilized ovum is thus swept down to meet the germ cell 
 of the male and become fertilized. 
 
 Along this variously constructed canal, at different periods 
 in the life of the individual, pass the matured ovum, the men- 
 
ANATOMY 37 
 
 strual flow, the uterine secretions, the fetus, the placenta and 
 lochia, (the discharge Avhich occurs during tlie puer])erium). 
 
 Although the bladder and rectum are not organs of repro- 
 duction, they are contained in the pelvic cavity and lie in such 
 close proximity to the internal genitalia that at least a passing 
 word must be devoted to their description. 
 
 The bladder is a sac of connective tissue which serves as a 
 reservoir for the urine and is situated behind the symphysis pubis 
 and in front of the uterus and vagina. Urine is conducted into 
 the bladder by the ureters, two slender tubes running down on 
 each side from the basin of the kidney across the pelvic brim to 
 the upper part of the bladder, which they enter somewhat 
 obliquely, at about the level of the cervix. It is thought that 
 pressure of the enlarged pregnant uterus upon the ureters at 
 this point may be one factor in the causation of pyelitis, a fre- 
 quent complication of pregnancy. The bladder empties itself 
 through the urethra, a short tube which terminates in the meatus 
 urinarius, a tiny opening in the vulva. 
 
 The rectum, the lowest segment of the intestinal tract, is 
 situated in the pelvic cavity behind and to the left of the uterus 
 and vagina. It extends downward from the sigmoid flexure of 
 the colon to its termination in the anal opening. The anus is 
 a deeply pigmented, puckered opening situated an inch and a 
 half or two inches behind the vagina. It is guarded by two 
 bands of strong circular muscles, the internal and external 
 sphincter ani. The skin covering the surface of the body extends 
 upward into the anus where it becomes highly vascular and 
 merges into the mucous lining of the rectum. Pressure exerted 
 during pregnancy by the enlarged uterus is felt in both the rec- 
 tum and bladder, frequently causing a good deal of discomfort 
 and almost painful desire to evacuate their contents. 
 
 The blood vessels in the anal lining just within the external 
 sphincter sometimes become engorged and inflamed, even bleed- 
 ing during pregnancy, as a result of the pressure exerted by the 
 greatly enlarged uterus. The distended blood vessels, which in 
 this condition are called hemorrhoids, not infrequently protrude 
 from the anus and become very painful. 
 
38 OBSTETRICAL NURSING 
 
 After having considered the structure and relative positions 
 of the pelvic organs one is able to picture more clearly the ar- 
 rangement and disposition of the uterine ligaments, all of which 
 are formed by folds of the peritoneum. They are twelve in num- 
 ber, five pairs and two single ligaments, namely : tw'o broad, two 
 round, two utero-sacral, two utero-vesical, two ovarian, one an- 
 terior and one posterior ligament. 
 
 The broad ligaments are in reality one continuous structure 
 formed by a fold of the peritoneum, w^hich drops down over the 
 uterus, investing the fundus, body, part of the cervix, and part 
 of the posterior wall of the vagina. It unites on each side of the 
 uterus to form a broad, flat membrane which extends laterally to 
 the pelvic wall, dividing the pelvic basin into an anterior and 
 posterior compartment, containing respectively the bladder and 
 rectum. Between the folds of the broad ligament are situated the 
 ovaries and ovarian ligaments, the Fallopian tubes, the round 
 ligaments and a certain amount of muscle and connective tissue, 
 blood vessels, lymphatics and nerves. 
 
 The round ligaments, one on each side, are narrow, flat bands 
 of connective tissue derived from the peritoneum and muscle 
 prolonged from the uterus, and containing blood ^and lymph ves- 
 sels and nerves. They pass upward and forward from their uter- 
 ine origin just below and in front of the tubal entrance, finally 
 merging in the mons veneris and labia majora. 
 
 The utero-sacral ligaments, of which there is one on each 
 side, arise in the uterus and, extending backward, serve to con- 
 nect the cervix and vagina with the sacrum. 
 
 The utero-vesical ligaments, one on each side, extend forward 
 and connect the uterus and bladder. 
 
 The ovarian ligaments, as previously described, are attached 
 to the uterine wall and to the inner end of the ovary, one on 
 each side. 
 
 The anterior ligament is a portion of the peritoneum which 
 dips down between the bladder and uterus, forming a pouch. It 
 is known also as the uterine-vesical pouch, or the vesico-uterine 
 excavation. 
 
 The posterior ligament is formed in much the same manner 
 by a portion of the peritoneum dipping down behind the uterus, 
 
ANATOMY 
 
 39 
 
 in front of the rectum, and forming the recto-vaginal pouch. 
 This is the Doughis' cul-de-sac previously referred to. 
 
 ExtemaJ Genitalia. — The vulva, or external genitalia, are 
 situated in the pudendal crease which lies between the thighs at 
 their junction with the torso, and extends posteriorly from the 
 pubis to a point well up on the sacrum. (Fig. 13.) 
 
 The mons veneris is a firm cushion of fat and connective tis- 
 sue, just over the symphysis pubis. It is covered with skin wiiich 
 contains many sebaceous glands and after puberty is abundantly 
 covered with hair. 
 
 The labia majora are heavy ridges of fat and connective tis- 
 sue, prolonged from the mons veneris and extended down and 
 
 Fossa navicuVarls _ ^Sjj 
 
 FiG. 13. — Diagram of external female genitalia. (Redrawn from Dickinson.) 
 
 back almost to the rectum, on each side, forming the lateral 
 boundaries of the groove. They are lined with mucous mem- 
 brane and covered with skin and hair, the latter growing thinner 
 toward the perineum until it finally disappears. 
 
 The labia minora are two small cutaneous folds lying between 
 the labia majora on each side of the vagina. Like the larger 
 
40 OBSTETRICAL NURSING 
 
 folds, they taper toward the back and practically disap- 
 pear in the vaginal wall. Their attenuated posterior ends are 
 joined together behind the vagina by means of a thin, flat fold 
 called the fourchette. The labia minora divide for a short dis- 
 tance before joining at an angle in front, thus forming a double 
 ridge anteriorly. In the depression between these ridges is the 
 clitoris y a small, sensitive projection composed of erectile tissue, 
 nerves and blood vessels and covered with mucous membrane. 
 The meatus urinarius is just below the clitoris and between two 
 small folds of the mucous membrane. 
 
 The vestibule is the triangular space between the labia 
 minora, and into it open the meatus urinarius, the vagina and 
 the more important vulvo-vaginal glands. 
 
 The vaginal opening* is below the vestibule and above the 
 perineum. It is partially closed by the hymen, a fold of mucous 
 membrane disposed irregularly around the outlet, somewhat af- 
 ter the fashion of a circular curtain. The hymen is ragged or 
 more or less scalloped in outline, and varies greatly in size in 
 different women, in some instances extending so far over the 
 opening as nearly or quite to close it. ^ 
 
 The fossa navicularis is a depressed space between the hymen 
 and fourchette, so named because of its boat-like shape. 
 
 The Bartholin glands, probably the largest and most impor- 
 tant of the vulvo-vaginal glands, are situated one on each side 
 of the vagina and open into the groove between the hymen and 
 labia minora. Reference is made to these glands because of the 
 danger of their becoming infected. A gonorrheal infection of 
 these glands is particularly troublesome. 
 
 The perineum is a pyramidal structure of connective tissue 
 and muscle which occupies the space between the rectum and 
 vagina, and by forming the floor of the pelvis serves as a sup- 
 port for the pelvic organs. The lower and outer surface of this 
 mass, representing the base of the pyramid, lies between the 
 vaginal opening and the anus and is covered with skin. As the 
 anterior part of the perineum is incorporated in the posterior 
 wall of the vagina, the entire structure becomes stretched and 
 flattened when the vagina is dilated during labor by the pas- 
 sage of the child's head. 
 
ANATOMY 41 
 
 Unless very carefully guarded at the time of delivery, and 
 often even then, the perineum gives way under the great tension 
 undergone at that time, and a tear is the result. The injury may 
 be only a slight nick in the mucous membrane or it may extend 
 to, or into the levator am, the most important muscle of the peri- 
 neal body, or if a "complete tear" will extend all the way 
 through the perineum and completely through the sphincter ani. 
 Such a tear is lamentable, as a break in the ring-shaped sphincter 
 muscle guarding the anal opening robs a woman of control of her 
 bowels, and is repaired with difficulty. 
 
 BREASTS 
 
 The breasts are large, specially modified skin glands of the 
 compound, racemose or clustering type, embedded in fat a_iid 
 connective tissue and abundantly supplied with nerves and 
 blood vessels. They are situated quite remotely from the pelvic 
 organs, but because of the intimate functional relation between 
 the two, the breasts of the female may be regarded as accessory 
 glands of the generative system. They exist in the male, also, but 
 only in a rudimentary state. 
 
 Although the breasts sometimes contain milk during in- 
 fancy, their true function is to secrete, in the parturient woman, 
 suitable nourishment for the human infant during the first 
 few months of its life. 
 
 These glands are symmetrically placed, one on each side of the 
 chest, and occupy the space between the second and sixth ribs 
 extending from the margin of the sternum almost to the mid- 
 axillary line. A bed of connective tissue separates them from 
 the underlying muscles and the ribs. (Fig. 14.) 
 
 They vary in size and shape at different ages, and with dif- 
 ferent individuals, particularly in women who have borne and 
 nursed children, when they tend to become pendulous. But in 
 general they are hemispherical or conical in shape with the nip- 
 ple portruding from one-quarter to one-half inch from the apex. 
 The nipples are largely composed of sensitive, erectile tissue and 
 become more rigid and prominent during pregnancy and at the 
 menstrual periods. Their surfaces are pierced by the orifices of 
 the milk ducts, which are fifteen or twenty in number. (Fig. 15.) 
 
42 
 
 OBSTETRICAL NURSING 
 
 Milk duclW 
 
 Lacteal orifices 
 
 3"T?lb 
 
 6IsT?lb 
 
 Fig. 14.-Sagittal section of breast showing structure of « 
 
 apparatus. 
 
 secrcforj 
 
ANATOMY 
 
 43 
 
 . The breasts are covered with very delicate, smooth, -white skin, 
 excepting for the areola;, those circular, pigmented areas one to 
 four inches in diameter, which surround the nipples. The 
 areolaB are darker in brunettes than in blonds, and in all women 
 grow darker during pregnancy. The surface of the nipples and 
 of the areolae is roughened by small, shot-like lumps or papillse 
 known as the tubercles of Montgomery. This roughness becomes 
 more marked during pregnancy, since the papillae grow larger 
 and sometimes even contain milk. 
 
 Fig. 15. — Front view of breast showing areola, tubercles of Montgomery 
 and orifices of milk ducts. 
 
 The secretory apparatus of the breasts is divided into fifteen 
 or twenty lobes, these in turn being divided into clusters of 
 lobules. The lobules in turn are composed of tiny, secreting cells, 
 called acini, in which the milk is elaborated from the blood. The 
 acini are minute globules lined by a single laj^er of cells and en- 
 veloped by a very delicate membrane. Tiny ducts carry the 
 milk from the acini to the main duct of the lobule, around which 
 the acini cluster. These ducts empty the milk into the larger 
 duct of the lobe, which runs straight to the nipple and opens 
 ■upon the surface. Just before reaching the surface, each of 
 these lactiferous sinuses expands into an ampulla, a minute res- 
 
44 OBSTETRICAL NURSING 
 
 ervoir for collecting the milk, which is secreted during the 
 periods between nursings. 
 
 These clusters of acini uniting to form lobules with tiny ducts 
 leading into the main duct of each lobule, closely resemble a 
 bunch of grapes. The separate grapes correspond to the acini, 
 their small stems correspond to the tiny ducts of the glands which 
 lead to a larger one, and the central stem of the grape cluster, to 
 the milk duct that opens upon the nipple. 
 
 The secretory tissue really constitutes a small part of the 
 breasts until they begin to function. But during lactation the 
 acini become enormously developed and enlarged. After lacta- 
 tion ceases, the acini assume a more or less tubal form, many of 
 them undergoing atrophic changes. 
 
CHAPTER II 
 PHYSIOLOGY 
 
 Puberty is that period during which childhood develops into 
 sexual maturity, and the individual becomes capable of repro- 
 duction. 
 
 The age at which puberty occurs varies with climate, race, 
 occupation and with individuals of the same status. But the 
 average age for girls, in temperate climates, is from the twelfth to 
 the sixteenth year; for boys from the fourteenth to the seven- 
 teenth year. Girls in southern climates sometimes mature as 
 early as the eighth or ninth year, while in colder regions puberty 
 may be delayed until the eighteenth or twentieth year. 
 
 At this time there are many physical and psychical manifes- 
 tations of the maturing changes in the internal female genera- 
 tive organs. The undeveloped girl grows rapidly at this stage. 
 Her entire body rounds out and assumes a more graceful con- 
 tour ; her breasts increase in size ; her hips broaden ; the external 
 genitalia enlarge and hair appears over the pubis and on other 
 parts of the body. 
 
 As this physical maturity progresses, there is a dawning sex 
 consciousness and the developing girl becomes shy, modest, re- 
 tiring and introspective. She is very likely to he emotional and 
 hysterical and to display a lack of stability and nervous control, 
 which are not in accord with her usual temperament. A for- 
 merly dependable child may become capricious, erratic, and per- 
 plexingly inconsistent. One day she may be quite her normal, 
 little-girl self and the next show inexplicably mature qualities. 
 Or she may display a bewildering number of moods and fancies 
 in the span of one short day. 
 
 Too much cannot be said of the importance of wise supervi- 
 sion and guidance of the girl's physical, mental and emotional 
 life at this critical, emotional period. Many gynecological, ob- 
 
 45 
 
46 OBSTETRICAL NURSING 
 
 stetrical and neurological difficulties in her later life may be 
 averted by her observance of sane rules of personal hygiene. 
 
 Vigorous and regular out-of-door exercise ; a simple, nourish- 
 ing and well-balanced diet; adequate sleep in a well-ventilated 
 room ; regular bathing, and correction of any discoverable physi- 
 cal defects are the essentials. 
 
 But of equal, if not greater, importance is an understanding 
 and sympathetic oversight of the girl's mental and emotional 
 life, a steadying sort of comradeship. 
 
 Her extreme sensitiveness and impressionability should be 
 recognized and borne in mind, and every effort made to save her 
 from strain and shock. Her nervous forces should be sedulously 
 conserved by protecting her against experiences and diversions 
 which would be unduly stimulating or irritating. Nor should 
 demands be made upon her uncertain nervous endurance which 
 she is able to meet only by great strain, if at all. 
 
 It is important to her future poise and health that her confi- 
 dence be courted, and when it is won, that all of her outpour- 
 ings be received with a respect and seriousness commensurate 
 with their great importance to her. Ridicule, and even unre- 
 sponsiveness or indifference to her interests, may, and often do, 
 result in a hurtful repression of one form or another. The logi- 
 cal consequence of such repression is an increasingly damaging 
 neurosis later on in her life, capable of greatly impairing her 
 health, happiness and usefulness. 
 
 In short, all phases of the life of the adolescent girl should 
 be made as wholesome, tranquil and free from stress and strain 
 as is humanly possible. 
 
 These comments upon the importance of mental hygiene at 
 puberty may seem irrelevant to a discussion of obstetrical nurs- 
 ing. But the preparation of the entire female organism for its 
 supreme function — that of child-bearing — is of concern to the 
 obstetrical nurse, and should be understood by her. Moreover, 
 every nurse is inevitably a health teacher, either by precept or 
 example, or both. An awareness on her part of the maturing 
 girl's needs will fit her to help many perplexed mothers whom 
 she meets along the way to a happy solution of this grave and 
 vexing problem. 
 
PHYSIOLOGY 
 
 47 
 
 The occurrence of puberty marks the establishment of ovula- 
 tion and menstruation. These two functions are usually per- 
 formed once a month, ovulation probably occurring about mid- 
 way during the inter-menstrual period. 
 
 Ovulation, which is the prime function of the ovary, may be 
 defined as the formation and development of the ovum, and its 
 expulsion, when mature, from tlie ovary. 
 
 The formation of each woman 's full quota of ova is probably 
 complete at birth, thoug:h the process may continue until about 
 the second year. At this time it is variously estimated that each 
 
 nucleolus 
 
 •membrdna 
 ranulosa 
 
 tleu^ 
 
 Fig. 16. — Diagram of human ovum. 
 
 of the two ovaries contains from 50,000 to 70,000 ova, but they 
 remain unmatured until puberty, the period at which ovulation is 
 most active. 
 
 As the entire complex human body has its origin in this 
 tiny ovum, its course of development is of momentous importance 
 to us, and at the same time it provides a tale of intense interest. 
 
 In its unmatured state, the ovum, termed a primordial fol- 
 licle, or oocyte, is a single cell, 1/125 inch in diameter, consist- 
 ing of clear protoplasm, the vitelliis, and a surrounding vitelli7ie 
 membrane composed of small, spindle-shaped epithelial cells. 
 The protoplasm contains a fairly large nucleus, or germinal ves^ 
 
48 OBSTETRICAL NURSING 
 
 icle, within which lies a nucleolus known as the germinal spot, 
 {Fig. 16.) 
 
 The primordial follicle probably lies dormant in this state 
 until puberty, when developmental changes take place, though it 
 is the belief of some authorities that follicles are in the process of 
 development from birth until the end of sexual life, though none 
 fully mature until puberty. 
 
 With the advent of puberty the cells composing the vitelline 
 membrane change in character and proliferate rapidly, with the 
 result that the ovum is surrounded by several layers of epithelial 
 cells. Some of the inner cells degenerate and liquify, thus sur- 
 rounding the ovum with fluid which is contained in a membrane 
 of vascular connective tissue, the theca folliculi; this in turn is 
 lined with epithelial cells, the memhrana granulosa. This struc- 
 ture constitutes a Graafian follicle, named for Dr. de Graaf who 
 first described it, and in the course of its maturation is pushed 
 toward the surface of the ovary, where it presents more or less 
 the appearance of a clear blister. 
 
 At one point in the enveloping membrana granulosa, the 
 cells proliferate into a mass in which the floating ovum becomes 
 embedded. This mass is termed the discus proligerus and the 
 fluid which surrounds it is the liquor folliculi. 
 
 Usually for some strange reason, one, and only one, ovum 
 ripens regularly each month during the years from puberty to 
 the menopause, excepting during pregnancy, when this function 
 is suspended. Occasionally, however, several ova mature at once, 
 a condition which may be one factor in the development of twins. 
 After puberty the ovary contains ova in all stages of develop- 
 ment, from the primordial follicle to the Graafian follicle just de- 
 scribed. 
 
 When a Graafian follicle containing a matured ovum reaches 
 the ovarian surface, its membrane becomes thinner and finally 
 ruptures because of increased tension in the ovary, due to certain 
 circulatory changes. The ovum surrounded by the discus pro- 
 ligerus is thus discharged into the peritoneal cavity near the 
 fimbriated end of the tube. Some ova enter the tube and others 
 float about in the peritoneal cavity, finally disintegrate and are 
 lost. 
 
PHYSIOLOGY 49 
 
 The torn envelope of the follicle which remains in the cortex 
 of the ovary becomes filled with blood, which forms into a clot. 
 This clot is first surrounded, and then invaded, by cells contain- 
 ing bright yellow pigment called lutein. The membrane formed 
 from these cells compresses the clot and brings about other 
 changes which speedily transform it into the corpus luteum. 
 
 If the discharged ovum becomes fertilized, the corpus luteum 
 remains practically unchanged for months and is termed the 
 corpus verum or corpus luteum of pregnancy. Its secretion is 
 believed to influence the implantation of the ovum and to pro- 
 mote the woman's general well-being during the period of ges- 
 tation. It continues to exist throughout pregnancy, and until 
 after delivery, when it is soon absorbed and replaced by normal 
 ovarian tissue, without the formation of scar tissue. 
 
 If fertilization does not occur, the body in the ovarian cortex, 
 which is then termed the corpus luteum of menstruation, or false 
 corpus, undergoes rapid degenerative changes and is almost 
 wholly absorbed within a few weeks. 
 
 By means of this rather complicated procedure the ovary is 
 saved from becoming a steadily enlarging mass of scar tissue, and 
 consequently devoid of reproductive powers, which would be the 
 ease if the wound made by the rupturing of each Graafian fol- 
 licle were to heal by the usual formation of cicatricial tissue. 
 
 Ordinarily the ovum remains unfertilized and is propelled 
 down the Fallopian tube, by the cilia in its lining, to tlie uterine 
 cavity, where it is lost in the uterine secretions and ultimately 
 carried out in the menstrual flow. 
 
 Each time that an ovum matures, however, and is discharged 
 from the ovary the lining of the uterine cavity increases in vas- 
 cularity and becomes thicker and more velvety ; a condition which 
 facilitates an attachment of the ovum in case of fertilization. 
 This preparation of the endometrium is termed " pre-menstrual 
 swelling," or in popular language, nest-building. 
 
 Of the enormous number of ova existing in each woman, 
 relatively few mature and it is apparent that still fewer are 
 fertilized, since each impregnation results in an abortion, a pre- 
 mature labor or a full term child. 
 
 Nature's lavish provision of something more than 100,000 ova 
 
50 OBSTETRICAL NURSING 
 
 for each woman, who uses only about 500 in the course of her 
 life, excites no little wonder. But whatever the purpose of this 
 enormous supply, its existence makes possible the removal of all 
 but a small fragment of ovarian tissue in cases of disease, without 
 interference with the process of ovulation, which in turn permits 
 reproduction. 
 
 Menstruation, which is the evidence of sexual maturity, is a 
 monthly hemorrhage from the uterus which escapes through the 
 vagina, normally recurring throughout the entire child-bearing 
 period, except during pregnancy and lactation. The duration of 
 this child-bearing period, or sexual activity, is about thirty years 
 and continues from puberty to the menopause. 
 
 The frequency of the menstrual periods varies in different 
 women from twenty-one to thirty days, but the normal interval 
 between periods is twenty-eight days, which corresponds in point 
 of time to the menstrual cycle. Thus it is usually four weeks, or 
 a lunar month, from the beginning of one period to the beginning 
 of the period following, making thirteen menstrual periods dur- 
 ing each calendar year. 
 
 Just why menstruation occurs about every twenty-eight days 
 is not known, but the belief is that, although menstruation is in 
 some way dependent upon ovulation, its periodicity is regulated 
 by the corpus luteum. It is also believed that the corpus luteum 
 of pregnancy holds menstruation in check during the nine months 
 of gestation. 
 
 The menstrual cycle is divided into four stages, and though 
 there is not entire unanimity of opinion concerning the changes 
 which take place during these four stages, the preponderance of 
 evidence is in favor of the following processes. 
 
 The first or constructive stage lasts about seven days. It is 
 during this stage that the preparative changes, which have 
 been described, are made for the reception of the matured ovum. 
 The uterus becomes engorged with blood and is somewhat en- 
 larged and softened as a result. The endometrium grows deep 
 red, thick and velvety, partly because of the greatly augmented 
 blood supply, and partly because of an actual increase of con- 
 nective tissue in its structure. There is also an increase in the 
 size and activity of the uterine glands and in the amount of their 
 
PHYSIOLOGY 51 
 
 secretions. If the ovum remains unfertilized, which is usually 
 the case, it does not attach itself to this elaborately prepared 
 lining, but passes out with the uterine discharges, and all of this 
 preparation and increased vascularity not only go for naught, 
 but must be undone. 
 
 The second stag"e, therefore, which lasts about five days, is 
 the destructive stage, during which the newly developed tissues 
 are broken down and the menstrual discharge occurs. During 
 this period the greatly increased secretions of the uterine glands 
 mix with the blood that oozes from the engorged endometrium 
 and with the disintegrated uterine tissues, and pour from the 
 vagina as the menstrual flow. 
 
 The third, or reparative stage, which follows, occupies about 
 three days. During this stage the destroyed uterine tissues are 
 regenerated by new growth from the deeper, uninjured tissues, 
 and the entire organ returns to its normal state. 
 
 The fourth, or quiescent stage, now follows, the damage hav- 
 ing been repaired, and lasts twelve or fourteen days. This is the 
 time remaining before Nature with unwearying patience begins 
 all over again to prepare for the reception and attachment of the 
 next matured ovum, in case of its possible fertilization. 
 
 It will be seen that tlie duration of the menstrual period, 
 which is coincident with the destructive stage of the menstrual 
 cycle, is about five days, but it is entirely within normal bounds 
 if it varies in length from two to seven days. 
 
 The discharge is usually scant at the beginning of the period, 
 increasing in amount until about the third day, after which it 
 diminishes steadily until its cessation. The normal odor of this 
 discharge, consisting as it does of blood and uterine secretions, 
 has been likened to that of marigolds. 
 
 The average amount of blood lost is from six to ten ounces, 
 but it varies greatly among women who are otherwise normal 
 and in good health. Some women regularly lose what seems to 
 be an alarming (juantity of blood at each period without suffer- 
 ing any apparent ill effect. Others lose so little that they are 
 scarcely aware of their menses. 
 
 As a rule the menstrual flow is more profuse among women 
 in warm climates than in cold regions. English women, for ex- 
 
52 OBSTETRICAL NURSING 
 
 ample, frequently menstruate profusely while in India, and upon 
 their return to England note a marked decrease in the amount 
 of the discharge. The same is often true of American women 
 who move from Southern to Northern states, while removal from 
 a low to a high altitude usually results in a more profuse flow. 
 
 The quantity of the menstrual discharge is affected also by 
 diet, living conditions and by any form of mental or physical 
 excitement or stimulation. 
 
 Accordingly, the highly strung, richly nourished women liv- 
 ing in luxurious circumstances are likely to menstruate more 
 freely than those less favored who are overworked and poorly 
 nourished. 
 
 A shock or great grief, or any great emotional experience ; a 
 sea voyage or a long railroad journey may bring on a period be- 
 fore it is due, while the regularity of the periods may be much 
 disturbed, temporarily, by a marked change of climate or alti- 
 tude, a serious illness or a decided change in one's daily regime. 
 
 The function may be entirely suspended for several months 
 or a year in women who suddenly take up hard work or violent 
 exercise, and persist with it regularly. In such cases the periods 
 gradually recur and finally become normal and regular. 
 
 The menstrual period is frequently attended by evidences of 
 marked mental and physical disturbances. While many women 
 are fortunate enough to suffer little or no inconvenience during 
 menstruation, the vast majority are more or less wretched and 
 miserable at this time, although in good health in all other re- 
 spects. Many are tired, have less endurance than usual and are 
 likely to take cold easily. Headaches with a sense of fullness, 
 dizziness, and heaviness are common accompaniments. Back- 
 ache is a frequent source of discomfort, while abdominal pain, 
 varying from an uncomfortable sense of dragging heaviness to 
 almost unendurable agony, is the rule rather than the exception. 
 And there may be pain in the hips and thighs as well. 
 
 This state of wretchedness is sometimes increased by a loss 
 of appetite, nausea and even vomiting. At the same time there 
 are changes in the breasts which are much the same as, though 
 slighter than, those occurring during pregnancy. They are 
 firmer, may be somewhat increased in size, and many women 
 
PHYSIOLOGY 53 
 
 experience a burning, tingling sensation, soreness and even pain. 
 The nipples are turgid and prominent and the pigmented areas 
 grow darker for the time being. 
 
 The skin over the rest of the body sometimes changes in ap- 
 pearance and pimples are common ; some women are pale and 
 others are flushed during their periods. 
 
 These physical disturbances accompanying menstruation 
 vary so widely in different women, and in the same women at 
 different times and under different conditions, that it is not pos- 
 sible to draw a classical picture of the condition. But all of the 
 symptoms above described will persist wath more or less severity 
 throughout the entire menstrual life of one woman, while per- 
 haps only one or tw^o of them will occasionally disturb another. 
 Whatever discomfort there may be usually begins from one day 
 to a week before the discharge appears; is at its height during 
 the following day and from that time subsides steadily, until the 
 normally comfortable state is regained. In fact, many women 
 feel better at the end of their periods and during the days 
 immediately following than at any other time during the 
 cycle. 
 
 Heat applied to the abdomen and lumbar region during the 
 uncomfortable days; hot baths, rest and quiet, will usually give 
 great relief, as might be expected when there is local congestion 
 and general nervous irritability. In this connection, it is worth 
 mentioning that the discomfort of many w'omen is needlessly 
 increased by their heeding the widespread but fallacious belief 
 that general bathing during menstruation is injurious. While 
 cold plunges and cold showers are not recommended, certainly 
 warm baths are innocuous and immensely satisfying. 
 
 In addition to the physical discomfort which is coincident 
 with menstruation, and quite as common, are the evidences of 
 mental and nervous instability. These often show themselves in 
 the form of unwarranted irritability, and in a lack of poise and 
 self-control. Drowsiness and mental sluggishness are not un- 
 common, and many otherwise cheerful women are almost over- 
 whelmed by depression during menstruation. 
 
 All of these departures from what we are accustomed to re- 
 gard as the normal, or average, mental and physical state of 
 
54 OBSTETRICAL NURSING 
 
 women are very baffling, as they may persist after every dis- 
 coverable defect lias been corrected. 
 
 But aside from all other considerations it is of obstetrical im- 
 portance for the sufferer to ascertain the cause of her discomfort 
 if possible. For example, a misplacement of the uterus is a 
 frequent cause of dysmenorrhea and, if it remains uncorrected, 
 may make conception impossible; or if conception perchance 
 does take place, the malposition of the uterus may later be the 
 cause of an interrupted pregnancy. 
 
 Endometritis is another cause of menstrual difficulty and if 
 allowed to persist may be one factor in the causation of abnormal- 
 ities in the attachment of the placenta. 
 
 There is evidently an intimate relation between the process 
 of menstruation and the functions of the ductless glands through- 
 out the body ; a relation which is far from being understood. 
 
 For example, the administration of various preparations of 
 ductless glands for maladies which are apparently unrelated to 
 menstruation, results not alone in an improvement of the condi- 
 tion treated, but frequently in much more comfortable men- 
 strual periods, as well. 
 
 It should be borne in mind, also, that the influence exerted 
 by a woman's mental, or psychic, state upon her menstrual pe- 
 riods is so apparent that it is being given increasingly serious 
 recognition. It is frequently observed that patients who are 
 under treatment for nervous and mental disorders, who are also 
 sufferers from painful menstruation, grow more comfortable dur- 
 ing their periods as their neurosis improves. 
 
 We have constantly before us examples of painful menstrua- 
 tion being relieved coincidently with an improved mental state 
 among women situated at the two extremes of the social and 
 financial scale. Indolent, self-centred and unoccupied women 
 at one end often become excessively nervous and irritable, and 
 suffer great pain w^ith each period, while the overworked, har- 
 assed, poverty-stricken women at the other extreme have simi- 
 larly trying menstrual experiences. When the self-indulgent 
 sister can be persuaded to engage in some form of physical activ- 
 ity and to interest herself in some work which requires mental 
 effort, and which perhaps makes an emotional appeal as well, she 
 
PHYSIOLOGY 55 
 
 frequently finds that her menstrual difficulties become less trou- 
 blesome. 
 
 In the case of the woman in poorer circumstances, an im- 
 provement in her mode of living which approaches the normal, 
 and a relief from undue stress and anxiety, will very often be 
 followed by more comfortable menstruation. 
 
 A recognition of these rather intangible facts is of conse- 
 quence to the nurse, as it deepens her appreciation of the neces- 
 sity for nursing her patient as a complete entity, mentally, physi- 
 cally, spiritually and emotionally. We are insistently reminded 
 at every turn that no one part of the patient, no one aspect of 
 her condition can be separately considered and the remainder 
 overlooked. 
 
 The patient can be nursed quite satisfactorily only when she 
 is nursed completely. 
 
 Relation Between Ovulation and Menstruation. — Menstrua- 
 tion and ovulation are apparently associated and interdependent, 
 but the exact relation between the two is still obscure and puz- 
 zling. It is generally accepted that complete removal of the 
 ovaries stops ovulation and is followed by a cessation of men- 
 struation, and yet cases have been recorded which suggest that 
 these two functions are not invariably correlative. 
 
 Evidence of this possible independence is that, although preg- 
 nancy must be preceded by ovulation, it has occurred before 
 puberty or after the menopause. And not infrequently preg- 
 nancy occurs during lactation, a period when the menstrual 
 function is usually suspended. 
 
 It has been claimed by some observers that menstruation has 
 occurred after the complete removal of both ovaries, which 
 would, of course, preclude the possibility of further ovulation. 
 It is possible, however, that in such cases either the ovaries were 
 not entirely removed, though believed to be, or that an acces- 
 sory ovary existed, since a very small fragment of ovarian tissue 
 will permit the occurrence of ovulation. 
 
 As to their chronological relation, information available at 
 present suggests that ovulation occurs about ten or twelve days 
 after the close of the preceding period, and that the corpus lu- 
 
56 OBSTETRICAL NURSING 
 
 teum formed at the site of the rupture reaches its highest devel- 
 opment some ten or twelve da.vs later, and that the degenerative 
 changes in the corpus luteum, in ease of non-fertilization of the 
 ovum, give rise to menstruation. 
 
 Modifications of Menstruation. Dysmenorrhea is painful 
 menstruation. 
 
 Menorrhagia is an abnormally copious menstrual flow. 
 
 Amenorrhea is irregularity or, to be exact, suppression of 
 the menses. The suppression may be due to an obliteration of 
 the neck of the uterus, or to an occlusion of the vaginal opening. 
 
 Vicarious menstruation is an escape of blood from other 
 parts of the body coincident with menstruation. Blood may ooze 
 through the skin covering the breasts ; also from hemorrhoids or 
 from the surface of ulcers. Or there may be nose-bleeding, vom- 
 iting of blood or pulmonary hemorrhage, particularly among 
 tuberculous patients. Vicarious menstruation usually occurs 
 among nervous, high-strung women and may be regarded as an 
 evidence of ill health. The amount of blood lost in this way is 
 much less than the amount of the menstrual flow. 
 
 The menopause, also termed the climacteric and the change of 
 of life, marks the permanent cessation of menstruation and of 
 sexual activity. It occurs ordinarily between the ages of forty 
 and fifty; the majority of women stop menstruating at their 
 forty-sixth year. The menopause has occurred as early as the 
 twenty-fifth year, and as late as the eightieth or ninetieth year. 
 But such cases are, of course, extremely rare and their infrequent 
 occurrence is of interest rather than of importance in an effort 
 to ascertain the general average. 
 
 As the child-bearing period is normally about thirty years in 
 duration, the prevailing belief is that the menopause comes ear- 
 lier to women who began menstruating early, than to those who 
 did not reach puberty until later. Some authorities contend, 
 however, that early menstruation indicates extreme vitality, and 
 that this vitality tends to prolong the child-bearing period. Ac- 
 cording to this theory, then, the menopause w'ould come late to 
 those who matured early and vice-versa. 
 
 As the menopause approaches, menstruation occurs irregu- 
 larly ; the discharge sometimes increases slightly but usually dim- 
 
PHYSIOLOGY 57 
 
 inishes in amount and finally disappears altogether, while the 
 generative organs all undergo atrophic changes. 
 
 Bearing iji mind the disquieting effect of adolescence, and of 
 ovulation, upon the general nervous, mental and physical state, 
 we may reasonably expect that a complete cessation of the ova- 
 rian function would be attended by more or less disturbance of 
 the general well-being. 
 
 It is true that very many women suffer a certain amount of 
 nervous instability at the metiopause; they tire easily; have "hot 
 flashes" and possibly headaches. But under ordinary conditions 
 the discomfort is not great, and after the function has entirely 
 ceased and they become physiologically adjusted to the new 
 order of things, these women often enjoy better health than ever 
 before. 
 
 Unfortunately wide currency has been given to exaggerations 
 concerning the symptoms of the menopause. The result is that 
 serious organic diseases which are in no way related to the cli- 
 macteric are, not infrequently attributed to it. For this reason 
 excessive bleeding, heart symptoms and what not are all too often 
 accepted as a matter of course, and accordingly neglected until 
 the patient is beyond medical aid. This is particularly and trag- 
 ically true of cancer of the uterus. 
 
 It is a wise precaution, therefore, to regard with apprehen- 
 sion an increase in the amount of the menstrual flow of any wo- 
 man past thirty, and not to accept it as a normal forerunner of 
 the menopause. 
 
In the dark womb where I began 
 My mother's life made me a man. 
 Through all the months of human birth 
 Her beauty fed my common earth. 
 
 — John Masefield. 
 
PART II 
 
 The Development op the Baby 
 
 CHAPTER III. DEVELOPMENT OF THE QTVUM, EMBRYO, FETUS, 
 PLACENTA, CORD AND MEMBRANES. The Ovum. The Sper- 
 matazoon. Fertilization. Heredity. Sex-determination. Most 
 Favorable Age for Motherhood. The Morula. Growth in the Uterus. 
 The Decidua. Ectoderm. Mesoderm. Entoderm. The Chorion and 
 Placenta. The Amnion. The Umbilical Cord. The Fetus. Growth 
 by Months. Factors Influencing the Size of Child. Multiple Preg- 
 nancy. Extra-uterine Pregnancy. 
 
 CHAPTER IV. GROWTH AND PHYSIOLOGY OF THE FETUS. Cir- 
 culation. Kidneys. Bowels. Head. Fontanelles. Occipital Meas- 
 urements. 
 
 CHAPTER V. SIGNS, SYMPTOMS, AND PHYSIOLOGY OF PREG- 
 NANCY. Duration of Pregnancy. Date of Labor. Signs of Preg- 
 nancy: Presumptive, Probable, and Positive. Physiological Changes 
 in the Maternal Organism: Uterus. Cervix. Vagina. Tubes and 
 Ovaries. Abdomen. Umbilicus. Breasts. Cardio-Vascular System. 
 Respiratory Organs. Digestive Tract. Urinary Apparatus. Bony 
 Structures. Skin. Carriage. Temperature. Mental and Emotional 
 Changes. Ductless Glands. 
 
CHAPTER III 
 
 THE DEVELOPMENT OF THE OVUM, EMBRYO, FETUS, 
 PLACENTA, CORD AND MEMBRANES 
 
 As we learned in the last chapter, some of the ova which are 
 discharged into the peritoneal cavity enter the fimbriated end 
 of the tube, while very many others perish. As a rule an ovum 
 enters the tubal opening adjacent to the ovary from which it 
 has been discharged, but it is possible for this tiny cell to travel 
 across the body and enter the tube on the opposite side. 
 
 This migration of the ovum, as it is termed, has been dem- 
 onstrated in cases in which pregnancy has followed removal of 
 the ovary on one side and the tube on the other. 
 
 There are various theories as to how and why an occasional 
 migrating ovum, floating around in a relatively large cavity, ever 
 enters the tubal opening, which, after 
 all, is not large. The most widely 
 accepted belief is that the motion of 
 the cilia lining the tubes creates a 
 suction which draws the microscop- 
 ical cell into the opening, the same 
 cilia being the means by which the 
 ovum is later propelled downward 
 through the tube to the uterus. 
 
 This journey of the ovum through 
 the tube is of enormous consequence. 
 During its course occur the events 
 which decide whether the ovum shall, 
 like most of its fellows, be simply 
 swept along to no end and lost, or whether by chance it is to 
 receive the mysterious impulse which begins the development of 
 a new human being. 
 
 The amazing power which enables this cell to reproduce itself, 
 and to develop with unbelievable complexity, is acquired some- 
 
 61 
 
 
 Fig. 17. — Diagram of 
 spermatazoa, the male cells 
 of germination. 
 
62 OBSTETRICAL NURSING 
 
 where in the tube by meeting and fusing with a spermatozoon, 
 the germinal cell of the male. (Fig. 17.) 
 
 The spermatozoa look very much like microscopic tadpoles, 
 with their flat, oval heads, tapering bodies and long tails. As 
 these tails serve somewhat as propellers, the male cells are capa- 
 ble of very rapid motion. But in spite of their strange appear- 
 ance, they are cells after all, and resemble the female cells in 
 that each one contains a nucleus, or germinal spot. 
 
 An almost inconceivably large number of spermatozoa, float- 
 ing in the seminal fluid, is deposited in the vagina at the time of 
 intercourse. Nature evidently supplies the male and female cells 
 with equal lavishness, in order to provide for the large number 
 of both kinds which must inevitably be lost, and still have enough 
 survive to accomplish the high purpose of their creation. A very 
 considerable number of spermatozoa enter the uterus, and are 
 enabled through their powers of motility, to travel up into the 
 tubes, in spite of the downward current created by the cilia. 
 And in the tube, usually in the upper end, they meet a recently 
 matured and discharged ovum which is being swept downward, 
 and are attracted to it somewhat as bits of metal are drawn to 
 a magnet. Although the ovum which is destined to be fertilized 
 is surrounded by several spermatozoa, only one actually enters 
 and fuses with it. 
 
 This fusion is termed impregnation, fertilization, or, in lay 
 parlance, conception, and the instant at which it occurs marks 
 the beginning of pregnancy. The establishment of this fact is 
 of no little importance, since it does away with any possible con- 
 troversy concerning the time at which a new life begins. The 
 origin of the child is exactly coincident with the fusion of the 
 male and female germinal cells. 
 
 And furthermore, the sex of the child and any inherited traits 
 and characteristics are also established at this decisive instant. 
 No amount of dieting, exercise nor mental effort on the part of 
 the expectant mother can alter or influence them in the smallest 
 degree, for the father has made his complete contribution toward 
 the creation of the new being, and after this event the mother 
 provides nourishment only. 
 
 All told, probably more than five hundred theories have been 
 
DEVELOPMENT OP THE OVUM AND EMBRYO 63 
 
 advanced to explain what it is tliat decides of which sex the forth- 
 coming child will be. 
 
 In 1907 Dr. Schenck attracted world wide attention by an- 
 nouncing his belief that either sex could be i)i'oduced in the ex- 
 pected child through the simple expedient of I'cgulatiiig the 
 mother's diet. Liberal feeding would result in boys, the sturdier 
 sex, and frugality in girls, the smaller, frailer type of baby. 
 But as the results of applying Schenck 's theory have scarcely 
 borne out his claims, it is given but scant attention to-day. 
 
 The present belief regarding the causation of sex is that al- 
 though there is but one kind of ovum, there are two kinds of 
 spermatozoa, one capable of producing a male, and the other a 
 female child. These two kinds are evidently deposited in the 
 vagina in about equal numbers, and the sex-determining form 
 that fertilizes any one ovum is a matter of the merest chance. 
 Statistics show, however, that more male than female babies 
 are born, the usual proportion being about 105 boys to 100 girls 
 among those that reach full term. Among abortions and prema- 
 ture births there is also a larger number of boys than girls, and 
 in elderly primiparae the ratio increases to about 130 boys to 100 
 girls. But as more boys die in infancy than girls, the two sexes 
 about even up in the number of those living to adult age. 
 
 Apparently, then, there is some factor operating slightly in 
 favor of the purposeful activities of the male-producing sperma- 
 tozoa. But so far no accurate means has ever been found where- 
 by it was possible to influence the development or discover the 
 sex of a child before its birth. 
 
 There is a wide difference of opinion concerning the time of 
 the month when fertilization is most likely to occur. Observa- 
 tions made upon the wives of sailors and under a variety of con- 
 ditions suggest that the most favorable period is just before or 
 just after menstruation which represents the second stage of the 
 menstrual cycle. 
 
 Dr. Williams believes, however, that fertilization is most likely 
 to occur about midway during the intermenstrual period. 
 But since it is probable that spermatozoa are constantly present 
 in the tubes of women who are exposed to the possibility of be- 
 
64 OBSTETKICAL NURSING 
 
 coming pregnant, it is difficult to do more than speculate about 
 the time of the month at which fertility is greatest. 
 
 Another moot question relates to the age of the woman at 
 which it is most desirable that the first child shall be born. Re- 
 cent observations made by Dr. John W. Harris upon a large num- 
 ber of pregnancies occurring in very young girls indicates that 
 from a standpoint which considers solely the physical welfare 
 of the mother and her infant, sixteen years is the most satisfac- 
 tory age at which to bear the first child. 
 
 However, when motherhood is considered from all stand- 
 points, social, ethical, spiritual as well as physical, the concensus 
 of opinion seems to be that the twenty-third year is the most 
 favorable age for motherhood to begin. Children have been 
 born to little girls nine years old and to women of sixty-two, but 
 the extremes of the reproductive years are not favorable periods 
 for child-bearing. 
 
 As soon as a spermatozoon enters an ovum, it disappears and 
 is completely absorbed, and, as the ovum in turn is instantly 
 possessed of new powers, the result of this union is a cell which 
 was previously non-existent. 
 
 This new cell is not only capable of reproduction by means 
 of segmentation or cell division, but in the course of its sub- 
 division and proliferation, it forms groups of cells which develop 
 into tissues and structures widely different from each other. 
 The entire complex human body, in addition to the placenta, 
 cord, and membranes, arises from the single, extraordinary cell. 
 
 It first divides into two ; these two divide into four ; the four 
 into eight and thus the process of division and sub-division con- 
 tinues until a solid mass is formed, shaped something like a mul- 
 berry and called the morula. (Fig. 18.) 
 
 While these developmental changes are taking place, the 
 morula is being carried down the tube toward the uterus, by 
 the swee|)ing motion of the ciliated membrane. The time con- 
 sumed by this journey has not been definitely ascertained and 
 though possibly it may be made in a few hours, it probably 
 takes from five days to a week. Since the embryo is constantly 
 moving during this time, it quite evidently has no attachment 
 to the mother and cannot, therefore, derive any great amount 
 
 ( 
 
DEVELOPMENT OF THE OVUM AND EMBRYO 65 
 
 of nourishment directly from her. The growth and develop- 
 ment to this point, then, must be due cliiefly to inherent powers 
 within the mass of cells itself. 
 
 In all probability, the embryo is still in the morula stage and 
 is about the size of the head of a pin when it reaches the uterus, 
 where it finds that the endometrium has been prepared for its 
 reception by the premenstrual swelling. The mucosa has grown 
 thicker, more velvety and vascular, and its glands have increased 
 in number and activity. The columnar epithelium of the endo- 
 metrium is replaced by a thick layer of large, vacuolated cells, 
 
 FiVst stages «{ «ell di'vi'sior^ 
 
 Morula stage's 
 
 Dlasioderirnic vesicle. 
 FiQ. 18. — Diagram of segmenting rabbit's ovum. 
 
 called decidual cells, and the uterine lining from now on is 
 termed the decidua gravidatis. While the normal uterine mucosa 
 is thin, averaging from 1 to 3 millimetres (0.039 to 0.117 inch) 
 in thickness, it increases to a thickness of about 1 centimetre 
 (% inch) during pregnancy. 
 
 The point at which the embryo attaches itself to this spongy 
 membrane is entirely a matter of chance. It usually rests some- 
 where in the upper part of the uterine cavity, promptly de. 
 stroys the minute underlying area of tissue by digestive action 
 and burrows into the decidua. As the margins of the opening 
 thus made meet and fuse above the ovum, it is completely in- 
 
66 OBSTETRICAL NURSING 
 
 capsulated in a cavity of its own that has no connection with 
 the uterine cavity. (Fig. 19.) 
 
 After this occurrence the decidua consists of three portions: 
 the hypertrophied membrane which lines the uterus as a whole, 
 called the decidua vera, which atrophies during the latter part 
 of pregnancy and is also thrown off in part with the membranes 
 during labor, and later in the uterine discharges; the decidua 
 hasalis, or the decidua serotina, is that portion lying directly 
 beneath the embryo which later enters into the formation of the 
 
 
 BlcLduQ GOpU 
 
 ai-i=. PoLnt 
 
 j\ ent 
 
 ronce 
 
 
 
 ^.. .^r .«iiiu-i * Aw 
 
 
 
 
 
 
 'f^:^f^::'-^\ 
 
 '-"'.-^^ .4.x '"*■'•"- " 
 
 *• *« 
 
 
 
 
 
 
 
 ■^ 
 
 
 
 ' v;!^"" 
 
 
 
 
 Huclewt. 
 
 Ovurn — 
 
 
 
 t ^ « » 
 
 
 
 
 
 Biotdua 
 
 bo so 
 
 IS 
 
 
 Fig. 19. — Ovum about 13 days old, embedded in the decidua. (The Bryce- 
 Teacher ovum from Human Embryology by Keibel and Mall.) 
 
 placenta ; and the decidua reflexa, which surrounds and covers 
 the buried embryo, consists of the developed and fused margins 
 of the pit in the mucosa, that have grown over the embryo. 
 
 As the cellular activity continues within the morula, fluid 
 appears in the centre with the result that the cells are rear- 
 ranged and pushed toward the periphery, thus forming a sac. 
 At this stage the embryo is called the blastodermic vesicle. 
 
 At one point on the inner surface of this vesicle the cells 
 proliferate and form a mass which is sometimes called the in- 
 ternal cell mass, or embryonic area, and the single layer of 
 cells comprising the remainder of the vesicular wall, the primi- 
 
DEVELOPMENT OF THE OVUM AND EMBRYO 67 
 
 tive chorion. The cells in the mass are at first disposed in layers, 
 the outer layer being termed the ectoderm; the inner layer the 
 entoderm, while a third layer which appears a little later is 
 called the mesoderm. 
 
 Although these three primitive layers of cells have all arisen 
 from the single cell formed by the fused spermatozoon and ovum, 
 they are even now very different in character. The differences 
 steadily increase until finally all of the complex fetal organs 
 and tissues, the membranes, cord and placenta, result from their 
 further specialization and development, as follows: 
 
 From the ectoderm arises the skin with its appendages, and 
 the salivary and mammary glands; the nasal passages, upper 
 part of the pharynx and the anus; the crystalline lens, the ex- 
 ternal ear, the entire nervous system, the sense organs and, in 
 part, the fetal membranes. 
 
 From the mesoderm are derived the urinary and reproduc- 
 tive organs; the muscles, bones, and connective tissues and the 
 circulatory systems. 
 
 From the entoderm are developed the alimentary canal, the 
 thymus, thyroid, liver, lungs, pancreas, bladder and the various 
 small glands and tubules. 
 
 It was formerly believed that the human being existed in 
 miniature in the first cell and that its development during preg- 
 nancy was entirely a matter of increase in size. But the micro- 
 scope has disproved this, and we now know that embryonic de- 
 velopment comprises both growth and evolution. 
 
 Much of the information accepted to-day is, of course, specu- 
 lative, having been deduced from observations made upon the 
 reproductive processes of lower mammals, since the youngest 
 human ovum which has been discovered and examined was prob- 
 ably two weeks old. But the evidence points qnite convinc- 
 ingly to the belief that the early stages of development consist 
 of proliferation of and alterations in the kinds of cells, their 
 arrangement into groups, and a differentiation of the functional 
 activity of these groups of cells before the mass assumes human 
 form and develops organs. 
 
 As to terminology, some authorities call this mass the embryo 
 during this stage of grouping and differentiation, which corre- 
 
68 OBSTETRICAL NURSING 
 
 sponds to the first six weeks of pregnancy, and the fetus from 
 then until the time of delivery. By others it is designated the 
 ovum during the first two weeks of pregnancy, the embryo from 
 the third to the fifth week, after which it is known as the fetus. 
 
 From the nurse's standpoint these distinctions are of no 
 consequence, for the mass may safely be called a fetus from 
 the time that the expectant mother looks to the nurse for guid- 
 ance and care. 
 
 It is scarcely warrantable to take the time and space which 
 would be necessary to trace in detail through its various stages 
 the intricate development of the human body^ with its attached 
 membranes. But the whole question is so important and so 
 interesting that we shall at least have a word of description as 
 to its size and characteristics at successive periods. 
 
 Although the exact length of time required for the matura- 
 tion of the fetus is not known, it is estimated that two hundred 
 and eighty days, or ten lunar months, elapse between the be- 
 ginning of the last menstrual period and the beginning of labor. 
 And in spite of the difference in size among the mothers, it is 
 found that the products of conception develop and grow at a 
 fairly uniform rate of speed. 
 
 A new human being is the ultimate result of conception, but 
 the chorion, amnion, placenta and umbilical cord must also be 
 created to serve as aids in building and protecting the developing 
 child during its uterine life. The part played by these accessory 
 structures is so vital, in spite of being temporary, that it will 
 be well for us to look into their origin and functions before con- 
 sidering the fetus itself which they serve. 
 
 The Chorion and Placenta. Very early in pregnancy, prob- 
 ably while the fertilized ovum is journeying down the tube, tiny, 
 thread-like projections, called villi, appear over the surface of 
 the primitive chorion, giving it the shaggy appearance of a chest- 
 nut burr. Shortly after this shaggy ovum reaches the uterus 
 and is embedded in the lining, the chorion, or the outer fetal 
 membrane, is formed, being partly derived from the ectodermal 
 layer of cells growing within the blastodermal vesicle. The 
 chorion grows rapidly in size and thickness, and the villi upon 
 its surface increase in size, number and complexity by frequent 
 
DEVELOPMENT OF THE OVUM AND EMBRYO 69 
 
 branching. In so doing the villi pusii their way into the ma- 
 ternal tissues surrounding them, and destroy the capillary walls 
 with which they come in contact. Maternal blood escapes through 
 the destroyed walls, forming tiny hemorrhagic areas, or "lakes 
 of blood." The chorionic villi float freely in these pools of 
 maternal blood, which is constantly being refreshed by an in- 
 flow of arterial and an outflow of venous blood through the 
 mother's vessels. 
 
 Blood vessels soon appear in these chorionic villi, and fetal 
 
 DlcLduQ basalts 
 
 (Plocenta) 
 
 _,Chorlon jrondosurn 
 
 //M(__AbdoiTional pedicle 
 ^Amnion 
 
 Chorion loeve 
 
 -DlclduQ CQpularLsj 
 ^J^-UterLne cavLty 
 
 ~ -Uterine ujoll 
 
 Fig. 20. — Diagram of fetus, cord, membranes and placenta in utero at au 
 early stage of their development. 
 
 blood then circulates through them. It becomes apparent, there- 
 fore, that the maternal and fetal blood streams are in such close 
 relation that they are separated by only the thin membrane which 
 forms the walls of the vessels in the villi. (Fig. 20.) 
 
 This arrangement makes it possible for the steadily proliferat- 
 ing villi to discharge one of their functions, which is to receive 
 from the maternal blood nourishment for the embryo, and give 
 up to the parent waste products from the growing body. This 
 exchange of nourishment and waste matter takes place by means 
 
70 OBSTETRICAL NURSING 
 
 of osmosis. But freely as the exchange of materials occurs, there 
 is never any contact, or mixing of maternal and fetal blood, nor 
 does maternal blood at any time flow through fetal vessels. It 
 was believed at one time that the fetus was nourished by milk 
 which was in some way secreted by the gravid uterus, but this 
 is disproved by present knowledge of the placental function. 
 
 The second function of the villi, particularly after they have 
 developed to the placental stage, is to assist in securely attach- 
 ing the embryo to the uterine wall. 
 
 The villi are equally distributed over the surface of the cho- 
 rion at first, but as the sac increases in size and pushes out into 
 the uterine cavity, they gradually atrophy and disappear, ex- 
 cepting over the small area beneath the vesicle where the chorion 
 is in contact with the decidua basalis. At this site the villi be- 
 come much more abundant, and it is here that the placenta even- 
 tually develops. This part of the chorion is termed the chorion 
 frondosum, while the remainder, which is in contact with the 
 decidua capsularis, is the chorion Ifrve. 
 
 As pregnancy advances and the fetal sac enlarges, the 
 chorion laeve covered by the decidua capsularis, or reflexa, is 
 pushed farther out into the uterine cavity, until finally it quite 
 reaches the opposite wall, meets the decidua vera and obliterates 
 the entire space which had existed between the two membranes. 
 This means that instead of a uterine cavity lined with decidua, 
 and a tiny capsule somewhere off to the side lined with chorion, 
 the latter has distended until it completely fills and really be- 
 comes the cavity within the uterine walls, thus lining the uterus 
 with chorion and crowding the original lining out of existence. 
 The decidudae capsularis and vera fuse in time and finally the 
 capsularis degenerates and disappears. 
 
 The Amnion. Returning for a moment to the blastodermal 
 stage of the ovum, we find that the amnion, or inner membrane, 
 first appears as a tiny vesicle over the dorsal surface of the em- 
 bryo. Very soon, however, it invests the embryo completely, and 
 the membranous sac is intact, excepting where it is pierced by 
 the umbilical cord. The amnion, too, is derived in part from 
 the ectoderm, but is a stronger, denser membrane than the cho- 
 rion. At first there is an appreciable space, and some fluid, be- 
 
DEVELOPMENT OF THE OVUJVI AND EMBllVO 71 
 
 tween the two membranes, but as the amnion increases in size 
 with the advance of pregnancy, it comes in contact with and is 
 loosely adherent to the chorion. 
 
 Very early in its development the amniotic sac contains a 
 pale yellow fluid known as the amniotic fluid, or liquor amnii, 
 in which the fetus floats. This fluid increases in amount until 
 the end of pregnancy and though the quantity is variable, it 
 usually amounts to about a quart. 
 
 The source of the liquor amnii is not definitely known, but 
 it is generally believed to be of maternal origin, secreted from 
 the amniotic membrane, though the possibility of its consisting 
 partly of fetal urine cannot be overlooked. It is about 99% 
 
 Plcicenlo 
 
 FiQ. 21. — Diagram showing general structure and relation of membranes, 
 placenta and cord. 
 
 water, containing particles of dead skin and lanugo, a soft downy 
 hair cast off from the body of the fetus, traces of albumen and 
 both organic and inorganic salts. 
 
 The amniotic fluid serves a variety of purposes. Since the 
 intestines of the fetus contain lanugo and particles of dead 
 skin, it is evident that the child swallows some of this fluid during 
 its uterine life, and possibly obtains in this way much of the 
 fluid necessary for its development. 
 
 The increasing bulk of the fluid serves to distend the fetal 
 sac and surrounding uterus, and thus provides the fetus with 
 room for growth and movement. It also prevents adhesions be- 
 tween the child's skin and the amnion, which are a factor, when 
 by mischance they do occur, in causing monstrosities and intra- 
 uterine amputations. The fluid with which it is surrounded 
 
72 
 
 OBSTETRICAL NURSING 
 
 keeps the fetus at an equable temperature in spite of variations 
 of temperature in the mother's environment, and minimizes the 
 danger of injury to the fragile little body, from pressure or 
 blows on the mother's abdomen. And by acting as a water wedge, 
 forced down by uterine contractions at the time of labor, it di- 
 
 :; 
 
 1^ 
 
 A 1 
 
 i 
 
 Pic 
 
 
 
 
 
 1 
 
 •.^"« 
 
 '^ilg^UHIi 
 
 ^"^•^1 
 
 1 ■ • / ' 
 
 
 \ ^ 
 
 :. ..-H 
 
 mr >- ■ 
 
 r -v 
 
 1 , 
 
 ■ ' la- 1 
 
 ' '1 
 
 4 
 
 1' 
 
 ^^ 
 
 mk 
 
 ' -^ ! 
 
 t 
 
 
 1 
 
 k^ , 
 
 
 
 ^^ 
 
 "^y^ 
 
 ,^0^ 
 
 Fig. 22. — Placental blood vessels. Note their branching, tree-like 
 arrangement. (Photographed from an injected specimen in the Obstetrical 
 Laboratory, Johns Hopkins Hospital.) 
 
 lates the cervix sufficiently to permit the expulsion of the full 
 term child. 
 
 The placenta. The placenta, in lay parlance the after-birth, 
 is really a thickened, amplified portion of the fetal sac, which 
 has developed at the site of the implantation of the ovum. It is 
 partly fetal and partly maternal in origin, being developed 
 
DEVELOPMENT OF THE OVUM AND EMBRYO 73 
 
 jointly from the chorion fondosum with its branching villi, and 
 the underlying decidua basalis. 
 
 The chorionic villi already referred to grow and branch in a 
 tree-like fashion (Fig. 22), and push their way farther and 
 farther into the uterine tissues creating the intervillous spaces 
 which fill with maternal blood. From the time that the first fetal 
 blood vessels appear in these floating villi, until the child is 
 born, there is a constant exchange of nutriment and waste mat- 
 ter between the maternal and fetal blood ; the arterial maternal 
 blood in the intervillous spaces giving to the fetal blood in the 
 villi the oxygen and other substances necessary to nourish and 
 build the growing young body, and receiving in return the 
 broken-down products of fetal activity. The waste is carried 
 by the maternal blood stream to the mother 's lungs, kidneys and 
 skin, by which it is excreted. 
 
 This exchange of substances is accomplished by osmosis and 
 also by selective powers of the cells in the villi. Thus the pla- 
 centa virtually serves the fetus as lungs, stomach, intestines and 
 kidneys throughout its uterine life. 
 
 In addition to the nutritive substances in the mother's blood, 
 such as albumen, iron and fat which are so altered by cell action 
 as to be absorbable through the villi, certain protective sub- 
 stances as the anti-toxines of diphtheria, tetanus, colon and ty- 
 phoid bacilli are evidently transmitted from the maternal to the 
 fetal circulation. It is claimed by some authorities that patho- 
 genic organisms, for example, anthrax, pneumonia and tubercle 
 bacilli, may be transmitted from mother to fetus, but the re- 
 ported cases are so rare that the accepted belief is that organisms 
 are seldom transmitted, if the placenta is healthy and intact. 
 But, according to Dr. Williams, the transmission of typhoid 
 occurs frequently, though malarial parasites cannot pass through 
 the villous membranes. 
 
 Only during comparatively recent years has accurate knowl- 
 edge of the origin and function of the placenta been available. 
 Many varied and interesting beliefs and superstitions gained 
 currency in the past, but all of them were erroneous. 
 
 The description of the circulation of the blood by William 
 Harvey in 1628 shed considerable light upon this puzzling ques- 
 
74 
 
 OBSTETRICAL NURSING 
 
 tion concerning the exchange of fuel and ash between the parent 
 and fetal bodies. But a mistaken belief that the maternal blood 
 
 Fig. 23. — Maternal surface of the placenta, surrounded by the membranes 
 and cord. (Prom a photograph taken at Johns Hopkins Hospital.) 
 
 actually entered and jflowed through the fetal vessels resulted 
 from his valuable discovery. 
 
 When we examine this interesting structure, the placenta, 
 
DEVELOPMENT OF THE OVUM AND EMBRYO 75 
 
 after it is cast off, we find it to be a flattened, fairly round, 
 spongy mass, eight or nine inches in diameter, about an inch 
 thick where the cord arises and thinning out toward the margin. 
 Continued from the margin are the filmy fetal membranes, 
 which together form a ruptured sac. The rupture in these mem- 
 
 FiG. 24. — Fetal surface of the placenta showing origin of cord. (From 
 photograph taken at Johns Hopkins Hospital.) 
 
 branes is the opening through which the amniotic fluid escapes, 
 and the child passes during birth. 
 
 The placenta weighs about a pound and a quarter, or 1/6 as 
 much as the child, and accordingly varies in size and weight with 
 the baby. The maternal surface (Fig. 23) having been detached 
 from the uterine wall, is rough and bleeding and is irregularly 
 divided into lobes while the inner, or fetal, surface is smooth 
 
76 OBSTETRICAL NURSING 
 
 and glistening and covered with the amnion. The fetal surface 
 (Fig. 24) is traversed by a number of large blood-vessels which 
 converge toward the point of insertion of the umbilical cord, 
 from the vessels of which they really arise. These vessels branch 
 and divide until their termination in the innumerable chorionic 
 villi floating in the lakes of maternal blood. 
 
 The Umbilical Cord. The cord, or funis, is a bluish white 
 cord about three-quarters of an inch in diameter, twisted and 
 tortuous throughout its length of about twenty inches. It is the 
 one actual link between the mother and her unborn child, one 
 end being attached to the abdomen of the fetus, about midway 
 between the ensiform and the pubis, and the other to the inner 
 surface of the placenta. The cord is derived from the abdominal 
 pedicle and is merely an extension of the caudal or tail end of 
 the embryo. It is covered with a layer of ectoderm which i&' 
 continuous with the ectodermal covering of the fetus. 
 
 The cord consists of a gelatinous mass known as Wharton's 
 jelly, in the centre of which are embedded three blood vessels; 
 two arteries through which the vitiated blood flows to the pla- 
 centa, whero it gives up its ash; and one vein which carries 
 oxygenated, nourishment-bearing blood back to the fetus. The 
 life of the fetus, therefore, is absolutely contingent upon an 
 uninterrupted, two-way flow of blood through the cord. 
 
 Tha Fetus. In tracing the development of the ovum after 
 its implantation in the uterine lining, we begin, as previously 
 stated, with a shaggy-looking vesicle, containing fluid, with a 
 clump of cells hanging toward the centre from their point of 
 attachment on the inner surface of the sac. This clump devel- 
 ops into the embryo. 
 
 During the first month the mass increases in size, becomes 
 somewhat elongated and curved upon itself with the two ex- 
 tremities almost in contact. The abdominal pedicle, which later 
 becomes the umbilical cord, appears ; the alimentary canal exists 
 as a straight tube and the thymus, thyroid, lungs and liver are 
 recognizable. The heart, eyes, nose, ears, and brain appear in 
 rudimentary form and the extremities begin to be evident as 
 tiny, bud-like projections on the surface of the embryo. 
 
 By the end of the fourth W3ek the sac is about the size of 
 
DEVELOPMENT OF THE OVUM AND EMBRYO 77 
 
 a pigeon's egg and has two walls. The outer wall, or chorion, 
 as we have already seen, is covered with villi, and the amnion, 
 or inner wall, is smooth ; the contained embryo is surrounded by 
 amniotic fluid and measures about 10 millimetres or .4 inch in 
 length. 
 
 By the end of the second month, or eighth week, the head 
 end of the embryo has greatly increased in size and is about as 
 
 Fig. 25. — Embryo, about 5.5 centimetres long in amniotic sac; uterine 
 wall incised, chorion split and turned back. Drawn by Max BrodeL 
 (From The Umbilicus and Its Diseases, by Thomas R. Cullen, M.D.) 
 
 large as the rest of the body. Bone centres appear in the rudi- 
 mentary clavicles; the kidneys and supra-renal bodies are 
 formed; the limbs are more developed, webbed hands and feet 
 are formed, the external genitalia are apparent but the sex is not 
 distinguishable. The amnion is distended with fluid, but it is 
 
78 
 
 OBSTETRICAL NURSING 
 
 not yet in contact with the chorion ; the chorionic villi have be- 
 come more luxuriant on that part of the chorion resting on the 
 decidua basalis, the future site of the placenta. The approximate 
 weight of the embryo is 4 grams and its length 25 millimetres 
 or an inch. 
 
 By the end of the third month, or twelfth week, centres of 
 ossification have appeared in most of the bones, the fingers and 
 
 €Days. 21 Days. 30Doys, aADoijs. e^Ulceks 
 
 tn* of e md End of 3 mo. End of 4 TTIa 
 
 Fig. 26. — Diagram showing appearance of fetus at different stages in its 
 
 development. 
 
 toes are separated and bear nails in the form of fine membranes ; 
 the umbilical cord has definite form, has increased in length and 
 begun to twist. The neck is longer, teeth are forming and the 
 eyes have lids. The amnion and chorion are now in contact, and 
 the villi have disappeared excepting at one point where a small, 
 but complete placenta has developed. The embryo is about 9 
 centimetres long and weighs about 30 grams. 
 
 By the end of the fourth month, or sixteenth week, all parts 
 show growth and development; lanugo appears over the body; 
 
DEVELOPMENT OF THE OVUM AND EMBRYO 79 
 
 the sex organs are clearly distinguishable and there is tarry fse- 
 cal matter, called meconium, in the intestines. The placenta is 
 larger, the cord longer, more spiral and also thicker because of 
 the Whartonian jelly which is beginning to form. The fetus is 
 about 15 centimetres long and weighs about 120 grams. 
 
 By the end of the fifth month, or twentieth week, the fetus 
 has both grown and developed markedly. It is now covered with 
 skin on which are occasional patches of vernix caseosa, a greasy, 
 cheesy substance consisting largely of a secretion of the seba- 
 ceous glands. There is some fat beneath the skin but tlie face 
 looks old and wrinkled. Hair has appeared upon the head and 
 the eyelids are opening. It is usually during the fifth month 
 that the expectant mother first feels the fetal movements which 
 are commonly referred to as "quickening." The body is about 
 25 centimetres long and weighs about 280 grams. 
 
 By the end of the seventh month, or twenty-eighth week, the 
 fetus still looks thin and scraA\aiy, the skin is reddish and is 
 well covered with vernix caseosa and the intestines contain an 
 increased amount of meconium. If born at this time the child 
 will move quite vigorously and cry feebly. Although it is not 
 likely to live for any length of time, every effort should be made 
 to save its life, for it may be that the high rate of mortality at 
 this age is due to the inadequacy of the attempts which are usu- 
 ally made to save the child rather than to the frailty of the child 
 itself. It is about 35 centimetres long and weighs about 1200 
 grams. 
 
 By the end of the eighth month, or thirty-second week, the 
 child has grown to about 42 centimetres in length and 1900 grams 
 in weight, but continues to look thin and old and wrinkled. Tlie 
 nails do not extend beyond the ends of the fingers but are firmer 
 in texture; the lanugo begins to disappear from the face but 
 the hair on the head is more abundant. If born at this stage, the 
 baby will have a fair chance to live, if given painstaking care. 
 This is true in spite of the ancient superstition, still widely cur- 
 rent, that a seven months' baby is more viable than one boni at 
 eight months (meaning calendar months). The fact is that after 
 the eighth lunar month, a little more than seven calendar months, 
 
80 OBSTETRICAL NURSING 
 
 the probability of the child's living increases rapidly with the 
 length of its intra-uterine life. 
 
 By the end of the ninth month, or thirty-sixth week, the in- 
 creased deposit of fat under the skin has given a plumper, 
 rounder contour to the entire body; the aged look has passed 
 and the chances for life have greatly increased. The baby now 
 weighs about 2500 grams and is about 46 centimetres long. 
 
 The end of the tenth month, or fortieth week, usually marks 
 the end of pregnancy. (Fig. 27.) The average, normally de- 
 veloped baby has attained a length of 50 centimetres (20 inches), 
 and a weight of 3250 grams, or about 714 pounds, boys usually 
 being about three ounces heavier than girls. 
 
 It must be remembered, however, that these figures merely 
 represent the average drawn from a large number of cases, for 
 there may be a variation in weight among entirely normal 
 healthy babies from a minimum of 2300 grams (5 pounds) to as 
 high as 5000 grams (11 pounds), or more. Babies actually 
 weighing more than 12 pounds are seldom born, in spite of 
 legends and rumors to the contrary. 
 
 The length of a normal baby is less variable than the weight. 
 In fact, it is so nearly constant in its increase during the suc- 
 cessive months of pregnancy, that the age of a prematurely born 
 fetus may be fairly accurately estimated from its length. This 
 fact is of no little practical importance, since it aids the obstetri- 
 cian in making a prognosis as to the child's prospect of living, 
 for he can estimate its intra-uterine age from its body length. 
 
 The size of the baby is affected by race, colored babies, for 
 example, averaging a smaller weight than white babies. And, 
 a;s might be expected, the size of the parents is likely to be re- 
 flected in the size of their infants, large parents tending to have 
 large children and vice versa. 
 
 The number of children which the mother has previously 
 borne is also a factor, since the first child is usually the smallest, 
 the size of those following showing an increase with the mother's 
 age up to her twenty-eighth or thirtieth year, provided the suc- 
 cessive pregnancies do not occur at too frequent intervals. 
 
 The expectant mother's general state of health, her state of 
 nutrition, the character of her surroundings and her mode of 
 
DEVELOPMENT OP THE OVUM AND EMBRYO 81 
 
 living may be expected to influence her baby's welfare. Hence, 
 women who live in comfortable, or luxurious circumstances usu- 
 allj' have more robust babies than those who are run down, poorly 
 
 FlO. 27. — Full term fetus in utero. Drawn by Max Brodel. (Used by 
 permission of A. J. Nystrom &Co., Chicago.) 
 
 nourished or overworked. All of which hints at the great value 
 of prenatal care which will be taken up in detail in a later 
 chapter. 
 
82 OBSTETRICAL NURSING 
 
 A multiple pregnancy is one in which the pregnant uterus 
 contains two or more embryos, these being termed twins when 
 there are two and triplets when there are three; quadruplets, 
 quintuplets and sextuplets when there are four, five and six em- 
 bryos, respectively, six being the largest accredited number on 
 record. 
 
 The tendency to multiple i^regnancies is apparently inherited, 
 and it sometimes happens that several members of the same 
 family connection have this predisposition, as evidenced by the 
 number of twins and triplets to be found among relatives. It is 
 estimated that twins occur once in 90 pregnancies and triplets 
 once in about 7000 cases. 
 
 Twin pregnancies may result from the fertilization of one 
 or of two ova, and are designated as single ovum or double ovum 
 twins respectively. In single ovum twins the egg becomes di- 
 vided early in its development and two embryos are formed. In 
 such a case there is one placenta, one chorion and two amnions 
 and the babies are of the same sex. 
 
 In double ovum twins two ova are fertilized ; both may come 
 from the same ovary or there may be one from each side. When 
 double ovum twins occur, there are two placentae, as a rule, 
 though they may be somewhat fused ; two amnions and two cho- 
 rions and the babies may be of the same sex or each of a different 
 sex. 
 
 Twins are often prematurely born and each one is likely to 
 be smaller than a baby resulting from a single pregnancy, but 
 their combined weight is greater than that of one normal baby. 
 
 An extra-uterine pregnancy may be defined as a pregnancy 
 which develops outside of the uterus, usually in a tube or ovary. 
 Although in the normal course of events the fertilized ovum 
 travels down the tube and becomes attached to the uterine lining, 
 it is possible for it to stop, and more or less completely develop 
 at any point along the way between the Graafian follicle, from 
 which it has been projected, and the uterus toward which it is 
 traveling. If the fetus develops in the ovary, it is termed an 
 ovarian pregnancy, and a tubal pregnancy if it occurs in the 
 tube, the latter being the most frequent variety of extra-uterine 
 pregnancy. 
 
DEVELOPMENT OF THE OVUM AND EMBRYO 83 
 
 In the opinion of Dr. Mall, only about 1 per cent of all extra- 
 uterine pregnancies are capable of going to term. There may be 
 an abortion, when the fetus and membranes are partly or com- 
 pletely extruded from the fimbriated end of the tube into the 
 peritoneal cavity; or a rupture of the tube, when the fetus, 
 with or without the membranes, may be expelled into the peri- 
 toneal cavity, or between the folds of the. broad ligament. If 
 the greater part of the placenta remains attached to the site of 
 its development, in the case of a ruptured tube, it is possible for 
 the fetus to live and grow and even go to term. But if the 
 placenta is nearly, or completely separated, the fetus perishes 
 and may be largely absorbed by the maternal organism, or 
 mummified, or putrefactive changes may take place. It is usu- 
 ally customary to terminate an extra-uterine pregnancy as soon 
 as it is diagnosed, for only a very small number can be expected 
 to go to term, the majority aborting, or rupturing the tube, with 
 serious hemorrhage from the mother as a frequent result. 
 
 To sum up the normal pregnancy, we find that in the course 
 of ten lunar months, following the fertilization of an ovum, the 
 uterus grows from a small, flattened, pelvic organ, three inches 
 in length, to a large, globular, muscular sac, constituting an 
 abdominal tumor about fifteen inches long ; it increases its weight 
 sixteen times, that is from two ounces to two pounds, while 
 the capacity of the uterine cavity is multiplied five hundred 
 times. Within the cavity is a child weighing about seven and a 
 quarter pounds, surrounded by a quart or so of amniotic fluid. 
 This fluid is contained in the sac composed of the fetal mem- 
 branes, the amnion and chorion, which are excessively developed 
 at one point into the placenta. The placenta, in turn, is at- 
 tached to the child by means of the umbilical cord. The total 
 weight of the uterus and its contents at term is usually about 
 fifteen pounds. 
 
 Quite as mj^sterious and inexplicable as the development of 
 these complex structures from one tiny cell is the fact that when 
 the new human being is ready to begin life as a separate entity, 
 further changes occur within the mother's body which produce 
 uterine contractions of such a character as to entirely empty tlie 
 uterus of its contents. 
 
CHAPTER IV 
 GROWTH AND PHYSIOLOGY OF THE FETUS 
 
 Although the fetus at term is in many respects simply a 
 diminutive, immature man, or woman, its anatomy and physiol- 
 ogy present certain characteristics which have adapted it to a 
 protected existence in a sac of fluid. Some of the fetal struc- 
 tures and functions become increasingly active after birth, while 
 others subside and disappear. 
 
 We have seen that after the first month of pregnancy the 
 placenta serves the fetus as a combined respiratory and diges- 
 tive apparatus, not alone in supplying the oxygen and nourish- 
 ment requisite for life and growth, but also in excreting the 
 broken-down products of fetal life. It apparently acts some- 
 what as a liver, too, in performing something akin to a glyco- 
 genic function. 
 
 Obviously, then, the fetus must possess a circulatory mech- 
 anism which is peculiar to itself alone, and not found in the in- 
 dependently existing human body, in which the lungs and ali- 
 mentary tract are functioning as intended. This mechanism is 
 provided by means of certain structures which exist in the fetal 
 circulatory system and which automatically disappear shortly 
 after birth. The nurse must be aware of these anatomical 
 changes that take place, in addition to growth, if she is to have 
 an intelligent grasp of her tiny patient's possible needs. 
 
 The structures which change or disappear after birth are the 
 foramen ovale, a direct opening between the right and left auri- 
 cles, and four blood vessels: the ductus arteriosus, ductus venosus 
 and the two hypogastric arteries. An understanding of the func- 
 tions of these vessels involves an understanding of the course 
 followed by the fetal blood currents, as indicated in Fig. 28, 
 page 85. 
 
 We see that there are three vessels within the umbilical cord : 
 the umbilical vein and two arteries. In spite of its name, the vein 
 
 84 
 
GROWTH AND PHYSIOLOGY OF THE FETUS 85 
 
 conveys arterial blood from the placenta to the fetus. After 
 piercing the baby's abdominal wall, it divides into two vessels; 
 the larger one, called the ductus venosus, empties into the in- 
 ferior or ascending vena cava, while the smaller branch joins the 
 
 Fig. 28. — Diagram showing course of fetal circulation through hypo- 
 gastric arteries, ductus venosus, ductus arteriosis and the foramen ovale. 
 (From The American Text Book on Obstetrics.) 
 
 portal vein, which enters the liver. The relatively large amount 
 of arterial blood sent directly to the liver may in part account 
 for the large size of this organ in the fetus. Upon its emergence 
 from the liver, this blood stream flow's into the inferior vena cava 
 
8G OBSTETRICAL NURSING 
 
 The ascending vena cava, then, pours into the right auricle a 
 mixture of arterial blood, which has come directly from the pla- 
 centa, and venous blood returned from the liver, intestines and 
 lower extremities. There is a difference of opinion concerning 
 the course of the blood stream after reaching the right auricle. 
 The general teaching, however, is that the eustachian valve, 
 guarding the foramen ovale, deflects the current through this 
 opening from the right into the left auricle. It then pours into 
 the left ventricle, is pumped into the arch of the aorta, from 
 which most of the blood is sent to the head and upper extremities, 
 though a small part carries nourishment to other parts of the 
 body. 
 
 The descending, or superior^ vena cava, carrying blood re- 
 turning from the head and arms also empties into the right au- 
 ricle ; this stream presumably crosses the stream which is directed 
 toward the foramen ovale, flows into the right ventricle by which 
 it is pumped into the pulmonary artery. The circulation of 
 blood through the lungs, however, is for their own nourishment, 
 and not for aeration as with the adult. For this reason most of 
 the contents of the fetal pulmonary artery empties into the 
 aorta through the ductus arteriosus, one of the temporary fetal 
 structures already referred to. From the aorta the stream is 
 directed in part to the lower extremities and the pelvic and ab- 
 dominal viscera, but most of it flows into the hypogastric ar- 
 teries. These are also temporary arteries. They lead to the 
 umbilical cord and, as the umbilical arteries, carry the venous or 
 vitiated blood through the cord to the placenta where it is oxy- 
 genated, freed of its waste in the chorionic villi and returned to 
 the fetus through the umbilical vein. 
 
 As soon as the child is born and it is obliged to obtain its 
 oxygen from the surrounding air, its pulmonary circulation of 
 necessity becomes immediately more important and is greatly 
 increased in volume. In fact, the entire fetal circulation is 
 readjusted to meet the needs of the new and independent func- 
 tions which the little body now assumes. The temporary struc- 
 tures are obliterated, since they are no longer needed, and the 
 lungs and intestines become more active in compensation. 
 
 As the ductus venosus and hypogastric arteries terminate in 
 
GROWTH AND PHYSIOLOGY OF THE FETUS 87 
 
 blind ends and become useless as soon as the umbilical cord is 
 cut, they soon begin to atrophy and are obliterated within a few 
 days after birth. This means tliat less blood is poured into the 
 right auricle, which naturally results in relatively less tension in 
 
 Fig. 29. — Diagram showing circulation of the blood after birth, with 
 hypogastric arteries, ductus venosus, ductus arteriosis and foramen ovale 
 in process of obliteration and pulmonary circulation greatly increased. 
 (From The American Textbook on Obstetrics.) 
 
 the right heart and an increased pressure in the left, which tends 
 to close the foramen ovale. The foramen ovale does not entirely 
 disappear at once, however, but closes gradually, sometimes re- 
 maining open for months. Occasionally it remains open per- 
 manentl3% and though some people have gone through life com- 
 
88 OBSTETRICAL NURSING 
 
 fortably with a patent foramen ovale, its ultimate failure to close 
 usually results in serious circulatory trouble. This is also true 
 of the ductus arteriosus, which sometimes, but not often, fails to 
 close. 
 
 The rule is that as the lungs expand and an increased amount 
 of blood is carried to them for aeration, the ductus arteriosus de- 
 flects a steadily diminishing stream from the right ventricle to 
 the arch of the aorta. Thus it gradually ceases functioning in 
 most cases and disappears in the course of a few weeks. The 
 abandoned vessels may degenerate and disappear in time or 
 they may persist in the form of small fibrous cords. (Fig. 29.) 
 
 Although the circulatory system shows the most elaborate ad- 
 justments to the protection afforded by intra-uterine life, there 
 are also other adaptations made by the fetal organism. 
 
 The baby acquires about 90 per cent of its weight during the 
 latter half of pregnancy, as well as a steadily increasing propor- 
 tion of solids and a decrease of fluids in its tissues, for in its early 
 days the embryo consists largely of water. But for all of that, its 
 existence and growth in utero, and the functioning of its heat 
 producing centre require surprisingly little oxygen and nourish- 
 ment. The amniotic fluid keeps the fetus at an equable tem- 
 perature, about 1° above that of the mother, and as space within 
 the uterine cavity permits of only limited movement, there is 
 very little combustion for the liberation of heat and energy. 
 
 The kidneys assume functional form at a very early fetal 
 age, probably about the seventh week, and the presence of albu- 
 men and urea in the amniotic fluid suggest that small amounts 
 of urine may be voided, particularly during the latter part of 
 pregnancy. 
 
 The bowels, on the other hand, are normally inactive, this is 
 spite of the fact that the baby evidently obtains fluid, and pos- 
 sibly some nutriment by swallowing amniotic fluid. But a dis- 
 charge of meconium may be caused by pressure on the cord or 
 by any condition which interferes with the umbilical circulation. 
 For this reason, meconium stained fluid escaping during labor 
 in a head presentation may be taken as an evidence of imminent 
 asphyxiation, due to an interruption of the umbilical circulation. 
 
 The head is the most important part of the fetus, from an 
 
GROWTH AND PHYSIOLOGY OF THE FETUS 89 
 
 obstetrical standpoint, since the process of labor is virtually a 
 series of adaptations of the size, shape and position of the fetal 
 skull to the size and shape of the maternal pelvis. And since the 
 pelvis is rigid and inflexible the adjustment must all be made 
 by the fetal headj- which is mouldable because of being incom- 
 pletely ossified at birth. If the head passes through the inlet 
 safely, the rest of the delivery will usually be accomplished with 
 comparative safety. But a marked disproportion between the 
 diameters of the head and pelvis, or limited mouldability of the 
 head, constitutes a serious complication, which will be discussed 
 later in connection with obstetrical operations. 
 
 A baby's head is larger, in proportion to its body, than an 
 adult's, while the face forms a relatively smaller part of the 
 baby's than of the adult's head. The major portion is the dome 
 or vault-like structure forming the top, sides and back of the 
 head, which in turn is made up of separate and as yet ununited 
 bones. They are the two frontal, two parietal, two temporal and 
 the occipital bone, with which the wings of the sphenoid bones, 
 though less important, may be included. 
 
 These bones are not joined in the fetal skull, but are sepa- 
 rate structures, with soft, membranous spaces between their mar- 
 gins, called sutures; while the irregular spaces formed by the 
 intersection of two or more sutures are called fontanelles, pos- 
 sibly so called by the early observers because the pulsation of 
 the soft tissues beneath these spaces suggests the spurting of a 
 fountain. 
 
 The sutures are named and situated as follows: The frontal 
 lies between the two frontal bones; the sagittal extends antero- 
 posteriorly between the parietal bones; the coronal between the 
 frontal bones and the anterior margins of the parietal, while the 
 lamhdoidal suture separates the posterior margin of the parietal 
 from the upper margin of the occipital bone. There are also the 
 temporal sutures between the upper margins of the temporal 
 bones and the lower margins of the two parietals, but they are 
 of no obstetrical importance, as they cannot be felt on vaginal 
 examination. (Fig. 30.) 
 
 There are two fontanelles of obstetrical significance. The 
 greater, or anterior fontanelle, also called the hragma or sinci- 
 
90 
 
 OBSTETRICAL NURSING 
 
 put, is located at the meeting of the coronal, sagittal and frontal 
 sutures. It is diamond or lozenge shaped, about an inch in 
 diameter and is not obliterated during labor. 
 
 The smaller or posterior fontanelle is the triangular space at 
 the inter-section of the sagittal and lambdoidaj sutures, and may 
 
 Fig. 30. — Side and top views of fetal skull giving average length of 
 important diameters. 
 
 be obliterated as the surrounding bony margins approach each 
 other during labor. 
 
 The coronal, frontal, lambdoid and sagittal sutures and the 
 anterior and posterior fontanelles are of greatest diagnostic value 
 as they can be felt through the vagina during labor. It is by 
 
GROWTH AND PHYSIOLOGY OP THE FETUS 91 
 
 recognizing and locating these sutures and fontanelles at this 
 time that the accoucheur is enabled to determine the exact posi- 
 tion and presentation of the fetus. 
 
 The fact that the skull is made up of separate bones, with 
 soft membranous spaces interposed between them, permits of its 
 being compressed or moulded to a considerable extent as it passes 
 through the birth canal. ()pi)osing margins may meet, or even 
 overlap, to such a degree that the diameter of tlie head will be 
 appreciably diminished and permit of its passage through a rela- 
 tively narrow canal. This mouldability varies greatly, however, 
 and the difference in the degree of compressibility of heads of 
 approximately the same size may spell the difference between an 
 easy and a difficult, or even an impossible labor. 
 
 A new-born baby 's head may be so distorted and elongated by 
 the moulding process that it is unsightly and gives the young 
 mother great concern. But the nurse can be quite confident in 
 her assurances that the little head will assume its normal, 
 rounded outline in a very few days. 
 
 The five most important diameters of the new-born baby's 
 head are : 
 
 1. The occipitot-frontal (abbreviation, O.F.), measured from the 
 root of the nose to the occipital protuberance, is 11.75 centimetres. 
 
 2. The biparietal (B.I.P.) is the longest transverse diameter, 
 being the distance between the parietal protuberances, and measures 
 9.25 centimetres. 
 
 3. The bi-temporal (B.T.) is the greatest distance between the 
 temporal bones and measures 8 centimetres. 
 
 4. The occipito-mental (O.M.) is the gi-eatest distance from the 
 lower margin of the chin to a point on the posterior extremity of the 
 sagittal suture, and measures 13.5 centimetres. 
 
 5. The sub-occipito bregmatic (S.O.B.) is measured from the 
 under surface of the occiput, where it joins the neck, to the centre 
 of the anterior fontanelle, a distance of 9.5 centimetres. 
 
 The greatest circumference of the fetal head is at the plane 
 of the occipito-mental and biparietal diameters and measures 
 38 centimetres. The smallest circumference is at the plane of 
 the sub-occipito-bregmatic and biparietal diameters, and meas- 
 ures 28 centimetres. 
 
92 OBSTETRICAL NURSING 
 
 These figures, however, like all of those which it is possible 
 to give, simply represent averages taken from a large number 
 of cases. Individual variations will be found among normal 
 babies, for boys' heads, for example, are usually larger than girls' 
 while the head of the first child is likely to be smaller than the 
 heads of those born subsequently. 
 
CHAPTER V 
 SIGNS, SYMPTOMS, AND PHYSIOLOGY OF PREGNANCY 
 
 Signs and Symptoms of Pregnancy. Unfortunately for all 
 parties concerned, the exact duration of pregnancy has never 
 been ascertained, since there is no way of knowing wlien the ovum 
 is fertilised, the moment which marks the beginning of preg- 
 nancy. 
 
 It is obviously impossible, therefore, to foretell exactly the 
 date of confinement. But labor usually begins about ten lunar 
 months, forty weeks or from 273 to 280 days after the onset of 
 the last menstrual period. 
 
 Thus the approximate date of confinement may be estimated 
 by counting forward 280 days or backward 85 days from the first 
 day of the last period. Or what is perhaps simpler, and amounts 
 to the same thing, one may add seven days to the onset of the 
 last period and count back three months. For example, if the 
 last period began on June third, the addition of seven days giyes 
 June tenth, while counting back three months indicates March 
 tenth as the approximate date upon which the confinement may 
 be expected. 
 
 This is probably as satisfactory as any known method of 
 computation, but at best it is only approximate, being accurate in 
 about one case in twenty. But it comes within a week of being 
 correct in half the cases, and within two weeks of the date in 
 eighty per cent of all pregnancies. 
 
 Another method sometimes employed by obstetricians is to 
 estimate the month to which pregnancy has advanced by meas- 
 uring the height of the fundus, and thus forecasting tlie prob- 
 able date of confinement. It is generally agreed that the ascent 
 of the fundus is fairly uniform and that at the fourth month it 
 is half way between the symphysis and umbilicus; at the sixth 
 month, on a level with the umbilicus; at the seventh month, 
 three fingers' breadth above; at the eighth month, six fingers 
 
 03 
 
94 
 
 OBSTETRICAL NURSING 
 
 above the umbilicus and at the ninth month just below the 
 xiphoid. At the tenth month, or term, the fundus sinks down- 
 ward to about the position it occupied at the eighth month. 
 (Figs. 31, 32 and 33.) 
 
 This method, however, is measuring by months, not days, and 
 leaves a wide margin for conjecture as to the exact date. 
 
 Fig. 31. — Height of fundus at each of the ten lunar months of pregnancy. 
 
 Still another method is to count forward 20 or 22 weeks from 
 the day upon which the expectant mother first feels the fetus 
 move. As we shall see presently, this experience, termed ' ' quick- 
 ening," usually occurs about the 18th or 20th week, but is so 
 irregular that it is unreliable as a basis for computation. 
 
 The possibility of estimating the date of confinement is still 
 further complicated by the fact that there is evidently consider- 
 
SYMPTOMS AND PHYSIOLOGY OP PREGNANCY 95 
 
 able variation in the length of entirely normal pregnancies. 
 Many healthy children are born before ten Innar montlis liave 
 elapsed, while more deliveries occur after than on the expected 
 date. The first pregnancy is usually shorter than subsequent 
 ones, and women who are well nourished and well cared for have 
 longer pregnancies, as a rule, than those less favored. 
 
 Although the symptoms of pregnancy have been observed 
 throughout the ages by women who have l)()rne children, and 
 accoucheurs of one sort and another who have attended thern^ a 
 
 Fig. 32. — Contour of abdomen 
 at ninth month of pregnancy, or 
 before the waistline drops. 
 
 Fig. 33. — Contour of abdomen at 
 tenth month of pregnancy, or after 
 the waistline has dropped. 
 
 positive diagnosis at an early stage of this condition is some- 
 times still baffling to the most experienced obstetricians. 
 
 So many symptoms of pregnancy are known to Avomen the 
 world over, that an expectant mother frequently recognizes her 
 pregnant state at a very early date. This is particularly true of 
 women who have previously borne children. But as these same 
 symptoms closely resemble those of other conditions, they are 
 not infrequently ascribed to impaired health, with the result that 
 the pregnancy is not discovered until it is well advanced, and 
 then sometimes only by accident. And one even hears of an occa- 
 
96 OBSTETRICAL NURSING 
 
 sional case in which a woman is entirely unaware of her condi- 
 tion until she goes into labor. 
 
 The converse is also true, for women sometimes erroneously 
 believe themselves pregnant because of the appearance of wel} 
 recognized symptoms, which are due to other causes. This con- 
 dition is known as pseudocyesis, or spurious pregnancy, and is 
 usually found in women approaching the menopause or in young 
 women who intensely desire offspring. It is a pathetic occur- 
 ence, and the patient is usually so tenacious of her belief in her 
 approaching motherhood that the obstetrician dispels it only 
 with great difficulty. 
 
 For all of these and other reasons it is customary to divide 
 the signs and symptoms of pregnancy into three groups, under 
 self-explanatory headings, namely : 'presumptive symptoms, and 
 prohalle and positive signs. Although it is never within the 
 province of a nurse to make a diagnosis, it is important that she 
 be familiar with symptoms. In obstetrics this seems to be par- 
 ticularly true, and especially so if the nurse be engaged in pre- 
 natal work or in any branch of public health nursing that brings 
 her in touch with possible or expectant motherhood. The wider 
 her grasp of obstetrical knowledge, the more helpful and reas- 
 suring can be her relation to her patient. To this end, therefore, 
 we will take up the most reliable symptoms and signs of preg- 
 nancy. 
 
 The presumptive signs, which consist largely of subjective 
 symptoms observed by the patient herself, are as follows : 
 
 1. Cessation of menstmation. This is usually the first symptom 
 noticed. A period may be omitted from any one of several causes, as 
 has been explained in Chap. II but in a healthy woman of the child- 
 bearing age, whose menses have previously been regular, the missing 
 of two successive periods after intercourse is a strong indication of 
 pregnancy. 
 
 2. Changes in the breasts. These also occur early. The breasts 
 ordinarily increase in size and finnness, and many women complain of 
 throbbing, tingling or pricking sensations and a feeling of tension and 
 fullness. The breasts may be so tender that even slight pressure is 
 painful. The nipples are larger and more prominent, while both they 
 and the surrounding areolae grow darker. The veins under the skin 
 are more apparent and the glands of Montgomery larger. If in addi- 
 
SYMPTOMS AND PHYSIOLOGY OF PREGNANCY 97 
 
 tion to these symptoms it is possible to express a pale yellowish fluid 
 from the nipples of a woman who has not had children, pregnancy may 
 be strongly suspected. But practically all of these symptoms may be 
 due to causes other than pregnancy, and, in the case of a woman who 
 has borne childi'en, milk may be present in the breasts for months, or 
 even years, after the birth of a child. 
 
 3. "Morning sickness," as the name suggests, is nausea, some- 
 times accompanied by vomiting, from which many pregnant women 
 suffer immediately upon arising in the morning. It varies in severity 
 from a mild attack when the patient first lifts her head to repeated and 
 severe recurrences during the day, and even into the night. More 
 frequently, however, the discomfort passes off in a few hours. When 
 the vomiting persists, it is termed "pernicious vomiting" and is usually 
 aceejjted as a possible symptom of a reHex,*to.\ic or neurotic condition, 
 all of which wdll be discussed with the complications of pregnancy. 
 Morning sickness may begin immediately after conception, but sets in 
 as a rule about the sixth week and continues until the third or fourth 
 month. It occurs in about half of all pregnancies and is particularly 
 common among women pregnant for the first time. But on the other 
 hand, it must be borne in mind that many non-pregnant women suffer 
 from nausea in the morning; many women go throughout the entire 
 period of gestation without any such disturbance, while others are en- 
 tirely comfortable in the morning and nauseated only during the latter 
 part of the day. 
 
 4. Frequent micturition. There is usually a desire to void urine 
 frequently during the first three or four months of pregnancy, after 
 which the tendency disappears, but recurs during the later months. 
 The inclination may be due in part to nervousness, but is largely caused 
 by pressure exerted by the enlarging uterus upon the bladder, and not 
 to any functional disturbance of the kidneys, as is sometimes believed. 
 Pressure on the outside of the bladder gives much the same sensation 
 as is experienced when the bladder is distended mth urine. After 
 the uterus rises from the pelvic cavity into the abdomen, it no longer 
 crowds the bladder, until it drops during the last month or six weeks, 
 when it again presses upon this organ and cause a desire to void, 
 
 5. Increased discoloration of the pigmented areas of the skin, 
 and also of the mucous membranes, is another early symptom of preg- 
 nancy. In addition to the deepened tint of the nipples and surround- 
 ing areola?, the so-called Imea nigra appears upon the abdomen, ex- 
 tending from the pubis toward the umbilicus. There are also the dark 
 bluish or purplish appearance of the vulval and vaginal linings; the 
 yellowish, irregularly shaped blotches which sometimes appear on the 
 face and neck, known as chloasma: dark circles under the eyes and 
 the strice on the abdomen. 
 
98 OBSTETRICAL NURSING 
 
 6. "Quickening" is the widely used term which designates the 
 mother's first perception of the fetal movements. It occurs about the 
 eighteenth or twentieth week, and is regarded by some obstetricians as 
 a.positive and by others as merely a strongly presumptive sign of preg- 
 nancy. The sensation is likened to a very slight quivering- or tapping, 
 or to the fluttering of a bird's wings imprisoned in the hand. Begin- 
 ning very gently, these movements increase in severity as time goes 
 on until they become very troublesome toward the latter part of preg- 
 nancy, amounting then to sharp kicks and blows. Women who have 
 had children can usually be relied upon to distinguish between quicken- 
 ing and the somewhat similar sensation caused by the movement of 
 gas in the intestines, but a woman pregnant for the first time may be 
 deceived. 
 
 There are many other possible symptoms of pregnancy, but 
 their jvalue is very uncertain. Even the ones described above are 
 not entirely dependable, but if two or more of them occur coin- 
 cidently, they probably indicate pregnancy. Dr. Slemons sums 
 it up by saying, "If, for example, menstruation has previously 
 been regular and then a period is missed, the patient has good 
 reason to suspect she is pregnant; if the next period is also 
 missed and meanwhile the breasts have enlarged, the nipples 
 darkened, and the secretion of colostrum has begun, it is nearly 
 certain that she is pregnant ; whether morning sickness and the 
 desire to pass urine frequently are present is of no importance. ' ' ^ 
 
 The probable signs of pregnancy are chiefly discoverable by 
 the physician after careful examination. They also are numer- 
 ous and uncertain, but there are four which are considered fairly 
 trustworthy. 
 
 1. Enlargement of the abdomen, which is first in order of im- 
 portance, is apparent about the third month. At this stage the growing 
 uterus may be felt through the abdominal wail as a tumor which steadily 
 increases in size as pregnancy advances. Rapid enlargement of the 
 abdomen in a woman of child-bearing age, therefore, may be taken as 
 fair, but not positive, evidence of pregnancy. But too much reliance 
 cannot be placed in this sign, as the abdomen may be enlarged by a 
 tumor, fluid or a rapid increase in fat. 
 
 2. Changes in the size, shape and consistency of the uterus which 
 take place duiing the first three months of pregnancy are very im- 
 portant indications. The.se arc discoverable upon vaginal examination, 
 which shows the uterus to be more ante-flexed than normal, considerably 
 
 * The Prospective Mother, by J. Morris Slemons. 
 
SYMPTOMS AND PHYSIOLOGY OF PREGNANCY 99 
 
 enlarged, somewhat globular in shape and of a soft, doughy consistency. 
 About the sixth week the so-called Ilegar's sign is perceptible through 
 bimanual examination, the fingers of one hand being pressed deeply 
 into the abdomen, just above the symphysis and two fingers of the 
 other hand passed through the vagina until they rest in the postenor 
 fornix, behind the cervix. The lower segment of the uterus, which may 
 be felt between the finger tijjs of the two hands, is extremely soft and 
 compressible. This sign, named for the man who first described it, 
 is one of the most valuable signs in early pregnancy. 
 
 3. Softening of the cervix occurs, as a rule, about the begin- 
 ning of the second month. In some cases, such as certain inflammatory 
 conditions and in carcinoma, this sign may not appear. 
 
 4. Painless uterine contractions, called Braxton Hicks from their 
 first obsei'ver, begin during the early weeks of pregnancy and recur 
 at intervals of five or ten minutes throughout the entire period of 
 gestation. The patient is not conscious of these contractions, but they 
 may be observed during the early months by bimanual examination, 
 and subsequently by placing the hand on the abdomen. One feels 
 the uterus growing alternately hard and soft as it contracts and relaxes. 
 
 But all of the probable signs of pregnancy, like- the presump- 
 tive symptoms, may be simulated in non-pre^ant conditions; 
 hence the appearance of any one of them alone may not be deeply 
 significant. But two or more occurring coineidently constitute 
 strong evidence of pregnancy. 
 
 The positive signs of pregnancy, of which there are three, are 
 not apparent until the 18th or 20th week, and all emanate from 
 the fetus. 
 
 1. Hearing and counting the fetal heart beat is unmistakable 
 evidence of pregnancy. The sound of the fetal heart beat is usually 
 likened to the ticking of a watch under a jiillow. The rate is from 120 
 to 140 per minute, being about twice as fast as the maternal pulse. 
 So long as its rhythm is regular, however, the rate may drop to 100 
 or increase to 160 beats per minute without being considered abnonnal, 
 or indicative of trouble with the fetus. 
 
 2. Ability to palpate the outline of the fetus is also a positive 
 sign of pregnancy, if the head, breech, back and extremities are unmis- 
 takably made out through the abdominal wall. 
 
 3. Perception of active and passive movements of the fetus is 
 accepted as a third incontrovertible sign of {)regnancy. There is some 
 difference of opinion concerning the value of "quickening" alone as a 
 positive sign of pregnancy. But if the fetal movements are also per- 
 ceptible by the obstetrician through the mother's abdominal wall or 
 
100 OBSTETRICAL NURSING 
 
 by vaginal examination, there can be no doubt about the diagnosis. 
 The movements felt by placing the hand upon the abdomen are termed 
 active movements, while the passive movements result from internal or 
 external ballottement. Ballottement is accomplished by giving a sharp 
 or sudden push to the head or an extremity, and feeling it rebound in 
 a few seconds to its original position. Passive movements may be felt 
 early in the fourth month, and active movements after the 18th or 
 20th week. 
 
 PHYSIOLOGY OF PREGNANCY 
 
 A general understanding of the physiology of pregnancy is 
 indispensable to an appreciation of the importance of observing 
 the present-day teachings about the hygiene of pregnancy. Upon 
 this, in turn, must rest intelligently administered prenatal care, 
 one of the most important branches of obstetrics. 
 
 The physiology of pregnancy really represents an adjustment 
 of the various functions of the maternal organism, which are 
 altered to meet the demands made upon the mother 's organs by 
 the body which is developing, growing and functioning within 
 hers. These adjustments are in the nature of an emergency 
 service, since they come into existence and operate only while 
 needed, which is during pregnancy, and promptly disappear 
 when the need for them ceases with the birth of the child. The 
 mother 's body then begins to return to its normal, non-pregnant 
 state, which, with the exception of the breasts, which function 
 for nine or ten months, is accomplished in a few weeks. 
 
 But in addition to the normal changes in physiology in the 
 course of pregnancy, there are frequently abnormal changes, too, 
 which may be symptoms of grave complications. The detection 
 of these symptoms, and the employment of treatment which 
 they indicate, constitute one of the most valuable aspects of 
 prenatal care. 
 
 Although, as might be expected, the alterations in the struc- 
 ture and functions of the maternal organism are most marked 
 in the generative organs, there are definite changes in other and 
 remote parts of the body as well. And there are adjustments in 
 metabolism, which, though not wholly understood, are now 
 widely recognized as important. It is pretty generally believed 
 that as a direct result of pregnancy, certain substances are ere- 
 
SYMPTOMS AND PHYSIOLOGY 'OF FRE<!}MAMCY 101 
 
 ated, possibly by the corpus luteum, which circulate in the blood 
 and definitely influence the maternal functions. It is possible 
 that a development of the present imperfect knowledge of these 
 substances will result ultimately in the discovery of a blood re- 
 action which will serve to diagnose pregnancy in an early stage. 
 
 At present, we know that, in spite of the creation of an in- 
 fant body weighing upwards of seven pounds, a placenta weigh- 
 ing more than a pound, together with an increase of about two 
 pounds in the weight of the uterine muscle, all in the short span 
 of nine months, the expectant mother has to eat very little more 
 during this period than she ordinarily does to maintain her own 
 bodily functions. This suggests a highly developed economy in 
 the use of nutritive material by maternal cells. 
 
 We also know that the mother excretes waste materials for 
 the fetus and must assume that this requires an increased, or 
 adjusted, functional activity of her excretory organs, the skin, 
 lungs and kidneys. Moreover, the secretory activity of the pre- 
 viously inactive mammary glands, in spite of their remoteness 
 from the pelvis, suggests a nervous or chemical stimulation, or 
 both, which occurs only during pregnancy. 
 
 The changes in the uterus itself, however, are unquestionably 
 the most marked that take place during the period of gestation. 
 Those that relate to the lining have been described in a previous 
 chapter. The change and growth in the muscle wall are amazing. 
 New muscle fibres come into existence; those already there in- 
 crease greatly in size and there is a marked development of con- 
 nective tissue. 
 
 The actual substance of the uterus is so increased that it is 
 converted from an organ weighing two ounces into one weighing 
 two pounds. From a firm, hard, thick walled, somewhat flat- 
 tened body in its non-pregnant state, the gravid uterus assumes 
 a globular outline and grows so soft that the fetus may be felt 
 through the walls. 
 
 During the first few months the uterine walls increase in 
 thickness, but later they grow progressively thinner, until by the 
 end of pregnancy they are only about 5 millimetres thick. 
 
 This early growth of the uterus is doubtless brought about 
 by general systemic changes rather than by the presence of the 
 
102 OBSTETJEliCAL NURSING 
 
 contained embryo. Evidence of this is found in the case of tubal 
 pregnancies when there is a definite enlargement of the uterus 
 during the early weeks. After the third month, however, the 
 growth of the uterus is apparently due to pressure which the 
 growing fetus makes on the uterine walls. 
 
 The cervix does not enlarge as a result of pregnancy, but it 
 loses its hard cartilaginous consistency, becoming quite soft, and 
 the secretion of the cervical glands is much more profuse. 
 
 The changes in the vagina are chiefly due to increased vascu- 
 larity. The blood vessels are actually larger, the products of the 
 glands are greatly increased and the normal pinkish tint of the 
 mucous lining deepens to red or even purple. 
 
 The most important changes in the tubes and ovaries is in 
 their position because of their being carried up from the pelvis 
 by the enlarging uterus into the abdominal cavity. Although 
 they increase in vascularity, ovulation is ordinarily suspended 
 during pregnancy. 
 
 The abdomen as a whole changes in contour as it stead- 
 ily enlarges, and the skin and underlying muscles are somewhat 
 affected as a result. The tension upon the skin is so great that 
 it may rupture the underlying elastic layers which later atrophy 
 and thus produce the familiar striw of pregnancy, known vari- 
 ously as the strics gravidarium and the linea albicantes. Fresh 
 striae are pale pink or bluish in color, but after delivery they 
 take on the silvery, glistening appearance of scar tissue, which 
 they really are. 
 
 In a woman who has borne children, therefore, we find both 
 new and old striae ; those resulting from former pregnancies be- 
 ing silvery and shining, while the fresh tears are pink or blue. 
 Striae may be found also on the breasts, hips and upper part of 
 the thighs, and as they are of purely mechanical origin, are not 
 necessarily associated with pregnancy alone. They may result 
 from a stretching of the skin by ascites, a marked increase in 
 fat or an abdominal tumor. 
 
 The same distension that causes striae sometimes causes a 
 separation of the recti muscles. This separation, known as 
 diastasis, is sometimes slight but frequently very marked, the 
 space between the muscles being easily felt through the thinned 
 abdominal wall. 
 
SYMPTOMS AND PHYSIOLOGY OF PREGiNANCY 103 
 
 The umbilicus is deeply indented during about the first three 
 months of pregnancy. But during the fourth, fifth and sixth 
 months the pit grows steadily shallower, and by the seventh 
 month it is level with the surface. After this it may protrude, 
 in which state it is descibed as a " pouting umbilicus. ' ' 
 
 The increased pigmentation at the umbilicus and in the me- 
 dian line is scarcely to be classified among the abdominal 
 changes, as the skin elsewhere presents the same discolored ap- 
 pearance. The degree of ]Mgnieiitation varies with the complex- 
 ion of the individual, as blondes may be but slightly tinted while 
 the discolored areas on a brunette may be dark brown, some- 
 times almost black. 
 
 The changes in the breasts during pregnancy were practically 
 all included in the enumerated signs and symptoms of pregnancy. 
 They increase in size and firmness and become nodular ; the nip- 
 ple is more prominent and together with the surrounding areola, 
 grows'much darker ; the glands of Montgomery are enlarged ; the 
 superficial veins grow more prominent, and after the third month 
 a thin, yellowish fluid can be expressed from the nipples. This 
 fluid, called colostrum, consists largely of fat, epithelial cells and 
 colostrum corpuscles and differs from milk, in its yellowish color, 
 and in the fact that it coagulates like the white of an egg when 
 boiled. The previously quiescent mammary glands develop very 
 early in pregnancy an ability to select from the blood stream 
 the necessary materials to produce a secretion. Colostrum is the 
 product of their activity until about the third day after delivery, 
 when milk appears. 
 
 Changes in the cardio-va-scular system are among those which 
 are not altogether understood, and it is still a moot question as 
 to whether or not there is an actual increase in the amount of 
 maternal blood during pregnancy. But results of the most re- 
 cent investigations suggest that there is a definite increase in 
 both the cells and the plasma. This increased amount circulating 
 through the heart subjects it to a certain amount of strain, with 
 the result that the organ is slightly hypertrophied and the pulse 
 pressure is higher. 
 
 The respiratory organs do not show any marked alterations. 
 The upward pressure of the enlarging uterus gradually shortens 
 the height of the thoracic cavity, but if it grows sufficiently wide 
 
104 OBSTETRICAL NURSING 
 
 in compensation, there is no decrease in the capacity of the 
 lungs. If this does not occur, the patient may suffer from short- 
 ness of breath. The larynx is sometimes reddened and edemat- 
 ous, a fact which explains the damaging effects which child-bear- 
 ing may have upon the voice of singers. 
 
 Changes in the digestive tract during pregnancy are the 
 morning sickness already described, and constipation. The lat- 
 ter is suffered by at least one half of all pregnant women, and is 
 due chiefly to pressure of the uterus on the intestines, though 
 impaired tone of the stretched abdominal muscles may be a fac- 
 tor. This condition is most troublesome during the latter part 
 of pregnancy. There also may be gastric indigestion causing 
 acidity, flatulence and heartburn, and intestinal indigestion giv- 
 ing rise to diarrhea and cramp-like pains. The appetite may be 
 very capricious during the early weeks, and become almost rav- 
 enous later on. 
 
 Changes in the urinary apparatus include frequency of 
 micturition mentioned among the symptoms of pregnancy. 
 
 The changes in the bony structures of the pregnant woman 
 are characterized by partial decalcification. This is accounted for 
 by the fact that the developing fetus requires a definite amount 
 of calcium in the formation of its osseous structures, and unles? 
 the expectant mother absorbs an adequate quantity from her 
 food, it must be extracted from the bones and similar structures, 
 such as the teeth. Her bones and teeth accordingly grow softer, 
 and we have the well-known adage, "for every child a tooth," 
 as well as the fact that fractures during pregnancy unite very 
 slowly. There are also the softened cartilages which were re- 
 ferred to in connection with the anatomy of the pelvis. A part 
 of the softening of the pelvic cartilages, however, is due to a 
 temporarily increased blood supply. As will be explained in the 
 chapter on nutrition, this partial decalcification of the mother 
 is entirely unnecessary, and the newer knowledge of nutrition 
 points the way to its prevention. 
 
 The skin changes consist chiefly in the appearance of strite 
 and the increased pigmentation to which reference has already 
 been made. There is also an increased activity of the sebaceous 
 and sweat glands and the hair follicles, the latter sometimes re- 
 
SYMPTOMS AND PHYSIOLOGY OF PREGNANCY 105 
 
 suiting in the hair becoming much more abundant during the 
 period of gestation. Although the pigmented areas on the 
 breasts and abdomen never quite return to their original bue, 
 the chloasmata, sometimes called the "masque des femmes en- 
 ceintes," practically alwaj's disappear and leave no trace, a fact 
 that is frequently a comfort to an expectant mother. 
 
 The carriage is somowliat affected during pregnancy because 
 the increased size and weight of the abdominal tumor shifts the 
 centre of gravity. In an effort to preserve an upright position 
 the woman throws back her head and shoulders and finally as- 
 sumes a gait that may be described as a waddle, particularly 
 noticeable in short women. 
 
 Temperature changes are probably not caused by pregnancy 
 per se, though some authorities believe that there is normally a 
 slight elevation during the latter part of the day. 
 
 Mental and emotional changes are usually included among 
 the alterations which occur during pregnancy, but the present 
 status of psychiatry suggests that this may not be altogether true. 
 It is a fact that many pregnant women show marked mental and 
 emotional unbalance, but as yet there seems to be no evidence 
 that these states are inherently due to pregnancy, though the 
 same condition may recur in the same woman each time that she 
 is pregnant. 
 
 "We shall consider this important subject more at length in 
 the chapter on mental hygiene, so it may be enough simply to 
 say at this juncture that, in a sensitively strung or uncertainly 
 poised woman, the state of being pregnant may be merely the 
 last straw, so to speak, that upsets her equilibrium ; and that 
 some other experience, which would be an equal strain upon her 
 slender ability to make adjustments, would result in exactly the 
 same mental or emotional distortion, just as certain physical 
 signs in pregnancy may be produced also in the non-pregnant 
 state, and are not, therefore, necessarily inherent to the gravid 
 state. 
 
 Changes in the ductless glands are in much the same cate- 
 gory. Functional disturbances of these glands occurring at any 
 time may give rise to great irritability, excitability or to other 
 mental symptoms. A non-pregnant woman with even a very 
 
106 OBSTETRICAL NURSING 
 
 slight degree of hyperthyroidism, for example, may be noticeably 
 unstable mentally or emotionally. Since there is evidently an 
 inter-relation and inter-dependence of the functions of the duct- 
 less glands, and since ovulation, the function of one of these 
 glands, is suspended during pregnancy, we can readily believe 
 that other glands would undergo changes as a result. Alterations 
 in the thyroid are particularly apparent as it becomes enlarged 
 and more active in the majority of pregnant women, as does also 
 the anterior lobe of the pituitary body. This increased activity 
 may tend to compensate for the suspended function of the 
 ovaries. But the alterations in the functions of the other glands, 
 compensatory though they be in part, apparently produce much 
 the same sort of nervous symptoms that they are capable of pro- 
 ducing in a non-pregnant woman. 
 
 Taking the condition as a whole, pregnancy is usually char- 
 acterized by an improved state of health. During the first few 
 months there may be lassitude and loss of weight, but the latter 
 part of the period is notable for an unusual degree of general well 
 being and for an increase in flesh over the entire body, which 
 may amount to as much as twenty -five or thirty pounds. 
 
 About fifteen pounds of the increased weight is lost at the 
 time of labor and a still further reduction occurs during the suc- 
 ceeding weeks when the mother's body returns approximately 
 to its original condition. But it sometimes happens that the 
 improved state of nutrition acquired during pregnancy becomes 
 permanent. 
 
There was a time when you were not. 
 
 You merry sprite, save as a strain, 
 
 The strange dull pain 
 
 Of green buds swelling 
 
 In warm, straight dwelling 
 
 That must burst to the April rain. 
 
 A little heavy I was then 
 
 And dull — and glad to rest. And when 
 
 The travail came 
 
 In searing flame . . . 
 
 But, sprite, that was so long ago ! — 
 
 A century ! — I scarcely know. 
 
 Almost I had forgot 
 
 When you were not. 
 
 — Eunice Tietjens. 
 
PART III 
 The Expectant Mother 
 
 CHAPTER VI. PRENATAL CARE. Instruction of the Mother, Exami- 
 nations, and Observations. Importance of Prenatal Care. The 
 Nurse 's Part. Personal Hygiene of Pregnancy. Excretions. Kid- 
 neys. Urine Tests. Skin. Bowels. Clothes: corsets, binders, shoes. 
 Diet. Fresh Air and Exercise. Rest and Sleep. Care of the Breasts. 
 Teeth. Travelling. Marital Relation. Common Discomforts during 
 Pregnancy. Nausea and Vomiting. Heartburn. Distress. Flatu- 
 lence. Diarrhea. Pressure Symptoms. Swelling of the Feet. Vari- 
 cose Veins. Hemorrhoids. Cramps in the Legs. Shortness of Breath. 
 Vaginal Discharge. Itching. Early Symptoms of Complications of 
 Pregnancy: Toxemias, Premature Terminations, Hemorrhage. 
 
 CHAPTER VII. MENTAL HYGIENE OF THE EXPECTANT 
 MOTHER. Common Causes of Mental and Nervous Breakdown 
 during Pregnancy. Nurse 's Attitude. 
 
 CHAPTER VIII. PREPARATION OF ROOM, DRESSINGS AND 
 EQUIPMENT FOR HOME DELIVERY. 
 
 CHAPTER IX. COMPLICATIONS AND ACCIDENTS OF PREG- 
 NANCY. Premature Terminations of Pregnancy. Definition of 
 Terms. Abortions. Causes: Abnormalities of Fetus; Abnormalities 
 in the Generative Tract; Acute Infectious Diseases; Mental or Emo- 
 tional Stress; Physical Shocks. Premonitory Symptoms. Prevention, 
 Treatment, and Nursing Care of Threatened, Incomplete, and Com- 
 plete Abortions. Missed Abortion. Therapeutic Abortion. Clerical 
 and Legal Aspects of Abortion. Criminal Abortion. Premature 
 Labor: Causes, Treatment and Nursing Care. Ante-partum Hemor- 
 rhage. Placenta Praevia: Cause, Symptoms, Treatment and Nursing 
 Care. Premature Sei)aration of a Normally Implanted Placenta : 
 Cause, Symptoms, Treatment and Nursing Care. To.xemias of 
 Pregnancy. Pernicious Vomiting of Pregnancy. Symptoms, Treat- 
 ment and Nursing Care of Reflex Vomiting, Neurotic Vomiting, 
 Toxemic Vomiting. Pre-eclamptic Toxemia : Symptoms, Prevention, 
 Treatment and Nursing Care. Eclampsia: Symptoms, Treatment 
 and Nursing Care. Nephritic Toxemia: Cause, Symptoms, Treat- 
 ment and Nursing Care. Acute Yellow Atrophy of the Liver: 
 Cause, Symptoms, Treatment and Nursing Care. Other Important 
 Complications of Pregnancy: Syphilis. Heart Lesions. Pulmo- 
 nary Tuberculosis. Thyroidism. Pyelitis. Gonorrhea. 
 
CHAPTER VI 
 PRENATAL CARE 
 
 The day is long since past when the obstetrician's concern for 
 his patient began when she went into labor. The obstetrician of 
 to-day watches and cares for his patient throughout pregnancy, 
 for he knows that by so doing he greatly increases her chances 
 of surviving the ordeal of childbirth, and the baby's prospect of 
 living through that perilous first year. 
 
 Although many conditions that result in invalidism or death 
 occur during labor or the puerperium, they have their begin- 
 nings during pregnancy. Their prevention, then, or early recog- 
 nition, followed by prompt and efficient treatment, will avert 
 many of the dreaded complications and emergencies associated 
 with childbearing. 
 
 In order to prevent these disasters it is necessary to super- 
 vise the expectant mother and care for her from early in preg- 
 nancy — from the time of conception if possible — until the onset 
 of labor, and this is prenatal care. It may be divided into in- 
 struction, examinations and observations, as follows : 
 
 1. a. Teaching the expectant mother the principles of personal 
 hygiene, as especially adapted to meet her needs, and helping her to 
 adopt them; 
 
 b. Describing to her the more apparent, normal changes of preg- 
 nancy which she is likely to notice and perhaps not understand, and 
 also the common symptoms of complications which she may detect and 
 should report; 
 
 2. The doctor's preliminaiy examination, early in pregnancy, com- 
 prising a study of the size, shape and proportions of the pelvis, and 
 later their relation to the size and mouldability of the baby's head; a 
 Wassermann test for syphilis; urinalysis and measuring the blood pres- 
 sure. In addition to these, a complete physical survey is made, con- 
 sisting of examinations of the heart, lungs, breasts, abdomen, a vaginal 
 smear for gonorrhea, and the patient's height, weight and temperature; 
 
 3. Constant watching for early symptoms of the complications 
 
 111 
 
112 OBSTETRIC AJj NURSING 
 
 of pregnancy, with speedy treatment of such symptoms when they 
 appear, and relieving the common discomforts of pregnancy; making 
 observations upon the presentation and size of the fetus, later in preg- 
 nancy, in order to plan ahead of time for the delivery, if the patient's 
 condition makes this advisable. 
 
 Prenatal care of this character is essentially preventive for 
 both the mother and the new-born baby. 
 
 We gain a faint impression of what it may prevent when we 
 learn that year after year, about 17,000 young women die 
 in the United States from causes associated with childbirth, 
 which are known to be largely preventable (during 1918 the 
 number was 23,000) ; and that each year about 112,000 babies 
 are born dead, and 100,000 of those born alive perish during the 
 first month of life, also from causes which are largely con- 
 trollable. 
 
 But 17,000 dead mothers and 200,000 dead babies, most of 
 whom might have lived, are not all that enter into the annual 
 erection of this national monument to neglect. There are also 
 the unrecorded and uncounted victims of little or no obstetrical 
 care who have had too much vigor to succumb completely and die, 
 and who, therefore, live on through years of wretched invalidism. 
 Sometimes, it is true, their disability is slight, so slight as to be 
 uninteresting, and of no statistical importance. But to the wo- 
 man herself, who must resume the functions of mother, home- 
 maker, wife and general utility person, the disability may be 
 enough to make life endlessly dreary and discouraging. And 
 yet, she is perhaps only just below the physical level upon which 
 she could live her life with joy and eagerness; and proper care 
 when the baby came would have left her upon that level. 
 
 The effect of the mother's impairment reaches far beyond her 
 own invalidism, for such women are not as well able to rear and 
 care for their children satisfactorily as are fresh, buoyant 
 mothers. Whatever makes for good obstetrics, therefore, makes 
 for a better race, and, as we shall see later, measures that tend 
 to improve the health of the race tend to lessen the hazards of 
 ehildbearing. 
 
 Ideal prenatal care, then, would really begin during the ex- 
 pectant mother 's own infancy, but we must be content here with 
 
PRENATAL CARE 113 
 
 a description of the care that is advisable, and desired, for ex- 
 pectant mothers from the beginning of pregnancy. 
 
 There is considerable difference of opinion among physicians 
 concerning the stage of pregnancy at which it is desirable to see 
 the expectant mother for the first time, and the frequency of 
 subsequent observations. But the growing tendency is for the 
 doctor to see his patient as early as possible, for the preliminary 
 examination, and to follow a fairly uniform routine in the kind 
 and frequency of subsequent observations, and in the personal 
 hygiene which the patient is advised to adopt. 
 
 Thus, it has become generally customary to see the patient, 
 take her temperature, pulse and blood pressure and make a urin- 
 alysis once a month during the first half of pregnancy, and then 
 every two weeks until the onset of labor, or possibly once a week 
 toward the end. These periodic examinations keep the physi- 
 cian constantly informed about his patient's condition, and fre- 
 quently disclose very early symptoms of a complication which 
 is easily amenable to treatment at that stage, but which might 
 prove serious if allowed to progress unchecked. Albumen in the 
 urine, for example, or an increase in the blood pressure, in a 
 woman who had no other sjTuptoms, would suggest the advisabil- 
 ity of watching for further symptoms of toxemia ; while an ele- 
 vation of temperature, even though the patient was not uncom- 
 fortable, might lead to the early discovery of tuberculosis, 
 pyelitis or some other infection not otherwise apparent. 
 
 (it is this stitch in time that means so much to the pregnant 
 woman and her expected baby. 
 
 But the most painstaking obstetrician requires the co-opera- 
 tion of his patient in innumerable little waj's, if she is to have 
 the fullest benefits of his skill; for it is not so much what the 
 doctor advises that counts as how the patient lives. 
 
 It is at this point that nurses are more and more being given 
 opportunity for immensely gratifying service. A private pa- 
 tient who is in the care of an obstetrician is, of course, super- 
 vised and instructed by her doctor. But there are other patients 
 — women who cannot afford this individual care, but who need 
 care none the less. And it is these expectant mothers that nurses 
 are helping the doctors to instruct in the principles of right liv 
 
114 OBSTETRICAL NURSING 
 
 ing, and are watching for danger signs, through visiting nurse 
 societies, out-patient departments of hospitals and through pre- 
 natal clinics. 
 
 The character and extent of the instruction and supervision 
 given by the nurses is, of course, decided by the medical board 
 of her organization, and is often affected by the conditions under 
 which the work is conducted. The nurses in a rural community, 
 for example, may take blood pressures and test urine for albu- 
 men, while in cities, rich in doctors and medical institutions, 
 these observations might not be among their duties. 
 
 In addition to this definite relation to expectant mothers, 
 nurses are meeting them, unofficially and informally, at every 
 turn; women who are needing, but not receiving, care from a 
 doctor or an organization ; women who are puzzled or troubled 
 over their condition, but do not know where nor how to obtain 
 advice ; women who could employ a physician but do not appre- 
 ciate the importance of his care. 
 
 Every nurse should recognize it as her duty to advise an un- 
 supervised, pregnant woman to place herself under medical care, 
 no matter under what conditions she meets her. 
 
 In the discharge of her duties, the nurse will sometimes need 
 no little ingenuity to adapt the routines of prenatal care, as 
 prescribed by her organization, to the mentality, traditions and 
 varied demands of the daily lives of her patients. But this w411 
 have to be done, for though in a general way the needs of all ex- 
 pectant mothers are the same, their circumstances and personali- 
 ties are infinitely varied. 
 
 It may require undreamed-of tact and resourcefulness to con- 
 vince a patient that details of care, which seem wholly unrelated 
 to her or her baby 's welfare, will actually increase their chances 
 for life and health. For this reason, it is of almost prime im- 
 portance that the nurse win her patient's friendship and confi- 
 dence. She will then scarcely realize that she is being taught, 
 but will do and continue to do as she is advised, because of an 
 almost insensible reliance upon the judgment and sincerity of 
 her counsellors. 
 
 It is not the single examination of a specimen of urine that 
 counts, nor the exercise taken with pleasure and enthusiasm 
 
PRENATAL CARE 115 
 
 during the first few days of its novelty. It is not the rest, fresh 
 air nor proper food, taken according to rule for a week or two, 
 that will keep her fit. It is the aggregate and repetition of the 
 infinite number of details that make up the expectant mother's 
 mental and physical life during twenty-four hours in each day, 
 seven days a week, throughout forty long weeks, that grow 
 longer and more monotonous as pregnancy advances ; it is the mo- 
 saic that she makes out of the minutiae of her daily life that 
 counts. And paradoxical as it seems, she must shape her days 
 to meet her own and her baby's needs with such steady per- 
 sistence that she finally lives them almost unconsciously of what 
 she is doing, and also without introspection. 
 
 Obviously, then, the expectant mother's mental attitude is of 
 considerable importance. 
 
 She should in general continue the diversions, work and 
 amusements that she is accustomed to and enjoys, if they are 
 not contra-indicated ; cultivate a cheerful, hopeful frame of 
 mind; guard against being self-centred and over watchful of 
 symptoms, and at the same time not adopt the dangerous habit 
 of uncomplainingly ascribing to pregnancy all of the discomforts 
 and unfamiliar conditions which may arise. In short, to forget 
 that she is pregnant in so far as that is consistent with the care 
 that she should take of herself. 
 
 She should understand that childbearing is a normal func- 
 tion, but, like other normal functions, may become abnormal if 
 neglected ; and that a sick pregnancy is not a normal one. 
 
 In connection with the patient's mental attitude and her 
 anxieties, the nurse may be of great comfort in helping to dispel 
 superstitions and the widely credited and depressing beliefs 
 concerning maternal impressions. 
 
 After one has traced the development of the human body in 
 the uterus, and even faintly understood its growth and method 
 of nourishment, it is impossible to believe that the mother's 
 thoughts or experiences could in any way deform or mark her 
 child, or alter its sex. That the mother's "reaching up," for ex- 
 ample, could slip the cord around the unborn baby's neck is 
 manifestly absurd, as well as the previously mentioned supersti- 
 tions about the eight-month baby 's slender chances for survival. 
 
116 OBSTETRICAL NURSING 
 
 But superstitions are always fondly cherished, for, as Gib- 
 bon tells us, "the practise of superstition is so congenial to the 
 multitude, that if they are forcibly awakened, they still regret 
 the loss of their pleasing vision. ' ' We can scarcely wonder how- 
 ever that even intelligent and educated people hold utterly im- 
 probable beliefs about pregnancy, for the most fanciful of them 
 are quite as easy to believe as the thing that we know actually 
 occurs — the development of a human body from a single cell. 
 
 These fanciful beliefs, however, are sometimes serious mat- 
 ters to the young woman who is traveling, day by day, toward a 
 great and mysterious event, and they should not be laughed to 
 scorn, but explained away seriously and with sympathy. She 
 may be told quite simply, that after conception she gives her baby 
 only nourishment; that the baby's connection with her body is 
 through the cord and placenta, in neither of which are there 
 nerves; and that even if the blood could carry mental and 
 nervous impulses, which it cannot, the maternal and fetal blood 
 never come in actual contact with each other. A tale which she 
 has heard about a woman who saw something distressing and 
 later gave birth to a marked child may cease to worry her if 
 she is reminded of the innumerable babies, beautiful and un- 
 marked, which are born to women who have had equally shock- 
 ing experiences. It is scarcely probable that any woman lives 
 through the ten months of pregnancy without seeing, hearing 
 or thinking things that would disfigure a baby if maternal im- 
 pressions could produce such results, and yet newborn babies 
 are very rarely blemished. Although the ultimate causes of 
 marks and deformities of the fetus are not definitely known, 
 they are probably to be found in faulty development very early 
 in the embryonic life, and, therefore, are not preventable. 
 
 , HYGIENE OF PREGNANCY 
 
 i In coming to the expectant mother's personal hygiene, we 
 * find that an understanding of the physiology of pregnancy al- 
 most of itself indicates what this hygiene should include. We 
 shall take it up in detail, however, and describe what is at pres- 
 ent considered a reasonable outline of the routine desired for the 
 average pregnant woman, who is found by careful examination 
 
' PRENATAL CARE 117 
 
 to be normal and free from complications, and needing only to 
 keep well. But, as has been said, and must be oft repeated, the 
 ideal routine cannot be deposited en bloc upon all expectant 
 mothers. It must be adjusted 'to the individual and to her cir- 
 cumstances. 
 
 Excretions. Although, as has been explained previously, the 
 pregnant woman does not have to eat for two, she does have to 
 eliminate the waste and broken-down products from two bodies, 
 through her own excretory organs : the kidneys, skin, lungs and 
 bowels. True, the amount of the baby's ash is not great, but is 
 of such a character that its elimination is important and in- 
 creases the strain upon the maternal excretory apparatus. 
 
 Kidneys. One of the most important factors in prenatal 
 care is promoting the function of the kidneys and watching their 
 output. It is probably more true of the kidneys than of any 
 other organs that a slight abnormality which would not give 
 trouble at other times may, if neglected during pregnancy, pro- 
 duce very grave results. The amount of urine passed in twenty- 
 four hours should be measured, and a specimen prepared, once 
 a month during the first half of pregnancy and every tw^o weeks 
 afterward. If less than three pints are passed the patient should 
 know, without further instruction, that she is not taking enough 
 water and must take more. And so it is the nurse's duty, in this 
 connection, to convince her patient of the importance of drink- 
 ing an abundance of water, and periodically measuring her urine 
 and sending specimens to the doctor for examination. 
 
 She is very likely to follow such advice if she is told that by 
 so doing she will help to prevent convulsions, for most women 
 know of this complication and dread it. 
 
 In preparing a specimen, a covered or corked receptacle which 
 is large enough to hold the voidings for twenty-four hours, must 
 be thoroughly washed and scalded ; in it should be collected the 
 total amount of urine voided during twenty-four hours and kept 
 in a place that is cool enough to prevent putrefactive changes. 
 The additional precaution of putting a teaspoonful of chloroform 
 into the receptacle is wise and does not injure the specimen. 
 The patient should be instructed to empty her bladder at any 
 designated hour, and then keep all urine voided from that time 
 
118 OBSTETRICAL NURSING 
 
 until the corresponding hour on the following day. The urine 
 should be shaken so as to mix thoroughly the different voidings, 
 and six or eight ounces poured into a bottle which has been 
 washed and scalded, carefully corked and labelled with the date, 
 patient's name, address and the total amount for twenty-four 
 hours. 
 
 If the nurse is called upon to test for albumen, either of the 
 following will serve, unless the doctor specifies a test which he 
 prefers : 
 
 Heat and acetic acid test: Fill a test tube about half full of 
 urine and gently boil the upper part in a flame ; add five drops of 
 2% to 5% acetic acid and again boil gently. The presence of 
 albumen is shown by a white cloud in the upper part of the urine. 
 
 Eshach's test: Fill a test tube half full of urine; add eight 
 or ten drops of Esbach's Solution. The presence of albumen is 
 shown by a white flocculent precipitate in the upper part of the 
 urine. 
 
 Skin. Under ordinary conditions, the skin serves as a pro- 
 tective covering for the body, helps to regulate the body tempera- 
 ture and acts constantly as an excretory organ. This last func- 
 tion is performed by the sweat glands which open upon the sur- 
 face of the body, and we are told that there are some twenty-eight 
 miles of these minute, tube-like structures in the skin. These 
 glands should be, and usually are, constantly active and they 
 daily pour upon the surface of the body an oily substance that 
 lubricates the skin and something over a pint of water contain- 
 ing waste matter, that is inimical to health if retained in the 
 body. We are not aware of this constant excretion of fluids, 
 which, therefore, is termed "insensible perspiration," but it con- 
 tinues even in cold weather and must not be interrupted if health 
 is to be preserved. If the oil, dust, particles of dead skin and 
 the waste material left by dried perspiration are allowed to re- 
 main upon the surface of the body, they will clog the pores and 
 gland openings and thus interfere with their functions. The re- 
 moval of this material, then, is an imperative health measure. 
 This is done automatically, in part, for the fluid evaporates, and 
 much of the solid matter is rubbed off on the clothing. But the 
 most important aids to the skin's activity are the drinking of 
 
PRENATAL CARE 119 
 
 plenty of water, deep breathing, exercise and warm baths ; baths 
 serving the doiiljle purpose of removing waste matter already 
 on the surface, and stimulating the glands to increased activity 
 in giving off still more. 
 
 This explains the importance to the expectant mother of thor- 
 ough and regular bathing, and of keeping her body evenly warm. 
 Most doctors advise a warm, not hot, shower or tub bath every 
 day, with soap used freely over the entire body, followed by a 
 brisk rub. The best time for this warm, cleansing bath, as a rule, 
 is just before retiring, as it is soothing and restful and tends to 
 induce sleep. Very hot baths are fatiguing, particularly during 
 pregnancy, and should never be taken except with the doctor's 
 permission ; but cold baths usually may be continued throughout 
 pregnancy if the patient is accustomed to them and reacts well 
 afterwards. Under these conditions the morning cold plunge, 
 shower or sponge is beneficial, as it stimulates the circulation and 
 thus promotes the activity of the skin. Some doctors forbid tub 
 bathing of any kind after the seventh month, on the ground 
 that as the patient sits in the tub her vagina is filled with water, 
 which may contain infective material. Should labor occur 
 shortly afterward an infection might result. As the patient is 
 heavy and somewhat uncertain on her feet, there is also the 
 danger of her slipping and falling while getting in or out of the 
 tub. 
 
 Other doctors permit tub baths throughout pregnancy, up 
 until the onset of labor; while as to hot foot baths, there seems 
 to be no reason for or against them at any time during the nine 
 months. 
 
 Bathing in a quiet stream or lake is apparently harmless, but 
 sea bathing, if the surf is rough, is inadvisable because of the im- 
 pact of the waves upon the abdomen and the general violence of 
 the exercise. 
 
 The importance of keeping the body evenly warm throughout 
 pregnancy cannot be overemphasized, for a sudden chilling or 
 wetting may so check the excretory function of the skin as to 
 throw a greater burden upon the kidneys than they can meet, 
 in their effort to eliminate the skin's share of the body waste. 
 Accordingly, a single chilling will sometimes be enough to pre- 
 
120 OBSTETRICAL NURSING 
 
 cipitate an eclamptic seizure. This may be one reason why we 
 see eclampsia more frequently during cold weather or after a 
 sudden drop in the temperature after warm or mild days. 
 
 Bowels. The bowels, also, eliminate a certain amount of 
 toxic material and if they do not move thoroughly at least once 
 a day, deleterious substances are absorbed into the system and 
 an extra tax is placed upon the kidneys in an attempt to excrete 
 them. 
 
 Unhappily, a large proportion of pregnant women suffer from 
 constipation, particularly during the later weeks, though women 
 who have always had a tendency of this kind may have trouble 
 from the very beginning of pregnancy. Sluggish peristalsis, due 
 to pressure by the enlarged uterus upon the intestines, is prob- 
 ably the prime cause, though impaired tone of the stretched ab- 
 dominal muscles also may be a factor. 
 
 The bowels should move regularly every day, and to this end 
 the patient should regularly attempt to empty them, immediately 
 after breakfast usually being the best time. The importance of 
 regularity in making the attempt cannot be overemphasized, even 
 though the bowels do not always move. 
 
 Exercise, the intake of an abundance of fluids, eating fresh 
 fruit, coarse vegetables and bulky cereals, such as bran, to stim- 
 ulate peristalsis, and drinking a glass of hot or cold water upon 
 retiring and arising are all laxative in their effect. As the regu- 
 lar use of enemata only tends to lessen intestinal tone, they should 
 not be employed unless ordered by the doctor; nor should the 
 patient take cathartics without the doctor 's order. But she may 
 safely increase the amount of her fluids and the bulk of her food, 
 in order to regulate her bowels, and may also take senna and 
 prunes cooked together. A simple way of preparing prunes for 
 this purpose is to pour a quart of boiling water over an ounce 
 of senna leaves and allow it to stand for about two hours. A 
 pound of well washed prunes should soak over-night in this infu- 
 sion, which has been strained, and the combination cooked until 
 tender. They may be sweetened with two tablespoons of brown 
 sugar, and the flavor improved by adding a stick of cinnamon or 
 slice of lemon while they are cooking. Half a dozen of these 
 prunes, with some of the syrup, may be taken at the evening 
 
PRENATAL CARE 121 
 
 meal to start with, and increased or decreased in number as 
 necessary. 
 
 Clothes. The chief purpose of clothes under all conditions 
 is to aid in keeping the body warm, thus helping to preserve an 
 even circulation and the activity of the sweat glands. As has 
 been pointed out, this is of especial importance during preg- 
 nancy. The expectant mother 's clothes should be not only suffi- 
 ciently warm, but they should be equally warm over the entire 
 body. They should be light and porous, and fairly loose, so as 
 not to interfere with the circulation or other body functions. 
 There must be no pressure on chest or abdomen ; no tight garters, 
 belts, collars or shoes. 
 
 The patient 's clothes, like every other detail in her care, will 
 have to be adapted to her environment and mode of living. If 
 her house is Avell and evenly heated during the cold months, she 
 may quite safely dress lightly while indoors; if it is' not, she 
 should be advised to wear underwear with high neck, long sleeves 
 and drawers, both indoors and out, except when the w^eather is 
 warm enough to induce free perspiration. At all times, how- 
 ever, the warmth of her clothing must be adjusted to the tern- 
 perature of the home, the climate and to the state of the weather. 
 
 Bearing in mind the importance of diversion and amuse- 
 ments, it becomes apparent that in addition to the hj'gienic 
 qualities mentioned, the expectant mother's clothes should be 
 as pretty and becoming as is consistent with her circumstances. 
 She is much more likely to go about and mingle with her friends 
 if she is fortified with the consciousness that she is becomingly 
 and well dressed. Which, of course, is not peculiar to pregnant 
 women. 
 
 The expectant mother's clothes should be so made that their 
 weight will hang from the shoulders instead of from the waist- 
 band. 
 
 And that brings us to the question of corsets, one of the most 
 discussed garments in her wardrobe. "Women who have not 
 been accustomed to wearing corsets will scarcely feel the need 
 of adopting them during pregnancy, except perhaps during the 
 later weeks when the heavy, pendulous abdomen needs to be 
 supported for the sake of comfort. This is particularly true of 
 
rZ'Z OBSTETRICAL NURSING 
 
 women who have borne children and whose flaccid abdominal 
 walls give but poor support to the uterus. 
 
 Women who have been wearing comfortable, well-fitting cor- 
 sets probably will not feel the need of making a change until 
 the third or fourth month. By this time the uterus has pushed 
 up out of the pelvis into the abdomen and accordingly the corsets 
 must be so constructed that they will accommodate themselves 
 to an abdomen that is steadily increasing in size and also chang- 
 ing in shape ; will provide support for both abdomen and breasts 
 and still not compress nor disguise the figure. To be entirely 
 satisfactory in their adjustability, the maternity corsets must 
 be made of very soft material and have elastic inserts and side, 
 as well as front or back lacings. They should extend well down 
 in front and fit snugly over the hips. The upper part may be 
 fitted with adjustable shoulder-straps that will support the 
 breasts and help to suspend some of the abdominal weight from 
 the shoulders; but at the same time will not interfere Avith the 
 development of the breasts nor compress the nipples. Many 
 women find great comfort in weaj'ing a short-waisted maternity 
 corset and a brassiere. 
 
 The front-lace corset is usually found to be the most satisfac- 
 tory, for the patient may lace it from below upward while lying 
 on her back. This enables her to draw it in snugly about the 
 hips, below the abdomen, and adjust the garment to the abdomi- 
 nal curve so as to really support, without compressing the uterus. 
 Other excellent corsets lace both front and back and are capable 
 of very comfortable adjustments. If the nurse clearly under- 
 stands the purpose of a maternity corset, she will be able to ex- 
 plain to her patient why the same style as she ordinarly wears, 
 no matter how large, will not be satisfactory during pregnancy, 
 and may be even harmful. 
 
 Even a properly fitting maternity corset may become uncom- 
 fortable during the last few weeks of pregnancy, and have to 
 be replaced by an abdominal supporter of linen or rubber. And 
 when this stage is reached, even the woman who has worn no 
 corsets may be made more comfortable by adopting such a sup- 
 port, particularly at night. There are many admirable binders 
 on the market, or the nurse and patient may fashion some such 
 
PRENATAL CARE 
 
 123 
 
 >-■ O) ^ 4) 
 
 2 ? .t; cj CO o b. 
 
 5f -; c^i *^ o o 3 
 
 > C > 3 H^ « 
 
124 
 
 OBSTETRICAL NURSING 
 
 au one as is shown in Figs. 34, 35, 36 and 37. Comfortable and 
 inexpensive stocking supporters, which meet all practical re- 
 
 FiG. 37. — Abdominal binder used in Figs. 34, 35 and 36, showing dart3 
 at top of front to fit it over the abdomen. 
 
 qiiirements, may be made by the patient from tapes or strips of 
 muslin. (Figs. 38 and 39.) 
 
 The expectant mother's shoes also merit considerable atten- 
 
 FiGS. 38 and 39. — Front and back view of home-made stocking sup- 
 porters made of webbing or 1-inch strips of muslin and a pair of child's 
 side garters. The straps are sewed together in tlie back, but pinned in 
 front to permit adjustment as the abdomen enlarges. (By courtesy of 
 the Maternity Centre Association, New York.) 
 
PRENATAL CARE 125 
 
 tion and thought. Her feet are larger than usual because they 
 are likely to be somewhat swollen during the latter part of preg- 
 nancy, and the increased weight of her body tends to spread 
 them. This added weight also increases the strain put upon 
 the arch and flat foot is a not infrequent result, unless the arch 
 is well supported. Another reason for the need of proper shoes 
 is that, as pregnancy advances, the body's centre of gravity 
 changes. The pregnant woman becomes unstable on her feet and 
 needs low, broad, firm heels. They need not necessarily be flat 
 at first, if the patient has been accustomed to wearing moderately 
 high ones, for the sudden lowering of the heels may injure her 
 arches. High French heels, of course, should be avoided because 
 they not only increase the difficulty and discomfort of walking 
 but cause backache, as well, by forcing a posture that adds to 
 the pressure on the lower part of the abdomen. They also in- 
 crease the risk of turning the ankles, tripping and falling. 
 
 The patient's shoes should be an inch longer than those she 
 ordinarily wears ; they should have broad toes and fit snugly over 
 the instep, in spite of being large. If her shoes are not comfort- 
 able the expectant mother Avill tire easily and tend to take less 
 exercise than she should. 
 
 Diet. — It is advisable for both nurse and patient to under- 
 stand, and keep clearly in mind, the purposes w^hich are served 
 by the food intake of the expectant mother, and what foods and 
 practices will defeat, and what will accomplish these purposes. 
 Her food should provide nourishment, as under ordinary condi- 
 tions; it should promote the functions of her skin, kidneys and 
 bowels, because of the wa.ste from her own and her baby's body 
 which she must excrete ; it should be adequate to build and nour- 
 ish the baby's body without drawing materials from the mother's 
 own tissues. Moreover, proper food during pregnancy is an es- 
 sential factor in preparing the mother to nurse her baby, which 
 is as important as nourishing the fetus in utero. 
 
 In order to accomplish these various ends the patient must 
 not only eat suitable food, but she must digest and assimilate it. 
 This requires that she sedulously guard against overeating, con- 
 stipation and indigestion of any kind. Indigestion may be 
 
126 OBSTETRICAL NURSING 
 
 avoided during pregnancy exactly as it is at other times, by eat- 
 ing proper food ; by cultivating a happy frame of mind ; by ex- 
 ercise, fresh air, adequate rest and sleep. 
 
 If accustomed to a fairly simple, well-balanced, mixed diet, 
 the average expectant mother will need to make little or no 
 change, excepting to make her evening meal light if it has been 
 a hearty one ; for she uses her nutritive material with surprising 
 economy and does not have to * ' eat for two, " as is so commonly 
 believed. It is a safe general principle that an amount and kind 
 of food that keeps the expectant mother, herself, in a state of 
 health and good nutrition, is favorable to satisfactory develop- 
 ment of the fetus until the latter part of pregnancy. 
 
 She will probably be able to understand why this is true if 
 it is explained that her baby gains nine-tenths of his weight after 
 the fifth month, and one-half of his weight during the last eight 
 weeks of pregnancy; also that if she takes too much food, the 
 excess is stored up in both her own and the baby's tissues; if 
 too little, the fetus is nourished and her body deprived. 
 
 It is very unwise for the mother to diet with the idea of keep- 
 ing the child small, and thus make labor easy, unless she is so 
 ordered by her physician. In general, it is the size of the fetal 
 skull that makes labor easy or difficult, and not the amount of 
 fat distributed over the child's body. And if the patient cuts 
 down the minerals in her diet to make the fetal bones soft, and 
 thus increase the compressibility of the skull, the fetus will ex- 
 tract lime from her bones and teeth, so that the only effect is 
 upon herself. 
 
 The expectant mother's meals should be taken with clock-like 
 regularity, eaten slowly and masticated thoroughly. Three meals 
 a day will usually suffice during at least the first half of preg- 
 nancy. The possible need for slight additional food after that 
 may be supplied more satisfactorily by lunches of milk, cocoa 
 or broth and crackers or toast, between meals and upon retiring, 
 than by taking larger meals. But if the patient has a tendency 
 to nausea, early in pregnancy, she will often be able to control 
 it by taking a little food regularly five or six times daily, instead 
 of the usual three meals. 
 
PRENATAL CARE 127 
 
 In general the expectant mother should eat an abundance of 
 fruit and vegetables, taking at least some uncooked fruit and a 
 green salad, daily, and making sure that her food contains a 
 good deal of residue, such as is provided by fruit and coarse 
 vegetables. This residue increases the bulk of the intestinal con- 
 tents, which stimulates peristaltic action and thus helps to over- 
 come the tendency toward constipation. As fat is less easily 
 digested, and more likely to cause nausea during pregnancy, 
 than carbohydrates, it is better for the patient to eat no more 
 fat than usual, but to supply the additional energy needed after 
 about the sixth month, by taking a little more starch. But after 
 all, only a slight increase is needed, and this chiefly during the 
 last three or four weeks. 
 
 It is of the greatest importance that every pregnant woman 
 drink an abundance of fluid, to act as solvent for her food and 
 waste material, and stimulate the activity of her kidneys, skin 
 and bowels. She needs about three quarts daily, and most of 
 this should be w^ater, the remainder consisting of milk, cocoa, 
 soup, and other liquids. 
 
 Alcohol should not be taken under any circumstances, except 
 upon a doctor's order, while tea and coffee, if taken at all, should 
 be used with moderation. The patient should be advised to 
 avoid fried food, pastry, rich desserts, rich salad-dressings and 
 any other food which would ordinarily disagree with her. In 
 fact any article of food that disagrees w4th her in a non-preg- 
 nant state should be avoided during pregnancy, no matter how 
 valuable it may be as nourishment to the majority of people. 
 
 On the other hand, it sometimes happens that an article of 
 food which is likely to disagree with other people will be easily 
 digested by the pregnant woman, and if it adds to the pleasure of 
 her meals should not be taboo, for the enjoyment of one's meals 
 promotes digestion. So-called "cravings" are not as common 
 in fact as they are in rumor, but the expectant mother may have 
 a capricious appetite and display strange likes and dislikes for 
 certain dishes, possibly because of her tendency to be nauseated. 
 
 The average pregnant woman with no symptoms of complica- 
 tions will be able to supply her needs, and at the same time 
 
128 OBSTETRICAL NURSING 
 
 keep within the bounds of safety if she selects her diet from such 
 groups as the following: 
 
 Animal Foods. — Milk and eggs are the most satisfactory, but for 
 the sake of variety, and to tempt her appetite, she will usually be 
 allowed to have fish, the various kinds of shell fish, beef, lamb, chicken 
 or game rather sparingly, preferably only once a day. Pork, veal, 
 and goose should be avoided as a rule, and particularly by women with 
 whom they ordinarily disagree. 
 
 Soups. — Thin soups and broths have little food value, but, because 
 of their appetizing flavor and aroma, are an aid to digestion, and fre- 
 quently will stimulate a flagging appetite and prompt the patient to 
 eat and assimilate more than she would without them. Cream soups and 
 purees obviously have a high food value, and, like thin soups and 
 broths, also supply a definite amount of fluid which the patient njust 
 have. 
 
 Vegetables. — The group of vegetables usually designated as "leafy" 
 are of even greater importance to the expectant mother than they are 
 to the average person. Of these, she may safely eat onions, asparagus, 
 celery, string beans, spinach, and make a point of taking a green salad, 
 such as lettuce, cress, or romaine, at least once daily. Sweet potatoes, 
 white potatoes, rice, peas, Lima beans, tomatoes, beets and carrots 
 may also be eaten with safety as a rule, but cabbage, caulifloAver, corn, 
 egg-plant, Brussels sprouts, parsnips, cucumbers, and radishes should 
 be taken with great caution and avoided altogether if they cause flatu- 
 lence or any kind of distress. 
 
 Fresh Fruits. — A necessary part of the diet is fresh fruit, and 
 among those fruits which are both beneficial and harmless are apples, 
 peaches, apricots, pears, oranges, figs, cherries, pineapple, grapes, 
 plums, strawberries, raspberries, blackberries, and grapefruit. These 
 are more likely to be laxative if eaten alone, as before breakfast and at 
 bedtime. Cooked fruits are also valuable articles of diet, but are prob- 
 ably less laxative than raw fruit. Some of the citrus fruits, oranges, 
 grapefruit and lemons, should be taken daily because of their anti- 
 scorbutic properties. 
 
 Cereals. — For their nourishing and laxative qualities, cereals are 
 important, and their food value is increased by the milk and cream 
 which are usually taken with them. Cooked cereals should invariably 
 be cooked longer than the usual directions suggest. Bran, eaten alone, 
 as a cereal or in combination with other grains, is an excellent laxative. 
 
 Breads. — Graham, cornmeal, whole wheat and bran bread are all 
 good. In general the expectant mother will be on the safe side if she 
 eats sparingly, if at all, of very fresh or hot breads and hot cakes. 
 
 Desserts. — Desserts are very important for they add to the at- 
 tractiveness of most people's meals, and if wisely chosen and properly 
 
PRENATAL CARE 129 
 
 made, may supply a good deal of easily digested nourishment. They 
 may include, in addition to fresh and cooked fruits and preserves, ice- 
 cream, a wide variety of custards, creams and puddings made largely 
 of milk, eggs, and some ingredient to give substance and firmness, such 
 as gelatine, cornstarch, rice, tapioca, farina, arrow-root and similar 
 materials. 
 
 Fresh Air and Exercise. If the nurse has become aware of 
 the value of promoting aJl of the normal physiological processes 
 of the pregnant woman, she already realizes how important are 
 fresh air and exercise to the patient and her expected baby. 
 
 The average individual uses every minute the oxygen con- 
 tained in four bushels of air, and since the pregnant woman 
 takes in through her lungs the oxygen for both herself and the 
 baby, she must have an adequate quantity of constantly chang- 
 ing air to supply at least this amount. She should spend at least 
 two hours of each day in the open air. If the weather is so 
 stormy or severe as to make it undesirable for her to go out from 
 under cover, because of the danger of getting wet or chilled, she 
 may wrap up well and take her airing on a protected porch or 
 in a room with all of the windows wide open. But this is only 
 a part of it, for the air in her house, or rooms, must be kept fresh 
 all day by being constantly changed ; this requires a steady in- 
 pouring of fresh air and outpouring of stale, vitiated air. 
 
 A very good way to accomplish this is to have one or more 
 windows open slightly, top and bottom, all the time. But there 
 must be no sudden changes of temperature, nor drafts, for fear 
 of chilling the patient's skin. At night she should sleep in a 
 room with the windows open, taking care to be well protected by 
 light, warm coverings. 
 
 Each detail of the expectant mother's daily routine seems to 
 be more important than the last. And so when we come to the 
 question of regular outdoor exercise we almost think that what- 
 ever else may be neglected, this is indispensable, since it pro- 
 motes digestion, stimulates the functions of the skin and lungs; 
 steadies the nerves, quiets the mind and promotes sleep. And 
 more than that, walking, which is probably the most satisfactory 
 form of exercise, also strengthens some of the muscles that are 
 used during labor. But exercise is downright injurious if con- 
 tinued to the point of fatigue, no matter how little has been 
 
130 OBSTETRICAL NURSING 
 
 taken. Each woman must be a law unto herself in this matter, 
 therefore, and must be impressed with the importance of stop- 
 ping before she is tired. She should start by walking only a 
 short distance, increasing gradually until she is able to walk 
 possibly as much as an hour in the morning and an hour in the 
 afternoon, if she can do so without fatigue. 
 
 All violent exercises and sports are of course to be avoided, 
 particularly swimming, horseback riding, and tennis. AVhile 
 motoring and carriage riding are pleasant diversions, they can- 
 not be classed as exercise. They should be taken only in com- 
 fortable vehicles and over smooth roads, so that there will be no 
 jarring nor jolting, and the jDatient should not do the driving 
 herself. 
 
 A certain amount of exercise, in the shape of light house- 
 work, may be taken indoors. It is distinctly beneficial, if not 
 continued to the point of fatigue, both because of the exercise 
 which it provides, and also the diversion and interest, for these 
 promote mental and physical health. But this indoor exercise 
 must not interfere with, nor to any degree replace, the daily 
 exercise out of doors ; nor must it include heavy work, such as 
 washing, sweeping, heavy lifting, running a sewing machine 
 by foot nor much running up and down stairs. However, the 
 amount and kind of work which a woman may comfortably and 
 safely do are so related to what she has been accustomed to, that 
 it is not possible to offer more than general suggestions, which 
 will help in the planning for each individual. All patients will 
 do well to moderate their activities at the time when they would 
 ordinarily menstruate. 
 
 There are patients to whom massage and gymnastics are bene- 
 ficial during pregnancy, when for some reason the out-of-door 
 activities are contra-indicated. This might be true of a patient 
 with heart trouble, for example, or one who is being kept in bed 
 to avert an abortion, and accordingly is a matter which must be 
 entirely in the doctor's hands. 
 
 Rest and Sleep. When we studied the bony structures of 
 the female body, we found that as the abdominal tumor of preg- 
 nancy increased in size and weight, the body's centre of gravity 
 
PRENATAL CARE 131 
 
 changed and the pregnant woman was required to make a con- 
 stant, though unconscious effort to stand upright. This is prob- 
 ably one reason for the fatigue which expectant mothers so often 
 feel without apparent cause, and for the fact that they are likely 
 to tire rather more easily than usual. 
 
 Accordingly, the patient may have to rest frequently during 
 the day, in order to avoid the ill effects of fatigue. She should 
 work and exercise in short periods rather than long, always lying 
 down when tired, and for an hour or two after the noon meal. 
 She must be particularly careful not to be over-active, nor to 
 overexert herself at the time when menstruation would occur 
 were she not pregnant, for fear of bringing on an abortion. 
 This precaution is particularly important during the first four 
 months, the period when abortions occur most frequently. 
 
 Since eight hours' sleep is usually considered necessary to 
 keep the average person in good condition, the pregnant woman 
 cannot expect to progress satisfactorily with less. In fact, it is 
 so important to her general well-being that she should be taught 
 and persuaded to do everything in her power to secure it. 
 
 Fresh air during the day and open windows at night; pru- 
 dent eating; a comfortable bed furnished with warm but light 
 bedding ; warm baths ; a hot water bag to the feet and a hot drink 
 upon retiring are all conducive to sleep. 
 
 But in addition to these, and perhaps of even more import, 
 are cheerfulness and a tranquil, untroubled state of mind. It 
 is well for the nurse to make a mental note of that intangible 
 but influential fact, for she can usually exert a great deal of 
 influence in shaping her patient's or patients' moods. 
 
 Breasts. — Breast feeding is the most urgent single need of 
 the baby, for whose coming we are making preparation, and 
 practically every mother, excepting those with definite physical 
 disability, can supply this need of her baby 's, if she gives herself 
 proper care both before and after its birth. It is true, that every- 
 thing that promotes her general health helps to prepare her to 
 nurse the baby, but there is need also for care of the breasts and 
 nipples themselves, to make the nursing satisfactory, and to 
 prevent sore nipples and possibly even breast abscesses. 
 
132 OBSTETKICAL NURSING 
 
 Briefly, this local care consists of supporting heavy breasts, 
 but avoiding pressure ; bringing out flat or retracted nipples and 
 toughening the skin which covers the nipples. 
 
 After they become heavy and uncomfortable the breasts may 
 be supported by brassieres, which are snug below the breasts, 
 loose over the breasts themselves and suspended from shoulder 
 straps ; or by some such binder as is shown in Figs. 34, 35, and 36, 
 which answers the same purpose. 
 
 If the patient's nipples are flat or retracted, she should be- 
 gin about the fifth month to make them more prominent in order 
 that the baby may grasp them easily. There are several ways 
 of accomplishing this, all of them in the nature of massage, but 
 whatever is done must be done regularly and persistently. One 
 simple and effective method is to grasp the nipple between the 
 thumb and forefinger, draw it out, hold it for a moment, then 
 release it and allow it to retract. This should be done over and 
 over, two or three times daily. Or the unstoppered opening of a 
 warm bottle may be placed over a flat nipple and held in place 
 until the nipple is drawn up into the neck of the bottle as it 
 cools and forms a vacuum. 
 
 The toughening of the nipples should be begun eight weeks 
 before the baby is expected. There are two general methods 
 which seem to give about equally satisfactory results; one is to 
 harden the skin with astringents and the other is to soften it with 
 ointments. In either case, the nipples should first be scrubbed 
 gently with a soft brush or cloth, warm water and soap, for 
 about five minutes night and morning. They may then be rubbed 
 with lanoline, cocoa-butter or vaseline and covered with a piece 
 of clean soft cloth or gauze, to protect the clothing; or they 
 may be bathed with a wash consisting of equal parts of a satu- 
 rated solution of boracic acid and 95% grain alcohol. Tannin, 
 benzoin and a great variety of astringents are also used, and 
 with satisfactory results. But the essential is to decide upon 
 some method of preparation, of proved value, and then persuade 
 the patient to employ it with faithful regularity. 
 
 Care of the Teeth. It is important that the pregnant 
 woman give her teeth excellent care, for in addition to the condi- 
 tions with which we all have to cope, she must combat the effect 
 
PRENATAL CARE 133 
 
 of her tendency to have an acid stomach. And her teeth are 
 prone to decay and crumble, since the fetus extracts lime salts 
 from her bones and teeth, unless she is careful to take in through 
 her food a supply which is adequate to meet the fetal needs. It 
 is therefore advisable for her to place herself under the care of a 
 dentist, as soon as she knows of her pregnancy, and have any 
 necessary work done at that time, as delay may be serious. 
 
 Some physicians think it advisable to have an X-ray examin- 
 ation of the teeth made as a routine, in order to discover any 
 existing pockets of pus at the apices of devitalized teeth. They 
 feel, that because of the somewhat unstable condition of the preg- 
 nant organism, these localized infections are more of a menace 
 to the expectant mother than to the ordinary individual, and that 
 in some cases they should be drained. 
 
 As to daily care of the teeth, the patient should use dental 
 floss and brush her teeth after each meal, and use an alkaline 
 mouth wash several times daily, particularly after vomiting and 
 before retiring. Much damage may be done by the acid secre- 
 tions in the mouth if they are allowed to bathe the teeth through 
 the long night stretches. Common cooking-soda, lime-water or 
 milk of magnesia make excellent mouth washes. 
 
 Traveling. In this day, when people travel so much and so 
 easily, it is common to hear discussions as to its advisability for 
 the prospective mother. Like many other details of prenatal 
 care, this point cannot be settled once for all women, nor for all 
 stages of pregnancy. Each patient's general condition must be 
 considered ; her tendency to nausea ; the length of the journey 
 and the ease with which it may be made, and whether or not 
 she has ever had, or been threatened with an abortion. In gen- 
 eral, traveling is less hazardous for the expectant mother to-day 
 than it was formerly, to just the extent that it causes less strain, 
 discomfort and fatigue. But as a rule it is considered wise for 
 her to avoid traveling during the first sixteen and the last four 
 wrecks of pregnancy, and at the times when menstruation would 
 ordinarily occur^ Obviously, then, in the interests of prevention, 
 a journey should not be undertaken at any time without a physi- 
 cian's approval. 
 
 The marital relation is usually considered inadvisable in all 
 
134 OBSTETRICAL NURSINU 
 
 cases after the eighth month of pregnancy, and among women 
 who have had abortions or miscarriages it is best omitted 
 throughout the entire period of gestation. This is particularly 
 true of elderly primiparae, 
 
 COMMON DISCOMFORTS DURING PREGNANCY 
 
 There are many minor disturbances which overtake the preg- 
 nant woman, and though not serious in themselves, her com- 
 fort is greatly increased by having them relieved, and this pro- 
 motes her general welfare. The relief of these discomforts, when 
 they are slight or only temporary, sometimes resolves itself into 
 little more than a question of nursing. When long continued or 
 severe, however, they constitute complications which the doctor 
 treats accordingly. 
 
 Nausea and vomiting are probably the commonest disturb- 
 ances of pregnancy and vary from the slightest feeling of nausea 
 when the patient first raises her head in the morning, to persist- 
 ent and frequent vomiting which then assumes grave proportions 
 and is termed "pernicious vomiting." Although it is possible 
 that even the slightest nausea is due to a mild toxemia, there 
 can be no doubt that in many instances the patient's mental at- 
 titude is an important factor. 
 
 Dr. Slemons makes the interesting observation, that women 
 who are unaware of their pregnancy for several months are sel- 
 dom troubled with nausea, while those who erroneously believe 
 themselves to be pregnant will suffer from this well-known symp- 
 tom of pregnancy, until convinced of their mistake. The nausea 
 then subsides. 
 
 As there is a marked tendency toward nausea during early 
 pregnancy, it may be brought on by slight causes which would 
 not produce it under ordinary conditions. Anxiety, grief, 
 fright, shock, incessant worrying, fits of rage, introspection, 
 brooding, or any great emotional stress may cause nausea when 
 the diet is entirely satisfactory. But indiscretions in diet, rapid 
 or over-eating also may cause nausea and vomiting in the ex- 
 pectant mother. 
 
 We seem to get back to the principles of personal hygiene a? 
 
PRENATAL CARE 135 
 
 preventives of nausea during ])reg:naney, for simple, light food, 
 taken in small (jiiantities five or six times daily, eaten slowly and 
 masticated thoroughly; the cultivation of a happy frame of 
 mind; exercise and fresh air all tend to avert this very uncom- 
 fortable condition. Its prevention is of great importance, as the 
 habit of vomiting is easily acquired but broken with difficulty. 
 The common causes of nausea, and their prevention, should there- 
 fore be explained to the average patient, for she will then be 
 able to help herself in warding it off. 
 
 Should "morning sickness" occur, however, it may be re- 
 lieved in many cases, by eating two or three hard, unsweetened 
 crackers or pieces of toast, with nothing to drink, immediately 
 upon awakening and then lying still afterwards for half or three 
 quarters of an hour. The sufferer should then dress slowly, sit- 
 ting down as much as possible while doing so, and eat her regu- 
 lar breakfast. Lying flat, without a pillow, and keeping veiy 
 quiet for a little while after meals, or whenever feeling the slight- 
 est premonitory symptom, will frequently prevent, and also re- 
 lieve nausea, and sometimes comfort is derived from the use of 
 either hot or cold applications to the abdomen. Some patients are 
 relieved by having hot coffee or even a full breakfast before 
 arising. 
 
 Heartburn, so called, which is experienced by many pregnant 
 women, has nothing to .do with the heart. It is caused solely 
 by an excess of hydrochloric acid in the stomach, and is usually 
 described as a burning sensation first in the stomach, then ris- 
 ing into the throat. It may be prevented, as a rule, by taking 
 a tablespoonful of olive oil, or a cupful of cream or rich milk, 
 fifteen or twenty minutes before meals, and avoiding fat and 
 fried food at the meals immediately following. 
 
 This apparent inconsistency in treatment is due to the facts 
 that fat taken into the empty stomach tends to inhibit the secre- 
 tion of acid, while fat and fatty foods taken witJi meals tend 
 to prolong their stay in the stomach and this in turn stimulates 
 the secretion of hydrochloric acid, the thing to be avoided. 
 
 A patient with a tendency to heartburn will be wise, there- 
 fore, if she generally eliminates oils, fats and fattv foods from 
 
136 OBSTETRICAL NURSING 
 
 her meals, and definitely avoids them when the burning occurs. 
 Since the painful, burning sensation is directly due to an excess 
 of acid in the stomach, the obvious step toward relief is to take 
 an alkali at once. A tablespoonful of lime-water is often satis- 
 factory ; a teaspoonful of sodium bicarbonate in water ; a small 
 piece of magnesium carbonate may be nibbled by itself, or any 
 alkaline water that the patient fancies may be taken. 
 
 Distress. There is another form of discomfort, often vague 
 and ill-defined, commonly called "distress" and occurring after 
 eating. It may be neither heartburn nor pain, but resemble 
 both and make the patient very miserable. It is usually seen in 
 women who eat rapidly, do not chew their food thoroughly or 
 eat more at one time than the stomach can hold comfortably. 
 The prevention, naturally, lies in taking small amounts of food 
 slowly and masticating thoroughly. 
 
 Flatulence may or may not be associated with heartburn, 
 but it is fairly common and rather uncomfortable. It is usually 
 due to bacterial action in the intestines, which results in the 
 formation of gas. As has been previously explained, the pres- 
 sure of the enlarged uterus upon the intestines and absence of 
 pressure by the abdominal muscles, retards normal peristalsis, 
 with the result that gas sometimes accumulates to a very uncom- 
 fortable extent. It is clear, therefore, that a daily bowel move- 
 ment is of prime importance in preventing and relieving flatu- 
 lence, and also that foods which form gas should be carefully 
 excluded from the diet. The chief offenders are parsnips, beans, 
 corn, fried foods, sweets of all kinds, pastry and very sweet des- 
 serts. Various intestinal disinfectants are employed, as in 
 non-pregnant states, and also yeast cakes, cultures of Bulgarian 
 bacilli and artificially fermented milk containing bacteria that 
 are antagonistic to the gas-producing forms. 
 
 In the opinion of some doctors, flatulence is sometimes an 
 early symptom of toxemia. 
 
 Diarrhea. Although diarrhea is not one of the commonest 
 disturbances of pregnancy, neither is it infrequent, and must be 
 borne in mind in connection with digestive troubles. Of course, 
 a pregnant woman may have an attack of diarrhea from the 
 same causes that produce it in any one else, and its relief would 
 
PRENATAL CARP] 137 
 
 be obtained by the usual methods, chiefly the correction of dietetic 
 errors. But on the other hand, it may be due entirely to the 
 uterine pressure on irritable intestines. Like flatulence, it is 
 regarded by some doctors as a possible symptom of toxemia. " 
 
 Pressure Symptoms. Under the general heading of pressure 
 symptoms are several forms of discomfort resulting from pres- 
 sure of the enlarged uterus on the veins returning from the lower 
 part of the body, thus interfering with the flow of blood back to 
 the heart. As both the cause and relief of these symptoms are 
 associated with the force of gravity, the nurse will usually know 
 what to do in mild cases without further explanation. In general 
 the heavy abdomen should be supported by a binder or properly 
 fitting corset, the patient should keep off her feet as much as pos- 
 sible and elevate the swollen part. 
 
 The commonest pressure symptoms are swollen feet, varicose 
 veins, hemorrhoids, cramps in the legs and shortness of breath, 
 and though they may appear at any time during the last half, 
 of pregnancy, they grow progressively worse as pregnancy ad- 
 vances. 
 
 Swelling of the feet is very common, .and when very slight 
 may not be serious nor particularly uncomfortable. The edema 
 may be confined to the hack of the ankle, which grows white and 
 shining, or it may extend all the way up the legs to the thighs 
 and include the vulva. Sitting down, with the feet resting on a 
 chair, or lying down with the feet elevated on a pillow will 
 naturally give a certain amount of relief. If the swelling and 
 discomfort are extreme the patient may have to go to bed until 
 they subside, but very often she will secure adequate relief by 
 elevating her feet for even a little while, several times a day. 
 But while employing these harmless, and clearly indicated meas- 
 ures, to make her patient comfortable, the nurse must be keenly 
 alive to the fact that while edema of the feet, legs and vulva 
 may be of solely mechanical origin, they are also symptoms of 
 toxemia, about the most dreaded complication of pregnancy. 
 And as recognition of the earliest signs of toxemia is among the 
 triumphs of prenatal nursing, even the slightest swelling must 
 be reported to the doctor and immediate steps taken to have the 
 urine measured and examined. 
 
138 
 
 OBSTETRICAL NURSING 
 
 Varicose veins are not peculiar to pregnancy, but are among 
 the pressure symptoms which frequently accompany this condi- 
 tion during the later months, particularly among women who 
 have borne children. The superficial veins in the legs will often 
 be equal to the tension put upon them the first time, but will 
 give way as the strain is repeated during subsequent pregnancies. 
 The distension of the veins is not serious as a rule, but may be 
 very uncomfortable; this, coupled with the unsightly appear- 
 ance, sometimes has a bad mental effect. Varicose veins may oc- 
 
 FiG. 40. — Eight angled position, to relieve edema or varicose veins of feet 
 and legs. (By courtesy of The Maternity Centre Association.) 
 
 cur in the vulva, but they are usually confined to the legs, and 
 both legs are about equally affected. But as the position of the 
 child in utero may exert greater pressure on the right than on 
 the left side, the veins on that side may be more distended; or 
 the right side alone may be affected. 
 
 Relief is obtained by keeping off the feet, and particularly by 
 elevating them and also by the use of elastic bandages. When 
 a woman finds it difficult or nearly impossible to sit or lie down 
 for any length of time, she may accomplish a great deal in a few 
 moments by lying flat on the bed with her legs extended straight 
 
PRENATAL CARE 139 
 
 into the air, at right angles to her body, resting against the wall 
 or head board, as shown in Fig. 40. This vight-angled position 
 for five minutes, three or four times a day will accomplish won- 
 ders in reducing varicose veins. 
 
 In addition to posture, a spiral elastic bandage will give re- 
 lief and help to ])revent the veins from growing larger, if ap- 
 plied freshly after each time that the leg is elevated. The most 
 satisfactory bandages, from the standpoint of expense, comfort 
 and cleanliness, are of stockinette or of flannel cut on the bias, 
 measuring three or four inches wide and eight or nine yards 
 long. If made of flannel, the selvedges should be whipped to- 
 gether smoothly so that there is neither ridge nor pucker at the 
 seam. The bandage should be applied spirally with firm, even 
 
 Pig. 41. — Elevated Sims ' position to relieve varicose veins of the vulva. 
 (By courtesy of The Maternity Centre Association.) 
 
 pressure, starting with a few turns over the foot to secure it, and 
 leaving the heel uncovered, carried up the leg to a point above 
 the highest swollen vessels. As a rule, it may be left off at night. 
 
 There are satisfactory elastic stockings on the market, but 
 they are expensive, often cannot be washed and seem to offer no 
 advantage over the bandages. 
 
 Engorged veins in the vulva may be relieved by lying flat 
 and elevating the hips, or by adopting the elevated Sims' posi- 
 tion for a few moments, several times a day. (Fig. 41). 
 
 Hemorrhoids are virtually varicose veins which protrude 
 from the rectum, but, unlike those in the legs, are extremely 
 painful. As it is the straining incident to constipation that 
 causes these engorged veins to prolapse, this condition constitutes 
 
140 OBSTETRICAL NURSING 
 
 one more reason for preventing constipation. A pregnant wo- 
 man whose bowels move freely every day rarely has hemorrhoids. 
 
 Should hemorrhoids appear, the first step is to have them 
 gently pushed back into the rectum. The patient can usually do 
 this for herself, quite satisfactorily, after lubricating her fingers 
 with vaseline or cold cream. Lying down, with the hips elevated 
 on a pillow; the application of an ice bag, cold cloths or witch- 
 hazel compresses to the anus will almost always give relief. 
 When the condition is severe, the physician may prescribe medi- 
 cated ointments, lotions or suppositories, but operation is seldom 
 resorted to during pregnancy, for fear of bringing on labor 
 prematurely. Sometimes the hemorrhoids are worse during the 
 first few days after labor, but as a rule they disappear with 
 the removal of the cause, which in this case is pressure made by 
 the enlarged uterus. 
 
 Cramps in the legs, numbness or tingling may be caused by 
 the pressure of the large, heavy uterus upon nerve trunks sup- 
 plying the lower extremities. The recumbent position ; applying 
 heat and rubbing the painful areas will often give comfort. 
 
 Shortness of breath is sometimes very troublesome toward 
 the end of pregnancy, and, as may be easily seen, is due to the 
 upward, and not downward pressure of the uterus. For this 
 reason it is aggravated by the patient 's lying down and relieved 
 by her sitting up or being well propped up on pillows, or a back 
 rest. 
 
 Vaginal discharge. The normal vaginal discharge is greatly 
 increased during the latter months of pregnancy, as was pointed 
 out in Chapter V, so that ordinarily the moderately profuse 
 yellowish or white discharge at this time has no particular sig- 
 nificance. Its existence should be noted, however, and brought 
 to the doctor's attention, for a very profuse discharge is likely 
 to be regarded as a possible evidence of gonorrhea. For this 
 reason a smear is usually made, when the discharge is excessive, 
 to establish or eliminate this diagnosis ; if it is positive, it indi- 
 cates the necessity for treatment to safeguard both mother and 
 baby. 
 
 As the normal vaginal discharge has antiseptic properties, it 
 should not be removed by douches, which many patients are 
 
PRENATAL CARE 141 
 
 eager to take ; but if it is irritating and causes itching or burn- 
 ing the patient may be made entirely comfortable by avoiding 
 the use of soaj) and 1)y l)athinj>' tlie vulva mtli a solution of 
 sodium bicarbonate or with olive oil. 
 
 Itching of the skin is a fairly common discomfort, and is 
 possibly ii result of irritating material being excreted by the 
 skin glands and deposited upon the surface of the body. The 
 local irritation usuall.y may be alla3'ed, if not very severe, by 
 bathing the uncomfortable areas with a solution of sodium bicar- 
 bonate, or a lotion consisting of a pint of lime-water, half an 
 ounce of glycerine and thirty drops of carbolic acid. It is a 
 good plan, also, for the patient to increase the amount of fluids 
 which she is taking, in order to promote the activity of the skin, 
 kidneys and bowels, and thus dilute the material that may be 
 responsible for the itching and increase its elimination through 
 all channels. In other words the itching may be due to a mild 
 toxemia. 
 
 Some women complain of discomfort caused by the stretching 
 of the skin over the enlarged a])domen, which becomes so tense 
 it feels as though it might tear apart. There is a very old and 
 widely current belief that this sensation may be relieved by 
 nibbing the abdomen with some kind of an oil or ointment. And, 
 moreover, that such oiling will not only increase the elasticity of 
 the superficial layers of the skin, but the deeper layers as well, 
 and that by this means striae may be prevented. There seems 
 to be little foundation for the fear that the skin will tear, or 
 belief in the efficacy of the oiling, but if a woman fancies that she 
 is safer and more comfortable after oiling her abdomen, there 
 is certainly no reason why she should not do so. 
 
 EARLY SIGNS OF COMPLICATIONS OF PREGNANCY 
 
 It is evident that by teaching the principles of personal hy- 
 giene to the expectant mother so convincingly that she will adopt 
 them, and sometimes, by employing simple nursing procedures 
 to relieve the various discomforts of pregnancy, much will be 
 accomplished toward promoting the welfare of both the patient 
 
142 OBSTETRICAL NURSING 
 
 and the expected baby. But this is not enough. The nurse must 
 also be on the alert to detect and report the early symptoms of 
 complications, for there may be times Avhen she will be the first 
 one to see the patient after a symptom has developed. 
 
 The principal complications of pregnancy which are amen- 
 able to preventive or early treatment are the toxemias, jDrema- 
 ture terminations of pregnancy and hemorrhage. 
 
 The causes of these conditions and the details of treatment 
 and nursing care are so inextricably associated with each other 
 that they are discussed together and at some length in another 
 chapter. But their most conspicuous, early signs are briefly 
 noted here, since watching for them constitutes a part of routine 
 prenatal care. 
 
 The toxemias are apparently caused by disturbed metab- 
 olism and impaired or inadequate excretory processes. Their 
 prevention is to be accomplished largely by observing the prin- 
 ciples of personal hygiene previously described, and in quickly 
 treating early symptoms. One of the commonest of these symp- 
 toms is headache, sometimes persistent and very severe. Others 
 are disturbed vision, dizziness and more persistent or severe 
 vomiting than could reasonably be called "morning sickness"; 
 puffiness under the eyes, or elsewhere about the face, or of the 
 hands; anything more than very slight swelling of the feet and 
 ankles ; high or increasing blood pressure ; mental depression ; 
 albumen in the urine, amounting to more than a trace, and 
 epigastric pain, are all possible symptoms of toxemia. A patient 
 in whom even one of these symptoms appears is iLsually placed 
 under close observation ; frequently put to bed and her diet 
 restricted to milk, or even water, until the symptoms subside. 
 
 The common symptoms of premature termination of preg- 
 nancy, (an abortion, miscarriage or i)remature labor) are 
 bleeding, Avith or without pain in the small of the back, followed 
 by cramp-like pains in tlio abdomen. Bleeding or a bloody dis- 
 charge, therefore, irrespective of pain should be regarded as a 
 symptom of pending labor and the patient should be put to bed 
 promptly, and kept quiet. Preventive treatment, after preg- 
 nancy has begun, consists largely of rest, particularly at the time 
 when menstruation Avould ordinarily occur; avoidance of physi- 
 
PRENATAL CARE 143 
 
 ca\ shocks and of overwork during the later weeks. Prolonged 
 failure on the part of the patient to feel fetal movements or 
 of the nurse or doctor to hear the fetal heartbeat after they 
 have once been manifest usually indicates the death of the child 
 and precedes its expulsion. 
 
 Bleeding, or a sudden increase in the size of the uterus with 
 a rapid pulse or general symptoms of shock, may be the symp- 
 toms of hemorrhage caused by placenta pnevia or premature 
 separation of a normally implanted placenta; upon the appear- 
 ance of any one of these signs the patient should be put to bed 
 and kept absolutely quiet. 
 
 To sum up, we find that the following symptoms may be fore- 
 runners of serious complications, and therefore should be watched 
 for and reported to the doctor immediately upon their discovery : 
 
 1. Persistent or severe vomiting. 
 
 2. Persistent or severe headache. 
 
 3. Dizziness. 
 
 4. Disturbed vision or the appearance of black spots before the 
 eyes. 
 
 5. Pi;ffiness under the eyes, or elsewhere about the face. 
 
 6. Swelling of the feet, ankles or hands. 
 
 7. Sharp pains, particularly in the epigastric region. 
 
 8. Prolonged failure to feel fetal movements after they have once 
 been felt. 
 
 9. Cessation of the fetal heartbeat, or a marked change in its 
 rate or rhythm. 
 
 10. Bleeding, or a bloody discharge. 
 
 11. Pain in the lumbar region, folloAved by cramp-like pains in the 
 abdomen, before the expected date of confinement. 
 
 12. Albumen in the urine. 
 
 13. High, or increasing blood pressure. 
 
 14. Unwarranted mental depression, anxiety or apprehension. 
 
 These are generally accepted as the cardinal danger signs of 
 pregnancy, any one of which, alone or in combination with one 
 or more of the others, is of significance and should be reported 
 to the doctor at once. 
 
 When all is said and done, our wish for the expectant mother 
 is for little more than that she shall live a normal, wholesome 
 life; that she shall be willing, and also be able to weave into her 
 every day life the principles of personal hygiene which every one 
 
144 OBSTETRICAL NURSING 
 
 should adopt ; that she shall be carefully watched for complica- 
 tions throughout the entire period of pregnancy, and that these 
 complications shall be speedily treated. 
 
 Adoption of personal hygiene, then, and prevention of com- 
 plications by their early detection and treatment — these we want 
 for every woman who is looking forward to motherhood. 
 
 For lack of these things there are sick and blind and maimed 
 babies and invalid women ; there are lonely, motherless children 
 and bereaved mothers in every corner of our land. 
 
CHAPTER VII 
 MENTAL HYGIENE OF THE EXPECTANT MOTHER 
 
 It is only once in a long time that the obstetrical nurse has a 
 patient who is suffering from such a marked mental disturbance 
 that her condition is diagnosed and treated as a psychosis. But 
 more often than not she has a patient who is secretly suffering a 
 good deal of mental stress and pain, which is not recognized and 
 not treated. 
 
 In fact, by virtue of the deep significance of the states of 
 pregnancy and motherhood, and the long period of time through 
 which they continue, it is scarcely possible for them not to pro- 
 duce a mental effect of some sort upon the average woman. 
 Sometimes this effect is a very happy one ; but all too often it is 
 quite the reverse. It is safe to say that the majority of maternity 
 patients are passing through deep waters, and the nurse's use- 
 fulness to these charges will be greatly broadened if she has at 
 least some understanding of the cause and character of these men- 
 tal sufferings. 
 
 In the ordinary course of events, from birth to death, we all 
 of us are being called upon continuously to adjust ourselves to 
 all sorts of experiences, situations and emotional strains peculiar 
 first to early childhood, then the school epoch, the period of 
 emancipation from home and finally to the life work. And as 
 we take our way, we develop habits of meeting the sorrow and 
 disappointments that come; the anxiety, criticism, success, fail- 
 ure, illness, poverty and what not. 
 
 Some individuals habitually face the issues of life, whether 
 large or small, and habitually overcome difficulties for themselves 
 and for other people. They are described by the psychiatrists 
 as being grown up, or psychologically evolved. 
 
 Others follow the course of least resistance; never face their 
 problems; are thoughtless and inconsiderate in their demands; 
 
 145 
 
146 OBSTETRICAL NURSING 
 
 are unable to make decisions and accordingly live upon the men- 
 tal and moral strength of others. Such people are referred to as 
 being infantile, or psychologically undeveloped. They are not 
 unlike the baby who gets "what he wants when he wants it" by 
 the unreasoning method of screaming and pounding upon his 
 high chair with a spoon. He is scarcely more irresponsible than 
 the hysterical adult who gains her point by developing a head- 
 ache or fainting, flying into a rage or tearing her clothes and 
 smashing china. Such people make little or no adjustment to 
 unsatisfactory conditions and have poor capacity for endurance 
 or sacrifice. 
 
 With not a few women this poor capacity is a result of life- 
 long indulgence or protection by unwise parents, and they never 
 reason out the question of obligation or responsibility because 
 they never have to. Everything is done for them. All rough 
 places are so consistently smoothed out that they never entertain 
 the idea that effort or adaptation on their part could possibly be 
 in order. 
 
 There are others who cherish trouble, make difficulty where 
 there need be none and steadfastly refuse to acknowledge good 
 fortune or see the silver lining. This is their method of secur- 
 ing attention, much as the baby cries or screams to the same end. 
 
 Between these extreme types are ranged people who display 
 innumerable shadings and degrees of psychological development. 
 Some cope satisfactorily with their life situation because that 
 situation is neither difficult nor beyond their capacity for ad- 
 justment. Others need a little bolstering up now and then to 
 bridge over the gap between the demands made upon them and 
 their ability to meet these demands. Still others have to be lit- 
 erally carried when disaster overtakes them, or they break down. 
 
 As might be expected, our ability to stand the big tests or 
 strains that may come to us; our manner of meeting them and 
 their effect upon us depend very largely upon how we have 
 habitually met the lesser trials that have come to us previously, 
 how we have habitually adjusted ourselves to the experiences of 
 life. For after all the test of life is a measure of one 's capacity 
 for adaptation to these experiences and to surroundings. 
 
 The strain that measures our ability to adapt ourselves may 
 
MENTAL HYGIENE OF EXPECTANT MOTHER 147 
 
 be one big stroke or it may be a long drawn out trial which 
 would be of small consequence were it of short duration. It is 
 the persistency and the monotony of a lesser care that so often 
 wears away the rock of our endurance. 
 
 If a strain proves to be too much for our adaptive capacity, 
 and we break down under it, our manner of breaking will be 
 characteristic of us, or an accentuation of what might have been 
 called our bendings under lesser difficulties in the past. 
 
 The expectant mother is no exception to these general prin- 
 ciples. She does not develop nervous breakdowns either more 
 or less frequently than the non-pregnant woman who is under 
 an equal strain. She is merely a human being whose adaptive 
 capacity is being tested. But the test is severe for there is, per- 
 haps, no greater strain upon the adaptive capacity of a human 
 being than that to which a woman is subjected during pregnancy, 
 confinement and the months directly following the birth of a 
 child. She maj' be expected to meet this strain just as she would 
 meet another equally great demand upon her adaptive ca- 
 pacity. 
 
 Otherwise, pregnancy of itself does not affect the brain or the 
 mind, any more than it affects the kidneys, for example. But 
 like the kidneys, the brain or the mentality may have difficulty 
 in coping with the additional strain that is put rpon it during 
 pregnancy, and if the strain is greater than the ability to func- 
 tion in either case there is likely to be a breakdown. 
 
 It is now generally believed, therefore, that there is no psy- 
 chosis which is typical of pregnancy. But that during pregnancy 
 one may see all types of neuroses and psychoses which are fre- 
 quently associated with other severe strains upon the individual. 
 We see depressions, excitement, paranoid trends, delusional and 
 hallucination states, hypochondriasis, obsessive fears, anxiety at- 
 tacks, hysterical manifestations as well as the so-called "neurotic 
 vomiting. ' ' 
 
 Aside from the delirium-like experiences often associated 
 with the toxemias of pregnancy, none of the above mentioned 
 conditions are referable to any disturbance of the physiologic or 
 metabolic functioning of the patient, so far as science can dem- 
 onstrate. They are merely accentuations of poor habits of ad- 
 
148 OBSTETRICAL NURSING 
 
 justment to difficulties, which the patient has betrayed aU her 
 life. 
 
 The psychoses of pregnancy and the puerperium require skil- 
 ful handling and the nurse is not called upon to care for them 
 except under the constant supervision of a physician. 
 
 She is, however, constantly brought face to face with facts 
 of fear and worry and conflicting desires which play a tremen- 
 dous role in the well-being of the patient during the months of 
 pregnancy and confinement. The chief source of happiness and 
 of unrest is the mother 's attitude toward the coming of the baby. 
 Just here it may be helpful to have a word about what is 
 meant by "conflict" and the "mechanism" which produces it. 
 As a starting point there must be a recognition of the fact that 
 the deepest and most influential feminine instinct is maternal — 
 the desire to have and care for a child. It is primal. It has 
 been in women since the dawn of Creation and although in many 
 women it is put down, stifled or complicated by other desires, 
 it cannot be destroyed. Not a few women deny this instinct, but 
 back of their denial is some reason, conscious or unconscious, 
 which is not harmonious with the idea of motherhood. The 
 woman may be selfish, for example; she may be vain and not 
 want to lose her grace and charm through pregnancy. 
 
 When some such feeling is strong it conflicts with the deeper 
 one of maternalism and there is a lack of harmony or a "con- 
 flict." It is just that — a conflict or struggle between two emo- 
 tions and the result is a state of mental unrest. A homely com- 
 parison might be found in the digestive disturbance which may 
 follow an effort to cope with two incompatible articles of food 
 at the same time. The patient may have nausea, vomiting, pain 
 or even more severe symptoms. The severity of the symptoms 
 and their effect upon the patient depend somewhat upon the 
 average vigor or stability ordinarily displayed by the digestive 
 tract under a lesser strain. People with so-called delicate diges- 
 tions may be greatly upset by combinations of food which others 
 are able to cope with and suffer little or no inconvenience. 
 
 When a well evolved individual has a desire which results 
 from our culture or civilization (a wish to preserve her grace 
 or her luxuries, for example), that is in conflict with a deeper 
 
MENTAL HYGIENE OF EXPECTANT MOTHER 149 
 
 primal instinct, she will often be able to reason out the situation, 
 and in the case of approaching motherhood, decide that the baby 
 is worth any sacrifice, any inconvenience, and go joyfully 
 through her period of expectancy. She will glory in the con- 
 sciousness of her ability to realize the supreme purpose of a 
 woman's creation. In other words she adjusts herself to the 
 situation, harmonizes the discordant desires and is mentally un- 
 disturbed. 
 
 A less well evolved woman, like a person with a delicate, easily 
 upset digestive tract, will have difficulty in making an adjust- 
 ment — in harmonizing her instinctive desire for motherhood and 
 her acquired desire for comfort, attention and the things de- 
 manded by convention. The conflict may be violent enough to 
 greatly upset her. This is particularly true if the demands of 
 our cultural state make it necessary for the patient to keep this 
 turmoil below the surface with no safety valve to relieve the 
 pressure. 
 
 This problem of the motlier's attitude toward the coming of 
 the baby is very general and varied as well. The mothers of 
 families already large and poverty stricken are usually quite 
 frank in expressing their dismay over the expected birth and 
 lament the prospect of this extra burden, but at the same time 
 they decide to make the best of it and they succeed in making 
 a pretty satisfactory adjustment. Moreover, they do not feel 
 the necessity for concealing their feelings or do not "repress" 
 them, and accordingly find some relief in being candid. 
 
 The mothers of the middle and upper classes, however, are 
 often surrounded by an atmosphere of conventional codes that 
 are stifling to mental honesty. Accordingly they are less genu- 
 ine in expressing their true attitude toward the coming child. 
 To many of them — the selfish, self -centered type — the new baby 
 will bring inconvenience rather than hardship. The importance 
 of their ego will be dimmed. There will be a cutting down of 
 luxuries and of freedom for social activities, and increased re- 
 sponsibility with closer confinement to the home. And while 
 they give utterance to joy and pleasure over the prospect of hav- 
 ing a baby, this does not quite reflect their inmost feelings. 
 
 Not a few women find an outlet for the tension caused by 
 
150 OBSTETRICAL NURSING 
 
 their conflict by being fretful and irritable or through conduct 
 which they would have displayed if annoyed or chagrined about 
 something other than the approaching birth of a child. Because 
 of this outlet they are not so likely to break down. 
 
 It is by no means the role of the nurse to pry into the affairs 
 of her patients, but she can often become the avenue of ventila- 
 tion for a patient suffering from a mental conflict, and with very 
 happy results. For one of the most helpful things that such a 
 person can do is to talk, and little by little bring out and put 
 into words the buried thoughts, dreads or shame that may be 
 causing the conflict. Very often the listener will say surpris- 
 ingly little and will express no definite opinions, but by a sympa- 
 thetic, responsive attitude encourage the worried person to pour 
 out the content of her mind. 
 
 Another source of unrest in the mind of the expectant mother, 
 especially during her first pregnancy, is the fear of death during 
 labor, or the development of complications. She is reluctant to 
 speak of these things to her husband, family or friends, lest they 
 laugh at her or regard her as a coward at the prospect of pain. 
 Or she may be unwilling to distress those who love her by ad- 
 mitting her fear. 
 
 Fear of death and disease are very common traits and equally 
 common is the hesitancy we all have in acknowledging them. 
 And so the patient keeps these things to herself and turns them 
 over and over in her mind; buries them and tries to put them 
 out of her thoughts. But they stick. Her fear and her dread 
 color everything that she hears, and very often and unwittingly 
 her friends and relatives make matters worse by recounting the 
 unhappy experiences of other mothers that they have known. 
 At the same time these communicative friends do not tell of the 
 immeasurably greater number of women who have come through 
 safely, nor does the patient dwell upon these in her mind. She 
 remembers the women who had convulsions or fever or a hemor- 
 rhage, or the one who died. 
 
 The nurse who sees the human being beyond the obstetrical 
 case will appreciate the pain which such a conflict causes and 
 by being sympathetic and responsive will try to make it easy for 
 her patient to talk it over. The patient should invariably find 
 
MENTAL HYGIENE OF EXPECTANT MOTHER 151 
 
 her nurse ready to listen and to give assurances of the proved 
 value of the pi-ecautions that are being taken to safeguard her 
 and her baby. Fur not a few women are torn, not alone by the 
 fear that things will go wrong with themselves, but with the fear 
 that harm may come to the baby that they long to take into their 
 arms and keep. 
 
 Other women are upset because of a habitual inability to make 
 decisions that will l)ring al)out a marked change in their lives. 
 They find it difficult to accept pregnancy because its consum- 
 mation will definitely alter their state. Life may prove to be 
 more satisfactory because of the baby, or it may be less so. But 
 in any event it cannot be the same and they dread making an 
 irrevokable change. 
 
 Still another cause of distress is the current belief as to 
 hereditary influence, and the possible effect upon the unborn 
 child of unsuccessful attempts at abortion which the patient has 
 made early in her pregnancy. Every family has its skeleton of 
 a relative who is "queer," feeble-minded, epileptic or who has 
 died in a sanitarium or state hospital for the insane. The fear 
 that the child may "strike back" to one of these individuals, and 
 suffer retardation in his mental development, often amounts to 
 little less than an obsession. 
 
 The nurse may often dispel such an anxiety by drawing upon 
 even her slender knowledge of embryology' and reassure her pa- 
 tient that we know very little about inheritance, but that the 
 evidence is that environment and early training are such impor- 
 tant determining factors, that a child is more likely to be af- 
 fected by the example and guidance of his parents during his 
 first few years than through transmission from their blood. 
 
 Attempted abortions during the early months of pregnancy 
 are more common than is generally supposed. Of their effect 
 upon the offspring we know very little. We do know, however, 
 that an attempt to produce an abortion often gives rise to a good 
 deal of secret worry on the part of the expectant mother. It is 
 the nucleus of many a vague depression during pregnancy, not 
 only because of remorse over wrong-doing, but also because of 
 fear that the child who is coming, in spite of the attempt to 
 destroy him, may suffer the consequences. This is another of 
 
152 OBSTETRICAL NURSING 
 
 the anxieties which the patient can seldom bring herself to dis- 
 cuss with her family or even with her physician But it so oc- 
 cupies her mind that she may allude to it, in a roundabout way, 
 to the nurse who becomes her constant companion, as though 
 describing the act of a friend. The nurse who reads between 
 the lines may often relieve a serious tension caused in this way 
 by discussing the matter casually and impersonally. Above all 
 she must not assume an attitude of disapproval, for it is not 
 within her province to go into the ethics or morality of the act. 
 Her function at this time is solely to give the patient an oppor- 
 tunity to ventilate her thoughts. 
 
 Another real cause of worry during pregnancy is the pa- 
 tient 's fear of her own inadequacy to care for and to rear a child 
 in the best possible manner. The idea of assuming the physical 
 care and the moral guidance of another human being is often lit- 
 tle less than terrifying to a young woman whose responsibilities 
 in the past have been shared or carried by some one else. Or to 
 the one who has gone through life hunting for, and exaggerating, 
 the difficulties in a situation, before attempting to meet it; and 
 perhaps to the one who is habitually conscientious in all of her 
 relations with other people. 
 
 Still another type, and one which presents a much simpler 
 situation, is the expectant or young mother who is scarcely suf- 
 fering from a mental strain, but has a little let-down in her 
 customary poise and self-control, such as we so often see in con- 
 valescents and chronic invalids. 
 
 Pregnancy, labor, and the puerperium are normal physiologi- 
 cal processes, it is true, but they impose a physical tax and the 
 patient is sometimes physically tired and after labor may suffer 
 something akin to surgical shock. 
 
 The physical weariness may be due to an insufficiency on the 
 part of some one of the internal secretions. But in any event 
 the patient feels tired and may show the same sensitiveness or 
 irritability that any of us show when tired and exhausted and 
 she will merit considerable forbearance on the part of those who 
 surround her. 
 
 But when we understand, even faintly, the conflicts which 
 are possible in the mental life of the expectant mother — the 
 
MENTAL HYGIENE OF EXPECTANT MOTHER 153 
 
 incompatibility of her age-old maternal instinct and the desires 
 born of our culture and civilization, it is not difficult to see that 
 her adaptive capacity may be sorely tested. 
 
 The cause of her trouble is not apparent to the patient's 
 associates but they are aware of its manifestations in the shape 
 of moods, temper tantrums, strange conduct and all sorts of 
 nervous and mental symptoms. If such a patient does not get 
 relief through talking things over, but continues to brood and 
 worry alone — to repress the cause of the conflict — she may not 
 be sufficiently adaptive to endure its ravaging effects, and have 
 a nervous or mental breakdown as a result. 
 
 It is hoped that the nurse may understand from this discus- 
 sion that the conflicting thoughts which her patient does not dis- 
 cuss, but buries and keeps below the surface of her mind, are 
 the factor that works harm in her mental life. If the nurse can 
 get her patient to ventilate these thoughts, they will be robbed 
 of much of their power to injure. But this patient, like any one 
 else, will talk freely only when she talks spontaneously and she 
 will do this only when she senses in her nurse a sympathy and 
 a sincere concern over her troubles. 
 
 Accordingly, the nurse should try to so attune herself as to 
 be receptive to evidences of the patient's moods and impulses, 
 and possibly from a chance remark get a clue to the repressed 
 desires which are working harm. She will then be able to meet 
 the patient on that ground. 
 
 It is not that the relief of the patient by means of mental 
 catharsis is necessarily a nurse's function. It is simply that a 
 patient suffering from a conflict should talk freely to some one, 
 it does not matter who, and by virtue of the long hours which 
 they spend together, the nurse very often happens to be that 
 some one. People do not ordinarily find it easy to lay bare their 
 inmost thoughts before the members of their family and the 
 patient may not discuss her conflict with her physician, which 
 of course is the ideal, because his visits are relatively short and 
 do not favor the ambling, desultory conversation into which the 
 nurse and patient may so easily drift. 
 
 On the other hand, the nurse must not look for trouble, in 
 order to be useful, nor by the slightest intimation give her pa- 
 
154 OBSTETRICAL NURSING 
 
 tient an idea that it is a common practice among expectant 
 mothers to worry, be fearful or alarmed. If the patient displays 
 these emotions the nurse must be ready, but she must not be 
 suggestive. Her attitude must be entirely passive for she is 
 simply a receptacle into which the patient may pour her con- 
 flicting thoughts. But the receptacle must be always available. 
 
 The positive course which the nurse may take is to be un- 
 failingly hopeful and courageous and take it for granted that 
 her patient is filled with joy and pride over her pregnancy. The 
 gratification is tliere by instinct, but it may be so buried and 
 complicated by other emotions that the patient is not wholly 
 aware of it. It may be surprisingly clarifying for the nurse to 
 say quite simply, "But, after all, it is a wonderful thing to have 
 a baby and you are proud and glad that he is coming. He will 
 be worth any sacrifice." 
 
 If the nurse will so far put herself in the patient 's place that 
 she is glad, sincerely glad, that the baby is coming, this attitude 
 will communicate itself to the expectant mother. Happiness and 
 enthusiasm are very infectious. 
 
 To sum it all up : The expectant mother who habitually 
 has not made satisfactory adjustments during her life may be 
 bending under a mental burden that is a little heavier than her 
 slender, unevolved powers can bear. The nurse's part is to 
 recognize this possibility and realize that while she cannot at- 
 tempt to correct the difficulty she can be a prop by simply being 
 optimistic and reassuring. A patient who may be suffering from 
 a mental conflict is often saved from a breakdown by little more 
 than a ready sympathy which is born of understanding. 
 
CHAPTER VIII 
 
 THE PREPARATION OF ROOM, DRESSINGS AND 
 EQUIPMENT FOR HOME DELIVERY 
 
 It sometimes devolves upon the nurse to give advice in se- 
 lecting and preparing the room to be used for a home confine- 
 ment, and very often to help the prospective mother in preparing 
 and assembling adequate equipments for the delivery and for the 
 care of herself and the baby afterwards. 
 
 Under such circumstances the nurse must feel under compul- 
 sion to do all in her power to make the home delivery satisfac- 
 tory, from the standpoint of the patient's happiness and con- 
 tentment and from the standpoint of surgical cleanliness and 
 efficiency as well, so that normal cases, at least, may be attended 
 with reasonable safety at home. 
 
 We know that the deaths, incident to childbirth, throughout 
 this country at large, have not declined during the past decade, 
 in spite of improved obstetrical methods and skill and the large 
 percentage of recoveries in hospitals where they are applied. In 
 the homes, in general, young mothers continue to die in dis- 
 tressingly large numbers, chiefly from infection, which we know 
 is largely preventable. Apparently, then, in some important 
 particulars the conditions surrounding the majority of home 
 deliveries are still such as to be almost a menace to life and 
 health. And as it is manifestly impossible for all obstetrical pa- 
 tients to be cared for in hospitals, home deliveries need to be 
 made safer, which virtually means, made cleaner. 
 
 This grave need cannot be dismissed by the nurse as some- 
 thing outside of her province. She may aid greatly, and there- 
 fore is under obligation to do so, in making home confinements 
 surgically clean, by being conscientious and thoughtful and 
 thorough in her preparations and assistance. 
 
 A relatively small percentage of obstetrical patients require 
 operative assistance, but without a single exception they all re- 
 
 155 
 
156 OBSTETRICAL NURSING 
 
 quire cleanliness; cleanliness of appliances and cleanliness of 
 methods. 
 
 As the first labor is usually longer and more difficult than 
 later ones, and the percentage of lacerations and operative inter- 
 ference is higher, primiparae should be delivered in hospitals 
 when possible, as well as all cases presenting any complication or 
 abnormality. But women who are normal, particularly multi- 
 parae, and these constitute the vast majority of obstetrical pa- 
 tients, should be able to remain at home in safety. 
 
 In most instances the patient who is to be delivered at home 
 will have to occupy her accustomed room and there is no alterna- 
 tive. Should there be a choice of rooms, however, one should 
 be selected that is cool and shady, if the confinement takes place 
 during the summer, but bright and sunny for occupancy during 
 most of the year; it should be conveniently near a bathroom if 
 possible, and have an adjoining room for the nurse and baby 
 to occupy. 
 
 The arrangement and furnishings of the room will not of 
 necessity vary greatly from those of a room which is to be 
 occupied by any patient. Carpets, upholstered furniture, heavy 
 draperies and curtains are no more suitable in this than in any 
 patient's room. 
 
 The ideal is : A room with a washable floor with small, light 
 rugs; freshly laundered curtains at the windows; a single, brass 
 or iron bedstead, about 30 inches high, with a firm mattress, and 
 so placed as to be accessible from both sides and with the foot in 
 a good light, either by day or by night ; a bedside table and two 
 others (folding card tables are a great convenience) ; a bureau; 
 a washstand, unless there is a bathroom on the same floor; one 
 or two comfortable chairs, two or three straight chairs and a 
 couch or chaise longue, all of which should be of wood or wicker 
 or covered with freshly laundered chintzes. 
 
 Barrenness is not only unnecessary but is to be avoided, for 
 the room should be as cheerful and pretty as is compatible with 
 cleanliness. There is usually no objection to pictures on the wall, 
 but the room should be free from useless, small articles which 
 are dust catchers, give the nurse unnecessary work, and occupy 
 space needed for other things. Between such a room as this and 
 
THE PREPARATION OF ROOM 157 
 
 the one which the nurse finds must be used, there may be a dis- 
 maying difference, and so once more siie must exercise her in- 
 genuity and resourcefulness; cliange and improve whei-e it is 
 possible and make tiie best of conditions that cannot be altered, 
 for the baby i>j coming and the mother must be safeguarded 
 from infection and other disaster, no matter what the room is 
 like. 
 
 Much as we should like ideally to equip and prepare every 
 room to be used for a home confinement, we cannot overlook the 
 importance of having preparations made witii as little disturb- 
 ance as possible to the patient and her household. Preparations 
 made with bustle and ostentation are suggestive of inefficiency ; 
 are bad for the patient, frequently causing her great alarm, and 
 in the main had better be omitted. The nurse who is able to 
 go into a home quietly and unobtrusively and accept what she 
 finds, even carpets and draperies, and still do clean work, is 
 doing better nursing than the one who arranges a faultless room 
 but upsets her patient and disrupts the household in the process. 
 
 Common sense, judgment and tact, then, will sometimes be 
 as important in preparing a room for home delivery as are wash- 
 able floors, curtains and furniture. 
 
 While we do not advise nor elect to have carpets, draperies 
 and upholstery in a delivery room, we know that they need not 
 menace the patient's welfare if all details of the work about the 
 patient, herself, are scrupulously clean. That is the one point 
 which the nurse must bear constantly in mind, the paramount 
 importance of clean work about the patient. 
 
 The room should be given a thorough housecleaning about 
 two weeks before the expected date of delivery. If there is car- 
 pet on the floor, there should be a large canvas or rubber, or an 
 abundance of newspapers available to protect it, about, and 
 under the bed; and if the bed is of wood, the sideboards and 
 foot should be covered to protect them from injury by soap, 
 water and solutions which may be spattered or spilled during 
 labor. If the bed is low, there should be four solid blocks of 
 wood prepared, upon which to elevate it, after removing the cas- 
 ters, and it is also a good plan to have a large board, or table 
 
158 OBSTETRICAL NURSING 
 
 leaves, in readiness to slip under the mattress to make it firm, 
 particularly if the bed is soft or sinks in the middle. 
 
 So much for the room. 
 
 In preparing the dressings and assembling the various ar- 
 ticles to be used the nurse will do well to remember that, although 
 it is possible to use a number of things during labor, it is also 
 possible to do excellent work with a meagre equipment supple- 
 mented with a cool head and ingenuity and training and above 
 all, an exacting conscience. The average nurse will wish, usu- 
 ally, to follow a median course in her preparations, having every- 
 thing at hand that will facilitate the work; be adequately 
 equipped for emergencies but not burdened with non-essentials. 
 
 As the wishes and methods of different doctors vary, the ar- 
 ticles needed in assisting them must of necessity vary also. But 
 in addition to the instruments which will be used, the following 
 articles will meet the ordinary requirements during a home con- 
 finement, and many of them, or adequate substitutes, are to be 
 found in the average household. 
 
 For the Mother and the Delivery: 
 
 Plenty of sheets, pillow cases, towels and night gowns. 
 
 4 or 6 T. binders or sanitary belts. 
 
 1 piece rubber sheeting or oilcloth, 1 x II/2 yards. 
 
 1 piece rubber sheeting or oilcloth, 2 x l^/^ yards. 
 
 Two or three dozen safety pins. 
 
 Hot water bag with flannel cover. 
 
 1 two-quart fountain syringe. 
 
 1 douche pan. 
 
 1 bed pan. 
 
 2 covered slop jars or covered pails. 
 
 3 basins, about 16, 14 and 12 inches in diameter. 
 
 2 stiff nail brushes, nail scissors and file or orange stick. 
 
 3 agate or enamel pitchers, holding at least one quart each. 
 Medicine glass. 
 
 Medicine dropper. 
 
 2 bent glass drinking tubes 
 
 100 bichloride tablets. 
 
 4 oz. chloroform. 
 
 4 oz. boric acid powder. 
 
 4 oz. green soap. 
 
 1 pint grain alcohol. 
 
 Small jar of vaseline to be sterilized. 
 
THE PREPARATION OF ROOM 159 
 
 Lard, olive oil, vaseline or albolene to oil baby. 
 Roll adhesive plaster 1 inch wide. 
 1 pkg-. absorbent cotton. 
 1 thermometer. 
 
 In addition to these, a certain supply of sterile dressiup;s will 
 be needed. Complete outfits of such dressings, sterilized and 
 ready for use, may be obtained from any one of a number of 
 firms, or the following may be prepared by the nurse or by the 
 patient, under the nurse's direction: 
 Dressings: 
 
 1 doz. sterile towels. 
 
 5 or 6 doz. perineal pads. 
 
 2 or 4 delivery pads, made of gauze and common cotton with top 
 laj'er of absorbent cotton, or newspapers covered with muslin. 
 
 5 or 6 doz. gauze sponges. 
 
 2 or 3 doz. gauze squares, 4 inches square. 
 4 or 5 doz. cotton pledgets. 
 
 1 pr. leggings, made of canton or outing flannel, either loose fitting 
 hose or a yard square folded diagonally and stitched. (See Fig. 
 110.) 
 
 3 sheets. 
 
 6 pieces cord-tie of bobbin or narrow tape, 9 inches long. 
 
 These may be put up into packages in the usual manner, 
 using muslin for wrapping, and sterilized in the patient's home 
 as follows : Fill a wash boiler about I/4 full of water and fashion 
 a hammock from a towel or strong piece of muslin, tied securely 
 W'ith strings at each end and hung from the handles so that the 
 bottom of the hammock in about half way down in the boiler. 
 As the weight of the dressings makes the hammock sag low, in 
 the middle, it is usually necessary to place a rack, or support of 
 some kind, in the bottom of the boiler to hold the dressings well 
 above the bubbling water, at the point where they hang lowest. 
 Pile the dressings into the hammock, cover the boiler tightly and 
 keep the w-ater boiling vigorously for one hour ; dry the packages 
 in the sun or by placing them in the oven for a few moments, and 
 at the end of twenty-four hours repeat the sfeaming and drying 
 process, wrap the packages in a clean sheet or paper and put 
 them away in a drawer or covered box where they should remain 
 until time to prepare for the delivery. The brushes, douche pan, 
 irrigation-bag, and other articles which must be surgically clean 
 
160 
 
 OBSTETRICAL NURSING 
 
 may be sterilized in the same way. The gloves may be sterilized 
 in this way or boiled immediately before delivery. If sterilized 
 by steam, the gloves should be thoroughly dried, dusted with 
 talcum inside and out to prevent them from sticking together, 
 and may be wrapped in packages or placed in individual cases 
 (Fig. 42). A small towel or piece of soft muslin and a ball of 
 gauze containing talcum powder, if placed in the case and ster- 
 
 FiG. 42. — Gloves with cuffs turned up, lying with small towel and 
 powder puff of gauze and talcum, on double envelope case in Avhich they 
 may be dry-sterilized. (From photograph taken at the Brooklyn Hospital.) 
 
 ilized with the gloves, are often a convenience to the doctor in 
 putting on the gloves. 
 
 The newspaper delivery pads offer excellent protection and 
 are made of six thicknesses of paper covered with a piece of 
 freshly laundered muslin, Avhich is folded over the edges and 
 basted in place. (Fig. 43). These pads may be made virtually 
 sterile by ironing them on the muslin side with a very hot iron, 
 folding the ironed surface inside without touching it; again 
 ironing on the outside and wrapping in a clean muslin or sheet, 
 
THE PREPARATION OF ROOM 
 
 161 
 
 also recently ironed, and putting away in a place protected from 
 dust. 
 
 The nurse herself should have : 
 
 A hypodermic syringe and 4 or 6 needles. 
 
 1 pr, long forceps to use as dressing forceps. 
 
 1 pr. short forceps. 
 
 1 pr. bhmt pointed scissors. 
 
 2 artery clami^s. 
 
 The doctor will usually supply himself with any articles 
 needed beyond those \vhieh have been enumerated, but the nurse 
 
 Fig. 43. — Reverse side of pad made of newspajjers and old muslin to 
 protect bed during a home confinement. If muslin is held in place with 
 safety pins it may be removed easily, washed and used for another pad. 
 (Courtesy of The Maternity Centre Association.) 
 
 should be sure about the following in order that she may prepare 
 whatever he may lack : 
 
 Instruments and sutures. 
 Hypodermic tablets. 
 Pituitrin and ergot, or ergotole. 
 Gauze packs. 
 Gloves and sterile gown. 
 Rubber apron. 
 
 Filtered, sterilized salt solution and infusion needles- 
 Chloroform inhaler. 
 
162 OBSTETRICAL NURSING 
 
 In planning the baby clothes, there are a few important fac- 
 tors to bear in mind. The clothes should be simple; not more 
 than twenty-seven inches long; warm, but light in weight, and 
 large enough to fit loosely. Like the dressings, complete layettes 
 may be bought outright, but if the mother wishes to make the 
 little garments herself, the following list will be found to pro- 
 vide an adequate supply of clothing for the new baby. (See 
 also Fig. 159.) 
 
 For the Baby, Layette: ^ 
 
 2 to 4 doz. diapers, preferably 18 in, square. 
 
 3 flannel bands, 6 or 8 inches wide and 27 in. long unhemmed. 
 
 3 shirts, size No. 2, of cotton and wool, silk and wool but not all 
 wool. 
 
 4 flannel petticoats, Gertrude style. 
 4 flannel nightgowns or slips. 
 
 6 white slips. 
 
 3 knitted bands with shoulder straps, to use after the cord separates. 
 
 Flannel kimono or square, one yard, to be used as extra wrap in 
 
 cool room. 
 Cloak and cap or other wrap for out-door use. 
 Additional Articles Which Are Needed or Useful in the Care of the 
 Baby: 
 Bath tub, tin, enamel, agate or rubber. 
 Drying frames for shirts and stockings. 
 Rubber bath apron. 
 
 Flannel, or Turkish toweling bath apron. 
 Low chair without arms. 
 Low table. 
 
 Screen to protect baby during bath. 
 Rack upon which to hang clothes to warm during bath. 
 Scales, with beam and basket and scoop, not the spring variety. 
 Hot water bag and cover. 
 Crib, basket or box, to be used as bed. 
 Folded felt pad, blanket or hair pillow for mattress. 
 Rubber or oilcloth to cover mattress. 
 6 crib sheets. 
 
 1 thermometer. 
 
 2 crib blankets. 
 
 Soft towels and wash cloths. 
 
 An old blanket to be used for bath blanket, 
 
 3 or 4 dozen safety jDins, assorted sizes. 
 Castile soap. 
 
 Boric acid powder. 
 
THE PREPARATION OF ROOM 163 
 
 Olive oil or albolene. 
 
 Absorbent cotton pledgets, preferably sterile. 
 
 Enamel pail and cover. 
 
 The above lists of dressings and articles for the baby can be 
 considerably modified and still be satisfactory. The leaflet of 
 ^'Advice for Mothers" issued by the Maternity Centre Associa- 
 tion, New York City (see p. 429), gives a somewhat curtailed list 
 of equipment which proves to be adequate and within the means 
 of most of the patients with whom the Association works. 
 
 It is usually a good plan for the nurse to advise the patient 
 to have her dressings ready by about the end of the seventh 
 calendar month, and the layette by the end of the eighth month. 
 A baby born before this time would probably be so frail that it 
 would be wrapped in cotton and not require the clothes ordi- 
 narily prepared for a full-term baby. 
 
CHAPTER IX 
 COMPLICATIONS AND ACCIDENTS OF PREGNANCY 
 
 The prenatal care which was outlined in an earlier chapter 
 becomes more impressive when one considers the disasters which 
 it is designed to prevent. And the nurse will be more eager and 
 able to watch her patient intelligently, and instruct her con- 
 vincingly, if she appreciates and understands something of the 
 conditions which she is helping to avert. She will give more 
 effective nursing care, too, when complications do occur, if she 
 gives it understandingly. In the toxemias, particularly, the 
 importance of the nursing care looms large, for it is painstaking 
 attention to details that makes this care so nearly a matter of 
 life or death to the patient. 
 
 In considering the complications of pregnancy, the nurse in 
 training needs a reminder that hospital experience is likely to 
 give her an exaggerated idea of the relative frequency with which 
 they occur. This is due to the fact that most maternity patients 
 in hospitals are there because they are known to be abnormal 
 in some way, or because they are pregnant for the first time, and 
 first pregnancies are more likely to end in difficult and compli- 
 cated labors than later ones. The vast majority of cases run 
 practically uncomplicated courses, for pregnancy, labor and the 
 puerperium are normal physiological processes. It is extremely 
 serious, however, to allow them to become abnormal. 
 
 Watchfulness throughout pregnancy, then, in the interest of 
 preventing disaster, cannot be too insistently advocated. 
 
 Some complications that are watched for during pregnancy 
 are peculiar to that condition alone, and these may be divided 
 into three general groups: 
 
 1. The premature terminations of pregnancy, which are desig- 
 nated as abortions, niiscarriages and premature labors. 
 
 2. Ante-partum hemorrhages, due to either a placenta praevia 
 
 164 
 
COMPLICATIONS AND ACCIDENTS OF PREGNANCY 165 
 
 or a premature separation of a normally implanted placenta, the latter 
 being termed "accidental hemorrhage." 
 
 3. The toxemias, including pernicious vomiting, pre-eelamptic 
 toxemia, eclampsia and possibly nephritic toxemia, though this con- 
 dition is not invariably associated with pregnancy. 
 
 There are other conditions, not necessarily inherent to the 
 state of pregnancy, but which should be detected and treated 
 early, since their development coincidently with expectant 
 motherhood may threaten the safety of the patient or the child, 
 or both. Probably the most serious of these is syphilis, though 
 gonorrhea, impaired kidneys, heart lesions, tuberculosis or a 
 general state of poor nutrition also may prove to be grave. 
 
 Any chronic, organic disease is likely to be increased in se- 
 verity by the strain which pregnancy puts upon the impaired 
 organs, in common with the rest of the maternal body. But 
 acute diseases usually run about the same course in pregnant, as 
 in non-pregnant women, except when an infection causes an 
 abortion, the shock of which, in turn, reduces the patient's re- 
 sistance against the complicating disease. 
 
 As we consider these various, dreaded complications which 
 may arise during pregnancy, infrequent though they be, we feel 
 that no amount of effort is too much to make, if we can, thereby, 
 save one mother or one baby from their destructive effects. We 
 are stirred by the urgency of preventing a premature ending of 
 pregnancy, for example, when we see it, not so much as simply 
 another obstetrical emergency, but in its true, tragic light as the 
 loss of an infant life and the bereavement of an expectant 
 mother. 
 
 PREMATURE TERMINATIONS OF PREGNANCY 
 
 The termination of pregnancy before the expected time is 
 termed an abortion, miscarriage, or a premature labor or birth, 
 according to the stage to which the pregnancy has advanced, but 
 there are wide variations in the accepted meanings of these 
 terms, among both lay and medical people. 
 
 In the lay mind, abortions are usually as.sociated with crim- 
 inal practice and the term is seldom used, while miscarriage is a 
 term which is loosely applied to all deliveries occurring before 
 the child is viable, or before the seventh month. It is not un- 
 
166 OBSTETRICAL NURSING 
 
 common, however, to hear the term abortion used to designate 
 the termination of a pregnancy before the end of the fourth 
 month; miscarriage, one which occurs between the end of the 
 fourth and seventh months, and premature labor as one which 
 takes place any time after the seventh month, but before the 
 expected date of confinement. 
 
 Medical people, on the other hand, seldom use the term mis- 
 carriage, but designate as abortions all terminations of preg- 
 nancy which occur before the end of the seventh month ; and pre- 
 mature labor, those occurring from that time until the estimated 
 date of confinement. It is these meanings which will be intended 
 when the terms abortion and premature labor are used in the 
 following pages. 
 
 Abortions. In the nature of things, it is impossible to say 
 how often abortions occur. They sometimes happen so early in 
 pregnancy that the patient is unaware of the accident; or, if 
 she does know of it, she may take no notice of it or regard it of 
 so little consequence that she does not consult a doctor; while 
 in many cases it is intentionally concealed because of having been 
 criminally induced. But such information as is available sug- 
 gests that at least one out of every five pregnancies ends in an 
 abortion. 
 
 Since the ovum is insecurely attached to the uterus until the 
 sixteenth or eighteenth week, an abortion is more likely to occur 
 during this time than later, while of this period, the second and 
 third months seem to be the most perilous. 
 
 Abortions are less likely to happen during first pregnancies 
 than succeeding ones; they occur more often among women 
 over thirty -five years old than in younger ones, and in all cases 
 are most likely to take place at the time when the menstrual 
 period would fall due were the woman not pregnant. Their 
 frequency probably increases with the number of pregnancies, 
 because of the tendency of muciparous women to have endome- 
 tritis, which, as we shall see later, is a causative factor. 
 
 Causes. There is a variety of causes of abortions and mis- 
 carriages, some entirely unavoidable, but many which are pre- 
 ventable, and it is well for the nurse to be familiar with those 
 which operate most frequently, as follows: 
 
COMPLICATIONS AND ACCIDENTS OF PREGNANCY 167 
 
 1. Certain abnormalities of the developing fetus are inconsistent 
 with life, and are, therefore, a frequent cause of abortion. Dr. Mall, 
 of Johns Hopkins University, showed after years of investigation that 
 at least one-lliinl of tlie embryos obtained from abortions were mal- 
 formed and would have developed into monstrosities had they lived to 
 term. It is often a great comfort to the expectant mother who loses 
 her baby early in pregnancy to realize that had she carried her baby 
 to term it might have been a monster, and that, therefore, she has not 
 lost a beautiful, normal child. Just why these abnonnalities occur is 
 not known, nor is there any known method of preventing or correcting 
 them. There also may be such defects in the placental development, that 
 the fetus does not derive sufficient nourishment to continue its develop- 
 ment, and dies very early as a result. 
 
 2. Abnormalities in the generative tract may cause abortions, 
 the most conunon of these being inllammation of the uterine lining 
 and a mal-position of the uterus itself. Gonorrheal infection is a fre- 
 quent cause of such an inflammation, which so alters the decidua that 
 a satisfactory implantation of the ovum is impossible, and it perishes 
 from lack of nourishment. Uterine misplacements, particularly retro- 
 flexion and prolapse, are important causative factors in abortions. This 
 is because the malposition interferes with the blood supply and lesions 
 in the endometrium result. This also presents an unsatisfactory lodge- 
 ment for the ovum and it cannot survive for long. 
 
 3. Acute infectious diseases all tend to cause the death of the 
 fetus and thus cause abortions. Fetal death in these cases is believed 
 to be due to the transmission of toxic material from mother to child, 
 as may occur also in such poisoning as phosphorus, lead and illumi- 
 nating gas. 
 
 4. Mental or emotional stress may be the cause of an abortion, 
 but less importance is attached to these factors to-day than formerly. 
 There is an occasional case, however, which can be explained on no 
 other grounds. 
 
 5. Physical shocks, such as falls, blows upon the abdomen, jump- 
 ing, tripping over carpets, jars, jolting or overexertion, may be the ex- 
 citing cause of an abortion Avhere there is a marked irritability of the 
 uterine muscles. This factor is largely influenced by individual stability, 
 however, as a slight jar will cause an abortion in one woman, and 
 violent experiences will have no effect upon another, at the same stage 
 of pregnancy. 
 
 Symptoms. For purposes of differentiation in treatment, 
 abortions are usually divided into three groups and designated 
 as threatened, complete and incomplete, but the premonitory 
 symptoms of all of the varieties are the same. They are bleeding, 
 
168 OBSTETRICAL NURSING 
 
 with pain that is usually intermittent, beginning in the small of 
 the back and finally felt as cramps in the lower part of the ab- 
 domen. Since menstruation is suspended during pregnancy, it 
 is a safe precaution to regard any bleeding during this period, 
 with or without pain, as a symptom of pending delivery. 
 
 Prevention of abortions is of course more satisfactory than 
 remedial treatment, and a nurse may be very helpful in this re- 
 spect, by explaining the underlying causes to the patients in her 
 care, and winning their cooperation in preventing a deplorable 
 accident. 
 
 Preventive treatment really begins very early. In the chap- 
 ter on menstruation we referred to the importance of a young 
 woman's ascertaining the cause of painful menses, in the inter- 
 est of good obstetrics, since inflammation of the uterine lining 
 or a uterine misplacement might be responsible not only for the 
 dysmenorrhea, but if neglected might, later, be factors in caus- 
 ing interrupted pregnancies. The correction of such physical 
 defects, then, no matter when they are discovered, is an im- 
 portant step in preventing abortions. 
 
 A misplacement may be corrected, frequently, by means of 
 a pessary, though suspension is done in some cases; an inflamed 
 lining, which provides unsatisfactory lodgement for the ovum, 
 may be removed by currettage. The new lining which replaces 
 the old one is sometimes capable of receiving and holding the 
 ovum. 
 
 There are also some more immediate preventive measures. A 
 woman who is pregnant for the first time, and who, therefore, 
 does not know whether or not she is likely to abort, should avoid 
 such risks as fatigue, sweeping, lifting or moving heavy objects, 
 running a sewing machine by foot, running, jumping, dancing, 
 traveling or any action which might jar or jolt her during the 
 first sixteen or eighteen weeks of pregnancy. 
 
 On the other hand, there are many groundless beliefs concern- 
 ing the causes of abortions which the nurse may well dispel. 
 Purgatives and other drugs have much less effect in causing 
 abortions under normal conditions than is generally believed. 
 But with a patient who has very irritable uterine muscles, such 
 a drug as quinine, for example, may act as the last straw in pro- 
 
COMPLICATIONS AND ACCIDENTS OF PREGNANCY 169 
 
 ducing an abortion which would almost certainly have been 
 brought on by some other slight stimulation had the drug not 
 been taken. Nor can reaching up, or sleeping with the arms 
 over the head, possibly separate the embryo from the uterine 
 lining, yet manj' women believe that they can. 
 
 In the case of an expectant mother who has had an abortion, 
 even more precautions than I have suggested will have to be 
 taken, for she is in greater danger of aborting than is a woman 
 who has not had this experience. It is of prime importance 
 that she have the cause of her previous abortion discovered, aiid 
 if possible, corrected. In addition to this, she should be par- 
 ticularly careful to observe precautionary measures as she ap- 
 proaches the stage of her pregnancy at which the previous abor- 
 tion occurred. The accident is most likely to be repeated at 
 about the same time, or a little earlier, in each succeeding preg- 
 nancy. The patient should remain quietly in bed for at least 
 a week before and after the time when an abortion is feared. 
 
 Complete rest and physical relaxation are such effective pre- 
 ventive measures that patients with a tendency to have abortions, 
 who have been willing to stay in bed throughout practically the 
 entire period of gestation, have gone through pregnancy without 
 interruption, and been delivered of normal babies at term. As 
 out-of-door exercise is clearly impossible in such cases, it is im- 
 perative that the patient keep her room particularly well-ven- 
 tilated all of the time, and, under the doctor's direction, have 
 massage or bed exercises. 
 
 Since abortion seems to be due, so often, to excessively irri- 
 table uterine muscle fibres that respond to even slight stimulation, 
 a patient who is known to have difficulty in carrying a child to 
 term is usually advised to avoid the marital relation throughout 
 pregnancy. 
 
 Some patients with defective uterine lining will have slight 
 bleeding for a long time, possibly throughout the entire period 
 of pregnancy, because a small area of the placenta has separated, 
 leaving, however, a sufficiently large attached area to nourish the 
 fetus. Such women should, of course, be under a doctor's care 
 and sedulously avoid all shocks to the uterine musculature, for 
 the separated area may very easily be increased to such a size 
 
170 OBSTETRICAL NURSING 
 
 that the fetus will be unable to secure adequate nourishment, 
 and die as a result. And the mother's life, too, may be endan- 
 gered by hemorrhage from the separated surfaces. 
 
 To sum up in a word, we may almost say that, after preg- 
 nancy has begun, preventive treatment consists of rest and avoid- 
 ing physical shocks, particularly during the first sixteen or eight- 
 een weeks and at the time when menstruation would occur were 
 the woman not pregnant. 
 
 Treatment, in the different degrees of abortion, employed by 
 most physicians, is usually along some such lines as the fol- 
 lowing : 
 
 1. Threatened. A threatened abortion is one in which there is 
 some loss of blood, associated with pain in the back and lower abdomen, 
 but without expulsion of the products of conception. The treatment, 
 as a rule, is absolute rest in bed and the administration of powerful 
 sedatives. 
 
 2. Incomplete. An incomplete abortion is one in which the fetus 
 is expelled but the placenta and membranes remain in the uterine cavity. 
 The treatment is removal of the retained tissues, followed by the same 
 care that is given during the normal puerperium. Prompt action in 
 completing the delivery is important because of the hemorrhage that 
 usually persists until the uterus is entirely emptied of its contents. 
 Since the pregnant uterus is very soft, the retained membranes are 
 more often removed manually than instnmientallj', for a curette may 
 be very easily pushed through the uterine wall, and peritonitis would 
 be likely to follow. 
 
 3. Complete. A complete abortion, as the term suggests, is one 
 in which all the products of coneei:)tion are expelled. The treatment and 
 care are exactly the same as are given after a nonnal delivery. This 
 point cannot be stressed too strongly, for it is because so many women 
 fail to appreciate the necessity for adequate post-partum care, that 
 abortions are so often followed by ill health and invalidism. 
 
 Mam' doctors follow these various remedial measures with a 
 search for the cause of the abortion just past, in order that it 
 may be corrected if possible and recurrent abortions prevented. 
 
 A missed abortion occurs but rarely, and is one in which the 
 embryo, or fetus dies, and is retained within the uterine cavity 
 for months, or even years, sometimes without any unfavorable 
 results to the mother. In these eases, symptoms of abortion some- 
 times appear and then subside without any part of the uterine 
 
COMPLICATIONS AND ACCIDENTS OP PREGNANCY 171 
 
 contents being expelled. In other eases there are no signs ex- 
 cept that the abdomen stops growing. There are cases on record 
 in which the fetus has become mummified and others in which 
 it has been partly absorbed by the maternal organism. 
 
 In addition to abortions which occur spontaneously there are 
 also induced abortions, and these are designated as therapeutic 
 or criminal, according to the motive for the induction. 
 
 Therapeutic abortions are resorted to when the i)atient's 
 condition is so grave that it is apparently necessary to empty 
 the uterus in order to save licr life Sucli a condition may exist, 
 for example, when pregnancy is i'om})lic'ated by pulmonary 
 tuberculosis, heart disease, toxemia, hemorrhage or some condi- 
 tion which is inherent to pregnancy. An abortion induced under 
 these circumstances is countenanced by law, as it is performed 
 to prevent the loss of life from disease ; but an abortion is not 
 legal if brought on to save the woman from suicide, because of 
 her unwillingness to become a mother. 
 
 The Catholic Church, however, teaches that it is never per- 
 missible to take the life of the child in order to save the life of 
 the mother. It teaches that, even according to natural law, the 
 child is not an unjust aggressor : and that both child and mother 
 have an equal right to life. 
 
 There is apparently no reason why a therapeutic abortion 
 should be followed by ill health, for, since it is performed openly, 
 it is done under clean, and otherwise favorable conditions, and 
 the patient is given adequate after-care. It is only because the 
 reverse conditions frequently prevail : the unclean delivery and 
 subsequent neglect which go hand in hand with the secrecy of 
 illegal performance that abortions are followed so often by 
 disaster. 
 
 As to the legal aspect of the matter, the laws relating to 
 therapeutic abortion vary in the different states. But they are 
 fairly uniform in their intent, and make quite clear the differ- 
 ence between this procedure and the induction of abortion for 
 any reason other than medical necessity. 
 
 Dr. Slemons writes of the seriousness of criminal abortion 
 in no uncertain terms, in "The Prospective Mother." "At Com- 
 mon Law" (an inheritance from England) he tells us, "abor- 
 
172 OBSTETRICAL NURSING 
 
 tion is punishable as homicide when the woman dies or when the 
 operation res alts fatally to the infant, after it has been born 
 alive. If performed for the purpose of killing the child, the 
 crime is murder; in the absence of such intent, it is manslaughter. 
 The woman who commits an abortion upon herself is likewise 
 guilty of the crime." 
 
 Premature Labor is the termination of pregnancy after 
 the seventh mouth, but before term. Premature births are much 
 less frequent than abortions or miscarriages. They usually occur 
 spontaneously, but are sometimes induced for therapeutic pur- 
 poses, or from criminal motives. 
 
 The premature baby's chances of living are directly propor- 
 tionate to the length of its uterine life. This has already been 
 stated, but will bear repetition in view of the widely current 
 fallacy that a seven-months' baby is more likely to live than one 
 born after eight months of pregnancy. The facts are that as 
 a rule, the nearer pregnancy approaches term, the more likely is 
 the baby to survive, provided it weighs four pounds or more, 
 and is forty centimeters or more in length. A smaller baby than 
 this has but a slender chance to live. * 
 
 We ordinarily designate as premature any baby that weighs 
 between 1500 and 2500 grams, or measures between thirty-six 
 and forty-five centimeters in length, and consider such a baby 
 has a favorable outlook if given special care. This special care of 
 premature babies will be described in connection with the care of 
 the baby. 
 
 Causes. Syphilis was formerly thought to be a common 
 cause of abortion, but although this has been disproved by recent 
 investigations, the disease is still regarded as a frequent cause 
 of spontaneous premature labor. In fact, Dr. Williams con- 
 siders syphilis the most frequent single cause of premature 
 births, and regards the birth of a dead, macerated fetus, or a 
 history of repeated premature labors, or stillbirths, as strongly 
 suggestive of syphilis. 
 
 "In my experience," he says, "the recognition and treatment 
 of this disease is the most important matter in connection with 
 the prophylaxis of premature labor. . . . Some idea of the im- 
 portance may be gained from the fact that in a series of 334 pre« 
 
COMPLICATIONS AND ACCIDENTS OF PREGNANCY 173 
 
 mature labors, I found that syphilis was the etiological factor 
 in over 40 per cent., while toxemia, placenta pnevia and fetal 
 deformity were concerned in 8.() and 3.3 per cent., respectively. 
 Sentex, who studied 485 eases in Pinard's clinic arrived at simi- 
 lar conclusions and found the underlying cause to be sypliilis in 
 42.7 per cent., albuminuria in 10.8 per cent., and abnormalities 
 of the fetus in 11.1 per cent." ^ 
 
 Other causes of premature births are the toxemias of preg- 
 nancy, chronic nephritis, diabetes, pneumonia, typhoid fever, oi-- 
 ganic heart disease, continuous overwork during tiie latter part 
 of pregnancy, and such poisoning as lead and illuminating gas, 
 while of alcoholism, Dr. Ballantyne says, "prematurity of birth 
 is an undoubted result." 
 
 Another important cause of premature births, of compara- 
 tively recent recognition, is previous operation upon the cervix, 
 particularly high amputations; Avhile placenta praevia and mal- 
 formations of the fetus, or monsters, are also reckoned with as 
 causative factors. Hydramnios sometimes brings on a premature 
 labor by so distending the uterus as to stimulate contractions. 
 
 Labor is sometimes induced prematurely when this procedure 
 may be expected to relieve an abnormality or complication which 
 threatens the life of the mother or baby, or both. Some of the 
 indications for this course are : seriously overtaxed heart or kid- 
 neys; a marked disproportion between the size of the child's 
 head and the mother 's pelvis, or a fetus that has been dead for 
 two weeks or more. However, the reasons for it and the methods 
 employed in inducing labor will be discussed more at length 
 in the chapter on obstetric operations. 
 
 A therapeutic induction of premature labor, like a thera- 
 peutic abortion, is not of itself usually considered any more seri- 
 ous for the mother than a normal delivery, since it can be per- 
 formed with care and cleanliness, qualities not usually associated 
 with the work of practitioners who are willing to do criminal 
 operations. 
 
 Treatment. The nursing care of the patient after a prema 
 ture labor is the same as that given after a normal delivery. 
 Much invalidism would be avoided if all women could be con- 
 
 ^ " Obstetrics, " by J. Whitridge Williams. 
 
174 
 
 OBSTETRICAL NURSING 
 
 vinced of the importance of staying in bed just as long, and hav- 
 ing just as good care after a premature as after a full-term 
 labor. The difficulty of so convincing her is perhaps due to the 
 fact that the small, premature child is expelled more quickly and 
 less painfully than a baby at term and there is comparatively 
 little blood lost in the course of its birth. 
 
 ANTE-PARTUM HEMORRHAGE 
 
 Ante-partum hemorrhage, which is a hemorrhage occur- 
 ring before delivery, is another serious complication of preg- 
 nancy. During the early months, hemorrhages are usually due 
 to abortion, menstruation or lesions of the cervix and are not 
 
 severe as a rule. But during the last 
 three months hemorrhages are almost 
 invariably due to placenta praevia or 
 premature separation of a normally 
 implanted placenta, and are often pro- 
 fuse. 
 
 Placenta Prx3cvia is one of the 
 most serious conditions met with in 
 obstetrics, the maternal mortality 
 being about 40 per cent, and the baby 
 death rate about 66 per cent. The 
 frequency with wiiich it occurs is 
 variously estimated as from one in 
 250 cases to one in every 1000. 
 
 In order to understand w'hat 
 is happening to the patient in this 
 condition, we must go back to the 
 question of the implantation of 
 the ovum. We learned that, as a 
 rule, after the ovum entered the uterus it attached itself 
 to a point in the uterine lining high up on the anterior or 
 posterior wall. Unhappily, the position of this point of at- 
 tachment is a mere matter of chance, and the ovum some- 
 times, but not often, is implanted so far down toward the 
 cervix that as the placenta develops at that site it partially 
 
 Fig. 44. — Diagram of 
 centrally implanted placenta 
 praevia. 
 
COMPLICATIONS AND ACCIDENTS OF PREGNANCY 175 
 
 Pig. 45.— Partial placenta praevia. Section of uterine wall and cervix 
 showing that part of the maternal surface of the placenta which extends 
 over the cervical opening and is exposed by dilation of the internal os, 
 with an escape of blood from the open vessels as a result. Drawn by Max 
 Brodel. (From "The Treatment of Placenta Praevia," by William B. 
 Thompson, M.D.— Johns Hopkins Hospital Bulletin, July, 1921.) 
 
176 
 
 OBSTETRICAL NURSING 
 
 or completely overlaps the internal os. It is the extent to 
 which the placenta grows over the cervical opening that 
 determines whether it is of the central, partial or marginal 
 variety. 
 
 A centrally implanted placenta prcevia (Fig. 44) is one which 
 entirely covers the os; a partial placenta prcevia (Fig. 45), as 
 the name suggests, only partially covers the opening, while if 
 it is implanted so high up that only its margin overlaps the os, 
 it is designated as marginal placenta prcevia. (Fig. 46.) 
 
 Another classification groups all placenta previa as complete 
 or incomplete, the latter comprising the partial and marginal 
 
 varieties, as well as the lateral which 
 is so attached that it does not quite 
 reach the edge of the internal os. 
 However, as these terms do not differ 
 widely and are clearly descriptive, the 
 differences are of no great moment to 
 the nurse, as the treatment is prac- 
 tically the same and the nurse 's duties 
 quite the same for all varieties. 
 
 Cause. Not much is definitely 
 known about the cause of placenta 
 praevia, but it is evident that multi- 
 parity is a factor, since the condition 
 is found about six times as frequently 
 among women who have borne chil- 
 dren, as it is among those who are 
 pregnant for the first time. A diseased 
 uterine lining is probably the fundamental cause, and this may 
 explain why the trouble is found more frequently among the 
 poorer classes, since such women as a class have less skilled 
 medical attention than those in better circumstance. 
 
 One theory is that an old endometritis results in a very un- 
 fertile soil for the implantation of the ovum and as a result 
 the ovum migrates to other parts of the uterine cavity in its 
 search for a more favorable site, and comes to lodge near the 
 lower segment. 
 
 Symptoms. The symptom of placenta prsevia is hemor- 
 
 FiG. 46. — Diagram of mar- 
 ginal placenta prsevia. 
 
COMPLICATIONS AND ACCIDENTS OF PREGNANCY 177 
 
 rhage, occurring during the latter part of pregnancy or at the 
 onset of labor. The cause of the hemorrhage is the separation 
 of that part of the placenta covering the internal os, when the 
 latter dilates, thus presenting an exposed, bleeding surface. The 
 hemorrhage is usually so profuse that uidess it is controlled, 
 both niotlier and child may bleed to deatli. 
 
 Treatment. Unhappily there is no preventive treatment for 
 placenta pra3via, beyond that which is included in treatment for 
 endometritis, and good care during the preceding puerperium. 
 
 Fig. 47. — Position of Champetier de Ribes' bag to stop hemorrhage, from 
 placenta praevia, by pressure. 
 
 Since the great danger in this complication is from hemor- 
 rhage the doctor's principal effort is directed toward its control. 
 Infection and shock are also feared but the first step is to stop 
 the bleeding. A common method is to stimulate the uterus to 
 contract ; that necessitates the removal of its contents, or the 
 induction of labor. 
 
 The separation of the placenta leaves open, bleeding vessels 
 in the uterine wall and placenta, which can only be closed by 
 pressure, until the uterus contracts on its own vessels. The doc- 
 tor sometimes makes pressure with tampons of gauze, by ruptur- 
 ing the membranes and bringing down tlie i^resenting part of the 
 child to press against the bleeding surface, or by introducing a 
 
178 OBSTETRICAL NURSING 
 
 rubber bag into the cervix and pumping it full of sterile water. 
 (Fig. 47.) By means of its weight and downward traction, this 
 bag presses against the bleeding areas and thus checks the 
 hemorrhage. It also tends to dilate the cervix, after which the 
 baby is sometimes born spontaneously and sometimes delivered 
 artificially. 
 
 Premature Separation of a Normally Implanted Pla- 
 centa. A placenta praevia, as has been explained, is abnormally 
 situated. But it sometimes happens that a pla(^enta that is 
 normally placed will separate prematurely, Avith hemorrhage as 
 the inevitable result. Such a hemorrhage is termed "acci- 
 dental" to distinguish it from the unavoidable bleeding caused 
 by a placenta prsevia. If the blood escapes from the vagina, 
 the hemorrhage is called "frank," but if it is retained within 
 the uterine cavity it is called a "concealed" hemorrhage. 
 
 Causes. Endometritis is probably an underlying cause, 
 though very little is definitely known on the subject. Previous 
 pregnancies are believed to be a factor, as this accident occurs 
 less often among women who are pregnant for the first time 
 than among those who have borne children, and also as the fre- 
 quency of the hemorrhages apparently increases with the number 
 of previous pregnancies. Nephritis is believed to be a possible 
 cause, as well as anemia, general ill-health, toxemia, physical 
 shocks, and frequently recurring pregnancies. 
 
 Symptoms. In a frank hemorrhage, the chief symptom 
 is an escape of blood from the vagina, occasionally accompanied 
 by pain. A frank accidental hemorrhage occurs once in about 
 every two hundred cases, according to Dr. Edgar's estimate, but, 
 although more frequent than placenta praevia, it is much less 
 serious. 
 
 A concealed accidental hemorrhage, on the other hand, is 
 an extremely grave complication for both mother and child, 
 for according to observations made by Dr. Goodell, the death 
 rate is 51 per cent, among mothers and 94 per cent, among 
 babies.^ The symptoms are acute anemia, abdominal pain, a 
 general state of shock, and usually an increased enlargement of 
 the uterus. The blood may be retained between the uterine wall 
 
 ^ ' ' The Practice of Obstetrics, " by J. Clifton Edgar. 
 
COMPLICATIONS AND ACCIDENTS OF PREGNANCY 179 
 
 and the placenta or membranes, or its escape from the vagina 
 may be prevented by the child's presenting part fitting tightly 
 into the outlet and acting as a plug. 
 
 Treatment. The treatment of a frank hemorrhage depends 
 upon its severity. If the bleeding is only moderate, labor is 
 ordinarily allowed to proceed normally and unassisted. If the 
 bleeding is profuse, however, the patient is usually delivered 
 promptly. 
 
 The treatment for a concealed hemorrhage consists of empty- 
 ing the uterus speedily in order that tlie muscles may contract 
 and stop the bleeding by closing the uterine vessels; and of 
 treating the accompanying shock which may be almost, if not 
 quite, as serious as the hemorrhage itself. 
 
 It is very disappointing to have to realize that there is very 
 little that a nurse may do, before the arrival of the doctor, for 
 a patient who is having an ante-partura hemorrhage. As has 
 been explained, it is often necessary to pack the cervix or intro- 
 duce a bag, for the purpose of stopping the bleeding by pressure, 
 and of stimulating the uterine contractions which will expel the 
 child and empty the uterus. These measures are surgical opera- 
 tions and quite evidently the nurse cannot attempt to perform 
 them. She can, however, put the patient to bed and have her 
 lie flat, without a pillow, and, partly for the mental effect upon 
 the patient, apply ice-bags or compresses to her abdomen. As 
 nervousness and excitement only tend to increase the bleeding, 
 the nurse has an excellent opportunity to try to soothe and quiet 
 a frightened Avoman, and convince her that she can help herself, 
 in this emergency, by quieting her mind and body. 
 
 Pending the doctor's arrival, the nurse should have a large 
 receptacle of water, boiling, to sterilize the instruments and 
 bags that he may want to use; clean towels and sheets, a nail 
 brush, hot Avater, soap, and a basin of an antiseptic solution 
 for his hands. 
 
 TOXEMIAS OF PREGNANCY 
 
 There is probably no group of complications which prove 
 to be more baffling to the obstetrician than the toxemias of preg- 
 
180 OBSTETRICAL NURSING 
 
 nancy. Certainly they are challenging the best efforts of many 
 earnest investigators, for it is known that the toxemias cause 
 some of the gravest conditions that arise during pregnancy, and 
 they are suspected of being the underlying cause of still others 
 which are as yet unaccounted for. 
 
 Comparatively little is known of the origin of the toxemias, 
 except that they are due to pregnancy. But happily, a good 
 deal is known about preventing them, and also about relieving 
 them, particularly in the early stages ; accordingly many mothers 
 and babies are saved who otherwise would perish. 
 
 The entire subject of the prevention and treatment of these 
 disorders will be somewhat simplified for the nurse if she will 
 recall the general question of the adaptations of the mother's 
 physiologj^ during pregnancy. She will then remember that 
 there were certain alterations of function which were necessary 
 to keep the maternal organism normal, while it bore the strain 
 of supplying nourishment to the fetus from its own blood stream, 
 and received in turn the broken-down products of fetal activity. 
 If these adaptations are insufficient to meet the demands made 
 upon the maternal organism, a serious toxic condition may 
 result. 
 
 To put the matter briefly, there is in the toxemias of preg- 
 nancy a disturbance of the mother's metabolism, involving the 
 liver and kidneys, and a resulting retention within her body of 
 something which should be excreted. The retention of this ma- 
 terial, which may be of fetal or maternal origin, or both, may 
 give rise to symptoms which range anywhere from slight head- 
 ache or nausea to coma, convulsions and death. 
 
 Beyond these general facts, there seems to be deep obscurity 
 concerning the cause of this group of complications, of which 
 pernicious vomiting, pre-eclamptic toxemia and eclampsia are 
 the most widely and generally recognized. 
 
 While nephritic toxemia and acute yellow atrophy of the liver 
 cannot be designated, quite accurately, as toxemias due to preg- 
 nancy, they are usually included in this group. This may be 
 because they are toxemias which have many features in common 
 with those of pregnancy, as to symptoms and treatment, and 
 
COMPLICATIONS AND ACCIDENTS OP PREGNANCY 181 
 
 because of the frequency with which they appear coincidently 
 with pregnancy, although not always due primarily to that 
 state. 
 
 From the nurse's standpoint, it will perhaps be as well to 
 regard all of the toxemias of pregnancy as manifestations of 
 the same general disturbance, which vary according to the stage 
 of pregnancy at which they appear, and which differ from each 
 other chiefly in severity, or degree, rather than in kind. 
 
 In all cases the patients need to have their toxicity lessened 
 by dilution, and this is accomplished by giving fluids, copiously, 
 and by increasing elimination by promoting the activity of the 
 skin, kidneys and bowels. And since the nervous system is irri- 
 tated by the toxins, sometimes slightly and sometimes pro- 
 foundly, the patient must be protected from outside irritation 
 and stimulation. This means quiet ; a soft light, or even dark- 
 ness in the room; gentle handling; and with mildly toxic, con- 
 scious patients, a pleasant, reassuring and encouraging man- 
 ner. With those who are unconscious, each touch must be the 
 lightest and gentlest possible. 
 
 These are the main features of the nursing care: forcing 
 fluids and keeping the patient warm and quiet. They offer 
 the nurse wide scope in adjustment and adaptation to each 
 patient, according to her immediate condition and to the methods 
 of the physician in charge. There is a difference of opinion 
 among doctors as to details of treatment, but the fundamentals 
 of the care are the same. In taking up, in turn, these mani- 
 festations of disturbed metabolism during pregnancy, we find 
 that vomiting is the first to appear. 
 
 Pernicious Vomiting of Pregnancy usually occurs during 
 the first three months. We learned in the preceding chapter that 
 a milder form of the malady, known as "morning sickness," is 
 present in about half of all pregnancies. This mild type ordi- 
 narily consists of a feeling of nausea, possibly accompanied by 
 vomiting, immediately upon raising the head in the morning, 
 and a capricious appetite. It appears at about the fourth or 
 sixth week and subsides in the course of a few weeks, sometimes 
 after no more care than the nursing which was described, leaving 
 the patient none the worse as a result of the attack. 
 
182 OBSTETRICAL NURSING 
 
 With some women, however, the distress does not disappear 
 in this prompt and satisfactory manner, in which case it is 
 described as ''pernicious vomiting." The nausea in the morn- 
 ing may then persist for hours; it may occur later in the day, 
 or even at night; it may come on during a meal and consist of 
 a single attack of vomiting, after which food is taken and re- 
 tained ; or it may be so persistent that the patient will be unable 
 to retain anything taken by mouth at any time of the day or 
 night. Such a condition, is, of course, serious, and may termi- 
 nate fatally. The patient may become exhausted from lack of 
 food or because of the toxic condition which is responsible for 
 the vomiting, or both. 
 
 There seem to be three possible classifications of pernicious 
 vomiting: (1) One of reflex origin, (2) one of neurotic origin, 
 and (3) one due to a toxemia, resulting from disturbed meta- 
 bolism. Not all physicians accept the possibility of all of these 
 factors, however, for while some recognize both toxemia and 
 neuroses as causes, they question the possibility of a reflex cause. 
 Others believe that all nausea of pregnancy, from the mildest 
 to the most severe form, is of toxic origin, while still others con- 
 tend that even the severest pernicious vomiting is always neu- 
 rotic. However, as toxicity under any conditions is very likely 
 to give rise to nervous symptoms, and as a nervous, unstable 
 woman may be made very ill by a slight degree of toxicity, it 
 may be that both factors sometimes enter into the causation of 
 this disorder. 
 
 Reflex vomiting-. Those who subscribe to the theory of 
 reflex vomiting believe that it may result from the irritation 
 caused by a retroverted uterus, or occasionally by an ovarian 
 cyst, an erosion on the cervix or by adhesions. 
 
 The treatment for reflex vomiting, quite obviously, consists 
 of correcting the disturbing condition, whatever it may be, after 
 which the nausea usually subsides in a short time. The nurse 
 should take care that her patient resumes a regular diet 
 very gradually, even after the cause of the nausea has been 
 removed, for the stomach has become irritable and the vomiting 
 habit, both mental and physical, though easily established, is 
 usually broken up with considerable difficultv. Breakfast in 
 
COMPLICATIONS AND ACCIDENTS OP PREGNANCY 183 
 
 bed; concentrated liquid foods or easily digested solids, particu- 
 larly carbohydrates; aerated Avaters; cold fruit juices and 
 cracked ice are easy to retain and tend to allay nausea. 
 
 Neurotic vomiting. Severe vomitiii<i' Avliidi is due to 
 some kind of mental stress or suffering-, and connnonly called 
 "neurotic vomiting," is not always so easily relieved. In the 
 opinion of many psychiatrists the vomiting frequently consti- 
 tutes a protection, or possibly a protest, which the patient has 
 developed subconsciously, because of some reason for fearing, 
 or not wanting, to become a mother. 
 
 It is difficult to outline the nursing care of such patients 
 with any degree of precision, as no two can be cared for in 
 quite the same way. While in some cases the patient is a selfish, 
 overindulged woman who objects to motherhood because of its 
 inconveniences, in others, she is tortured by fear of inability to 
 go through her pregnancy successfully, though sincerely want- 
 ing to ; or she may be bewildered and overwhelmed by the pros- 
 pect of the dangers of childl)irth and responsibilities of mother- 
 hood, a truly pathetic figure whose distress may often be greatly 
 relieved by the nurse who has enough insight to grasp the situa- 
 tion. As I have discussed this subject more at length in the 
 chapter on mental hygiene, I shall say only a word here, as a 
 reminder that the nurse will need all of the tact, resourceful- 
 ness, sympathy and understanding which she is capable of offer- 
 ing, if she is to give real help to some of her patients who suffer 
 from neurotic vomiting. 
 
 In addition to the mental nursing, which will be necessary, 
 the patient also needs physical care, for though her trouble may 
 be of emotional origin, she is, nevertheless, physically ill. As 
 a rule, the best results are obtained by putting the patient to 
 bed and separating her from her family as completely as possible. 
 A daily routine should be adopted and rigidly observed, and 
 the patient repeatedly assured that the course being followed 
 will end in recovery. 
 
 It is usually considered advisable not to offer food by mouth, 
 in the beginning, but instead to give nourishment, as well as 
 large amounis of saline and sugar solutions by enemata, during 
 tlie first few days. One routine is to give 500 cubic centimetres 
 
184 OBSTETRICAL NURSING 
 
 v&ry slowly, every six hours at first, gradually decreasing the 
 treatments to one a day as the patient improves. The rectum is 
 irrigated with a simple enema, once daily, immediately preced- 
 ing one of the injections, consisting of an ounce of dextrose or 
 glucose and one dram of salt to a pint of water. 
 
 Small amounts of liquid nourishment are finally given by 
 mouth, and given frequently, the quantity being increased grad- 
 ually as the patient improves. Very light and easily digestible 
 solid foods, chiefly carbohydrates, are added by degrees, and 
 in the end, five or six small meals, rather than three full ones, 
 are given in the course of the day. 
 
 In some cases the patient is induced to drink, daily, two or 
 three quarts of sugar solution (an ounce of lactose to a pint of 
 water), and to nibble at will on olives, walnuts, crisp crackers, 
 or some such articles of food, which are kept within reach on her 
 bedside table. These are usually retained, excepting in very 
 severe cases, to the patient's great encouragement. 
 
 The duration and severity of the attacks vary widely. Some 
 patients are very ill and for a long time, even requiring an abor- 
 tion before showing signs of improvement, while others recoyer 
 in a few days if wisely managed. If a patient once suffers from 
 neurotic vomiting, she is very likely to have it in subsequent 
 pregnancies, particularly if the circumstances of her life remain 
 unaltered. 
 
 Toxemic vomiting is regarded by some doctors as a very 
 grave and very rare complication of pregnancy, which is usu- 
 ally fatal; by others as simply a severe form of the very com- 
 mon ' ' morning sickness, ' ' which they believe is always toxic, no 
 matter how mild ; while still others, as already stated, doubt the 
 occurrence of such a condition as toxemic vomiting of preg- 
 nancy. I mention these differences of opinion in order that 
 the nurse may be aware of their existence and be prepared to 
 adjust herself whole-heartedly to the different methods of treat- 
 ment for which they are responsible. For no matter what else 
 may vary, the earnestness and sincerity of the nurse's attitude 
 must be a veritable Gibralter of reliability. 
 
 The chief symptoms of toxemic vomiting, in addition to 
 persistent vomiting, as described by those who recognize its 
 
COMPLICATIONS AND ACCIDENTS OF PREGNANCY 185 
 
 occurrence, are coffee-ground vomitus; a diminished amount of 
 urine, possibly containing albumen, acetone bodies and casts; 
 coma and sometimes convulsions. The disease may run its course 
 swiftly and the patient die in a week or ten days, or it may 
 persist less acutely for weeks, in which case there is extreme 
 emaciation and prostration. In those cases Avhich come to 
 autopsy there is a definite and characteristic, central necrosis 
 of the liver lobule. 
 
 The treatment and nursing care vary widely because so 
 little is definitely known about the cause, and because of the 
 varieties of theories concerning it which are held by different 
 obstetricians. Some believe that prompt emptying of the uterus 
 is about the only course which is effective, whilo others foel that 
 because of the probable toxicity of the patient it is advisable also 
 to stimulate all of the excretory organs. Accordingly, they give 
 free purges, colonic irrigations, hot packs and copious amounts 
 of sugar and saline solution by mouth, rectum, intravenously and 
 by infusion. 
 
 Corpus luteum, too, is sometimes given hypodermically two 
 or three times weekly. Although this treatment is not in uni- 
 versal use or favor, some patients seem to be given absolute relief 
 by its administration. 
 
 A fairly typical method of treating toxemic vomiting, and 
 of which the nursing care forms a large part is somewhat as 
 follows: When the vomiting is only moderately severe, the 
 patient is put to bed and isolated from relatives and friends, 
 because of her nervousness resulting from the toxemia. She 
 is given an abundance of very cold, 5 per cent, lactose solution 
 by mouth in water or lemonade ; from four to six ounces being 
 given every half hour if she is able to retain it. If she is unable 
 to take, by mouth, a total of about three litres of this solution, in 
 the course of twenty-four hours, she is sometimes given one or 
 two litres (of a 10 per cent, solution) by rectum by means of the 
 drip method. At least three hours are devoted to giving this 
 amount of fluid, the rectum being first washed out with a simple 
 enema. 
 
 It is usually considered important to persist in giving small 
 amouot^ of practically any article of food that the patient 
 
186 OBSTETRICAL NURSING 
 
 fancies, in order to encourage her in the belief that she can 
 take nourishment and also to accustom her stomach to receive 
 and retain food. Olives and nuts are particularly valuable for 
 this purpose and are often kept on the patient's bedside table 
 where she can reach them and nibble on them at will. Ice cold 
 fruits and fruit juices are useful, while strained apple sauce, ice 
 cold, is very valuable as a starting point from which a more 
 generous diet may be gradually developed. All foods should be 
 very cold except broths, which should be very hot. The dietary 
 is gradually increased to six small meals daily from which fats 
 and proteids are omitted. 
 
 In more severe cases, or if the patient does not improve, an 
 injection of 300 cubic centimetres of fresh 5 per cent, solution 
 of glucose is given under each breast daily, and sometimes a 
 mild sweat-bath, given with blankets and lasting twenty minutes. 
 (See page 197 for sweat-bath.) 
 
 In very severe cases when the patient is unable to retain any- 
 thing taken by mouth ; loses weight and strength ; when possibly 
 the urine decreases in amount and contains acetone bodies and 
 ammonia, the situation is serious and the treatment is more 
 drastic. All effort to give fluid by mouth is abandoned and in 
 addition to the sub-mammary injection of glucose solution, a 
 colonic irrigation of one and a half to two gallons of sodium 
 bicarbonate solution (from 2% to 5%) at 110° F., is given once 
 daily by the drip method. The daily hot pack is continued; a 
 mustard leaf is applied to the abdomen if necessary to relieve the 
 pain and nausea; glucose solution may be given intravenously 
 and also a nutritive enema, three times daily, consisting of a raw 
 egg, four ounces of peptonized milk and one-half ounce of 
 whiskey. 
 
 The method employed at the Toronto General Hospital in 
 treating patients suffering from toxemic vomiting is outlined 
 as follows by Dr. J. G. Gallic: "The patient is given as much 
 as she is able to drink. A nutrient enema is given three or four 
 times daily, consisting of six ounces of a 10 per cent, solution of 
 glucose in saline. Bromide and chloral may have to be added 
 to the last nutrient in the evening. A simple enema is given 
 each morning. Nutrients are discontinued when the urine be- 
 
COMPLICATIONS AND ACCIDENTS OF PREGNANCY 187 
 
 comes free of acetone bodies. In more severe cases, where fluid 
 cannot be taken by mouth, it may be supplied interstitially or 
 intravenously, a 5 per cent, solution of glucose being used. When 
 vomiting ceases, and solid food can be taken, the feeding is 
 begun very carefully with small quantities of carbohydrates. 
 Lactose is added where possible to any fluid taken. Frequent 
 small meals are then instituted — six between 7 a.m. and 10.30 
 p.m.j thus reducing to the smallest space of time the period of 
 starvation during the twenty-four hours. Protein may be added 
 to the diet wlien nausea is under control, but fat should be left 
 out for some time." 
 
 Such a course of treatment, quite evidently, is designed to 
 relieve a toxic condition, in which increased elimination is im- 
 portant, and to quiet an irritable nervous system. 
 
 As the patient with toxemic vomiting is often very uncom- 
 fortable because of a bad taste and dryness of her mouth, some 
 kind of a mouth wash which she finds refreshing should be used 
 frequently. And since a degree of toxicity which is capable of 
 producing such a condition as is described above will almost 
 inevitably produce nervous symptoms, as well, the nurse's atti- 
 tude toward her patient must always be one of sympathy, en- 
 couragement and optimism. 
 
 When the patient's condition is so desperate that pregnancy 
 is terminated, with the hope of saving her life, ether or nitrous 
 oxide gas, or both, is used as an anesthetic rather than chloro- 
 form, which of itself tends to produce a liver necrosis. 
 
 Pre-eclamptic Toxemia is the most common of all the tox- 
 emias of pregnancy, occurring several times in every hundred 
 pregnancies. It develops more frequently among women who 
 are pregnant for the first time than among those who have borne 
 children, and one attack usually confers an immunity against a 
 recurrence. 
 
 As pre-eclamptic toxemia usually responds to treatment, but 
 if neglected, frequently ends in the much more serious disease 
 of eclampsia, the imperative need of supervision and care during 
 pregnancy are once more borne in upon us. 
 
 Symptoms. Pre-eclamptic toxemia seldom appears before 
 the second half of pregnancy, usually not until after the sixth 
 
188 OBSTETRICAL NURSING 
 
 or seventh month, and the symptoms vary widely in severity. 
 They may range from headache and nausea, so slight as to cause 
 the patient little or no inconvenience, to coma and death. 
 
 The patient may be entirely normal for six or seven months 
 and then notice that her rings and shoes are a little tight, be- 
 cause of the slight swelling of her hands and feet. Puffiness 
 of the eyelids may appear, and other parts of the body may 
 also be slightly swollen. Headache, dizziness, lassitude, drowsi- 
 ness, depression, apprehension, nausea and vomiting are all 
 symptoms, as also are high blood pressure and a diminished 
 amount of urine, containing albumen. The patient frequently 
 complains of visual disturbance, which may be only a slight 
 blurring, but in severe cases may amount to total blindness. 
 
 Other symptoms, when the condition is grave, are epigastric 
 pain ; rapid pulse ; extreme nervousness and excitement, which 
 may amount almost to insanity; or drowsiness, which grows 
 deeper and deeper until the patient sinks into a coma. Under 
 such conditions, she may die without recovering consciousness, 
 but more frequently, eclampsia ensues. The child may perish 
 as a result of the toxemia and a dead, premature baby be born. 
 
 Prevention is of course, the most important aspect of the 
 treatment and is accomplished by means of the pre-natal care 
 and supervision which were described in the last chapter. In 
 this connection must be mentioned again the danger, during 
 pregnancy, of overeating. It is more and more frequently ob- 
 served that toxemic seizures follow in the wake of a single, large, 
 heavy meal, such as one is so likely to take at Thanksgiving or 
 Christmas time. This is particularly true of patients who have 
 had nausea or wlio have even slightly disabled kidneys, which, 
 though able to meet the ordinary demands made by pregnancy, 
 are inadequate to cope with the sudden strain imposed by a large 
 meal. In such a case, toxic materials which should be excreted 
 are retained within the body, and the familiar symptoms of 
 toxemia are the result. 
 
 Much the same condition is produced by the patient 's getting 
 wet or chilled. The excretory function of the skin is interfered 
 with, under such circumstances, and the kidneys are unable to 
 
COMPLICATIONS AND ACCIDENTS OF PREGNANCY 189 
 
 do enough extra work to make up for the skin's failure, and 
 again toxic material is retained, instead of being excreted. 
 
 Treatment and Nursing Care. As might be expected, the de- 
 tails of treatment and nursing care of a pre-eclamptic patient 
 vary with different doctors and with the severity of the attack. 
 But the essentials of treatment, the country over, may be summed 
 up as rest and elimination, coupled with close watching for 
 unfavorable symptoms. 
 
 The surest way to have the patient really rest is to put her 
 to bed, even in mild cases, and recovery is so hastened, thereby, 
 that she is well paid for the temporary inconvenience. 
 
 Since it is widely believed that the metabolic disturbance, 
 in toxemia, is related to the nitrogenous part of the diet, the 
 course usually followed in this particular is a reduction of the 
 nitrogen intake. This is accomplished by putting the patient on 
 a very low protein diet or a milk diet, consisting of two quarts 
 of milk daily. This amount of milk provides adequate nourish- 
 ment, for the time being, and also supplies a large part of the 
 fluid which is needed to promote elimination. In addition to 
 this, however, the patient is given one, or better still, two quarts 
 of water every day, and free saline purges. 
 
 Very frequently this treatment is all that is necessary. The 
 blood pressure falls in a few days, the albumen in the urine 
 gradually disappears, the patient completely recovers and in 
 due time has a normal labor. 
 
 But in more severe and less amenable cases it is necessary 
 to increase the eliminative treatment and give copious colonic 
 irrigations ; sweat baths, in the form of hot packs or hot air baths, 
 and even venesection and saline infusions, in order to relieve 
 the symptoms. Sometimes, even these are not enough and the 
 high blood pressure and albumen, Avhicli are probably the most 
 significant symptoms, will continue. If so, and the patient grows 
 worse, or if she simply fails to respond to the treatment, the 
 usual practice is to induce labor. A daily output of five grams 
 of albumen to a litre of urine, and a blood pressure of 200 milli- 
 metres are usually regarded as insistent indications that preg- 
 nancy should be terminated. Otherwise^ eclampsia, always so 
 
190 OBSTETRICAL NURSING 
 
 dreaded, is practically sure to follow and endanger the life of 
 both mother and child. 
 
 It may be mentioned here that the normal blood pressure, 
 during the latter part of pregnancy, is about 120 millimetres. 
 A gradual increase to 130, or even 140 millimetres, may not be 
 serious, but a sudden rise or a pressure of 150 millimetres should 
 be regarded Avith alarm, even though all other symptoms be 
 absent. The reason for this is that eclampsia may, and some- 
 times does, occur with little or no warning except the high, or 
 suddenly increasing blood pressure. 
 
 Eclampsia. Pre-eclamptic toxemia, as the name suggests, is 
 a condition that frequently precedes eclampsia, and the impor- 
 tance of the prevention, early recognition and prompt treatment 
 of this forerunner is due to the seriousness of eclampsia which 
 threatens to ensue. This disease, which may be defined as a tox- 
 emia occurring before, during or after labor, is one of the gravest 
 complications which arise in obstetrics. It is usually associated 
 with both tonic and clonic convulsions, unconsciousness and 
 coma. 
 
 Patients who have a tendency to kidney trouble and to di- 
 gestive disturbances, such as so-called "billiousness," are evi- 
 dently likely to have eclampsia; and in eclampsia there is a 
 peripheral necrosis of the liver which occurs in no other condi- 
 tion. These facts suggest that possibly when metabolism is pro- 
 ceeding normally, the liver converts certain material, whose re- 
 tention within the body is inimical to health, into a form which 
 the kidneys can excrete without great effort; that if the liver 
 fails in this function, the kidneys are unable to stand the in- 
 creased strain put upon them, as is evidenced by casts and 
 albumen which appear in the urine, and the retained material 
 gives rise to toxemia. It is possible that disturbed functions of 
 other glandular organs, such as the thyroid, may play a part 
 in causing eclampsia, but this, too, is only conjecture. 
 
 The frequency with which the disease occurs has been vari- 
 ously estimated at from one in 500 to one in 100 cases, appar- 
 ently being more common in first pregnancies than subsequent 
 ones, but more serious when occurring among women who have 
 had children before. One attack is believed to confer an im- 
 
COMPLICATIONS AND ACCIDENTS OF PREGNANCY 191 
 
 munity, or, as Dr. ('lii|)man puts it, "the woman with 
 eclampsia vaccinates herself." The average death rate from 
 eclampsia is from 20 to 35 per cent, of tiie mothers and about 50 
 per cent, of tlie babies, except where the desired care can be 
 given, either at liome oi- in a iios|)ital, when tlie mortality is 
 greatly reduced. Tliese figures vai-y, somewhat, according to 
 the time of the onset, as the disease is usually more fatal if the 
 convulsions occur before or during labor, than afterward. 
 
 Some authoi-ities feel, however, that eclampsia is (juite as fatal 
 after, as before, labor. 
 
 Symptoms. The symptoms, as a rule, are those of pre-eclamp- 
 tic toxemia which have persisted and grown more severe, ac- 
 companied by convulsions and coma. The blood pressure may 
 be from 150 to 250 millimetres and the urine, in addition to 
 showing many and varied casts, contains albumen, which varies 
 in amount from a few grams per litre to more than a hundred in 
 severe cases. In those cases which prove fatal and come to 
 autopsy, there is always found a characteristic, peripheral necro- 
 sis of the liver, and since it is found in no other disease it defi- 
 nitely establishes the diagnosis. It is true that this is of no help 
 to the poor woman who died, but it is of help to those investiga- 
 tors who are so earnestly studying the disease with the hope of 
 finding its cause and cure. 
 
 Although there are frequently pre-eclaraptic symptoms which 
 have grown worse, with or without treatment, it sometimes hap- 
 pens that the patient has no warning discomfort and the first 
 sign of the disease is a convulsion ; or a patient who has been 
 treated for pre-eclamptie toxemia may apparently recover, even 
 to the extent of having the albumen disappear from her urine, 
 and suddenly have a convulsion. 
 
 Convulsions, which are both tonic and clonic in character, 
 occur in about 99.5 per cent, of all eclamptic eases and are very 
 distressing to watch. They are sometimes preceded by an aura, 
 but often are so unheralded that they may even occur while the 
 patient is asleep. They ordinarily begin witli a twitching of 
 the eyelids; the eyes are wide open and staring and the pupils 
 are first contracted and then dilated. The twitching extends to 
 the. muscles about the nose and mouth, then to the neck and arms, 
 
192 OBSTETRICAL NURSING 
 
 and so on until the entire body is convulsive. The patient's face 
 is usually cyanotic and badly distorted, the mouth being drawn 
 to one side; she clenches her fists, rolls her head from side to 
 side and tosses violently about the bed. She is totally uncon- 
 scious and insensible to light, and during the seizure may not 
 breathe beyond giving one or two struggling gasps. Her head 
 is frequently bent backward, her neck forming a continuous 
 curve with her stiffened, arched back. Another distressing fea- 
 ture is the protruding tongue and the frothy saliva, which is 
 blood stained if the patient is not prevented from biting her 
 tongue by the introduction of some sort of a mouth gag between 
 her teeth. 
 
 Such is the typical eclamptic convulsion. 
 
 The attacks vary greatly in their intensity and duration. 
 There may be only a few twitches, lasting ten or fifteen seconds 
 or violent convulsions lasting as long as two minutes, their num- 
 ber and severity increasing with the seriousness of the patient's 
 condition. In mild cases there may be but one or two convul- 
 sions, particularly if the onset is either late in labor or post- 
 partum. But as a rule, there are several convulsions ; ten, twenty 
 or thirty, and sometimes, though rarely, as many as a hun- 
 dred. 
 
 The patient always goes into a coma after a convulsion and 
 this also varies in length and profundity, her condition during 
 the intervals being very suggestive of the probable outcome of 
 the disease. If the attacks recur frequently, as they usually 
 do in extreme cases, the patient is likely to remain unconscious 
 during the entire interval ; but she will usually awaken between 
 attacks that are far apart, and this is regarded as a hopeful sign. 
 The respirations are labored and noisy as a rule, and the pulse 
 full and bounding, in which case the outlook is good. The tem- 
 perature is often normal, but may go as high as 104° F. or 105° 
 F., dropping rapidly as the attacks subside. But a weak, rapid 
 pulse together with a high temperature, and above all, a per- 
 sistently high blood pressure, no matter what the other symptoms 
 may be, are always unfavorable. 
 
 Concerning the varied results of eclampsia, the opinion seems 
 to be growing that if it develops during late pregnancy, labor 
 
COMPLICATIONS AND ACCIDENTS OF PREGNANCY 193 
 
 is likely to set in and a premature child be born spontaneously -, 
 in some eases, however, for reasons already given, labor is in- 
 duced, while in others the mother dies undelivered. The fetus 
 may die, after w^hich the convulsions practically always cease 
 and the infant is often born later in a macerated state ; or the 
 patient may recover, go to term and give birth to a normal, 
 healthy baby. 
 
 When eclampsia occurs during labor the pains usually in- 
 crease in force and frequency, thus hastening delivery, after 
 which the convulsions usually cease. It will be noted that death 
 or expulsion of the fetus is in almost all cases followed by imme- 
 diate cessation of the symptoms and by ultimate recovery. 
 
 Treatment and Nursing Care. There is so little definite in- 
 formation about the cause of eclampsia that there is quite nat- 
 urally some difference of opiidon as to the best methods of cura- 
 tive treatment. Unquestionably, prevention is of first impor- 
 tance and this is accomplished through the watchfulness and care 
 during the antenatal period as described. 
 
 Dr. Edgar characterizes eclampsia as a preventable disease, 
 and though an occasional ease will develop in spite of preventive 
 treatment the general results achieved tend to bear out his defi- 
 nition. For example, in a series of 1200 maternity cases at Belle- 
 vue Hospital during 1920, prenatal care was given to 900 women 
 and not one case of eclampsia occurred among them, while among 
 the remaining .300 women who had not been seen during preg- 
 nancy, there were ten eclamptics. It is but fair to bear in mind 
 that as some of these patients were taken into tlie hospital because 
 of their having eclampsia, the proportion is abnormally high. 
 The Henry Street Settlement reports through its maternity ser- 
 vice that there was but one case of eclampsia among 7600 women 
 who were given prenatal care bj^ its nurses in 1920, These fig- 
 ures, contrasted with the average of one case in about every 500 
 pregnancies, furnish astounding evidence of what can be done 
 through i)renatal care in the prevention of this one disease alone. 
 
 As to curative treatment, the variations of opinion are after 
 all of little consequence to the nurse, for there is almost entire 
 ■ananimity concerning the general principles, and it is these that 
 shape the nursing*care. Broadly speaking, they comprise effort 
 
194 OBSTETRICAL NURSING 
 
 to dilute the toxic material in the system, promote its elimina- 
 tion through the various excretory channels and quiet the pa- 
 tient's nervous excitability. 
 
 Since eclampsia occurs only in connection with pregnancy, 
 and the convulsions usually cease if the fetus dies or is born, one 
 line of reasoning is that the most effective way to treat the dis- 
 ease is to terminate pregnancy. Formerly this was almost always 
 done, and is still practised by some obstetricians. Those who do 
 not agree with this theory contend that the eclamptic woman is a 
 very ill woman whose nervous system is so irritated that the 
 slightest stimulation or irritation works harm. In view of this 
 they feel that manual or instrumental dilation of the cervix, 
 preparatory to delivering the child through that channel, or de- 
 livery through an incision in either the abdominal wall or cervix, 
 constitutes a shock that outweighs the advantages of emptying 
 the uterus; therefore, that as a rule, less harm is done by non- 
 interference, quieting the patient and increasing her eliminative 
 functions, than by terminating pregnancy. This line of reason- 
 ing also takes into consideration the fact that from 15 per cent, 
 to 20 per cent, of the cases of eclampsia are postpartum, indicat- 
 ing that convulsions may occur even after the uterus has been 
 emptied. 
 
 The growing tendency is to adopt a middle course and treat 
 each individual case according to the conditions and indications 
 which it presents. Thus the same doctor will hastily induce labor 
 in a case where the blood pressure and albumen remain alarm- 
 ingly high, or increase, in spite of all efforts to reduce them, and 
 in another case will go to the extreme of conservatism, doing 
 nothing but quiet the patient with morphia or chloral, or both, 
 and stimulate all of her excretory organs with abundant fluids. 
 
 But the nurse's duties, and I may say her opportunities, for 
 she is privileged to do much, are virtually the same no matter 
 which course is followed, except, of course, the preparation for 
 delivery, if this is performed. 
 
 The nurse is concerned with helping to reduce the intake of 
 nitrogenous food, or proteids; diluting the toxines retained in 
 the body; promoting the activity of the kidneys, bowels, liver, 
 lungs and skin ; guarding the patient against all avoidable stim- 
 
COMPLICATIONS AND ACCIDENTS OF PREGNANCY 195 
 
 ulation from without, such as noise, light, ungentle handling and 
 undue resistance to the patient's convulsive movements; and 
 protecting her from injuring herself by biting her tongue, falling 
 out of bed or striking the wall or head of the bed during con- 
 vulsions. 
 
 By striving to accomplish these general results for her eclamp- 
 tic patient the nurse will aid immeasurably in saving her life. 
 
 A milk diet is the means of reducing the nitrogen intake ; or 
 in some cases even that small amount of proteid is deemed too 
 much, and only water is given until 24 to 48 hours after the con- 
 vulsive seizures have ceased. From three to five litres of these 
 fluids should be given in the course of twenty-four hours, in 
 order to increase elimination by way of both kidneys and skin, 
 and it usually taxes the nurse's patience and ingenuity to give 
 this amount, for the patient will seldom take large quantities of 
 fluids willingly, even when quite conscious. A surprising amount 
 of water may be giA'en to the sleeping or unconscious patient by 
 dropping it into her mouth from the point of a teaspoon, taking 
 care to give it only at tliose moments when she is lying quite 
 still. If the nurse attempts to hold the restless patient's head, 
 or so much as places her hand upon the chin to steady it in order 
 to give water, the irritation, though slight, may be enough to 
 cause a return of the tossing and struggling. 
 
 Litliia water and cream-of -tartar lemonade (a teaspoonful of 
 cream of tartar to a pint of water), are frequently given because 
 of their diuretic and diaphoretic action ; but whatever the fluid, 
 it must be given persistently, with greatest gentleness and with 
 care that the patient does not choke nor aspirate it into her 
 lungs and thus possibly cause pneumonia. Food even in liquid 
 form is not given while the patient is unconscious, because of this 
 danger of aspiration and subsequent pneumonia. 
 
 The bowels are stimulated to greater activity by powerful 
 purges, such as croton oil, in olive oil, dropped on the back of 
 the tongue, or salts or castor oil given by stomach tube. 
 
 Copious colonic irrigations^ alternating with hot packs so 
 that one or the other is given every six, eight or twelve hours, 
 according to the seriousness of the case, are frequently given and 
 with excellent results. A colonic irrigation may be given by 
 
196 OBSTETRICAL NURSING 
 
 means of the Murphy drip metliod or through a rectal tube so 
 contrived that a two-way flow of fluid is possible. Water, nor- 
 mal saline (2 drams of salt to a quart of water), or a weak solu- 
 tion of sodium bicarbonate (an ounce of soda to a quart of 
 water) , are all used for colonic irrigations, which are given at a 
 temperature of 110° F., very slowly, with the receptacle for the 
 solution placed so low that the flow is under very slight pres- 
 sure. The patient should lie on her left side, in a comfortable 
 position and be warmly covered. The tube should be introduced 
 from 12 to 18 inches, and the stop cock arranged so that it will 
 take from twenty to thirty minutes for each gallon of fluid to 
 run in and out. About two gallons are usually used for the 
 first irrigation, the amount being increased until five gallons are 
 used each time. The beneficial effects of the colonic irrigations 
 are two-fold, for in addition to removing the toxic material that 
 may be in the colon and rectum, a good deal of fluid is absorbed 
 through the intestinal wall. 
 
 The function of the lungs may be promoted by using oxygen 
 and by keeping the air in the patient's room fresh and con- 
 stantly moving, but moving so gently that there is no perceptible 
 draft. The nurse must remember that the skin also is an excre- 
 tory organ whose function is being stimulated, and this necessi- 
 tates its being kept warm. 
 
 Some obstetricians feel that it is as important to increase 
 the excretions of the skin as of the kidneys, and that inability to 
 induce perspiration is an unfavorable sign. Others, who dis- 
 agree on this point, believe that the skin is of minor importance 
 but that the bowels are of equal consequence with the kidneys. 
 However, the nurse will do no harm, and will err on the safe 
 side if she takes care to keep her patient warm and constantly 
 protects her from being chilled, that is from exposure or changes 
 in the temperature of her surroundings. A flannel nightgown 
 or dressing gown will help to this end, or if neither is available, 
 at least the patient's chest and arms may be protected by warm 
 bedjacket, or sweater, put on backwards and fastened at the 
 back of the neck. This protection, together with a number of 
 blankets, with or without hot water bags between them, will often 
 induce a slight but constant perspiration, particularly if fluids 
 
COMPLICATIONS AND ACCIDENTS OF PREGNANCY 197 
 
 by mouth are being forced at the same time. This may be all 
 of the stimulation that the skin needs, and has the advantage of 
 not greatly disturbing the patient, a point that cannot be too 
 constantly borne in mind. 
 
 If something more is needed, the hot dry pack is a widely used 
 and usually efficacious method of producing a sweat and can be 
 given easily in the patient's home with no more equipment than 
 the average family possesses or can obtain. The articles needed 
 are two rubber sheets or two heavy quilts ; four blankets ; three, 
 four or five hot water bags; an ice cap or a basin with ice and 
 
 Fig. 48. — Patient in hot pack given Avitli dry blankets and hot-water 
 bags. The blankets are turned back in this picture to show their arrange- 
 ment. (From photograph taken at Johns Hopkins Hospital.) 
 
 two cloths for the patient 's head ; a pitcher of the fluid that she 
 is taking, and a feeding cup, drinking tube, small i)itcher or a 
 spoon with which to give it. One rubber sheet (or one of the 
 quilts), and two blankets should be slipped under the patient, 
 after the regular bedclothes have been loosened at the foot. 
 If the patient is having convulsions it is better to leave on 
 her a warm garment with sleeves to insure against her arms 
 and chest being uncovered, otherwise the nightgown may be 
 removed. 
 
 The patient is covered with one blanket which is tucked be- 
 
198 OBSTETRICAL NURSING 
 
 tween her legs and around her body with her arms out, so that 
 no two surfaces of the skin come in contact. The blanket on 
 which she lies is brought up about her; another blanket should 
 be laid over this and tucked in well about the neck, shoulders 
 and entire body, while the fourth blanket is next wrapped around 
 her from below. One long or tAvo short hot water bottles should 
 be placed on each side of the patient and one at her feet, all 
 being placed outside the four blankets. The second rubber sheet, 
 or quilt, is thrown over the whole and the ice cap, or cold com- 
 presses (changed every four or five minutes) placed on her fore- 
 head. (Fig. 48.) 
 
 A patient may usually be left in such a pack as this from half 
 an hour to an hour, but since any sweat bath is more or less de- 
 pressing, she must be watched constantly for evidence of ex- 
 haustion, such as a weak, rapid, irregular pulse and increased 
 weakness, or the sudden relaxation of an active eclamptic patient. 
 
 In some instances the hot-water bags may be inadvisable, be- 
 cause of supplying more heat than the condition of the patient 
 warrants; but if they are used, the nurse must remember how 
 easily an unconscious or ill person is burned. She must watch 
 the bags, move them frequently and take care that one of them 
 does not slip under the patient. And while the pack is in prog- 
 ress, an even greater effort than ever should be made to force 
 the fluids. 
 
 If the blankets are wrapped snugly about the patient, alter- 
 nately from below and above as described, they will frequently 
 provide all of the restraint that is necessary should she have a 
 convulsion while in the pack. The importance of protecting her 
 against exposure and chilling while in the pack cannot be too 
 insistently stressed. 
 
 If I have seemed to dwell at surprising length upon rudimen- 
 tary nursing details, in this connection, it is because the patient 's 
 life literally depends upon the nurse's conscientious and pains- 
 taking attention to these same details. The doctor may study 
 the case ever so earnestly and order the treatment ever so wisely, 
 but if every detail of that treatment is not thoughtfully and 
 skilfully carried out, it may do the patient more harm than 
 good. And on the other hand. I can think of no circumstance 
 
COMPLICATIONS AND ACCIDENTS OP PREGNANCY 199 
 
 that gives the nurse deeper gratification than the almost miracu- 
 lous improvement in an eclamptic patient, sometimes only over- 
 night, after she has taxed to the utmost all of her ingenuity to 
 make her ministrations effective. 
 
 Appliances for giving hot packs and hot-air baths are usually 
 found in all hospitals, and the nurse will use them as directed, 
 which obviates any necessity for describing them here. But in 
 addition to correctly adjusting and using the appliance itself, 
 she must watch her patient for evidence of exhaustion or shock ; 
 protect her from burns ; keep cold applications on her head and 
 give her as much fluid as possible. And when the hot pack is 
 over, the patient must be taken from it gradually ; one blanket at 
 a time, or the heat slowly reduced, and then the greatest care 
 taken that she is not chilled while being put into dry clothing, 
 for she must be kept warm and perspire slightly even after the 
 sweat is finished. 
 
 Restraint during convulsions should be as mild as possible, 
 for resistance only increases the patient's excitement, and sus- 
 tained effort should be made to reduce it instead. To this end 
 there are innumerable details to be considered. Every act must 
 be performed as quietly as possible. The nurse must walk lightly 
 and if her tread will be made softer by wearing bedroom slip- 
 pers, she should wear them. She should consciously guard 
 against kicking or striking the bed. All talking should be in 
 low tones; doors opened and closed quietly; papers should not 
 be rustled nor furniture scraped on the floor. The room should 
 be as dark as is feasible and the source of light screened fr9m 
 the patient's eyes. 
 
 She should be saved from biting her tongue by having placed 
 between her teeth something that will serve as a mouth gag and 
 still not cut nor bruise the mucous membranes. In a private 
 home, one will find that a cork answers admirably ; or the handle 
 of a wooden spoon well wrapped with gauze or a clean handker- 
 chief ; or a small roll of bandage or clean cloth tightly rolled. 
 Another method is to take a fresh handkerchief, or napkin, in 
 the fingers by opposite corners, twist it slightly into a roll and 
 force it between the teeth and tie the two corners firmly together 
 at the back of the neck. 
 
200 OBSTETRICAL NURSING 
 
 Venesection. The large intake of fluids tends to dilute and 
 eliminate the toxins which are giving so much trouble, but an- 
 other very prompt and efficacious measure is to withdraw from 
 500 cubic centimetres to 1000 cubic centimetres of blood by 
 venesection, according to the condition of the pulse. In prepar- 
 ing for a venesection the nurse will slip a small rubber, covered 
 with a towel, under the arm that is to be opened, and scrub the 
 inner surface of the elboAV with soap and solutions according to 
 the wishes of the doctor in charge, and cover the cleaned area 
 with a dry sterile towel or one wet with a disinfecting solution. 
 A sterile towel should be slipped under the patient's arm, one 
 laid over the arm above and one below the cleaned area so that 
 the entire surrounding field is protected by sterile towels. 
 
 For the puncture there will be needed a sterile canula, or in- 
 fusion needle, with a piece of rubber tubing attached; a sterile 
 receptacle for the blood, usually a 1000 cubic centimetre, gradu- 
 ated measuring-glass; both dry and alcohol sponges or cotton 
 pledgets; adhesive plaster, or a bandage to hold in place the 
 small dressing which is .applied after the needle is withdrawn ; 
 and a tourniquet for tight application to the upper arm to impede 
 the return of the venous blood and thus distend the large vein to 
 be seen near the surface of the inner curve of the arm. This vein 
 usually may be easily pierced, without incising the skin, the 
 canula pointed toward the hand to meet the blood stream, after 
 which the tourniquet is removed. Sometimes it is necessary to 
 incise the skin in order that the vein may be exposed and the 
 needle inserted into it directly. In this case the doctor will need, 
 in addition to the articles already mentioned, a scalpel, a pair of 
 tissue forceps, three or four artery clamps, a needle holder, skin 
 needles and sutures. 
 
 A venesection is practically always followed by a drop in the 
 blood pressure and a marked improvement in the general con- 
 dition. 
 
 Infusions, or subcutaneous injections of saline solutions, are 
 also frequently given to eclamptic patients with beneficial results. 
 About 1000 cubic centimetres at 105° F. is introduced slowly into 
 the tissues, and the solution may be normal saline, consisting of 
 two drams of common salt to a litre of distilled water, filtered 
 
COMPLICATIONS AND ACCIDENTS OF PREGNANCY 201 
 
 and sterilized; or possibly one containing five grains each of 
 sodium bicarbonate and sodium chloride to the litre. 
 
 The articles necessary, in addition to the soap and solutions 
 for cleaning up the skin, are a small rubber to protect the bed; 
 three or four sterile towels ; a flask of the solution at 105° F. ; 
 sterile infusion bottle, or can, with rubber tubing fitted with a 
 piece of glass tubing at some point in its length, through which 
 the flow of the solution may be watched, a stopcock, and an in- 
 fusion needle (I cannot refrain from cautioning the nurse to be 
 sure that the tubing does not leak; is not collapsed and stuck 
 together at any point along its length, and that the needle is 
 sharp, free from rust and contains a wire as evidence of not being 
 clogged) ; two hot water bottles about half full, with air ex- 
 pelled ; a pole or stand upon which to hang the bottle ; a package 
 of gauze sponges, or squares, and narrow strips of adhesive. 
 
 The fluid is usually introduced between the breast tissues 
 and underlying muscles; the area to scrub up in preparation 
 being just below the breast, where the curve begins, and toward 
 the axilla. The bottle which contains the solution should be 
 stoppered with sterile cotton, or, if a can, covered with a sterile 
 towel, and hung between the hot water bottles, to keep the fluid 
 warm, and held in place with a towel pinned around them, top 
 and bottom. (Fig. 49.) 
 
 If the nurse is to give the infusion, she should grasp the end 
 of the needle, to which the tubing is attached, with her right 
 hand, pierce a piece of sterile gauze; open the stop cock and 
 allow the air and cold fluid to escape, leaving a drop on the point 
 of the needle; lift the patient's breast with her left hand and 
 quickly plunge the needle in just under it. The direction of the 
 needle should be parallel to the chest wall to insure its running 
 below the breast tissue, and above, not between the ribs. The 
 needle, and the gauze through which it runs, may be held in 
 place by means of narrow strips of adhesive plaster. The stop 
 cock should be so adjusted that the warm fluid will flow into the 
 tissues very slowly, about an hour being required to introduce 
 1000 cubic centimetres. During this time the patient must be 
 kept well covered and the solution kept at about 105° F. as some 
 of the heat is lost in its course through the tubing. A hot water 
 
202 OBSTETRICAL NURSING 
 
 Fig. 49. — Infusion being given under breast; needle held in place by 
 strips of adhesive and the solution kept warm by hot-water bottles sus- 
 pended on each side of the infusion bottle. 
 
COMPLICATIONS AND ACCIDENTS OF PREGNANCY 203 
 
 bag placed upon the bed, over a coil of the tubing, is another 
 means of maintaining the desired temperature, but it must be 
 watched and mo-ed from time to time, to guard against burning 
 the patient. In hospitals where the infusion apparatus is 
 equipped with a heater, hot water bags are, of course not needed, 
 but they are of practical service in a patient's home. 
 
 Termination of pregnancy is resorted to much less frequently 
 than formerly, because it is believed that an eclamptic patient 
 is particularly susceptible to infection and also that the shock 
 of an induced labor is serious to so ill a woman. 
 
 The method of terminating pregnancy, when this is finally 
 deemed necessary, depends upon the condition of the cervix ; the 
 size of the child; and upon the patient's general condition. The 
 method may be simple induction of labor, by the introduction 
 of a bougie, if haste is not imperative; introduction of a bag; 
 manual dilation of the cervix, if it is soft and partly obliterated ; 
 vaginal hysterectomy, or even cesarean section. 
 
 Chloroform is not used as an anesthetic, in eclampsia, nor 
 to relieve the labor pains nor control the convulsions because of 
 its tendency to increase the liver necrosis which is incidental to 
 the disease. 
 
 Recovery is comparatively rapid, when it occurs. The blood 
 pressure drops to normal ; the albumen and casts disappear from 
 the urine and all symptoms subside in from two to four weeks. 
 (Chart I.) And, happily, since one attack confers an immunity, 
 the patient who recovers from eclampsia need not fear a recur- 
 rence of the disease. 
 
 Nephritic Toxemia is a serious toxemia, sometimes compli- 
 cating pregnancy, and though it may occur at anj^ time during 
 the period of gestation, it usually develops during the latter 
 months. As a rule, it is simply an exacerbation and accentuation 
 of a previously existing, chronic nephritis, of which the patient 
 may, or may not, have been aware ; though in some instances the 
 disability of the kidneys may arise during pregnancy. In many 
 cases, so far as the kidneys are concerned, the patient is entirely 
 normal in the non-pregnant state, and even during pregnancy, up 
 to a certain point; then her kidneys prove to be unequal to the 
 
204 
 
 OBSTETRICAL NURSING 
 
 added metabolic strain of pregnancy, and signs of renal insuffi- 
 ciency appear. 
 
 Such a patient will suffer from toxemia, with each recurring 
 
 Name vA^^I^^eAV. MS. 
 
 Date -^-^^fi• ^ ^C'..r...Ai\ 
 
 Cram* y 
 Alb.per/\ eo ^ 
 Liter. 
 
 Chart 1. — Chart showing relatively rapid disappearance of albumen 
 from the urine and return of blood pressure to normal, after delivery in 
 eclampsia. 
 
 pregnancy, the symptoms almost always appearing earlier, and 
 with increased severity, with each pregnancy, as the permanent 
 damage to the kidneys is increased by each successive attack. 
 Syiiiptoins. The symptoms in nephritic toxemia are prac- 
 
COMPLICATIONS AND ACCIDENTS OF PREGNANCY 205 
 
 tically the same as those in chronic nephritis: lassitude, head- 
 ache, visual disturbances, edema, high blood pressure and casts 
 and large amounts of albumen in the urine. In some instances, 
 the patient suffers such slight discomfort that the increased blood 
 pressure and urinary symptoms are the only precursors of coma, 
 and possibly convulsions which cannot be distinguished from an 
 eclamptic seizure. 
 
 As the patient may die in the coma, no matter how suddenly 
 it develops, the value of regular urinalyses and observations upon 
 the blood pressure, which are included in prenatal care, must 
 once more be mentioned. 
 
 In severe, chronic cases infarcts (hemorrhagic or necrotic 
 areas) appear in the placenta. These may be extensive enough 
 to interfere with the nourishment of the fetus, which, being al- 
 ready weakened by the toxic effects of the disease, is unable to 
 survive. As a result, nephritic toxemia is second only to syphilis 
 in causing premature deaths. When the child dies, the symptoms 
 usually begin to subside in a week, or possibly two, and the dead 
 fetus is expelled. 
 
 Treatment and Nursing Care. The treatment and nursing 
 care are virtually the same as for pre-eclamptic toxemia ; rest 
 in bed, milk diet, forced fluids, purges, and in addition, observa- 
 tions upon the intake and output of fluids. The output of urine 
 will not equal the amount of fluid which the patient takes in, 
 at first, but in those patients who improve, the amount of urine 
 gradually increases until it equals the amount of fluid ingested. 
 The edema and other symptoms improve, except the high blood 
 pressure and the albumen in the urine, which sometimes persist 
 for months. (Chart 2.) 
 
 If the patient has coma or convulsions, the treatment is the 
 same as in eclampsia. 
 
 A patient with inadequate kidneys who has never been able 
 to carry a child to term may sometimes achieve this coveted end 
 by going to bed a few weeks before the period in her pregnancy 
 Avhen the toxic symptoms have usually appeared, taking only 
 milk for food, drinking large amounts of water, and keeping 
 her bowels moving freely. 
 
 It is impossible to distinguish between eclampsia and neph- 
 
206 
 
 OBSTETRICAL NURSING 
 
 ritic toxemia during an attack, but this is of no importance at 
 the time, as the treatment of the two diseases is the same. 
 
 But during the puerperium, the differential diagnosis may be 
 made, for in eclampsia the blood pressure falls rapidly to nor- 
 
 Name .^u5iavj. ASA!a\Xito. Ward -aXAjCm--. 
 Date..j5-ft.3A,>.....\,lo...*.W. _ 
 
 Jan. 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28 
 
 B P 
 HMHG 
 
 Grams 
 Alb. 
 
 per. 
 Iirer. 
 
 230 
 220 
 210 
 200 
 190 
 180 
 170 
 
 _i 
 
 z: " ze: 
 
 1 1 
 
 c J 
 
 1 
 
 
 i; J 
 
 
 ! : 
 
 ^ - 
 
 
 J 
 
 i -y- 
 
 
 i 
 
 1 3 ' ' -U' 
 
 
 ! 
 
 5 y^ i i 1 j 
 
 1 
 
 
 Qi ^ i I j 1 1 i ! 
 
 
 !^ 1^ i i 1 1 i 1 
 
 ! 
 
 ^ f^ \ \ \ \ \ 1 i 
 
 i 
 
 ^ i ! i i 1 ! ! i ! 
 
 j 
 
 ^ I ! 1 j M { ! 1 ! I 
 
 
 i ! i ii 1 i ! I i i 
 
 i 
 
 
 J 1 
 
 ji u ! n» j 1 i [mi ! ! ! 
 
 
 
 mT- ^ 
 
 I ! { i 
 
 1/ ■ ^ \ y 
 
 •1 1 i^. 
 
 j 1 1 
 
 Ji i iC^ 
 
 II 1 x_ 
 
 
 1 
 
 \ ] \ ^^ 
 
 * *\.>^ 
 
 
 -U4-i-i -4 
 
 
 
 U_L 
 
 
 X^^-a i . 
 
 J-^ V 
 
 
 \ ^ ^J^^ 
 
 T ^»-i 
 
 
 in ) r 
 
 1 ^. 
 
 1 
 
 * i 
 
 t N 
 
 
 ! 1 
 
 1 
 
 ^■■"*^. • 
 
 ; ; 
 
 
 
 i 
 
 1 
 
 i 
 
 ! 
 
 1 1 
 
 
 
 
 
 i 
 
 
 
 ! 
 
 |_ p. 
 
 
 i i 
 1 j 
 
 1 
 
 
 ! i 
 
 ■ 
 
 1 
 
 i ! i ■ 
 
 
 i 
 
 I i ' 
 
 H H 
 
 
 i i ! 
 
 1 H H 
 
 
 i ' • i 
 
 ■ HI 
 
 
 1 I i '. i 
 
 lUn 
 
 1 
 
 1 1 i i 
 
 
 i i 1 i 1 
 
 DBOi 
 
 ■1 ■■ M M M ^ ' '.! ! 1 
 
 Chart 2. — Chart showing persistence of high blood pressure and of 
 albumen in the urine, after delivery, in nephritic toxemia with convulsions. 
 
 mal and the casts and albumen disappear from the urine in from 
 two to four weeks. In nephritic toxemia, on the other hand, al- 
 though the blood pressure falls somewhat, and the albumen de- 
 
COMPLICATIONS AND ACCIDENTS OF PREGNANCY 207 
 
 creases in amount as the patient's general condition improves, 
 by the end of the puerperium the blood pressure is still elevated 
 and casts and albumen are still present in the urine. 
 
 In eclamptic cases that come to autopsy, there is a typical, 
 peripheral necrosis of the liver, but in nephritic toxemia there 
 is no liver lesion. 
 
 Acute Yellow Atrophy of the Liver is one of the grave 
 but very rare toxemias of pregnancy and though it may occur at 
 any stage it usually appears during the latter part of pregnancy 
 or during the puerperium. This complicating condition is not 
 peculiar to pregnancy alone, although from forty to sixty per 
 cent, of the cases which occur are in pregnant women. 
 
 The symptoms, which sometimes come on suddenly in a 
 woman who previously has been entirely well, may suggest phos- 
 phorus poisoning. They are abdominal pain, headache, vomiting, 
 and diarrhea followed in some cases by coma and convulsions, and 
 in others by violent delirium. With these symptoms are jaun- 
 dice and a diminished amount of urine, which contains albumen, 
 casts, and usually a good deal of blood. The picture is practically 
 that of pernicious vomiting plus jaundice and pain. 
 
 Little is known of the ultimate cause of the disease, but it 
 produces rapid atrophic and degenerative changes in the liver, 
 and though mild cases sometimes recover, the outcome is usually 
 fatal. It was formerly thought that the termination of preg- 
 nancy virtually cured the condition, but the present belief is 
 that delivery produces little or no effect. The tendency now, 
 therefore, is simply to employ the same kind of eliminative treat- 
 ment that is used in eclampsia. 
 
 Among the more serious complications of pregnancy, which 
 are not due to that condition, but which it is important to recog- 
 nize and treat early, may be included syphilis, heart lesions, 
 pulmonarj' tuberculosis, thyroidism, gonorrhea and pyelitis. 
 
 "Syphilis is one of the most important complications of 
 pregnancy," in the opinion of Dr. Williams, "as it is the most 
 important single cause of fetal death." 
 
 In support of this contention, Dr. Williams reports upon a 
 series of 10,000 consecutive deliveries which took place under his 
 observation, and in which syphilis caused 26.4 per cent, of the 
 
208 OBSTETRICAL NURSING 
 
 deaths among 705 babies who died after the seventh month of 
 pregnancy or during the first two weeks after birth. Further- 
 more, nearly as many more babies who were discharged alive, at 
 the age of two weeks, died in a short time or gave evidence of 
 having syphilis later on in life. 
 
 Believing in the importance of diagnosing and treating this 
 disease during pregnancy, Dr. AVilliams subsequently made obser- 
 vations upon 4,000 cases in which Wassermann tests were given, 
 and to which 421 women gave positive reactions. In this series 
 of 4,000 deliveries, 302 babies died during the last two months 
 of uterine life, or the first two weeks of extra-uterine existence. 
 The relative frequency of the various causes which worked de- 
 struction in these 302 little lives is given by Dr. Williams in the 
 following table : — 
 
 Syphilis 104 cases 34.44% 
 
 Dystocia '. . . 46 " 15.20 " 
 
 Toxemia 35 " 11.55" 
 
 Prematurity 32 " 10.59 " 
 
 Cause unknown 26 " 8.61 " 
 
 Placenta praevia and i^remature 
 
 separation 16 " 5.28 " 
 
 Deformity 11 " 3.64 " 
 
 Eleven other causes ' . . 32 " 10.69 " 
 
 Total 302 100.00 " 
 
 It will be seen from these figures that syphilis caused almost 
 as many deatlis as the three causes, next in order, combined. 
 
 The effect upon the child's chances for life, of treating the 
 expectant mother for syphilis, is suggested by comparing the 
 results among the 421 syphilitic women who were not treated at 
 all; those treated insufficiently by receiving but two or three 
 doses of salvarsan and no after-treatment of mercury (because of 
 the patient's lack of cooperation or because treatment was in- 
 stituted too late in pregnancy) ; and those treated satisfactorily, 
 which meant the administration of from four to six doses of sal- 
 varsan followed by mercurial treatment continued sufficiently 
 long to result in a Wassermann reaction that was negative, and 
 remained so. 
 
 Among those mothers who were not treated, 52 per cent, of 
 the babies were born dead or had syphilis ; among those treated 
 
COMPLICATIONS AND ACCIDENTS OP PREGNANCY 209 
 
 incompletely, 37 per cent, and among those treated until cured, 
 syphilis caused the death of or was demonstrable in but 6.7 
 per cent, of the babies.^ 
 
 The deductions to be made from these dramatic figures is, 
 that although syphilis seems to have about the same effect upon 
 the pregnant, as the non-pregnant woman, it constitutes a seri- 
 ous menace to infant life and health. 
 
 Accordingly, it is very important that every pregnant 
 woman be given the Wassermann test as early as the third or 
 fourth month, and any woman who gives a positive reaction 
 should be urged to submit to intensive treatment until cured. 
 Her compliance will apparently multiply by seven or eight her 
 expected baby's chances for life. 
 
 Heart Lesions sometimes present grave complications dur- 
 ing pregnancy, or at the time of labor, because the damaged or 
 weakened heart is unable to meet the greatly added strain put 
 upon it at these times. Spontaneous, premature labor sometimes 
 results from serious heart trouble, while in some cases labor is 
 artificially induced to relieve the overworked organ of the strain 
 that is evidently exhausting it. Quite obviously it is an im- 
 portant step toward the prevention of both these deplorable 
 occurrences to have the difficulty recognized early. Rest in bed 
 and the same kind of medical treatment that would ordinarily be 
 given for a poorly compensating heart will sometimes enable the 
 disabled organ to carry its load throughout pregnancy. But care 
 is necessary. 
 
 Pulmonary Tuberculosis is so common under all condi- 
 tions that it is not surprising to find it fairly often among preg- 
 nant women. Since the treatment for this disease consists 
 largely of effort to conserve the patient's forces and build up the 
 bodily resistance, the drain which pregnancy makes upon the sys- 
 tem is likely to be inimical to the tuberculous patient 's improve- 
 ment. It is the general opinion, therefore, that the tuberculous 
 
 ^ * ' The Value of the Wassermann Keaction in Obstetrics, Based upon 
 the Study of 4,547 Consecutive Cases." Johns Hopkins Hospital Bulletin, 
 Oct., '20. ' ' The Significance of Syphilis in Prenatal Care and in the. 
 Causation of Infant Death. ' ' Johns Hopkins Hospital Bulletin, May, 
 1921. 
 
210 OBSTETRICAL NURSING 
 
 patient grows worse during pregnancy, and is still further weak- 
 ened by the ordeal of labor and the drain of nursing her baby. 
 
 Some women with tuberculosis improve during the period 
 of pregnancy, but decline after delivery. The disease may ad- 
 vance rapidly in such cases and the patient succumb very .early. 
 
 There is gi'eat reluctance to terminate pregnancy in tubercu- 
 lous patients, except in extreme cases as a last resort, to save 
 the mother's life, or when, after the child is viable, its chances 
 for life would seem to be better if it were brought into the world, 
 because of the mother's possible death. 
 
 Certain it is that the care which is given to the non-pregnant 
 tuberculous person is needed to an even greater degree by the 
 expectant mother who is suffering from this disease. And under 
 such care, it not infrequently happens that the patient will go 
 through pregnancy safely, and if the care is continued after de- 
 livery, and her baby not allowed to nurse, her ultimate recovery 
 does not seem to be retarded by the experience. 
 
 Tuberculosis is sometimes, though not frequently, transmitted 
 from the mother to the fetus; but babies born of these mothers 
 are not likely to be robust, particularly as they must be deprived 
 of that bulwark of early infancy — maternal nursing. 
 
 Thyroidism in pregnancy has been, and still is, so widely 
 discussed and studied that the nurse will do well to at least take 
 cognizance of that fact, even though no definite conclusions seem 
 to have been generally accepted. 
 
 The toxemias of pregnancy are so shrouded in mystery, and 
 knowledge of the functions and inter-relations of the ductless 
 glands is still so meagre, though it is known that one, the ovary, 
 is inevitably concerned with pregnancy, that one is not surprised 
 to find certain investigators considering these two problems to- 
 gether. Nor is it surprising that directly opposite views are held 
 concerning the relation of thyroidism to toxemia. 
 
 Since the nurse will sometimes care for toxemic patients who 
 are treated for thyroidism, either by means of gland therapy or 
 operative procedure, she should understand the rationale of such 
 treatment when she meets it. 
 
 Dr. Williams says, for example, "A considerable amount of 
 work has been done in this direction, but the consensus of opin- 
 
COMPLICATIONS AND ACCIDENTS OF PREGNANCY 211 
 
 ion is that abnormalities of the thyroid secretion play no part in 
 the causation of eclampsia." 
 
 On the other hand, it will be remembered that the thyroid 
 gland is usually somewhat enlarged during pregnancy, and in 
 this connection Dr. Edgar observes that "The normal enlarge- 
 ment of this organ in tlie gravida has been wanting in certain 
 cases of eclampsia. ' ' 
 
 Dr. Edward P. Davis summarizes his opinions on the subject 
 as follows: "Hyper-thyroidism in pregnancy produces a toxic 
 condition in the mother, which exposes her to the danger of the 
 toxemia of pregnancy and her child to the dangers which accom- 
 pany that condition. During pregnancy, the patient has a rapid 
 pulse, often with high tension, and attacks of breathlessness and 
 syncope, and intense nervousness. When uterine contractions 
 begin, the action of the heart becomes exceedingly rapid; there 
 is difficulty in breathing and the patient is brought into great 
 distress. It is often necessary to give prompt assistance in la- 
 bor, and this may require the performance of cesarean section. 
 The child is exposed to the risks of rapid delivery, although, if 
 section be performed, the risk to the child is reduced to the low- 
 est point. When the placenta is examined, it is found that cer- 
 tain changes have taken place in its structure which interfere 
 with the circulation of the blood through the placenta, and may 
 indirectly bring about the death of the fetus. The child is also 
 subject to the same toxic conditions ^diich the mother has had 
 and may die from failure of the liver and kidneys or in con- 
 valescence. 
 
 "A minute discussion of the subject would be occupied 
 largely by the question of exactly what are the poisons which 
 cause this condition, and this question has not yet been definitely 
 answered. 
 
 "So far as neutralizing the results of excessive action of the 
 thyroid, it is best accomplished by rest, a diet from which meat 
 and other heavy proteins are excluded, regulation in the action 
 of the bowels and the avoidance of nervous excitement or undue 
 exertion. If the action of the heart is excessively disturbed, 
 those drugs which control cardiac action must be used. In ex- 
 treme cases, morphine and atropine are given." 
 
212 OBSTETRICAL NURSING 
 
 Pyelitis is a fairly common, and sometimes a very painful 
 and serious complication arising during the latter half of preg- 
 nancy. It is an inflammation of the pelvis of the kidney, most 
 frequently the right, caused by a damming back of urine, because 
 of pressure of the enlarged uterus on the ureter where it crosses 
 the pelvic brim ; and by infection, which may travel up from the 
 bladder or be conveyed by the lymph and blood streams, fre- 
 quently from the intestines. The colon bacillus is the commonest 
 offender, though the streptococcus, gonococcus or even the 
 tubercle bacillus may be the cause. 
 
 Frequently the patient will be entirely well, aside from a 
 slight irritability of the bladder causing frequent micturition, 
 and suddenly have paroxysms of acute pain in the region of the 
 kidney, which may be swollen and very painful on palpation. 
 She will have fever and sometimes chills and a catheterized speci- 
 men of urine will contain pus and bacteria. The kidney may 
 suddenly empty itself of pus after which the pain and swelling 
 will subside, only to recur when the pus accumulates again. 
 
 The treatment is rest in bed, a bland diet and an abundance 
 of milk and water to drink. As the infection is often of intes- 
 tinal origin, drugs are usually given to prevent intestinal fer- 
 mentation and keep the bowels moving freely. Sometimes, 
 though rarely, when the patient does not improve under treat- 
 ment, pregnancy is terminated to relieve the pressure on the 
 ureter and thus drain the diseased kidney by permitting an un- 
 obstructed flow of urine. 
 
 The tendency of the disease is to subside spontaneously, but 
 sometimes it is necessary to incise and drain the kidney, or even 
 to remove it ; while in others the infection is so virulent that the 
 patient dies of septicemia. 
 
 Gonorrhea during pregnancy may cause great discomfort 
 in the shape of irritation and itching of the vulva, or even ex- 
 coriation of the mucous membrane, and sometimes abscesses of 
 the vulvovaginal glands. Occasionally the infection reaches the 
 decidua and causes an abortion. But the chief danger in gonor- 
 rhea is that, after delivery, if the disease has remained uncured, 
 the organisms may travel up from the vagina to the uterine cav- 
 ity and tubes, and there set up an inflammation, or possibly cause 
 
COMPLICATIONS AND ACCIDENTS OF PREGNANCY 213 
 
 a general postpartum infection. The greatest danger to the child 
 is that its eyes may become infected during the passage of the 
 head through the birth canal. This is the reason for the very 
 great care that is taken of the eyes of the newborn, which will 
 be described in a later chapter. 
 
 It is very important, therefore, for the sake of both mother 
 and child, that gonorrhea be discovered early, for treatment 
 started at this stage is often attended by very gratifying results, 
 as the disease may be entirely cured before it is able to invade the 
 uterus and tubes. This is because the closure of the internal os, 
 by the membranes, converts the vagina and cervix into more or 
 less of a cul-de-sac, to which the infection is restricted. Being 
 thus localized, it may often be eradicated with relatively little 
 trouble. 
 
 The yellow vaginal discharge, characteristic of gonorrhea, 
 may become profuse and purulent. It is removed by means of 
 low, very gently given douches. Tampons and vaginal supposi- 
 tories are sometimes used, while abscesses and abrasions are given 
 appropriate surgical treatment. 
 
 The nurse must observe the strictest technique while caring 
 for these patients because of the danger of infecting herself and 
 others with the discharges. She should wear a gown and rubber 
 gloves when giving douches or dressing diseased vulva, and be- 
 cause of the possibility of contamination by splashing fluids, she 
 should hold her head well to one side in addition to protecting 
 her eyes with goggles. All utensils for each patient should be 
 isolated and they should also be washed and boiled after each 
 time that they are used. 
 
"Lying-in is neither a disease nor an accident, and any 
 fatality attending it is not to be counted as so much per cent, of 
 inevitable loss. On the contrary, a death in child-bed is almost 
 a subject for an inquest. It is nothing short of a calamity which 
 it is right that we should know all about, to avoid it in future." 
 
 Florence Nightingale. 
 
PART IV 
 
 The Birth of the Baby 
 
 chapter x. presentation and position of the fetus. 
 
 Breech, Head, Face, and Vertex Presentations. Longitudinal and 
 Transverse Presentations. Position of Fetus. Time of Engage- 
 ment. Methods of Ascertaining Position and Presentation of Fetus. 
 Abdominal Palpation. Vaginal Examination. Rectal Examination. 
 Auscultation of the Fetal Heart. 
 
 CHAPTER XI. SYMPTOMS, COURSE, AND MECHANISM OF NOR- 
 MAL LABOR. Onset of Labor. Three Stages of Labor. 
 
 CHAPTER XII. NURSE'S DUTIES DURING LABOR. General Prin- 
 ciples of Treatment and Nursing Care. Psychology of the Patient. 
 Preparation for Vaginal Examination or Delivery. Nurse 's Duties 
 during First Stage. Second Stage. Maintaining of Surgical Cleanli- 
 ness. Immediate Care of the Child. Resuscitation of New-born 
 Child. Third Stage. Immediate Aftercare of the Patient. Nurse 's 
 Duties if the Doctor Is Delayed. Prolapsed Cord. Post-partum 
 Hemorrhage. Obstetrical Anesthesia: Chloroform. Ether. Nitrous 
 Oxide Gas Analgesia. Twilight Sleep. Complete Anesthesia. 
 
 CHAPTER XIII. OBSTETRICAL OPERATIONS AND COMPLICATED 
 LABORS. Conditions Giving Rise to Operations. Preparation for 
 Operation in the Home. Perineal Lacerations. Episiotomy. Breech 
 Extraction. Version. The Use of Forceps. Symphysiotomy. 
 Vaginal Hysterotomy. Cesarean Section. Ruptured Uterus. De- 
 structive Operations. Induced Abortions and Premature Labors. 
 Accouchment Force. 
 
CHAPTER X 
 
 PRESENTATION AND POSITION OF THE FETUS 
 
 Returning for a moment to the pregnant uterus at term, we 
 find it to be a thin-walled, muscular sac containing the mature 
 fetus, attached by means of the umbilical cord to the placenta 
 
 Pio. 50. — Most frequent attitudfe of fetus in uterine cavity, at term. 
 
 217 
 
218 
 
 OBSTETRICAL NURSING 
 
 and floating in the amniotic fluid, which is contained within a 
 sac formed by the amniotic and chorionic membranes. 
 
 The average fetus at term is about 50 centimetres long, 
 weighs about 3250 grams and is curved and folded upon itself 
 into an ovoid mass, occupying the smallest possible space. (Fig. 
 50.) Its most frequent attitude is with the back arched ; the head 
 bent forward, with chin resting upon chest; arms crossed upon 
 chest below chin ; thighs flexed upon abdomen and knees bent. 
 
 With a few exceptions the long axis of the fetus is parallel to 
 the long axis of the mother, and most frequently the head is 
 
 Fig. 51. — Illustrations from the first textbook on obstetrics, Koesslin's 
 " Rosengarten, " 1513, which gives an amusing impression of early ideas 
 of the position of the fetus in utero. 
 
PRESENTATION AND POSITION OF THE FETUS 219 
 
 downward. It was formerly believed that the child stood upright 
 in the uterus until toward the end of pregnancy and then somer- 
 saulted to the position it occupied immediately before birth. 
 (Fig. 51.) But it is now known that though the fetus may move 
 about and change its position during the early part of preg- 
 nancy, it is not likely greatly to alter its relation to the mother's 
 body during tlie tenth lunar month. 
 
 It seems advisable to define here certain terms which are in 
 
 Fig. 52. — Attitude of fetus in breech presentation. 
 
 common use in discussing patients in labor, and which will be 
 employed in the following pages. 
 
 A nullipara (0-para) is a woman who has not had children. 
 
 A primigravida is a woman who is pregnant for the first time. 
 
 A primipara (1-para) applies to a woman during her first labOr and 
 until the beginning of her second labor. 
 
 2-para, 3-para and 4-para apply to women in succeeding labors 
 which correspond to the numerals used. 
 
 A multipara is a woman who has had more than one child. 
 
220 
 
 OBSTETRICAL NURSING 
 
 There is also a terminology, with abbreviations, -which is 
 fairly generally used in this country and England to designate 
 the position which the child, about to be born, occupies in rela- 
 tion to its mother's body. A diagnosis of this position is, of 
 course, absolutely necessary to a skilful management of labor, 
 and the nurse should understand the meanings of the terms used, 
 and also their distinctions and subdivisions. 
 
 The presentation of the fetus is the term which is employed 
 
 Fig. 53. — Attitude of fetus in vertex presentation. 
 
 to indicate the part of the baby's body which is at the brim of 
 the mother's pelvis. Thus the part of the fetus which is lower- 
 most is designated as the presenting part and gives the presenta- 
 tion its name. If the breech is downward, therefore, it is a 
 hreech presentation (Fig. 52), and if the head is the lower pole 
 it is termed a head, or cephalic presentation. (Fig. 53.) The 
 head presentations are divided into two main groups, which are 
 designated, respectively, as face and vertex presentations. For 
 
PRESENTATION AND POSITION OF THE FETUS 221 
 
 example, if the baby 's neck is so arched that the chin rests upon 
 the chest, the crown of its head, or the vertex, is the part that 
 is lowest in the birth canal and is the part that will be seen 
 first at the vaginal outlet. Therefore, this is called a vertex, or 
 occipital presentation. But if the neck is bent sharply back- 
 ward, the face becomes the presenting part and we have a face 
 presentation. 
 
 The breech, face and vertex presentations are sometimes re- 
 ferred to as longitudinal presentations since in these instances the 
 long axes of the bodies of mother and child are parallel. In 
 transverse presentations, however, the child lies across the uterus, 
 with one side or the other at the pelvic brim. 
 
 The transverse presentations are infrequent, occurring once 
 in about 250 cases, and are regarded as abnormal because spon- 
 taneous delivery under such circumstances is extremely rare. 
 They are more likely to be seen, w^hen they do occur, among 
 multiparas and w^omen who have contracted pelves. 
 
 The longitudinal presentations, however, constitute something 
 over 99 per cent, of all cases and are regarded as normal, since 
 the child occupying this relationship may be born spontaneously. 
 In about 3 per cent, of the longitudinal presentation the breech 
 is the presenting part and in about 97 per cent, it is the head. 
 Of these, the vertex presentation is the one most commonly seen 
 and is the one in which the child is most easily delivered. Face 
 presentations are very rare, occurring in only a fraction of 1 
 per cent, of all cases. 
 
 In addition to the child's presentation, there is also its 
 position, whicli is an entirely different matter, for in each longi- 
 tudinal presentation the presenting part may occupy any one of 
 six positions. 
 
 By position is meant the relation of some arbitrarily chosen 
 point on the presenting part of the fetus, to the right or left 
 side of the mother, and to the front (anterior), side (transverse) 
 or back (posterior) segment of that side. 
 
 Taking these up in turn, w^e find, that in transverse presenta- 
 tions the shoulder, acromion process, is the point on the baby's 
 body which is chosen, to give the four possible positions their 
 names. 
 
222 OBSTETRICAL NURSING 
 
 In breech presentations the sacrum is the arbitrarily chosen 
 point. 
 
 In face presentations it is the chin, or mentum, while in ver- 
 tex presentations the occiput is the point chosen. 
 
 Presentation, then, describes the relation of the long axis of 
 the entire fetal body to the mother's body, while position de- 
 scribes the relation between the baby 's shoulder, sacrum, face or 
 occiput to the mother's pelvis. 
 
 If the child is so placed in the uterus that the head is the 
 presenting part; the neck arched with chin on chest, and the 
 occiput directed toward the mother's left side, and more to the 
 front than to the side, the presentation would be longitudinal, 
 of the vertex variety, and the position would be a left-occipito- 
 anterior. The arbitrarily chosen point on the child's body (the 
 occiput) would be directed toward the left, anterior segment of 
 the mother's pelvis. This is the situation most commonly seen 
 
 ^^'^/VA^^^€^'P%rnLoi 
 
 LOP 
 
 Pig. 54. — Diagram showing the six possible positions in a vertex 
 presentation. 
 
 and the description of this presentation and position are abbre- 
 viated, by taking the first letter of each word, into L. 0. A. 
 
 If the occiput were turned directly toward the mother's left 
 side, neither to the front nor the back, we should have a left- 
 occipito-transverse, L. 0. T., and if it were directed toward the 
 left posterior segment of the pelvis the position would be left- 
 occipito-posterior, or L. 0. P. As there are three corresponding 
 positions on the right side, anterior, transverse and posterior, 
 there are six possible positions for tlie child to occupy in the 
 vertex, or occipital presentations, as follows : 
 
 Left-occipito-anterior, abbreviated to L.O.A. 
 Left-occipito-transverse, abbreviated to L.O.T. 
 
PRESENTATION AND POSITION OF THE FETUS 223 
 
 Right-occipito-posterior, abbreviated to L.O.P. 
 Right-oceipito-anterior, abbreviated to R.O.A. 
 Right-oecipito-transverse, abbreviated to R.O.T. 
 Right-occipito-posterior, abbreviated to R.O.P. (Fig. 54.) 
 
 Similarly there are six face (Fig. 55) and six breech (Fig. 
 56) presentations. Thus, if the chin (mentum) is resting in the 
 
 WiT/r 'r^ )c^ JV- ^"^ 
 
 V {^^"^ ) I ^"^1 # 
 
 V w"' "^ / v ^ ■", / y 
 
 RMPX^ ^-^ -^LMP 
 
 Fig. 55. — Diagram showing the six possible positions in a face presentation. 
 
 left anterior segment of the mother's pelvis, the position would 
 be left-mento-anterior, or L. M. A. If the breech presents and 
 the sacrum is in that relation the position is left-sacro-anterior, 
 or L. S. A. 
 
 In describing the transverse presentations, four words, in- 
 stead of three are used; thus, left-acromio-dorso-anterior, or 
 L. A. D. A. 
 
 There are but four varieties of transverse presentations, 
 
 RST/>-3tO ^F-^\L51 
 
 ftCLPXS^, J V J^^\ ^p 
 
 Fig. 56. — Diagram showing the six possible positions in a breech 
 presentation. 
 
 since the shoulder is either anterior or posterior: thus left- 
 acromio-dorso-anterior, left-acromio-dorso-posterior and the 
 two corresponding positions on the right side. 
 
224 OBSTETRICAL NURSING 
 
 During the last two to four weeks of pregnancy, particularly 
 among the primiparse, the top of the fundus settles to the level 
 which it reached at about the eighth month, and the lower part 
 of the abdomen becomes more pendulous than formerly. The 
 patient usually breathes much more comfortably after this 
 change in contour takes place, but, at the same time, she may 
 have cramps in her legs as a result of ^he increased pressure; 
 more difficulty in walking; frequent micturition and desire to 
 empty her bowels, while the vaginal discharge may be consider- 
 ably increased. It is at this time that the presenting part enters 
 the superior strait and is spoken of as being "engaged." 
 
 The time at which engagement takes place depends upon 
 three factors: Whether the patient is a multipara or a primi- 
 para ; the size and normality of the pelvis ; the size and position 
 of the fetus. It is often helpful to the obstetrician in planning 
 for the delivery to know whether or not the presenting part is 
 engaged, particularly in primiparaB. 
 
 Although in primiparse engagement usually occurs about 
 four weeks before labor begins, it does not normally take place 
 in multiparas until immediately before labor. This difference 
 is accounted for in the increased tonicity of the uterine and ab- 
 dominal muscles of primiparous women. In certain abnormal- 
 ities, or marked disproportion between the diameters of the 
 child's head and mother's pelvis, engagement may not take place 
 until labor is well advanced, or possibly not at all. 
 
 The presentation and position of the fetus are ascertained by 
 means of abdominal palpation, vaginal examination, rectal ex- 
 amination and auscultation of the fetal heart. 
 
 Palpation of the child's body through the mother's abdom- 
 inal wall is possible under ordinary conditions, because the uter- 
 ine and abdominal muscles are so stretched and thinned that 
 the various parts may be made out through them. But it is 
 sometimes difficult in hydramnios and is practically impossible in 
 very fat patients or in the case of a ruptured uterus when the 
 fetal outline is obscured by hemorrhage. This procedure has 
 been practiced only during comparatively recent years, and is 
 regarded by many obstetricians as one of the most important 
 factors in reducing the frequency of puerperal infections and 
 
PRESENTATION AND POSITION OF THE FETUS 225 
 
 thus in decreasing maternal deaths. The explanation is that in 
 general the dangers of puerperal infection are believed to in- 
 crease in direct proportion to the number of times a patient is 
 examined vaginally ; and since it has been known how to diag- 
 nose the child's position by means of abdominal i)alpation, the 
 
 Fig. 57. — First maneuver in abdominal palpation to disco\er pixitioTi 
 
 of fetus. 
 
 necessity' for vaginal examinations is not so great and the}' are 
 accordingly made less frequently. 
 
 Rectal examinations may also be regarded as a factor in pre- 
 venting infection, for, since much the same information may 
 be obtained by means of them as by vaginal examinations, after 
 the onset of labor, they often replace direct exploration of the 
 easily infected birth canal. 
 
22C 
 
 OBSTETRICAL NURSING 
 
 Abdominal palpation, as usually practiced, consists of four 
 maneuvers, with the patient lying flat and squarely on her back 
 with the abdomen exposed. The nurse should bear in mind that 
 successful palpation requires even pressure. Cold hands applied 
 to the abdomen or quick, jabbing motions with the fingers will 
 
 Fig. 58. — Second maneuver in abdominal palpation. 
 
 usually stimulate the muscles lying beneath them to contract, 
 thus somewhat obscuring the outline of the child. Such palpa- 
 tion is also very uncomfortable for the patient; but firm, even 
 pressure, started gently, with warm hands, does not hurt. 
 
 First Maneuver. The purpose of the first maneuver is to 
 ascertain what is in the fundus ; this is usually either the head or 
 the breech. The nurse should stand facing the patient and gen- 
 
PRESENTATION AND POSITION OF THE FETUS 227 
 
 tly apply the entire tactile surface of the fingers of both hands 
 to the upper part of the abdomen, on opposite sides and some- 
 what curved about the fundus. (Fig. 57.) In this way the out- 
 line of the pole of the fetus which occupies the fundus may be 
 made out. If the head is uppermost, it will be felt as a hard, 
 
 Fig. 59. — Third maneuver in abdominal palpation. 
 
 round object which is movable or hallottnhle between the two 
 hands, and if the breech, it will be felt as a softer, less movable, 
 less regularly shaped body. 
 
 Second Maneuver. Having determined whether the head or 
 the breech is in the fundus, the next step is to locate the child's 
 back and the small parts in their relation to the right and left 
 sides of the mother. This is accomplished by slipping the hands 
 
228 
 
 OBSTETRICAL NURSING 
 
 down to a slightly lower position on the sides of the abdomen 
 than they occupy in the first maneuver, and making firm, even 
 pressure with the entire palmar surface of both hands. The 
 back is felt as a smooth, hard surface under the palm and fingers 
 of one hand, and the small parts, or hands, feet and knees, as 
 
 Fig. 60. — Fourth maneuver in abdominal palpation. (This series of pic- 
 tures is from photographs taken at Johns Hopkins Hospital.) 
 
 irregular knobs or lumps, under the hand on the opposite side. 
 (Fig. 58.) 
 
 Third Maneuver. Unless the presenting part is engaged, the 
 third maneuver virtually amounts to a confirmation of the im- 
 pression gained by the first maneuver, by showing which pole is 
 directed toward the pelvis. The thumb and fingers of one hand 
 
PRESENTATION AND POSITION OF THE FETUS 229 
 
 are spread as widely apart as possible, applied to the abdomen 
 just above the symphysis and then brought together to grasp 
 the part of the fetus which lies between them. If not engaged, 
 the head will be felt as hard, round and movable, while the 
 breech will be less clearly defined. (Fig. 59.) 
 
 Fourth Maneuver. The fourth maneuver is of particular 
 
 First and second nnaneuvers 
 
 Third and fourth maneuvero 
 
 Fig. 61. — Diagrams showing relation of nurse's hands to fetus in the 
 four maneuvers of abdominal palpation. 
 
 value after the presenting part has become engaged. The nurse 
 faces the patient 's feet in this position, and directs the first three 
 fingers of each hand down into the pelvis, on either side of the 
 fetus, to ascertain whether it is a face or vertex presentation, by 
 discovering whether chin or occiput is the higher cephalic promi- 
 nence in the mother's pelvis. (Fig. 60.) If it is a vertex presen- 
 
230 
 
 OBSTETRICAL NURSING 
 
 tation, the neck will be flexed, with the chin on the chest and 
 consequently higher in the pelvis than the occiput. The nurse's 
 fingers of one hand will accordingly come in contact with the 
 chin on the side opposite to the child's back, before the fingers 
 of the other hand reach the occiput. If, however, it is a face 
 presentation, the neck will be bent sharply backward and the 
 nurse's fingers will feel the occiput first, and on the same side 
 as the baby's back. This maneuver tells, also, how far into the 
 pelvic the presenting part has descended. 
 
 "Recto vaginal 
 'septum 
 
 ^T?ectuTn 
 
 Fig. 62. — Diagram showing method of ascertaining position of fetus 
 by means of rectal examination. Examining finger palpates head through 
 recto-vaginal septum. 
 
 Vaginal Examination. The information obtained by va- 
 ginal examination, before the cervix is dilated, is rather uncertain 
 since the child's presenting part must be palpated through the 
 fornix. But after complete, or even partial dilatation, the ex- 
 ploring finger is able to feel the sagittal suture and one fonta- 
 nelle, in a vertex presentation, and diagnose the position by dis- 
 covering the direction of the suture and whether it is the anterior 
 or posterior fontanelle that is felt. The anterior fontanelle, it 
 
PRESENTATION AND POSITION OF THE FETUS 231 
 
 will be remembered, is relatively large and four-sided, while the 
 posterior is small and more nearly triangular in shape. In a 
 face presentation, the features may be felt ; in a breech the exam- 
 ining finger can palpate the buttocks and genital crease. 
 
 Because of the possible danger of introducing infective ma- 
 terial into the birth canal, the tendency is to make fewer and 
 fewer vaginal examinations, and then only after the most pains- 
 taking preparation which will be described presently. Needless 
 to state, vaginal examinations are not within the province of the 
 nurse. 
 
 Rectal Examinations. More and more frequently rectal ex- 
 aminations are being employed to obtain information about the 
 child's position, as the examining finger is able to feel the sur- 
 face of the presenting part through the recto-vaginal septum, 
 after the cervix is dilated, and there is no danger of infecting the 
 birth canal while so doing. For this reason nurses are frequently 
 taught to make rectal examinations, thereby increasing the value 
 of their assistance to the doctor in w^atching the progress of 
 labor. (Fig. 62.) 
 
 Auscultation of the fetal heart is valuable in confirming the 
 diagnosis of presentation and position which has been made by 
 palpation. In vertex and breech presentations the heartbeat is 
 best heard through the baby 's back and in face presentations it 
 is transmitted throu^'h the chest, which presents a convex sur- 
 face in this case and fits into the curve of the uterine wall. In 
 anterior vertex presentations the heart is heard a little to the 
 side and below the umbilicus ; in transverse, further to the side.^ 
 and in posterior, well toward the back. 
 
CHAPTER XI 
 
 SYMPTOMS, COURSE AND MECHANISM OF NORMAL 
 
 LABOR 
 
 Labor may be defined as the process by means of which the 
 product of conception is separated and expelled from the 
 mother's body. It ordinarily occurs about 280 days from the 
 beginning of the last menstrual period. (See p. 93.) 
 
 The cause of labor is not known. Many theories have been 
 advanced to explain why the uterine contractions, which have 
 occurred painlessly throughout pregnancy, and without expul- 
 sive force, finally become painful at the end of the tenth month 
 and so changed in character as to extrude the uterine contents; 
 but as yet, none is wholly satisfactory nor generally accepted. 
 Nor is it known why some labors are premature and some delayed. 
 
 The onset of labor is usually marked by the patient's becom- 
 ing conscious of the uterine contractions through dragging pains 
 which may be felt first in the back and then in the lower part 
 of the abdomen and the thighs. At first the pains are feeble 
 and infrequent, but they gradually grow more severe and more 
 frequent. Intestinal colic is sometimes mistaken for labor pains, 
 but when the paroxysms are rhythmical and the uterus is felt, 
 through the abdominal wall, to grow hard as the pain increases 
 and soft as it subsides, there can be no doubt but that the pa- 
 tient is in labor. The first signs of labor may be a gush of am- 
 niotic fluid, caused by the rupture of the membranes, or ^of 
 blood, but these are not typical. 
 
 For purposes of convenience, labor is usually described as 
 consisting of three periods or stages. The first stage begins with 
 the onset of labor and lasts until the cervix is completely dilated ; 
 the second stage begins with the complete dilatation of the cervix 
 and lasts until the child is born ; the third stage begins with the 
 birth of the child and lasts until the placenta is expelled. 
 
 5232 
 
SYMPTOMS, COURSE AND MECHANISM OF LABOR 233 
 
 The entire duration of labor may vary from a few moments, 
 comprising a few pains, to several days of severe and exhausting 
 pain, but the average length of the first labor is 18 hours and of 
 subsequent labors about 12 hours, divided respectively into the 
 three periods as follows : 
 
 
 1st stage. 
 
 2nd stage. 
 
 3rd stage. 
 
 Total. 
 
 Primipara 
 
 16 hours 
 
 1% hours 
 
 15 minutes 
 
 18 hours. 
 
 Multipara 
 
 11 liours 
 
 45 minutes 
 
 15 minutes 
 
 12 hours. 
 
 The longer labor in primiparous women is due to the greater 
 tone, and thus the greater resistance offered by the muscles of 
 the cervix and perineum. Elderly primiparae are likely to have 
 longer labors than young primipara. 
 
 First Stage. This is frequently called the stage of dilata- 
 tion. During this period the contractions of the uterine muscles 
 make pressure upon the amniotic sac of fluid, forcing it gradu- 
 ally down and into the cervix as a water wedge, widening the 
 internal os first, then the external os,. until the entire canal is 
 fully dilated (thinned out) ; shortened to about one-half inch 
 in length and finally obliterated so that it is uninterruptedly 
 continuous with the lower uterine segment. (Figs. 63, G4, 65, 66.) 
 
 The first stage pains begin by being mild and occurring at 
 intervals of from 15 to 30 minutes, but they gradually increase 
 in frequenc,y and intensity until at the end of 14 to 16 hours they 
 are very severe and recur every three or four minutes, each pain 
 lasting about one minute. The pains begin in the back, pass 
 slowly forward to the abdomen and down into the thighs. 
 
 The patient is entirely comfortable, as a rule, between pains 
 and until they become very frequent will usually feel able, in 
 fact prefer, to be up and about, but if she is on her feet when 
 a contraction begins she will usually seek relief by assuming a 
 characteristic leaning position (Fig. 67) or by sitting down, 
 until the pain subsides. As dilatation advances, the patient has 
 an increasing, sometimes persistent, desire to empty the bowels 
 and bladder because of encroachment upon these two organs by 
 the descending head. She may vomit, also, when the cervix be- 
 comes nearly or quite dilated. 
 
 In the course of this stretching process, the cervix sustains 
 
234 
 
 OBSTETRICAL NURSING 
 
SYMPTOMS, COURSE AND MECHANISM OP LABOR 235 
 
 many tiny lesions, from which blood oozes and tinges the vaginal 
 discharge. This blood-stained secretion is often called the 
 "show" and usually appears toward the end of the first stage. 
 
 As a rule, when the cervix is fully dilated the membranes 
 rupture and there is a sudden gush of that part of the fluid 
 which was below the fetus in the amniotic sac, but the rupture 
 
 Fig. 67. — Characteristic position which patient often assumes during pains 
 
 in first stage. 
 
 of the membranes does not necessarily mark the end of the first 
 stage. In some instances they rupture before the cervix is fully 
 dilated ; in others, though not often, before the patient goes into 
 labor, thus producing what is known as a "dry" labor. 
 
 The abdominal muscles do not contract very forcibly during 
 the first stage, the expulsive force in this period coming almost 
 entirely from the uterine contractions. The patient's cries at 
 this time are sharp and complaining in contrast to the groans 
 and grunts which accompany the second stage. 
 
236 
 
 OBSTETRICAL NURSING 
 
 Complete dilatation of the cervix marks the termination of 
 the first stage. 
 
 Second Stage. The second stage is sometimes called the 
 stage of descent, or expulsion, of the fetus. The patient should 
 and is usually quite willing to be in bed throughout the second 
 stage, during which she should not be left alone. The pains are 
 now regular, occurring at intervals of about two minutes from 
 the beginning of one to the beginning of the pain following, and 
 as the contractions last about one minute and are excruciatingly 
 
 Fig. 68. — Diagram indicating the rotation and pivoting of baby's head 
 
 during birth. 
 
 painful, the patient has very little respite from her suffering. 
 Her face is flushed and she may perspire freely. 
 
 The abdominal and respiratory muscles are brought into ac- 
 tive use during the second stage, contracting simultaneously 
 with the uterine muscles and increasing their expulsive force. 
 These are apparently controlled by the patient 's will at first, and 
 she is able somewhat to increase their power by taking a deep 
 breath, closing her lips, bracing her feet, pulling against some- 
 thing with her hands, straining with all her might and ''bear, 
 ing down." Finally, however, the whole bearing down process 
 becomes involuntary, is accompanied by intense pain and the 
 
SYMPTOMS, COURSE AND MECHANISM OF LABOR 237 
 
 deep grunting sound, which is characteristic of the well-advanced 
 second stage. Under normal conditions, the child descends a lit- 
 tle farther into the pelvis with each contraction, and finally the 
 presenting part begins to distend the perineum and to separate 
 the labia advancing at the height of each pain and slipping 
 back a little as it subsides. 
 
 Fig. 69. — Anterior shoulder being' slipped from under symphysis to 
 facilitate birth of posterior shoulder. 
 
 The baby descends into and through the mother's pelvis by 
 means of a series of twisting and curving motions, accommodat- 
 ing the long axes of its head to the long diameters of the pelvis. 
 The head being somewhat compressible and mouldable, because 
 of imperfect ossification, is capable of a good deal of accommo- 
 dation to the mother's pelvis. 
 
238 OBSTETRICAL NURSING 
 
 The mechanism of labor, therefore, is virtually a series of 
 adaptations of the size, shape and mouldability of the baby's 
 head to the size and shape of the mother's pelvis. If the head 
 passes through the inlet satisfactorily, the rest of the labor will 
 usually be accomplished with comparative safety. But a 
 marked disproportion between the diameters of the head and pel- 
 
 
 Fig. 70. — Delivery of posterior shoulder. 
 
 vis may interfere with the engagement or descent of the head 
 and produce a serious complication. 
 
 The long diameter of the head must first conform to one of 
 the long diameters of the inlet, usually oblique, and then turn 
 so that the length of the head is lying antero-posterior in con- 
 formity to the long diameter of the outlet through which it next 
 passes. As the head descends and rotates it also describes an 
 arc because the posterior wall of the pelvis, consisting of the 
 sacrum and coccyx, is about three times as deep as the anterior 
 
SYMPTOMS, COURSE AND MECHANISM OF LABOR 239 
 
 wall formed by the symphysis. That part of the baby's head 
 which passes down the posterior wall of the pelvis must therefore 
 travel three times as far in a given time a? the part which simply 
 slips under the short symphysis pubis. 
 
 In a vertex presentation, left-occipito-anterior position, while 
 the occiput passes under the symphysis and appears at the dis- 
 tending vaginal outlet, the face passes down the posterior wall 
 and along the floor of the pelvis. As pressure is exerted by the 
 rapidly succeeding contractions, the head pivots about the pubis, 
 thus extending the neck and pushing the face farther downward 
 
 Initial point \K^\ 
 
 of reparation ^^^^^^;^ \ 
 
 Duncan 
 
 InlUal 
 of £>epafat 
 
 Schult:ie 
 
 Fig. 71. 
 
 -Diagrams showing Duncan and Schultze mechanisms of placental 
 separation. 
 
 and forward. After emergence of the back and top of the head 
 below the symphysis, the forehead appears over the posterior 
 margin of the vagina, then the brow, eyes, nose, mouth and chin 
 in turn, and the entire head is born. (Fig. 68.) The baby's 
 head then drops forward, in relation to its own body, with its 
 face toward the mother's rectum and the occiput in front of the 
 pubis, but soon the occiput rotates toward the mother's left side, 
 resuming the relation that it bore to the inner aspect of her 
 pelvis before expulsion. The undelivered shoulders are now an- 
 
240 
 
 OBSTETRICAL NURSING 
 
 tero-posterior, one under the pubis and the other resting on the 
 perineum. (Fig. 69.) The lower, or posterior shoulder is born 
 first (Fig. 70), followed quickly by the anterior shoulder and 
 the rest of the body, and the amniotic fluid which was behind 
 the child's body. Thus is the second stage completed. 
 
 Fig. 72. — Longitudinal section through uterus showing thinness of 
 uterine wall before expulsion of fetus, contrasting sharply with thickened 
 wall in Fig. 73. (From photograph of specimen, to which twin placentae 
 are still adherent in upper segment, in the obstetrical laboratory, Johns 
 Hopkins Hospital.) 
 
 Third, Stage. The third stage, sometimes termed the 
 placental stage, is that period following the birth of the child, 
 during which the placenta is delivered. For a few moments 
 after the baby is born the tired mother lies quietly and free from 
 pain, as there is a temporary cessation of the uterine contrac- 
 
aYMPTOMS, COimSE AND MECHANISM OP LABOR 241 
 
 tions, and she often sleeps as a result of the anesthetic given 
 during the second stage. 
 
 The uterus has greatly decreased in size, the fundus now 
 lying below the umbilicus where it may be felt as a firm, solid 
 mass. The uterine contractions are resumed in the course of a 
 few moments and as they persist, the uterus grows smaller, 
 thereby greatly decreasing the area 
 of placental attachment. As the 
 placenta is non-contractile it can- 
 not accommodate itself to this 
 decreased area of attachment, and 
 so is literally squeezed from its 
 moorings. It is then gradually 
 forced down into the lower uterine 
 segment where it may be located by 
 the distension of the abdominal 
 wall which it produces just abovd 
 the symphysis. After the separa- 
 tion of the placenta is complete the 
 uterus rises in the abdominal 
 cavity until the fundus is felt 
 above the umbilicus. The placenta, 
 finally, may be completely expelled 
 spontaneously, or expressed by 
 slight pressure made upon the 
 fundus by the accoucheur. 
 
 The placental detachment may 
 begin at the centre, the area of 
 separation spreading to the margin, or the detachment may 
 start at the margin of the placenta and extend toward the centre. 
 Either is normal. These two modes of placental separation are 
 named the Schultze and the Duncan, respectively, from the men 
 who first described them. (Fig. 71.) 
 
 In the Schultze mechanism, which occurs most frequently, 
 the separating process begins at the centre of the placenta and 
 the glistening fetal surface appears at the vaginal outlet. In 
 this case there is practically no bleeding during the third stage 
 
 Fig. 73. — Longitudinal sec- 
 tion througli uterus, immedi- 
 ately after labor, showing 
 marked thickening of wall as a 
 result of muscular contraction. 
 (From i)hotogra])h of specimen 
 in the obstetrical laboratory, 
 Johns Hopkins Hospital.) 
 
242 OBSTETRICAL NURSING 
 
 as the inverted placenta blocks the vagina and holds back the 
 blood. 
 
 In Duncan 's mechanism the detachment begins at the margin, 
 the placenta rolls upon itself and presents at the outlet by its 
 roughened maternal surface and there is usually slight but con- 
 tinuous bleeding from the time the separation begins. When 
 the placenta is delivered, the collapsed membranes trail after it 
 like a tapering cord. A good deal of blood is lost at the time 
 of the placental expulsion and immediately afterwards, but this 
 profuse bleeding usually subsides in a few moments. Although 
 the loss of blood may be as much as 500 cubic centimetres with- 
 out its being regarded as serious, the average amount is about 
 350 cubic centimetres. 
 
 The patient has been through a severe ordeal and at the end 
 of the third stage of labor she is usually tired out and cold. 
 
CHAPTER XII 
 THE NURSE'S DUTIES DURING LABOR 
 
 The extent of the nurse's helpfulness during labor, both to 
 the patient and to the doctor, will depend very largely upon 
 the intelligence with which she grasps what is taking place and 
 upon her own attitude, as an individual, toward the patient and 
 the miraculous event which approaches. Important as is the 
 preparation of the room and dressings, this other factor is al- 
 most equally influential. 
 
 It will be wiser, therefore, for the nurse to try to picture 
 the process of labor in each instance, and to be guided by a few 
 broad principles that apply to all cases under all conditions, 
 rather than to try to memorize the details of her duties and of 
 the desirable equipment and preparation. 
 
 The process of labor we have just described. 
 
 As to the general principles : If there is any time in a nurse 's 
 career when she should give scrupulous attention to establishing 
 and maintaining asepsis, it is during labor, for the patient 's life 
 may, and often does depend upon it. If there is any time when 
 she should be watchful for developments and for symptoms of 
 complications, it is during labor, for again the patient's life may 
 depend upon this. 
 
 Her powers of adaptability to doctor, patient and surround- 
 ings may be severely tried, for though they all may be infinitely 
 varied, the nurse must invariably be clear-headed and efficient 
 and the adequacy of her service must never fail. 
 
 The sympathetic insight, which should constantly underlie 
 the work of the obstetrical nurse, will be needed at this crucial 
 time of labor in the fullest and finest and completest sense. This 
 is almost her test as a nurse and as a womanly woman, for she 
 needs to be both, supremely. 
 
 Perhaps she had better imagine for a moment what this 
 occurrence, that we baldly term labor, may mean to the patient 
 
 243 
 
244 OBSTETRICAL NURSING 
 
 and look at it as nearly as possible from the standpoint of the 
 patient herself. It is one of the most stirring and momentous 
 experiences of her life, particularly if the expected baby is her 
 first child. She is about to realize the sweetest and tenderest 
 of dreams — that of motherhood — cherished throughout nine long 
 months. She is also approaching a period of excruciating pain, 
 and knows it, with her eyes wide open to the possibility of not 
 surviving it ; and an event so amazing in its mystery and wonder 
 that to only the most stolid can it fail to be a deeply emotional 
 experience. 
 
 And so, the young woman, to whom we refer so impersonally 
 as "the patient," is an intensely personal being at this time, 
 experiencing a number of the most poignant of the human emo- 
 tions: awe, expectancy, doubt, uncertainty, dread and in some 
 cases fear amounting almost to terror. And through it all her 
 body is being racked and exhausted with pain that grows harder 
 and harder to bear. 
 
 It is known that the ravaging effects of pain, coupled wiih 
 great emotional stress, such as fear, worry, doubt, anger or 
 apprehension, upon the physical well-being of surgical patients, 
 is such that death itself may be caused by excessive fear and 
 suffering. Accordingly, many careful surgeons take elaborate 
 precautions to tranquillize a patient who is about to be operated 
 upon, if for no other reason than to increase his chance for 
 recovery. 
 
 There can be no doubt that nervous and emotional disturb- 
 ances are detrimental to the physical well-being of the patient 
 in labor, also, and this fact alone is enough to warrant an effort 
 to avert them. If the nurse appreciates the significance of the 
 emotional influence and shapes her attitude and conduct accord- 
 ingly, she will thereby help to increase the ease and safety of 
 the actual delivery. Just what that attitude shall be, no one 
 can say, for it must be developed, in each case, in such a way 
 as to win the confidence and meet the needs of that particular 
 patient. 
 
 But in all cases the nurse should impress her patient with 
 her sincere sympathy and appreciation of the fact that she, the 
 patient, is going through a difficult time. Through it all the 
 
THE NURSE'S DUTIES DURING LABOR 245 
 
 nurse must be cheerful, encouraging and optimistic ; very gentle ; 
 very calm and reassuring in all that she does in preparing for 
 the delivery. She must steadily increase the patient's realiza- 
 tion of the part which she herself must play in the effort which 
 is being made to carry the event through to a happy issue. 
 
 The occasion need not, should not, be a mournful one but it 
 is often a very sacred one to the patient, and the nurse should 
 be dignified, almost reverential in her bearing. 
 
 If the patient feels secure in the belief that her ordeal is 
 not being taken lightly ; that it is being regarded seriously, as it 
 merits, and that every known precaution is being taken, and 
 taken confidently, to safeguard her and her baby's welfare, her 
 actual physical condition will be favorably affected by the con- 
 dition of mind thus produced. And her patience and courage 
 will often be strengthened if the nurse will explain, from time 
 to time, the cause of certain conditions that normally arise, and 
 which otherwise might give her alarm. It is the mysterious 
 events, the unexpected and unexplained that so often terrify. 
 
 This giving of comfort and strength to the variety of tem- 
 peraments and mentalities which the nurse meets among her 
 patients will involve a very sensitive adjustment of manner on 
 her part, but it is one aspect of her duty, none the less, and one 
 which will give her great satisfaction. 
 
 FIRST STAGE 
 
 Happily, the onset of labor is usually gradual, as has been 
 described, and there is accordingly ample time during the first 
 stage for deliberate and unhurried preparation for the birth of 
 the baby. The character of the preparation and of the nurse's 
 assistance will vary greatly according to the wishes of the at- 
 tending doctor ; the duration of labor ; the circumstances and con- 
 dition of the patient, and whether she is at home or in a hospital. 
 
 It is a fairly general routine, at present, both in hospitals 
 and in the home, to give the patient a soap-suds enema and a 
 shower or sponge bath, at the onset of labor; to braid her hair 
 in two braids and dress her in freshly laundered stockings and 
 nightgown and a dressing go^vn. The enema is given to empty 
 the rectum of material which might be expelled during labor 
 
246 OBSTETRICAL NURSING 
 
 and contaminate the field. For this reason, enemata are often 
 given until the fluid returns clear, virtually irrigating the 
 rectum, and are repeated every six or eight hours during the 
 first stage. The enema should be given to the patient in bed 
 and expelled into a bed-pan, as it is not wise for her to use the 
 toilet after labor has begun. Sometimes the vulva and perineal 
 region are shaved and scrubbed at the onset of labor, either be- 
 fore or immediately after the bath and enema. But the time and 
 sequence of the different steps in the preparation for labor are 
 governed entirely bj^ the wishes of the individual doctor, to 
 which the nurse may very easily adjust herself. 
 
 The patient should be given a bed-pan and encouraged to 
 void every four hours. If she is unable to do so, and the bladder 
 becomes distended, the doctor will usually wish to have her 
 catheterized, and with a rubber catheter. This distension is not 
 uncommon, and in extreme cases the bladder may reach to the 
 umbilicus. The nurse should therefore observe the amount of 
 urine which the patient voids and also watch the lower abdomen 
 for bladder distension, which may be observed easily, excepting 
 in very fat patients. 
 
 The seriousness of a distended bladder lies in the fact that 
 it may markedly retard labor, partly by interfering with the 
 descent of the baby's head and partly through reflex inhibition 
 of the uterine contractions. The prevention of a distended 
 bladder during labor, therefore, is of considerable importance. 
 
 As the pains are infrequent and not severe at first, the patient 
 will usually prefer to be up and about, most of the time during 
 the first stage, when it occurs in the daytime, and many doctors 
 think it important that she should be. They feel that patients 
 tend to stay in bed too much during the first stage, since being 
 on their feet would really promote their comfort and also have 
 a tendency to make the pains more regular and efficient. But, 
 on the other hand, the patient must be cautioned against tiring 
 herself, and should, therefore, lie down often enough and long 
 enough to avert fatigue. When labor begins at night, it is well 
 to advise the patient to stay in bed and to sleep as much as 
 possible until morning. Even though her sleep be disturbed 
 and broken by the labor pains, she will be much less tired in 
 the morning than if she had gotten up and had no sleep at all. 
 
THE NURSE S DUTIES DURliNG LABOR 247 
 
 The patient should also be advised against trying to hasten 
 labor by bearing down during first stage pains, since the only 
 result at this time will be to waste her strength which will be 
 needed later. This is one of the points that the nurse will do 
 well to explain; that no voluntary effort on the patient's part, 
 during the first stage, will advance labor and if she tires herself 
 by making such efforts before the second stage pains begin she 
 will not be able to use them as effectively as she would were she 
 in a rested condition. 
 
 Bearing in mind the importance of conserving all of her 
 forces, it is usually advisable for a patient in labor to have no 
 visitors, particularly the type of person who would be likely to 
 offer advice and gratuitous information. 
 
 She should drink water freely and take some kind of light 
 nourishment about every four hours. As pain of any kind tends 
 to retard digestion, the diet during labor is usually restricted 
 to fluids, such as broths, weak tea or coffee and sometimes milk or 
 cocoa; while occasionally crackers and crisp toast are allowed. 
 Whatever nourishment is given must be very light because of 
 the probability of the patient's vomiting and the possibility of 
 her having to be given complete anesthesia before the termina- 
 tion of labor. 
 
 The maternal temperature, pulse and respirations should 
 be taken every two or four hours and the fetal heart rate from 
 every hour to every two hours, according to the wishes of the 
 doctor. 
 
 The time at which the nurse should call the doctor is the 
 subject of considerable discussion. Doctors never want to be 
 called too late, neither do they wish to be called unnecessarily 
 early, though they prefer to have the nurse err on that side, 
 if at all. On general principles the doctor should be notified 
 as soon as the patient goes into labor, in order that he may make 
 his various plans with the pending delivery in mind. But if 
 the nurse remembers that in primiparae the first stage of labor 
 usually lasts about sixteen hours and in multiparae about eleven 
 hours, she will realize that if the pains begin between the hours 
 of eleven p.m. and seven a.m., and are of average character, mild 
 and infrequent, she is not warranted in disturbing the doctor's 
 much needed sleep, unless he has explicitly requested her to do 
 
248 OBSTETRICAL NHRSING 
 
 so. But under average conditions he should be notified by seven 
 'clock in the morning that the patient is in labor ; at what hour 
 the pains began; their character and frequency at the time of 
 the report; the patient's temperature, pulse and respirations 
 and general condition and the fetal heart rate. 
 
 During the early hours of the first stage the nurse should 
 begin to arrange the room and bed for delivery. She will need 
 two, or preferably, three tables, though the top of a bureau may 
 be used in place of one table. A washstand or the bathroom 
 should be equipped for the doctor with soap ; two sterile brushes ; 
 nail scissors or clippers and file or orange stick; hot water; 
 alcohol and a solution of bichlorid 1-1000, biniodid 1-5000, lysol 
 2 per cent, or any solution that he may wish ; sterile gloves and 
 sterile vaseline or albolene to lubricate his hands. In short, an 
 equipment which will enable him to prepare his hands exactly 
 as he would for performing a major operation. 
 
 A large receptacle of water may be boiled, covered and set 
 aside to cool ; a boiler or large kettle placed in readiness for boil- 
 ing instruments or other appliances that the doctor may bring; 
 the room may be given a final cleaning : floor wiped up, furniture 
 and all small articles wiped with a damp cloth; the unopened 
 packages of dressings, sterile douche pan, irrigation-bag and 
 basins may be placed on the tables, ready to be opened when 
 needed, together with the other articles which have been pre- 
 pared. 
 
 In preparing the bed in a patient's home, it is practically 
 always advisable to make it firm by slipping a board, or the 
 leaves from a dining-table, between the mattress and springs. 
 The bed should be made up with three freshly laundered sheets, 
 the entire mattress being protected by means of a rubber placed 
 under the lower sheet ; next a rubber draw sheet, covered by 
 one of muslin, while the top sheet, light blanket and counterpane 
 should be left free at the foot. A flat hair pillow is better than 
 one of feathers. 
 
 If the doctor wishes to make a vaginal examination, it de- 
 volves upon the nurse to prepare the patient with the most 
 scrupulous care, as it is by means of vaginal examinations, made 
 without careful preparation, that so many parturient women 
 
THE NURSE'S DUTIES DURING LABOR 249 
 
 are infected. In fact, even the most conscientious preparation 
 sometimes seems to be an inadequate safegcuard, for infection 
 has been known to follow in its wake. For this reason, some 
 obstetricians prefer to make no vaginal examination during 
 labor, when previous inspection has indicated that the case is 
 normal, depending rather upon rectal examinations for guiding 
 information. 
 
 The patient should be placed in bed, on a douche pan, with 
 knees flexed and well separated; gown tucked up under her 
 arms; draped with a sheet or the bedding folded down to her 
 knees according to the extent of the area to be prepared; and 
 the articles needed for the preparation arranged on a table at 
 the bedside. The nurse should trim her nails, scrub her hands 
 with soap and hot water; shave the vulva, supra-pubic region 
 and inner surface of the thighs and rinse with sterile water. In 
 shaving the vulva, the strokes should be from above downward, 
 greatest care being taken not to allow hair, soap or water to 
 enter the vaginal opening. She should then scrub her hands 
 vigorously for three minutes, scrubbing about the nails with 
 especial thoroughness. Some obstetricians have the entire area 
 from the umbilicus to the knees prepared as for an operation, 
 while others prepare only the supra-pubic region, inner surface 
 of the thighs and the vulva. The number and kind of solutions 
 which are used in this preparation also vary greatly, but in gen- 
 eral the shaving is followed by a thorough scrubbing, by clean 
 hands, with green soap and sterile water, then iodin, lysol or 
 alcohol and bichlorid or biniodid solution, according to the cus- 
 tom of the doctor. (Fig. 74.) 
 
 But the kind and number of the solutions are probably not 
 so important as the nurse's technique. Throughout the entire 
 course of the preparation she must apply the principles of what 
 she was taught about the technique of preparing the skin for 
 an operation and regard the perineal region in the same light 
 as she would the field which was being prepared for a major 
 operation ; scrubbing from the centre toward the periphery, 
 always, in order not to carry infective material from an unclean 
 to a clean area, which in this case is the vaginal outlet. 
 
 The supra-pubic region and abdomen are scrubbed across, 
 
250 
 
 OBSTETRICAL NURSING 
 
THE NURSE'S DUTIES DURING LABOR 
 
 251 
 
 back and forth, working up from the symphysis; the strokes 
 on the thighs are up and down; in the groin, down toward the 
 rectum, and away from the vagina, never toward it, and fluids 
 poured upon the vulval region must never run into the vagina 
 from over surrounding skin. A sponge or scrub ball must be 
 discarded after approaching the rectum, or stroking away from 
 the vagina in any direction. Some obstetricians instruct the 
 nurse to place a firm, sterile cotton pad or scrub ball between 
 
 Fig. 75. — Patient draped for vaginal examination; vulva covered Avith 
 sterile towel. (From photograph taken at Johns Hopkins Hospital.) 
 
 the labia, against the vaginal opening while scrubbing and flush- 
 ing the adjacent areas, to preclude the possibility of introducing 
 fluids. But with a painstaking nurse this is scarcely necessary. 
 After the surrounding areas have been prepared, the labia 
 are separated and the inner surfaces scrubbed, first across, then 
 from above downward, and flushed by pouring the solution 
 directly between the folds. After the patient has been given 
 this preparation, a dry sterile towel or pad is placed over the 
 vulva ; the douche pan is removed, the back and hips are dried. 
 
252 OBSTETRICAL NURSING 
 
 after which the patient is so draped with a clean sheet that only 
 the perineal region is exposed, and a sterile towel is slipped 
 under the buttocks. (Fig. 75.) 
 
 To summarize the preparation for vaginal examination or 
 delivery : 
 
 1. Trim nails and scrub bands witb soap and bot water. 
 
 2. Sbave vulva. 
 
 3. Scrub and soak bands. 
 
 4. Scrub vulva, inner surface of thigbs and lower abdomen witb 
 green soap and sterile water, alcohol, 70%, and lastly bicbloride 
 1-1000 or lysol 1% or 2%, using sterile sponges and taking care 
 not to contaminate vulva from surrounding fields. 
 
 5. Cover vulva witb sterile towel or pad. 
 
 This may be taken as a description of a fairly typical method 
 of preparing a patient for vaginal examination or for delivery, 
 which is widely employed and with satisfactory results. But it 
 is by no means the only satisfactory procedure, for many other 
 and different methods of preparation also are followed by excel- 
 lent results, as measured by the patient's temperature during 
 the puerperium. 
 
 The details of preparation vary so greatly, even among dif- 
 ferent doctors in the same hospital, that the nurse will simply 
 have to bear in mind the general principles of asepsis and anti- 
 sepsis, and adjust herself to the practices of the individual doc- 
 tor. And she must remember that in spite of the best planning, 
 there will be emergencies and precipitate labors, when the prep- 
 aration will necessarily be modified, and sometimes so curtailed 
 that even the bath and enema are omitted. 
 
 But in all cases the nurse can, and must, bear in mind that 
 on one point there is virtually no difference of opinion among 
 obstetricians of to-day ; and that is the imperative necessity of 
 having everything sterile that is brought to the perineal region 
 or used in any way in connection with the delivery, or as nearly 
 sterile as is possible under the circumstances. 
 
 By many doctors this is considered the most important 
 factor, as to surgical cleanliness, in the entire preparation. In 
 their opinion the local preparation of the patient may, with 
 safety, be restricted to clipping the pubic hairs (instead of shav- 
 
THE NURSE'S DUTIES DURING LABOR 253 
 
 ing), and scrubbing the vulva with only soap and water. But 
 these doctors believe at the same time that the patient is dan- 
 gerously susceptible to infection which may be conveyed to her 
 from without, and accordingly they do not permit vaginal 
 examinations to be made during labor, and make the most ex- 
 acting demands concerning the maintenance of perfect surgical 
 technique, by all who assist with the delivery. 
 
 In this connection, much depends upon the actual steriliza- 
 tion of the rubber gloves, either by boiling or by steam under 
 pressure ; and the method of putting on the gloves, in order that 
 once having been sterilized, they may be kept so. It is useless 
 to attempt to sterilize gloves by boiling, if they are thrown 
 
 Fig. 76. — Wrong and right methods of boiling gloves. Note that 
 gloves in basin at the left are partly above the surface of the water and 
 therefore will not be sterilized. Those in basin at the right are kept below 
 the surface by the weight of the towel and will be sterilized by the boiling 
 water. 
 
 loosely into a kettle of water. There will practically always 
 be enough air in the fingers to keep at least a part of the gloves 
 out of the water, and consequently unaffected by its heat. They 
 should be put into a covered wire basket that will be entirely 
 submerged, or they may be wrapped in a towel, the weight of 
 vvhich will carry them below the surface of the water (Fig. 76), 
 and insure their being completely covered while boiling, which 
 should continue for ten to fifteen minutes. The doctor will 
 usually want boiled gloves placed in a large basin of bichlorid 
 solution, 1-1,000, or lysol 2 per cent., from which he may remove 
 them after scrubbing his hands. If dry gloves are used, there 
 should be in readiness a sterile towel and powder with which to 
 
254 
 
 OBSTETRICAL NURSING 
 
 dry and powder the hands before putting on the gloves. (Fig. 
 77.) 
 
 Whether boiled or steamed, the cuffs of the gloves should 
 first be turned up toward the hand, to make it possible to put 
 them on without touching the glove fingers with ungloved hands. 
 (Fig. 78.) For no matter how long and carefully the hands are 
 scrubbed and soaked, they cannot be made absolutely sterile, 
 
 
 i ^ ^wv 
 
 l^^^^il...,^^^^^^^^^ ^mm^M ^^, ^ 
 
 Fig. 77. — Powdering hands before putting on dry gloves. (From photo- 
 graph taken at the Brooklyn Hospital.) 
 
 and therefore, in relation to the gloves which are sterile, the bare 
 hands must always be regarded as unclean. Too much thought 
 and attention cannot be given to the sterilization and handling 
 of the gloves, for the patient's very li^'e may depend upon their 
 aseptic condition. 
 
 After the doctor has seen the patient, the nurse will make 
 observations and communicate with him in accordance with in- 
 
THE NURSE'S DUTIES DURING LABOR 
 
 255 
 
 structions which she must make sure to obtain from him at that 
 time. Many doctors Avish to be with a primipara continuously 
 from the time the cervix is completely dilated, and with multi- 
 paras after it is half dilated. But that, of course, is a matter 
 
 Fig. 78. — Successive steps in proper method of putting on sterile gloves 
 to avoid contaminating outside of gloves with bare fingers. (From photo- 
 graphs taken at the Long Island College Hospital.) 
 
 which each doctor decides for himself. The nurse's responsi- 
 bility is to learn his wishes. 
 
 Watch fulnesa, then, is of extreme importance; watching 
 for symptoms of complications or change in the patient's condi- 
 tion, and watching the progress of labor in order to keep the 
 doctor fully informed about his patient's condition. Nurses 
 are very frequently taught to make rectal examinations for the 
 sake of increasing the value of their assistance in this respect. 
 
 Although unexpected symptoms do not, as a rule, develop 
 
256 OBSTETRICAL NURSING 
 
 suddenly during the first stage, the nurse must be none the less 
 vigilant for them. The doctor should be notified if the pains 
 suddenly grow either more or less frequent, or more or less 
 severe ; if there is any bulging of the perineum ; if the membranes 
 rupture; if there is any bleeding or a prolapsed cord; if there 
 is extreme restlessness or any evidence of unusual distress; a 
 rising temperature or pulse ; a temperature of 100° F. or a pulse 
 of more than 100 or less than 60 ; a fetal heart rate of more than 
 150 or less than 116, or any marked change of any kind in the 
 patient's condition. 
 
 During the latter part of the first stage, and during the 
 second stage, the patient has an almost continuous desire to 
 empty her bowels, because of pressure made upon the rectum 
 by the descending head. This is another point which the nurse 
 may explain to her patient, in assuring her that frequent at- 
 tempts to use the bed-pan will give no relief. 
 
 The end of the -first stage is reached when the cervix is fully 
 dilated, at which time the pains occur about every two minutes, 
 are stronger and more severe, and the patient begins to feel like 
 bearing down. The membranes frequently rupture at this point 
 and the vaginal discharge is blood tinged. The patient should 
 remain in bed and not be left alone from this time on. 
 
 To sum up the nurse's duties during the first stage of labor, 
 when the patient is almost entirely in the nurse 's care : 
 
 1. She must be a sympathetic, encouraging friend to the patient 
 
 2. She must help the patient to preserve her strength by giving 
 her light nourishment about every four hours; by advising her 
 not to bear down; not to exhaust herself by walking about too 
 much but to lie down when tired. 
 
 3. She must watch the progress of labor and watch for symptoms 
 of complications. 
 
 4. She must employ strictest aseptic and antiseptic methods. 
 
 5. She must prepare for the birth of the baby. 
 
 SECOND STAGE 
 
 The second stage is shorter, harder and more perilous than 
 the first. The uterine contractions are stronger ; more frequent 
 and more expulsive, and the baby steadily curves and rotates 
 its way down through the birth canal. 
 
THE NURSE'S DUTIES DURING LABOR 257 
 
 With the onset of the second stage the nurse should complete 
 the preparations for the baby 's birth, bearing in mind that with 
 a primipara the baby probably will not come for an hour and 
 a half or two hours, but may come in half an hour or less if the 
 patient is a multipara. Everything which is to be used should 
 be conveniently placed, but the packages are not necessarily 
 opened at this time. 
 
 In addition to the sterile dressings, basins, gloves, instru- 
 ments and various other articles which have been enumerated, 
 the nurse must remember that there should be for the baby a 
 box or basket lined with a blanket and containing one, or pre- 
 ferably two, hot-water bottles at 125° F. ; in hospitals, an adhe- 
 sive strip for the baby 's name or a name necklace ; a binder of 
 flannel or sterile gauze, according to the custom of the doctor ; 
 sterile olive oil or albolene for the first oiling and one or two 
 tubs, in case the baby needs to be resuscitated. 
 
 There will be needed, also, a covered basin for the placenta; 
 chloroform and an inhaler; Wassermann tubes, for those doc- 
 tors who make this test as a routine; hypodermic syringe and 
 needles, with pituitrin, ergotole and drugs for stimulation which 
 the doctor may specify. (Figs. 79, 80.) 
 
 In the meantime, the force and frequency of the pains should 
 be noted, and some doctors require a record of both the fetal 
 and maternal pulse rate every half hour, and notification if the 
 baby's is over 150 or below 116, or the mother's over 100 or 
 below 60. Extreme restlessness, distress, vaginal bleeding, pro- 
 lapsed cord, a temperature of 100° F., or any marked change 
 must be communicated to the doctor immediately, if it occurs 
 before he has started for his patient. 
 
 The patient may complain of intense pain in her back and 
 cramps in her legs during the second stage. Pressure made 
 by the nurse's hand, or a small pillow slipped under the small 
 of the back will frequently relieve the backache, while cramps 
 in the legs may be relieved by straightening, and slightly elevat- 
 ing the leg, and rubbing it while in that position. As these pains 
 are usually due to pressure they have no serious significance 
 and subside as soon as the child is born. 
 
 The nurse may find herself in any one of three situations 
 
258 
 
 OBSTETRICAL NURSING 
 
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THE NURSE '8 DUTIES DURING LABOR 
 
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 OBSTETRICAL NURSING 
 
 during the second stage. The doctor may arrive in ample time 
 to conduct the delivery; he may be slightly delayed and the 
 nurse endeavor to retard labor, according to instructions; or 
 the baby may be born, with or without the expulsion of the 
 placenta, before his arrival. 
 
 When the doctor arrives at the onset of, or during the second 
 stage of labor, the nurse acts solely under his direction, the 
 nature of her offices depending somewhat upon the condition and 
 surroundings of the patient, and whether or not the nurse is 
 the only person at hand to give assistance. In any case, the 
 gloves, and instruments for repairing a tear should be boiled 
 and in readiness; the dressings and other articles to be used 
 
 PiQ. 80. — Instruments for normal delivery shown in boiling basin on 
 table in Fig. 79: Needle holder. Blunt hook. Blunt scissors. 2 small 
 Kelly clamps. Mouse tooth forceps. 4 towel clips. 2 large perineal 
 needles and 2 cervical needles in gauze sponge. 
 
 are to be conveniently arranged upon the tables and opened at 
 the proper time. 
 
 After having everything ready and at hand for the delivery, 
 the nurse may be called upon to clean up and act as an assistant, 
 or to give the anesthetic. If she cleans up, she should wear a 
 sterile gown and gloves, and if it is the doctor's custom, a cap 
 and mask as well, having prepared her hands somewhat as fol- 
 lows : ^ 
 
 1. Scrub hands and arms with hot water and green soap for five 
 minutes, paying especial attention to the fingers and nails. 
 
 2. Clean and trim nails and scrub again for five minutes. 
 
 * Routine preparation of hands at Johns Hopkins Hospital. 
 
THE NURSE'S DUTIES DURING LABOR 
 
 261 
 
262 
 
 OBSTETRICAL NURSING 
 
 3. Soak and scrub hands and forearms in alcohol, 70%, for two 
 minutes. 
 
 4. Soak in bichloride solution, 1-1000, for five minutes, 
 
 5. Put on gloves out of second bichloride solution, avoiding con- 
 tact with fingers of ungloved hand. (See Fig. 78.) 
 
 Pig. 82. — Patient draped with sterile towels, leggings, sheet and de- 
 livery pad for delivery. (From photograph taken at Johns Hopkins 
 Hospital.) 
 
 The patient is given a final scrubbing with green soap and 
 sterile water and an antiseptic solution, by some one with clean 
 hands, and is further protected by means of sterile leggings, a 
 sterile towel across the abdomen and one covering the inner sur- 
 face of each thigh, held in place by sterile clips or safety pins. 
 
THE NURSE'S DUTIES DURING LABOR 263 
 
 The lower half of the bed is covered with a sterile sheet while a 
 sterile delivery ])a(l is sli])p('d under the patient's hips. (Fig. 
 82.) 
 
 If the delivery is made with the patient lying on her side, 
 the sterile dressings are so arranged as to cover all but the 
 perineal region after she is placed in the desired position. 
 
 This brings up the question of the nurse's obligation to pro- 
 tect her patient from tlio embarrassment of unnecessary ex- 
 posure at any time during lal)or. The field which is prepared 
 must be uncovered temporarily, and while the patient is being 
 draped for examination or delivery a certain amount of exposure 
 is unavoidable ; but there are many little ways in which the nurse 
 may show her consideration for the patient in this connection 
 and the patient always appreciates the protection. 
 
 During the second stage, the preservation of asepsis, watch- 
 ing the progress of lal)or and watching for unfavorable symp- 
 toms, are of even greater importance than during the first stage. 
 After the patient has been prepared and draped with sterile 
 dressings, neither they nor the perineal region should be touched 
 with anything unsterile. 
 
 If for any reason it has not been possible to sterilize sheets 
 and toAvels, or more are needed after the prepared supply has 
 been exhausted, the inner surfaces of towels and sheets that have 
 been ironed either by hand or machinerj', and folded with the 
 ironed surfaces inside without being touched, may be regarded 
 as practically sterile. 
 
 As the second stage advances, the patient may gi'eatly aid 
 the progress of labor by voluntarily bearing down during pains, 
 and the nurse in turn may be called upon to hel)) by encourag- 
 ing her and explaining just what she should do. At the begin- 
 ning of a pain the patient should take a deep breath, close her 
 lips, brace her feet and strain with all her strength. If she opens 
 her mouth and cries out, she fails to use her pains to the best 
 advantage. The etfect of this bearing down may be increased 
 by providing the patient with straps, attached to the foot of 
 the bed, upon which she may pull during the contractions, as 
 she bears down. (Fig. 83.) Or, what is often a great comfort 
 to her, she may pull upon the nurse's hands as the latter braces 
 
264 
 
 OBSTETKICAL NURSING 
 
 herself so as to offer strong resistance. If the nurse can be spared 
 from other duties to give this kind of assistance, it is indeed a 
 comfort to the patient, who appears to derive from it both a 
 moral and physical sense of being helped in her struggle. It is 
 also important to assure the patient, between pains, that she is 
 doing well, and that her efforts are advancing the baby, if this 
 is true ; and if not, she may under ordinary conditions be urged 
 to make greater effort. 
 
 Before the head can be seen at the outlet or its advance noted 
 
 Pig. 83. — Patient pulling: on straps while bearing down during second 
 stage pains. (From photograph taken at Johns Hopkins Hospital.) 
 
 by perineal bulging, the stage of its descent is often ascertained 
 by palpating through the perineum, the fingers of a gloved hand 
 pressing upward, on one side of the vulva. (Fig. 84. See 
 Figs. 85, 86, 87, and 88 for appearance, advance and birth of 
 head during normal delivery.) 
 
 Immediately after the birth of the head, and before the birth 
 of the body, the nurse is frequently asked to wipe tlie baby's 
 mouth and eyes and sometimes to drop nitrate of silver into the 
 eyes. In such a case she should wipe out the mouth very gently 
 
TIIK NURSE'S DUTIES DURING LABOR 
 
 267 
 
 iu^ lustily, in oi'der fully to expand its lunj^s. This provides 
 for oxygenation of its blood, which has taken place, until now, 
 through the placental circulation. In many cases the baby cries 
 satisfactorily without aid, but not infrequently must be stimu- 
 lated to do so. In all instances the first step is to clear the air 
 
 Fig. 8G. — Adviince of the head indicated by strctcliiug of the vulva and 
 
 perineum. 
 
268 
 
 OBSTETRICAL NURSING 
 
 FiQ. 87. — Holding back the head at the height of a pain to prevent a 
 
 perineal tear. 
 
THE NURSE'S DUTIES DURING LABOR 269 
 
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 'SVa* 88. — Birth of the head immediately followed by external rotatioA.. 
 
270 
 
 OBSTETRICAL NURSING 
 
 passages of the mucus lodged in tlie mouth and throat, by some 
 one of the many approved methods. One is by means of a piece 
 of wet sterile gauze wrapped about the little finger, and wiped 
 gently about in the back part of the baby's mouth (Fig. 89), 
 
 Fia. 89. — Wiping mueus from baby's mouth Avith gauze ■wrapped about 
 
 little finger. 
 
 though many doctors object to this procedure for foar of abrad- 
 ing the very delicate mucous membrane, no matter how lightly 
 it is done. They prefer to hold the baby by its feet, with the 
 head hanging down and the neck sharply curved Inickward, when 
 by gravity the mucus will drop out of the mouth ; or, holding 
 the baby by the feet, to run the thumb and forefinger along the 
 
THE NUUSKS DUTIES Dl'KINCJ LAIUJU 271 
 
 neck on either side of the trachea, toward the mouth, and force 
 out the mucus in that way. If the l)ahy does not cry well after 
 the mucus is removed, it may usually be stimulated to do so if 
 held by the feet, head downward, and the back gently rubbed 
 (Fig. 90) or the face stroked or the buttocks spanked two or 
 three times. When holding the baby in this position the nurse 
 should slip one finger between the ankles and grasp them firmly. 
 
 Fig. 90. — Stroking baby's back to stiiimlate resi)irations. 
 
 After the baby has cried well it may be laid on the foot of 
 its mother's bed. At this juncture it seems pertinent to stress 
 two points which must be remembered throughout the entire 
 routine of the baby's care, namely: the importance of protecting 
 it from infection and from being chilled. As the baby lies on 
 the mother's bed, before the cord is cut, it finds itself in a room 
 which is many degrees cooler tlian the very warm habitat from 
 which it has just emerged; it is struggling to establish its func- 
 tions, which are suddenly deprived of the mother's help, chief 
 
272 
 
 OBSTETRICAL NURSING 
 
 of which at the moment are respiration and the circulation. Body 
 warmth is one of the most valuable aids in promoting an even 
 circulation, and accordingly the baby should be kept warm from 
 the beginning. For tliis purpose tlicre should be a small sterile 
 
 Fig. 91. — Showing two clamps on cord after pulsation has ceased. 
 
 blanket, or piece of flannel, in readiness to protect the little body 
 as it lies on the bed, awaiting further developments. The hands 
 and feet of the newborn baby that lies uncovered for even a 
 quarter of an hour, or more, are nearly always cold, and as this 
 must be guarded against in an older, more securely established 
 baby, it cannot be desirable for the newly born. 
 
 As soon as the cord ceases to pulsate, it is usually clamped 
 
 A B 
 
 Fig. 92. — Wrong and right method of tying knot in cord ligature. 
 
 A will slip. B will not. 
 
 with two clamps about two inches apart (Fig. 91) and cut be- 
 tween the clamps. The scissors should have blunt points, in 
 order not to scratch or cut the baby, who may be wriggling 
 vigorously by this time. The cord is tied tightly with a sterile 
 
THE NURSE'S DUTIES DURING LABOR 273 
 
 cord ligature, in a square knot that will not slip (Pig. 92), about 
 an inch from the abdominal wall. It is considered a safe pre- 
 caution, after removing the damp, to bend the cord back upon 
 itself and tie it a second time with the same ligature, as the 
 danger of hemorrhage from a loosely tied cord is serious when 
 the baby is kept sufficiently warm. The placental end of the 
 cord is also tied, or it remains clamped until the placenta is 
 expelled, because of the possibility of there being another child 
 in the uterus and the danger of its bleeding to death through 
 the open cord. 
 
 Some doctors do not tie the cord, but crush the vessels with 
 a clamp which is left on the cord for about half an hour and 
 then permanently removed, but this should not be done by a 
 nurse upon her own responsibility. 
 
 Very often the person who performs the delivery removes 
 the blood, mucus and vernix from the baby's body, as soon as 
 the cord is tied, by sponging it thoroughly with albolene or 
 olive oil; wraps the cord stump with a sterile, dry or alcohol 
 sponge and applies the abdominal binder while an assistant holds 
 the baby by the feet, head down. It is also very common simply 
 to oil the baby with unsterile lard, oil or vaseline, cover the cord 
 with sterile gauze and leave the bath, cord-dressing and binder 
 to be attended to later. 
 
 If the delivery takes j^lace in a hospital the baby must be 
 marked before it is taken from the delivery room, with adhe- 
 sive plaster, upon which its mother's name is plainly printed, 
 or with the name necklace, now so frequently used. 
 
 The baby is once more wrapped in a warm blanket and placed, 
 with a hot -water bottle, at 125° F., in the basket or box, which 
 was prepared for it. Although the baby should be well covered, 
 care must be taken to leave the face fully exposed as a young 
 baby is easily suffocated. It was formerly customary to lay the 
 new baby on its right side, but with the present fuller knowl- 
 edge of the fetal circulation and the changes which take place 
 after birth, this practice has been largely done away with. 
 
 Resuscitation of the Newborn Baby. If the baby breathes 
 feebly, or even if it does not cry vigorously, the effort to stimu- 
 late the respirations may have to be continued for an hour or 
 
274 
 
 OBSTETRICAL NURSING 
 
 more after the cord is tied. In addition to the simple methods, 
 previously described, which are very commonly employed at 
 the time of labor, such as stroking the baby's back or holding 
 him by the feet and spanking him (Fig. 93), the following 
 measures are sometimes resorted to if tlie baby's condition de- 
 mands it : 
 
 One method is to hold the baby with its chest resting on the 
 
 T'iG. 93. — Rtiimilatiiiff respirations l)y holdiii}? the baby head downward 
 and sharply spanking liini. Note the method of <irasping the baby's ankles 
 with one finuer between them to prevent his slippinf^- from the nurse's 
 liand. 
 
 palm of one hand, with head, legs and arms hanging forward, 
 thus compressing the chest wall and favoring expiration (Fig. 
 94), and then turning it over on its back, in the other hand, 
 in w'hich position the head, legs and arms hang backward, thus 
 pxpanding the chest and favorhig an inspiratory movement. 
 
THE NURSE'S DUTIES DURING LAliGR 
 
 275 
 
 (See Fig. 95.) Alternate repetitions of these positions, about 
 twelve times a minute, will often stimulate the child to breathe 
 satisfactorily. 
 
 Another method is alternately to plung^e the baby into tubs 
 of hot and cold water. But as there is doubt about the wisdom 
 
 Fig. 94. (See also Fifj. Of..) 
 Figs. 94 and 95 show method of stimulating respirations by resting 
 the baby alternately on his chest and back on the nurse's hands. (From 
 photographs taken at Bellevue Hospital.) 
 
276 
 
 OBSTETRICAL NURSING 
 
 of chilling the entire surface of the baby's body, the cold plange 
 is forbidden by many doctors, who, instead, dash a little cold 
 water upon the face and chest, while the body is immersed in 
 water at about 110° F. 
 
 Fig. 95. — Eesuseitating the baby. (See also Fig. 94.) 
 
 A widely used and efficacious method is to hold the baby con- 
 tinuously in a tub of water at about 110° F., and alternately 
 extend and fold its body, thus keeping it warm while stimulating 
 inspiration and expiration. (Figs. 96, 97.) 
 
THE NURSE'S DUTIES DURING LABOR 277 
 
 Direct insufflation may be employed while the baby is in the 
 warm water, by protecting its face with clean dry gauze and 
 bloAving directly into its mouth at intervals corresponding to 
 those of normal inspiration. (Fig. 98.) 
 
 Fig. 96. (See also Fig. 97.) 
 Figs. 96 and 97 show method of resuscitating the baby by alternately 
 extending and folding his body under warm water. (From photographs 
 taken at Johns Hopkins Hospital.) 
 
 Another procedure is to hold the baby by the shoulders, with 
 its body hanging down, thus expanding the chest, and then to 
 toss it quickly upwards, folding the legs upon the chest to com- 
 press it. This method is objected to by many obstetricians on 
 the ground that it both exhausts and chills the baby- 
 
278 OBSTETRICAL NURSING 
 
 The outstanding' requirements in resuscitating a baby are to 
 stimulate its respiratory movements, by alternately expanding 
 and contracting the chest ; to promote its circulation by keeping 
 
 Fig. 97. — Resuscitating the baby. (See also Fig. 96.) 
 
 it warm, and to avoid exhausting the very frail little body. 
 Gentle handling, therefore, is important. 
 
 THIRD STAGE 
 
 After the birth of the baby, some doctors request the nurse 
 to rest one hand on the mother's abdomen in order to feel the 
 
THE NURSE'S DUTIES DURING LABOR 
 
 279 
 
 fundus as it rises while expelling the placenta, and to keep him 
 informed concerning its consistency. Others regard this as a 
 dangerous practice and forbid it. 
 
 As a rule, there is little bleeding until the placenta has sepa- 
 rated. If bleeding does occur, it is the practice of some doctors 
 to have the uterus gently massaged through the abdominal wall, 
 to stimulate contractions, while others consider tbis inadvisable. 
 
 After the placenta separates and descends into the lower 
 
 Fig. 98. — Stimulating respiration by means of direct insufiflation, the 
 baby's face being covered with clean gauze. (From photograph taken 
 at Johns Hopkins Hospital.) 
 
 uterine segment, it produces a bulging just above the symphysis, 
 while the fundus may be felt as a firm, hard ma.ss above the 
 umbilicus. Since the placenta is entirely separated from the 
 uterus at this time, its complete expulsion is usually aided, when 
 it does not occur spontaneously, by gentle pressure upon the 
 fundus. Tbe accoucheur holds his hand just below the vaginal 
 outlet, to receive the placenta (Fig. 99), which he turns over 
 and over in his hands, thus twisting the membranes, and grad- 
 ually draws it away from the mother, the membranes trailing: 
 
280 
 
 OBSTETRICAL NURSING 
 
 after in the form of a tapering cord. (Fig. 100.) It is impor- 
 tant that the placenta and membranes be carefully examined 
 to make sure that they are intact, for if fragments of either 
 are retained within the uterus they will prevent its firm con- 
 traction and thus may be a cause of post-partum hemorrhage. 
 For this reason, only very gentle pressure and traction are used 
 in expressing the placenta and withdrawing the membranes, for 
 the use of force might leave small particles adhering to the 
 
 Fig. 99. — Delivery of the placenta. 
 
 uterine lining, which would otherwise separate with the rest, 
 in due time, as a result of the uterine contractions. 
 
 Having been inspected, the placenta should be placed in a 
 covered receptacle to be disposed of as the doctor directs, as 
 many physicians make a routine laboratory examination of the 
 placenta and wish to have it kept for this purpose. 
 
 With the birth of the placenta comes a gush of blood, as the 
 uterine vessels, some of which are as large as a lead pencil at 
 this time, are left wide and gaping. The bleeding usually sub- 
 sides very shortly, however, as the blood vessels are closed by 
 involuntary contraction of the network of uterine muscle fibres 
 in which they are enmeshed, and which are sometimes referred 
 
THE NURSE'S DUTIES DURING LABOR 281 
 
 to as "living ligatures." If the bleeding continues, these eon- 
 tractions should be stimulated by massage. This is done by 
 grasping the uterus through the abdominal wall firmlj' with 
 one hand and kneading vigorously. Rubbing the top of the 
 fundus with the fingers usually is not enough. The fundus 
 should be grasped by the entire hand ; the thumb curved across 
 the anterior surface and the fingers, directed deep into the abdo- 
 men, behind it. (Fig. 101.) 
 
 Pituitrin or ergot, or both, are frequently given to further 
 stimulate contractions of the uterine muscles. Since the action 
 
 Fig. 100. — Tmsting the membranes while withdrawing them from 
 uterus. 
 
 of pituitrin is quick, but evanescent, and the effect of ergot is 
 slower and more lasting, both a quick and lasting effect is ob- 
 tained by giving them together. 
 
 The expulsion of the placenta ends the third stage and com- 
 pletes the process of labor. 
 
 Immediate After-care of the Patient. Tlie patient should 
 be bathed and dried about the thighs and buttocks, the vulva 
 being bathed with alcohol or an antiseptic solution, and a sterile 
 perineal pad applied. The douche-pan, wet towels, delivery pad 
 and draw sheet are replaced by a dry draw-sheet and a towel or 
 pad slipped under the patient's hips, while a fresh nightgown 
 
282 
 
 OBSTETRICAL NURSING 
 
THE NURSE'S DUTIES DURING LABOR 283 
 
 is put on if the one worn during labor is wet or soiled. The 
 perineal pad is very commonly held in place by a T. binder, with 
 which all nurses are familiar, but some doctors prefer an abdomi- 
 nal binder to which a perineal strap is attached. This abdominal 
 support may be a straight swathe or a Scultetus bandage, vary- 
 ing with tile wislu's of the doctor, and it may or may not be used 
 in conjunction with a pad, so applied as to make pressure over 
 the fundus. Other doctors forbid the application of any kind 
 of a perineal dressing from the time of delivery, but instead, 
 have a large, sterile pad slipped under the patient to receive the 
 'discharge. 
 
 The patient is usually tired and cold at the conclusion of 
 labor, and may even have a nervous chill. Although this chill 
 is not serious, the patient is none the less uncomfortable, and 
 she should be warmly covered, be given something hot to drink, 
 and a hot-water bag placed at her feet. 
 
 All possible effort must now be made to secure for her rest, 
 quiet, and an opportunity to sleep. Every one but the doctor 
 and the nurse had better be excluded from the room, which 
 should be absolutely quiet, somewhat darkened and well venti- 
 lated. In addition to this, the majority of doctors now require 
 that either they or the nurse shall stay with the patient and keep 
 one hand resting on the fundus for at least an hour after de- 
 livery as a safeguard against post-partum hemorrhage. As long 
 as the fundus is felt through the abdominal wall as a firm, hard 
 mass, its irregularly arranged muscle fibres are contracted upon 
 the blood vessels, and will prevent an escape of blood. But if 
 the fundus feels soft and boggy, its muscles are relaxed, the 
 constrictions are somewhat released from the open vessels, and 
 serious bleeding may occur unless they are stimulated to con- 
 tract again. 
 
 If the Doctor Is Delayed. It sometimes liappens that labor 
 progresses with unexpected rapidity, or that the doctor is de- 
 layed in his arrival and the nurse is accordingly confronted with 
 the emergency of being alone with the patient during part or 
 all of the delivery. 
 
 When the baby is making such rapid descent that the nurse 
 fears it may be born before the doctor's arrival, she may some- 
 
284 OBSTETRICAL NURSING 
 
 what retard labor by covering her hand with a folded, sterile 
 towel, if she has not had time enough to put on gloves, and hold 
 back the head by pressing against the perineum during pains, 
 at the same time instructing the patient to open her mouth, 
 breathe deeply and try not to bear down. It is sometimes easier 
 for the patient not to bear down if she lies on her side. 
 
 If by mischance, or in spite of her efforts, the baby so far 
 descends that the brow appears before the doctor's arrival, the 
 nurse cannot safely hold it back longer because of the danger 
 of the baby becoming asphyxiated. She should, up to this point, 
 hold the head back during pains in order that the perineum 
 may be stretched slowly, with the hope of preventing a tear. 
 (See Fig. 87.) It is the sudden distension of the perineum and 
 expulsion of the baby's head at the height of a pain that fre- 
 quently causes lacerations. If fecal matter is expressed during 
 pains, the field should be wiped, downward, with sterile sponges 
 and bathed with the antiseptic solution at hand. 
 
 After the brow is born, the nurse may gradually release the 
 pressure and allow the head to emerge, and remembering the 
 position of the child and the mechanism of its birth, assist 
 Nature in its complete delivery. After the head is born, it drops 
 down toward the mother's rectum, after which external rotation, 
 or restitution, takes place. (See Fig. 88.) A finger should be 
 slipped around the neck in search of coils of cord, which, if felt, 
 should be slipped over the baby's head. Otherwise, pressure 
 upon the cord in that unnatural position might so interfere with 
 the circulation as to asphyxiate the baby. 
 
 The shoulders may be born spontaneously or the nurse may 
 grasp the head with both hands, curving the fingers of one hand 
 under the baby's chin, and of the other, under the occiput, and 
 make gentle, downward traction (See Fig. 69) in order to slip 
 the anterior shoulder from under the symphysis; and then pull 
 gently upward, to deliver the lower or posterior shoulder (see 
 Fig. 70), after which the rest of the body follows easily. 
 
 This description of how a nurse may conduct a normal de- 
 livery by fairly typical and generally approved methods is only 
 intended to guide her in an emergency, when there has been no 
 understanding between her and the doctor about what she should 
 
THE NURSE'S DUTIES DURING LABOR 285 
 
 do in event of his absence ; or when he has authorized her to use 
 her best judgment in safeguarding the lives of mother and baby. 
 
 It is obviously of extreme importance for the nurse to ascer- 
 tain definitely the doctor's wishes in this connection, as he some- 
 times will be unwilling to have the nurse give any attention to 
 either mother or baby, even to tie the cord, before his arrival. 
 
 Prolapsed Cord. If the umbilical cord should prolapse at 
 any time during labor, in the absence of the doctor, or lacking 
 
 Fig. 102. — Drawing showing how prolapsed cord may be pressed be- 
 tween baby 's head and pelvic brim^ thus cutting off placental circulation. 
 
 instructions, the nurse should elevate the patient 's hips, in order 
 that gravity may lessen the pressure on the cord as it lies be- 
 tween the presenting part and the pelvic brim. Otherwise, the 
 interference with the placental circulation may result in asphyx- 
 iation of the baby. (Fig. 102.) 
 
 The elevated Sims position is often effective. Or, a straight 
 chair may be upturned and pushed under the mattress, from 
 
286 OBSTETRICAL NURSING 
 
 the foot toward the head, in such a way that the patient will be 
 lying on an incline which slopes upward from the head of the 
 bed toward the foot. Or the chair may be placed in the same posi- 
 tion on top of the mattress, with the top of the chair-back under 
 the patient's shoulders. The chair should be padded with pil- 
 lows in order to minimize the patient's discomfort as she lies 
 in this trying position, 
 
 Post-partum Hemorrhag'e. Should a post-partum hemor- 
 rhage occur, in the absence of the doctor, the nurse should mas- 
 sage the fundus, unless she has been instructed not to, and have 
 some one elevate the foot of the bed on blocks or the seat of a 
 firm, straight chair. The use of ice bags or cold compresses on 
 the abdomen is sometimes helpful and some physicians advise 
 placing the baby at the mother's breast immediately, since the 
 suckling stimulates the uterine muscles to contract. 
 
 In anticipation of a post-partum hemorrhage, the nurse must 
 have a clear understanding of the doctor's wishes, particularly 
 in regard to the administration of pituitrin and ergot which 
 are so widely and efficaciously used to check post-partum bleed- 
 ing. 
 
 ANESTHETICS 
 
 Those of us who are accustomed to seeing anesthetics used 
 to relieve patients of the worst of their pain, during labor, find 
 it hard to realize that until comparatively recent years women 
 went through this suffering without mitigation. 
 
 The use of anesthesia was introduced into obstetrical prac- 
 tice, in 1847, by Sir James Y. Simpson of Scotland, who first 
 used ether but later adopted chloroform when he learned that it 
 also had anesthetic properties. Its use in America was subse- 
 quently introduced by Dr. Channing of Boston. 
 
 In the early days, the idea of using anesthesia during labor 
 was greeted Avith a storm of protest, both from the clergy and 
 the laity, because of their belief that the relief of women in child- 
 birth was contrary to the teachings of the Bible, as set forth in 
 God's curse on Eve, when He said, "In sorrow thou shalt bring 
 forth children." 
 
 There is to-day practical unanimity of opinion concerning 
 the advantages which are derived from the use of anesthesia 
 
THE NURSE'S DUTIES DURING LABOR 
 
 287 
 
 when any operative procedures are employed ; but there is still 
 some objection to its use in spontaneous deliveries. Tiiis is partly 
 on medical grounds because of the possible ill etl'ects of 
 anesthetics and is partly a persistence of the early religious pro- 
 test. However, in the vast majority oi" cases, some kind of an 
 anesthetic, or analgesic, is administered to the woman in labor 
 because the advantages of its use are generally conceded. 
 
 The agents used are chloroform, ether and nitrous oxid gas, 
 
 Fig. 103. — Method of giving chloroform for obstetrical aiifpsUiesia. 
 
 while what is popularly called "tAvilight sleep" is produced, 
 completely or in a modified degree, by the hypodermic adminis- 
 tration of scopolamin and morphine. 
 
 Chloroform. Of these various drugs chloroform is appar- 
 ently the anesthetic most widely used in normal obstetrics. Its 
 advantages are that it is easy to give ; (juick in its action and is 
 followed by little or no nausea or other ill effects. For some rea- 
 son, as yet not explained, the woman in labor enjoys a certain 
 amount of immunitj' against chloroform poisoning, but this toler- 
 
288 OBSTETRICAL NURSING 
 
 ance exists only during labor as the puerperal woman is subject 
 to the same dangers as any other individual. 
 
 Chloroform is not usually administered until the patient is 
 well along in the second stage, or until the head may be felt 
 through the perineum, or is in sight. The patient's face should 
 be oiled and protected with a towel or gauze folded across her 
 brow, mouth and chin to prevent burns that might follow the 
 inadvertent dropping of chloroform on her face. With the be- 
 ginning of a pain, a few drops are poured on the inhaler which 
 is held about an inch from the face to give a free admixture 
 of air, and the patient is told to breathe in deeply. (Fig. 103.) 
 The inhaler is removed as soon as the pain subsides, but reapplied 
 as soon as another pain begins. The patient retains conscious- 
 ness and is able to talk under this degree of anesthesia, but her 
 suffering is greatly relieved. It has the advantage, also, of 
 lessening the danger of perineal tears, as the accoucheur has 
 better control of the delivery when the patient lies quietly than 
 when she tosses violently about the bed, and a tear resulting 
 from the sudden delivery of the head at the height of a pain 
 may in this way be averted. 
 
 This light, intermittent anesthesia, now so widely used, is 
 called obstetrical anesthesia or anesthesia a la reine, after Queen 
 Victoria, upon whom it was first employed at the birth of her 
 seventh child, in 1853. 
 
 When the perineum is distended to its maximum, obstetrical 
 anesthesia is not always sufficient, and complete anesthesia may 
 be employed ; but even this requires very little chloroform. 
 Under ordinary conditions, the anesthesia is discontinued as 
 soon as the child is born, for unless there is an extensive tear, 
 the patient is sufficiently anesthetized to permit of a perineal 
 repair and the delivery of the placenta. 
 
 Chloroform is not often given early in labor because of the 
 general belief that its free or prolonged use lessens the force 
 and frequency of uterine contractions, thus prolonging labor, 
 and also may unfavorably affect the child. But small doses seem 
 to stimulate rather than retard contractions, and by having her 
 pain relieved, the patient is prompted to make greater effort to 
 use her abdominal muscles, an end greatly to be desired. 
 
THE NURSE'S DUTIES DURING LABOR 
 
 289 
 
 If complete anesthesia is needed for more than a few mo- 
 ments, after the child is born, ether usually replaces the chloro- 
 form, being considered more satisfactory for prolonged 
 anesthesia, but many obstetricians prefer not to give it until 
 after delivery because of its possible effect upon the child. 
 
 Fig. 104. — Giving ether for obstetrical anaesthesia. Ether is ])oured 
 into cone whicli is covered with nurse's hand to j)revent evaporation. 
 When the beginning of a contraction is folt l)y liand on abdomen, the 
 cone is placed about an inch from the patient's face. (From photograph 
 taken at the Maternity Hospital, Cleveland.) 
 
 As chloroform poisoning is likely to produce degenerative 
 changes in the liver, and eclampsia also causes a liver necrosis, 
 chloroform is not used for an eclamptic patient. 
 
 Ether, also, is used widely in normal obstetrics and is al- 
 most always preferred for continuous anesthesia, because of its 
 
290 
 
 OBSTETRICAL NURSING 
 
 being safer than chloroform. Unlike chloroform, ether is some- 
 times given in the first stage after the pains have become severe 
 and frequent. About a dram of ether is poured into the cone 
 which is held just off the patient's face (Fig. 104) until the 
 beginning of a contraction, at which time it is lowered and held 
 
 Fig. 105. — As pain increases and patient becomes accustomed to ether, 
 the cone is lowered and held close to her face until pain subsides. Suf- 
 ficient ether to control the next pain is then poured into cone. (From 
 photograph taken at the Maternity Hospital, Cleveland.) 
 
 close to her face (Fig. 105.) As the action of ether is slower 
 than chloroform, it should be poured into the cone in advance 
 of a pain, which the nurse anticipates by feeling the uterus 
 begin to grow hard under the hand which she keeps upon the 
 patient's abdomen. If the ether is not poured into the cone 
 
THE NURSE'S DUTIES I)URL\G LABOR 291 
 
 until a pain begins, its anesthetic effect may be lost because of 
 the delay in its administration. 
 
 At the Cleveland Maternity Hospital, where etiier is used 
 during normal labor, the nurses are taught to give it as has 
 just been described, with further instructions from Miss Mac- 
 Donald, as follows: "A patient will vaporize about one dram 
 of ether per pain during the early first stage, gradually vaporiz- 
 ing a greater amount until she will vapori/e two or three drams 
 per pain near the end of the second stage. Should tlie patient 
 reach the excitement stage of etlier before she is in the second 
 stage of labor, discontinue the ether for from five to fifteen 
 minutes, then give a lessened amount. 
 
 "Should it be necessary to control the descent of the pre- 
 senting part, light anesthesia may be given. This may be man- 
 aged by putting al)out two drams of etlier in the cone at intervals 
 frequent enough to sufficiently retard the descent of the present- 
 ing part. This procedure almost obliterates contractions. Lift 
 the cone from the face for a few moments at frequent intervals 
 to admit air. Keep the ether vapor of such concentration as 
 avoids choking, coughing or vomiting. This may be done by 
 administering a small amomit frequently, rather than a large 
 amount at longer intervals. When the desired stage is reached, 
 try to keep the patient at this degree of anesthesia by giving a 
 few drams of anesthetic at regular intervals." 
 
 Nitrous Oxid Gas Analgesia. The effect of this drug is 
 termed analgesia rather than anesthesia, because the patient does 
 not lose consciousness but is unconscious of pain. From a med- 
 ical standpoint it is considered practically ideal for use in 
 obstetrics. If given skillfully it seems to have no bad effects 
 upon the child ; it tends to stimulate, rather than diminish uterine 
 contractions; it may be started, with safety, as soon as the patient 
 begins to suffer severely, and continued for several hours if 
 necessary. 
 
 Its disadvantages are that it is very expensive; it can be 
 given safely only by a skillful, trained person; the apparatus 
 necessary for its administration is expensive, heavy and difficult 
 to transport. But when these difficulties can be overcome, its 
 use is attended with very satisfactory results. 
 
292 OBSTETRICAL NURSING 
 
 "Twilight Sleep," so called, or Ddmmerschlaf, as it is 
 termed in Germany, has been and still is discussed so widely, 
 that the nurse should know something of it, whether or not she 
 aids in its administration. It may be described as a state of 
 amnesia, or forgetfulness, produced by the hypodermic injection 
 of morphin and seopolamin. The patient, therefore, is conscious 
 of pain at the time but speedily forgets it. 
 
 This treatment was first used widely in Freiburg. Follow- 
 ing an enthusiastic report from there upon a large number of 
 cases in which it had been used, there was such a clamor for 
 it by American women, that its temporary use was practically 
 forced upon obstetricians in this country. It Avas given what 
 appears to have been a fair trial, but its continued use in this 
 country has not been widespread. Those obstetricians who ob- 
 ject to its use describe its disadvantages as follows: It cannot 
 be used outside of a well-conducted hospital; it requires the 
 constant attendance of a well-trained obstetrician or obstetrical 
 nurse throughout the entire course of labor; it is suitable for 
 use in certain selected normal cases only ; it prolongs the second 
 stage and increases the percentage of cases in which operative 
 interference is necessary; it has an asphyxiating effect upon 
 the child and increases the percentage of fetal deaths. 
 
 On the other hand, the use of seopolamin and morphin is a 
 routine in certain excellent maternity hospitals, and by many 
 obstetricians of the first rank, who maintain that with a nurse 
 in attendance and the observance of ordinary precautionary 
 measures, the advantages far outweigh the disadvantages of a 
 modified "twilight sleep." An anesthetic is usually adminis- 
 tered during the second stage, after the use of the scopolamin- 
 morphin treatment. 
 
 Complete Anesthesia. If an emergency should arise and 
 the nurse be required to change from the light anesthesia a la 
 reine, and to give complete anesthesia, her responsibilities in- 
 crease, for she must watch carefully the patient's pulse, respira- 
 tions, color and pupils. The flat pillow which is ordinarily left 
 under the patient's head during normal labor, should be removed 
 and the inhaler should be held closely over her face with the 
 
THE NURSE'S DUTIES DURING LABOR 
 
 293 
 
 nurse 's fingers so placed as to hold it in position and also to hold 
 the patient's jaw forward and up. (Ficr. 106.) 
 
 The ether sliould he dropped in clean drops, not poured, upon 
 the inhaler. The dripping should he steady, hut slow at first, 
 gradually increased as the patient becomes accustomed to the 
 fumes. 
 
 With the average, normal patient who is taking ether well the 
 
 Fig. lOG. — Method of lioMing inhaler aiul .supimithig- patient's jaw 
 in giving etlier for complete anesthesia. (From photograph taken at Johns 
 Hopkins Hospital.) 
 
 respirations become somewhat stertorous and more rapid, in- 
 creasing to possibly 36 or 40 per minute ; the i^idse starts at a 
 little above the normal rate and increases to 116 or 120 and then 
 drops to normal, which is slightly below the rate at which it 
 started; the color is normal at first and then may become crim- 
 son, or it may change very little; the pupils first dilate, and 
 then contract almost to a pin point. 
 
294 OBSTETRICAL NURSING 
 
 Unfavorable signs are: respirations that are rapid and shal- 
 low, then possibly slow, but still shallow; increasing pulse rate, 
 this being so serious that the ether is usually stopped if the pulse 
 approaches 140, and stimulation is promptly given; cyanosis 
 which is slight at first and then extreme, and dilated pupils. 
 
 It is obviously not wise nor possible to attempt, by means 
 of a few^ paragraphs and illustrations to teach a nurse so tech- 
 nical and important a procedure as the administration of an 
 anesthetic, but it is hoped that these general suggestions may be 
 helpful, particularly to the nurse who is unexpectedly confronted 
 by an emergency. 
 
 Under all conditions the nurse must remember that no mat- 
 ter what anesthetic is given, nor by whom it is administered, 
 she must guard against the very prevalent tendency to talk freely 
 while the patient is going under, in the belief that she is un- 
 aware of what is going on about her. Many patients suffer 
 great mental distress because of hearing, or partly hearing con- 
 versation not intended for their ears, which takes place in their 
 hearing while they are incompletely anesthetized. 
 
CHAPTER XIII 
 
 OBSTETRICAL OPERATIONS AND COMPLICATED 
 
 LABORS 
 
 Unhappily, not all labors run the smooth and uncomplicated 
 course which was described in the last chapter. Certain ab- 
 normalities sometimes arise to complicate delivery, occasionally 
 necessitating operative interference or relief. 
 
 There is little that a nurse can do alone, in the presence 
 of complicated labor, but her preparations and assistance will 
 be more effective if she understands the purpose of the opera- 
 tions, and she will better appreciate the gravity of cercain symp- 
 toms, which she is required to watch for and report, if she real- 
 izes the extreme seriousness of their import. 
 
 The principal conditions which give rise to, or follow com- 
 plications, prevent spontaneous delivery or necessitate operations 
 at the time of labor are perineal lacerations ; contracted or mal- 
 formed pelves; marked disproportion between the diameters of 
 the child's head and mother's pelvis; ruptured uterus; exhaus- 
 tion of the mother ; poor muscle tone or certain chronic and acute 
 diseases of the mother ; death of the fetus ; prolapsed cord ; cer- 
 tain presentations of the fetus in which spontaneous delivery is 
 doubtful or impossible. 
 
 The preparations for operations in hospitals are all so care- 
 fully planned and systematized that in the presence of such 
 emergencies the nurse will merely have to carry out the cus- 
 tomary routine, but in a patient's home she may have to exercise 
 a good deal of originality in attempting to meet the needs of the 
 occasion and imitate hospital provisions. 
 
 A satisfactory operating table may be fashioned in any one 
 of a number of ways. If the bed is high enough, it may some- 
 times be made fairly satisfactory by slipping a board, such as a 
 cable leaf, under the mattress to make it firm. The use of a 
 
 293 
 
296 OBSTETRICAL NURSING 
 
 kitchen table is time-honored, but it is an unsafe practice unless 
 the available table is very secure and firm, which is usually not 
 the case with present-day kitchen tables. A flat-topped chest 
 of drawers, with the casters removed, makes an excellent 
 operating table, for it is firm, a good height and about the right 
 size. Or an ordinary bureau may be pressed into service after 
 taking out the casters and removing the mirror by unscrewing 
 its supports. The front and sides of a bureau, or chest of 
 drawers so used should be protected from the damaging effects 
 of fluids and solutions by being covered with a bed-rubber or 
 newspapers. A pad for the top of the improvised operating table 
 may be arranged by folding a blanket or quilt to the proper size 
 and folding over that the rubber draw-sheet and a clean muslin 
 sheet. 
 
 If the operation requires that the patient be held in the 
 lithotomy position (on her back with thighs and knees flexed 
 and knees well separated), and the doctor's equipment does not 
 include a strap to hold the legs, one may be improvised from a 
 sheet. It should be folded diagonally, over and over, into a 
 strip possibly a foot wide, passed over one shoulder and the 
 tapering ends used to tie around the legs, above the knees, to 
 hold them in the desired position. Bandages or tapes are not 
 always satisfactory, for the support is subject to a good deal 
 of strain, and narrow strips sometimes cut painfully into the 
 legs and shoulders. Certainly if tapes or bandages are used, 
 cotton pads or folded towels should be interposed between them 
 and the patient's skin. 
 
 In general, the nurse will prepare as for a normal delivery, 
 in each instance adding such details of equipment, or preparation 
 as the contemplated operation requires. Rigid asepsis must be 
 observed throughout the preparations and the operations. When 
 large instruments or appliances are to be used, a wash boiler 
 is probably the safest thing in which to boil them, for it is 
 scarcely possible entirely to cover them with water in a smaller 
 receptacle ; and they must be well covered while boiling, or they 
 will not be sterile. 
 
 Perineal Lacerations. A large proportion of women during 
 the birth of the first baby sustain some degree of perineal lacera- 
 
OBSTETRICAL OPERATIONS 297 
 
 tion, which may amount to nothing more than a nick in tfte 
 mucous membrane, or it may extend entirely across the peri- 
 neal body and tear through the rectal sphincter. The causes 
 of these tears are generally conceded to be rigidity of the perineal 
 muscles; disproportion between the size of the child's head and 
 the vulval opening; a sudden expulsion of the child's head, be- 
 fore the perineum is fully distended, and certain abnormalities 
 in the mechanism of labor. Lacerations may, therefore, be pre- 
 vented, or limited, in many cases by holding back the baby's 
 head and allowing it to dilate the perineum slowly. But in spite 
 of the most skillful and careful efforts, tears of some degree 
 occur in most primiparae, and probably in half of all multipara. 
 These injuries are usually described as being of the first, second 
 or third degree, according to their extent. 
 
 A first degree tear is one that extends only through the 
 mucous membrane, usually at the margin of the perineum, with- 
 out involving any of the muscles. 
 
 A second degree tear is one that extends down into the 
 perineal body and may involve the levator ani, or even extend 
 down to, but not through the rectal sphincter. Such a tear 
 usually extends upward on one or both sides of the vagina mak- 
 ing a triangular injury. 
 
 A third degree tear extends entirely across the perineal 
 body and through the rectal sphincter and sometimes up the 
 anterior wall of the rectum. This variety is often called a 
 complete tear, in contradistinction to those of first and sec- 
 ond degree, which are incomplete. 
 
 It is a fairly general custom to repair these lacerations at 
 the time of labor, no matter what their extent, the sutures being 
 introduced but not tied, during the third stage. The patient 
 is usually sufficiently anesthetized to permit of this, without 
 further anesthesia, in all but complete tears, and as there is 
 usually but very slight bleeding before the expulsion of the 
 placenta, the field is comparatively clear and the stitches are 
 easily put into place. They are not tied, as a rule, until after 
 delivery of the placenta because of the strain which its expul- 
 sion would put upon the fresh stitches. In all but very slight 
 tears, the doctor will usually want the patient turned across the 
 
298 OBSTETRICAL NURSING 
 
 bed, with her hips brought to the edge, and her legs supported 
 in the lithotomy position. As the few instruments necessary 
 for perineal repairs should be boiled and placed in readiness 
 before labor, there is usually no further preparation for the 
 nurse to make, and the perineal dressing, after the stitches have 
 been taken, is ordinarily the same as that following a normal 
 delivery. (See Fig. 80 for necessary instruments.) 
 
 Some physicians prefer not to repair perineal tears until 
 some days after labor, contending that the congestion of the 
 soft parts immediately after delivery is not favorable to a satis- 
 factory union. When the repair is made subsequently, there- 
 fore, the nurse prepares as she would for any perineal opera- 
 tion, performed independently of labor. Repairs are not often 
 postponed for more than a few days, since long delayed or 
 neglected attention frequently gives rise to gynecological dis- 
 orders, such as descensus or prolapse of the uterus. 
 
 Episiotomy. Some obstetricians prefer to anticipate a peri- 
 neal tear by making an oblique incision, usually on one or 
 both sides, extending downward and outward from the margin 
 of the vaginal outlet down into the perineum. This operation 
 is termed episiotomy, and the incision is sutured after labor just 
 ■as a tear would be. It is the belief of those who perform this 
 operation that the clean-cut incision heals more satisfactorily 
 than an irregular tear, and that by directing the incision to the 
 side, away from the median line, the integrity of the rectal 
 sphincter is preserved, even though the perineum tears beyond 
 the end of the incision, when distended during the birth of the 
 head. 
 
 Breech Extraction. In some cases of breech presentation, 
 particularly among primipars, it is necessary to assist nature 
 in the delivery of the child in order to save its life. Complete 
 anesthesia is usually necessary at such times and the jiatient is 
 preferably on a table or at the edge of the bed in a lithotomy 
 position. 
 
 In the majority of cases, no effort is made toward assistance 
 until the body is born as far as the umbilicus, partly because of 
 the difficulty of taking hold of the child securely before that 
 time, and partly because the perineum is not likely to be fully 
 
OBSTETRICAL OPERATIONS 299 
 
 distended, in which case a serious tear would probably result. 
 But after the body has been extruded as far as the umbilicus, 
 it is usually considered imperative to complete the delivery 
 within eight minutes to save the child froi asphyxiation, due 
 either to pressure on the cord between the head and pelvic brim, 
 or to premature separation of the placenta. The baby's feet or 
 legs are grasped by a towel to prevent slipping, and downward 
 traction is made on the body until the tips of the scapulas appear 
 at the outlet. During this procedure the nurse may be called 
 upon to make pressure on the uterus with the idea of keeping 
 the baby 's head flexed forward ; preventing the arms from be- 
 coming extended upward above the head and also to help in 
 expelling the child. 
 
 After the scapula appear, the arm lying posteriorly is brought 
 down over the chest and delivered. The body is then rotated 
 until the other arm lies posteriorly and that is delivered. After 
 delivery of the arms and shoulders the head is usually delivered 
 by what is known as Mauriceau's maneuver as follows: The 
 accoucheur slips the index finger of one hand into the vaginal 
 outlet and into the child's mouth, and supports the body of 
 the child upon his hand and forearm; two fingers of the other 
 hand are slipped around the back of the neck and curved for- 
 ward like hooks over the shoulders and strong downward trac- 
 tion is made by these fingers ; not by the one in the baby 's mouth. 
 The occiput emerges from beneath the symphysis, after which 
 the body is lifted upward and the chin, nose, forehead and entire 
 head are born. 
 
 Version. By version is meant the turning of the child within 
 the uterus so that the part which was presenting at the superior 
 strait is replaced by another part, in order to hasten or facilitate 
 delivery. It is usually performed as the patient lies flat on her 
 back, completely anesthetized, and with great gentleness, for 
 fear of rupturing the uterus. 
 
 Common indications for a version are a transverse presenta- 
 tion; a prolapsed cord, when the head has just begun to enter 
 the superior strait ; and in some cases of placenta prtevia. When 
 the fetus is so turned that the head becomes the presenting part, 
 the procedure is termed a cephalic version; if so turned that 
 
300 OBSTETRICAL NURSING 
 
 the breech presents, it is termed a podalic version. The methods 
 of accomplishing these ends are described as external version, 
 if the turning is done entirely with the hands working through 
 the abdominal wall; internal version if one entire hand is intro- 
 duced into the uterine cavity, and oomhined version when one 
 hand is outside on the abdomen and two fingers of the other are 
 introduced through the cervix into the uterus. 
 
 External cephalic version is often performed late in preg- 
 nancy, or early in labor, in transverse and also in breech presen- 
 tations, to secure a vertex presentation because of the high fetal 
 death rate in breech extractions. Podalic version, or making 
 the breech the presenting part, is often performed in trans- 
 verse presentations, in placenta prgevia and when the cord or 
 extremities are prolapsed. Having converted the presentation 
 into a breech, the usual breech extraction is performed. 
 
 Forceps are instruments which are used to extract the child 
 when presenting by the head in certain conditions which en- 
 danger the life of mother or child. The value of forceps in 
 obstetrics can scarcely be overestimated, as before their invention 
 the only operative method of delivering a live baby was by means 
 of version and extraction, and in these the fetal death rate was 
 high. The obstetrical instruments in use up to that time, there- 
 fore, were all for the destruction of the child in utero. 
 
 Forceps were devised, and first used, in great secrecy, early 
 in the 17th century, by a Dr. Chamberlen, in England, who jeal- 
 ously guarded all information relating to his invention from 
 every one but members of his own family. 
 
 There were several doctors in the Chamberlen family who 
 practiced obstetrics and who used these forceps, but knowledge 
 concerning the nature of the instruments and methods of using 
 them was not shared with members of the medical profession 
 outside of that family, until the beginning of the 18th century. 
 Since that time the use of forceps has been widely extended 
 and the original Chamberlen instruments have been so modified 
 and altered and improved by different obstetricians, that there is 
 now a bewildering number and variety in existence and in use. 
 Probably the most widely used are those which were devised by 
 Dr. Tarnier of France and Dr. Simpson of England, respectively. 
 (Fig. 107.) The Tarnier instrument is known as an axis trac- 
 
OBSTETRICAL OPERATIONS 301 
 
 tion forceps, and can be used in all kinds of forceps operations, 
 while Dr. Simpson's are suitable for use only in low forceps 
 cases. 
 
 There are two groups of indications for the use of forceps; 
 those relating to the condition of the ciiild and those relating 
 to the motlier. 
 
 Indications for their use in the interests of the child are 
 
 Fig. 107. — T\vo widely used forceps. A, Tarnier axis-traction forceps. 
 B, Simpson forceps. 
 
 symptoms of asphyxia, and these are the passage of meconium, 
 in head presentations, and a change in the rate or rhythm of 
 the fetal heartbeat. As pressure on the abdomen of the fetus 
 during labor, in breech presentations, is veiy likely to express 
 meconium, this is not of special significance in these cases. But 
 in head presentations, the escape of meconium suggests paralysis 
 of the rectal sphincter muscles, due to imperfect oxygenation, 
 which, in turn, is caused by interference with the placental 
 circulation by pressure on the cord or premature separation of 
 the placenta. 
 
 Conditions which menace tlie life of the mother, and indicate 
 
302 
 
 OBSTETRICAL NURSING 
 
 the use of forceps, are inadequate contractions of the uterine 
 and. abdominal muscles ; exhaustion, as indicated by an increase 
 in the maternal pulse rate or elevation of temperature, and in 
 certain chronic and infectious diseases, when the patient may 
 be unable to stand the strain of the second stage. 
 
 Forceps are usually employed when the head fails to make 
 satisfactory advancement after two hours of good, second-sta^ge 
 pains, or when it remains in one place on the perineum for an 
 hour, in spite of good, second-stage pains. 
 
 Otherwise, there is danger of necrosis or sloughing of the 
 
 Fig. 108. — Patient in position and draped for forceps operation. 
 (From photograiA taken at Johns Hopkins Hospital.) 
 
 soft parts as a result of pressure, with a subsequent recto-vaginal 
 or vesico-vaginal fistula. 
 
 Among the acute conditions in which forceps are indicated 
 are typhoid fever ; pneumonia ; acute edema of the lungs, hemor- 
 rhage from premature separation of the placenta; intra-partum 
 infection and eclampsia, while they are sometimes used in such 
 chronic conditions as pulmonary tuberculosis; various heart 
 lesions, particularly when there is broken compensation. 
 
 Before appljnng forceps the operator will usually wish to 
 satisfy himself that the following conditions exist : Complete 
 dilatation of the cervix, otherwise severe lacerations with hemor- 
 
OBSTETRICAL OPERATIONS 
 
 303 
 
 rhage may result ; the liead must have entered the pelvis, other- 
 wise an imperfect application of the forceps may result in death 
 of the fetus and serious injury to the mother; the position of 
 the child's head must he known in order that the forceps may 
 be properly applied over the ears; the membranes must have 
 ruptured or the forceps may slip. 
 
 Forceps operations are usually desi^ated as being high, mid 
 or low, depending upon the level to which the head has de- 
 scended into the pelvis. If the head is at the superior strait, a 
 
 Fig. 109. — Forceps sheet used in Fig. 108. 
 
 high forceps operation is necessary ; mid forceps if the head is 
 half way down and on a level with the ischial spines and low 
 forceps when the head is on or just above the perineum. 
 
 The application of low forceps is a simple operation and at- 
 tended by little danger to mother or child ; mid forceps is more 
 serious and high forceps is very serious for the child and some- 
 times for the mother. 
 
 When forceps are applied, the patient must be at the edge 
 of the bed or preferably on a table, in the lithotomy position 
 (Fig. 108), and completely anesthetized. She should be shaved 
 and scrubbed as for a normal delivery, after which a sterile 
 
304 OBSTETRICAL NURSING 
 
 towel soaked in biehlorid 1-1,000 or lysol 2 per cent., is placed 
 over the vulva and allowed to remain until the operation is 
 performed. She should be draped with sterile leggings and 
 towels, one of which is folded over the centre of a wide strip 
 of adhesive about twenty inches long, and hung curtain-like 
 over the rectum by strapping the free ends to the buttocks on 
 each side, while over all is placed a sheet with three openings; 
 two slits for the legs to pass through and one rectangle which 
 exposes the field of operation, (Figs. 109, 110.) 
 
 Fig. 110. — Two types of easily made leggings suitable for use during 
 delivery or obstetrical operations. 
 
 Pubiotomy, or hebotomy, consists in sawing through the 
 pubic bone on one side of the symphysis with a string or Gigli 
 saw. This operation is performed in some cases of moderately 
 contracted and funnel pelves, through which the normal ex- 
 pulsive forces of labor are unable to force the child. The 
 separation of the bone allows it to gape, because of the hinge- 
 like movement of the sacro-iliac joint, and thus the superior 
 strait is appreciably widened and the child may be 
 delivered by high forceps or version. As the bone heals by 
 fibrous union, there is sometimes permanent enlargement of the 
 
OBSTETRICAL OPERATIONS 305 
 
 pelvis and there are seldom any unsatisfactory after-effects, such 
 as impairment of locomotion. Pubiotomy is sometimes the opera- 
 tion decided upon when a patient is seen for the first time after 
 labor is well advanced, and a conservative Caesarean section is 
 thought inadvisable because of the risk of infection. But the 
 operation is becoming more and more rare, for the general prac- 
 tice of measuring the pelvis and supervising patients during 
 pregnancy discloses serious disproportions early enough to make 
 a Cesarean section the elective operation. 
 
 Symphysiotomy. This operation is a cutting through the 
 cartilage of the symphysis pubis, instead of through the pubic 
 bone, as in pubiotomy. It was formerly performed for much 
 the same reasons that pubiotomy is now used, but has been prac- 
 tically abandoned since the development of the latter operation. 
 The reasons for giving it up were that the close proximity of 
 the bladder to the symphysis resulted in frequent injuries to 
 that organ, and as the cartilage of the symphysis does not heal 
 as well as the pubic bone, the patients frequently experienced 
 difficulty in walking and showed a tendency to tire more easily 
 after the operation than before it was performed. 
 
 Vaginal Hysterotomy, or vaginal Caisarean section, as it is 
 sometimes called, consists of incising the cervix anteriorly and 
 posteriorly, delivering the child and placenta and suturing the 
 wounds. It is sometimes performed in cases which for some rea- 
 son require immediate delivery, as in severe cases of eclampsia. 
 It is only possible when the relation between the pelvis and the 
 child's head is such as to permit the child to pass through the 
 inlet. It is rarely done in primiparae, because rigidity of the 
 outlet prevents proper exposure ; or in multiparas at term as the 
 incisions have to be extended so high to deliver a term baby, that 
 there is danger of tearing the lower uterine segment. 
 
 Caesarean Section is the operation by means of which the 
 child is delivered through an incision in the abdominal and 
 uterine walls. It is believed by some that the operation was 
 named for Julius Caesar, who was presumably delivered by this 
 method, but this seems scarcely probable. The operation was 
 frequently fatal in those days and, moreover, as the uterine wall 
 was not sutured after the child was extracted, a woman was not 
 
306 OBSTETRICAL NURSING 
 
 likely to have other children afterward even if she did live, and 
 Cffisar's mother had several children after he was born. An- 
 other explanation for the name is that during Caesar's reign a 
 law was passed which required that the abdomen be opened and 
 the child extracted in every case in which a woman died late 
 in pregnancy, as one means of increasing the population. 
 
 Thus it will be seen that the operation itself is very ancient, 
 but as performed to-day it embodies the most modern and scien- 
 tific knowledge and methods. The usual indications for it are 
 cases of contracted or deformed pelves; cases of tumors which 
 block the birth canal or when very speedy delivery is imperative 
 as in some cases of eclampsia. 
 
 The anatomical indications for Cesarean section are depen- 
 dent upon the degree and character of the pelvic contractions 
 and upon the size and mouldability of the child's head in rela- 
 tion to the pelvis. This explains why in two women with pelves 
 of the same size and shape, one will have a spontaneous delivery 
 and one will require a section. The former has a relatively small 
 child which can pass through her pelvis; while the second 
 woman's baby is too large, or the head not sufficiently mould- 
 able, to pass through hers. 
 
 This is one exemplification of the great importance of pelvim- 
 etry and of constant watching during pregnancy, for the best 
 results from Cesarean section are obtained when it is recognized 
 that spontaneous delivery is unlikely or impossible; the opera- 
 tion accordingly is performed at a time which is deliberately 
 selected by the obstetrician. The elected time is often about two 
 weeks before the expected date of confinement in order that the 
 baby may have the longest possible intra-uterine life and that 
 the operation may be performed before the patient goes into 
 labor. In these cases in which it is known that a section is to 
 be performed vaginal examinations are omitted after the pelvic 
 measurements are taken, in order to minimize the possibilities 
 of infection, this being one of the great risks of the operation. 
 
 Until recent years the operation was usually delayed until 
 after the patient had been vaginally examined, had been in labor 
 long enough to be exhausted and the only other courses open 
 were high forceps or a destructive operation upon the child. The 
 
OBSTETRICAL OPERATIONS 307 
 
 results of the operation undertaken under such circumstances 
 were not good, and the maternal deaths from infection were so 
 frequent that the operation on the whole was very hazardous. 
 But improved surgical technique and extended knowledge of 
 the pelvis have so revolutionized Caesarean section that it is now 
 successful in the majority of cases. 
 
 There are three main types of Caisarean section : conservative, 
 radical and extraperitoneal. 
 
 The conservative operation consists of opening the abdomen 
 in the mid-line; incising the uterus; extracting the child and 
 placenta, and suturing both uterine and abdominal walls. This 
 is the usual operation when there is a choice, but because of the 
 danger of infection, it is ordinarily performed only before the 
 onset of labor or in the early part of the first stage, and many 
 obstetricians are loath to undertake it then if the patient has 
 been examined vaginally, particularly if the technique of the 
 examination was open to question. 
 
 In the radical oi)eration the abdomen and uterus are incised ; 
 the child and i)lacenta extracted and the uterus is amputated 
 just above the cervix. This operation is usually performed when 
 labor is well advanced and there is fear of infection. 
 
 In the extraperitoneal operation the incision in the abdomen 
 is made low down on one side, the peritoneum is not incised 
 but is peeled back from tlie bladder and lower part of the uterus. 
 The uterus may thus be opened and the child and placenta ex- 
 tracted, without entering the peritoneal cavity, thereby greatly 
 reducing the risk of infection, and also without necessitating the 
 removal of the uterus as a safeguard against infection. This 
 operation, also, is performed late in labor when infection is feared, 
 but is considered very difficult and tlierefore is not common. 
 
 The nurse's duties in connection with a Ca^sarean section are 
 the same as those in any abdominal operation plus preparations 
 for receiving and reviving the baby. 
 
 A Ruptured Uterus is a splitting of the uterine wall at 
 some point, usually in the lower uterine segment, that has be- 
 come thinned or weakened and unable to stand the strain of fur- 
 ther stretching incident to uterine contractions, and is accom- 
 panied by an extrusion of all or a part of the uterine contents 
 
308 OBSTETRICAL NURSING 
 
 into the abdominal cavity. The rupture of a uterus during labor 
 is a very rare accident, occurring but once in from 500 to 1,000 
 cases and usually only in prolonged labors, obstructed labors or 
 certain faulty presentations. It is also a very grave accident, 
 since the baby nearly always dies and sometimes the mother as 
 well. 
 
 The cause of a ruptured uterus mry be found in scar tissue, 
 following a CECsarean section or an injury; inherent defects in 
 the tissues comprising the uterine wall; contracted pelves; neg- 
 lected transverse presentations and the accident may occur 
 during a version. It is usually preceded by extreme tenderness 
 in the lower uterine segment, the part that is being abnormally 
 stretched. The common symptoms, after the rupture has oc- 
 curred, are sudden and acute abdominal pain during a contrac- 
 tion, which the patient describes as being unlike anything she 
 has ever felt and as though "something had given way" inside 
 of her. There is immediate and complete cessation of labor 
 pains because the torn uterus no longer contracts. Sooner or 
 later the patient has sj^mptoms of shock because of the hemor- 
 rhage, which is usually internal, though there may be vaginal 
 bleeding as well. Her face becomes pale and drawn and covered 
 with perspiration ; her pulse is weak and rapid ; she appears ex- 
 hausted and collapsed and may complain of chilly sensations 
 and air hunger. 
 
 Abdominal palpation shows that the lower uterine segment is 
 even more sensitive than formerly and that the presenting part 
 has slipped away from the superior strait while at the side of the 
 fetus the contracted uterus, partly or entirely empty, may be 
 felt as a hard mass. The symptoms of shock may be delayed for 
 some time when they will be accompanied, as a rule, by abdom- 
 inal distension, due to hemorrhage, and a slight elevation of 
 temperature. 
 
 The prevention of this disaster lies in performing version and 
 prompt extraction in transverse presentations, as soon as the 
 cervix is dilated, and in interference if the presenting part does 
 not engage after an hour of strong, second-stage pains. 
 
 The treatment of a ruptured uterus is influenced by many 
 factors. Possibly the most frequent course followed is to open 
 
OBSTETRICAL OPERATIONS 309 
 
 the abdominal cavity and repair or remove the uterus, after 
 extracting the fetus and placenta, according to existing condi- 
 tions and the jndgment of the operator. Sometimes the fetus is 
 removed through tlie vagina and the uterus repaired through 
 that channel. 
 
 Destructive Operations have as their purpose the crush- 
 ing or dismembering of the child in utero so that it may pass 
 through the pelvis. In the early days such operations were re- 
 sorted to fairly often in the presence of conditions that threat- 
 ened the mother's life and which apparently could not be met in 
 any other way. They are performed less and less frequently 
 to-day because of the success attending the performance of Cae- 
 sarean section, version, pubiotomy and forceps operations. They 
 are never sanctioned by the Catholic Church in cases where the 
 child is alive. 
 
 Induced Abortions and Premature Labors. As was ex- 
 plained in the chapter on complications and accidents of preg- 
 nancy, it is sometimes deemed advisable, or necessary to term- 
 inate pregnancy by artificial means, in the interests of the mother 
 or child or both. 
 
 The procedures are termed induced abortion, induced prema- 
 ture labor and accouchement force. The effects of these opera- 
 tions, per se, when skillfully performed, for therapeutic pur- 
 poses, are not usually considered more serious for the mother 
 than a normal delivery, since they can be performed with delib- 
 erate care and cleanliness and can be followed by adequate after- 
 care. When the reverse conditions prevail, as in criminal abor- 
 tions, the patient's subsequent suffering or ill health are more 
 likely to be due to the poor obstetrics and unclean work which 
 is characteristic of practitioners who are willing to do illegal 
 operations, than to the termination of pregnancy itself. It is 
 important that the nurse fully appreciate this and be as scrupu- 
 lously careful in her preparations for, and assistance with these 
 operations as for a major operation or a normal delivery. 
 
 Induced abortion applies to the termination of pregnancy 
 before the child is viable, or before the end of the twenty-eighth 
 week, and is performed solely in the interests of the mother, as 
 the fetus is always lost. It is resorted to in those cases where 
 
310 OBSTETRICAL NURSING 
 
 the mother is suffering from some condition, which may or may 
 not be inherent to pregnancy, which threatens her life or health 
 but which it is believed may be cured or arrested if uncompli- 
 cated by pregnancy. Such conditions may be toxemic vomiting; 
 nephritis, particularly with evidences of increasing renal insuf- 
 ficiency; bleeding, due to an incomplete abortion; a dead fetus; 
 infection following an attempt at criminal abortion. Contracted 
 pelves and pulmonary tuberculosis are sometimes taken as indi- 
 cations for inducing abortions, but with the development and 
 improvement of obstetrical operations, more and more women 
 are able to go nearly, or quite, to term and be delivered of live 
 babies; while increasing medical knowledge concerning the care 
 of patients with tuberculosis, and also with some heart lesions, 
 is applied so successfully during the prenatal period that some 
 pregnancies which formerly would have been terminated, are now 
 allowed to continue, and with happy results. 
 
 The methods of induction depend upon the stage to which 
 pregnancy has advanced and also upon the importance of haste. 
 In the very early stages, one method is for the operator to dilate 
 the cervix with a dilator; insert one finger into the cervix and 
 up into the uterus and separate the placenta from its uterine at- 
 tachment, while making pressure on the uterus from above with 
 the other hand on the abdomen. Another method is to introduce 
 a gauze pack into the cervix, packing it and the vagina firmly 
 and leaving the packing for twenty-four hours. When it is re- 
 moved the ovum frequently follows. Sometimes the membranes 
 are ruptured, after which the amniotic fluid drains off and the 
 ovum is expelled ; or vaginal hysterotomy is sometimes performed 
 when the patient's condition is such that haste is imperative. 
 The termination of pregnancy before viability is never sanctioned 
 by the Catholic Church, because of the almost certain loss of the 
 child. 
 
 Induction of premature labor. This procedure is the ter- 
 mination of pregnancy after the twenty-eighth week, or after 
 the child is viable, and may be performed to save either the 
 mother or the child or both, from conditions which would evi- 
 dently work destruction if allowed to persist. The indications 
 for inducing labor prematurely may he a seriously overtaxed 
 
OBSTETRICAL OPERATIONS 
 
 311 
 
 heart or kidneys ; pulmonary tuberculosis ; preeclamptic toxemia 
 or nephritic toxemia ; chorea, neuritis ; pyelitis ; placenta prasvia ; 
 a fetus that has been dead for two weeks, with no signs of labor; 
 in some cases of nephritis when the fetus during previous preg- 
 nancies has died, and it is believed that the child may be saved 
 by inducing labor before the stage in pregnancy at which the 
 others perished. 
 
 Labor is sometimes induced when the mother's pelvis is 
 
 Fig. 111. — Kubber bougie used in inducing labor, 
 
 normal, but the child has grown as large as is safe in anticipa- 
 tion of a spontaneous labor, and particularly if the expected 
 date of confinement has passed. 
 
 A common method of inducing labor when haste is not im- 
 portant, is to introduce one or more bougies (Fig. Ill) through 
 the cervix into the uterine cavity between the membranes and 
 the uterine wall. The presence of the bougies will often stimu- 
 
 FiG. 112. — Champetier de Eibes' bag. 
 
 late the uterine contractions and bring on labor, with expulsion 
 of the fetus, in from six to twenty-four hours. 
 
 More speedy results are. obtained by the use of rubber bags, 
 which may be collapsed before introduction and expanded after- 
 ward by filling them with sterile salt solution. There is a great 
 variety of bags for this purpose, two of which that are frequently 
 used are the Champetier de Ribes (Fig. 112) and the Voorhees 
 
312 
 
 OBSTETRICAL NURSING 
 
 bags. (Fig. 113.) They come in graduated sizes, the largest 
 holding about 500 cubic centimetres. 
 
 The operation is performed with the patient in the dorsal 
 
 Fig. 113. — ^Voorhees' bag, collapsed. 
 
 position. The cervix is drawn down into sight, with forceps, and 
 if intact, is slightly dilated. The bag is rolled tightly, held in 
 suitable forceps (Fig. 114), and after being well lubricated is 
 
 Fig. 114. — Eubber bag rolled and held in forceps for introduction 
 into uterus. 
 
 introduced through the slightly dilated cervix into the lower 
 uterine segment, and pumped full of sterile salt solution. The 
 solution is first measured in order to be sure that the bag is 
 filled to its desired capacity, and is then introduced by means 
 
 FiQ. 115. — Syringe for introducing sterile water into bag after its in- 
 sertion into the uterus. 
 
OBSTETRICAL OPERATIONS 313 
 
 of a syringe, (Fig. 115), through the rubber tubing which is 
 attached to the lower end of the bag, and which is then closed 
 off by the stop cock, to prevent escape cf the fluid. It is very im- 
 portant that the solution be sterile in view of the possibility of 
 any rubber bag rupturing, particularly when pressed upon by 
 the contracting uterus. (Sec Fig. 47 for position of bag after 
 introduction into uterus.) 
 
 The presence of this bag stimulates uterine contractions, the 
 cervix dilates, the bag is expelled and in some instances the child 
 is delivered spontaneously and in others by means of forceps. 
 The effect of this bag in producing labor may be hastened by 
 tying a weight to the end of the tubing and allowing it to hang 
 over the side of the bed. This traction and pressure help to 
 dilate the cervix and seem to increase the irritation of the uterine 
 muscles, thus increasing the force of their contractions. 
 
 Accouchement force is a speedy, forced delivery requiring 
 the forcible widening of an intact, or partly dilated cervix, 
 manually, or instrumentally. It is sometimes performed when 
 existing conditions require extreme haste, as in certain heart 
 lesions; eclampsia; concealed or accidental hemorrhage or in 
 any condition which suddenly arises to threaten the life of the 
 patient or her expected baby. But as the shock of this operation 
 is great and the condition which threatens the patient can usu- 
 ally be better relieved by means of some one of the operations 
 already described, it is less and less frequently performed. 
 
THE MIRACLE* 
 by 
 
 Elizabeth Newport Hepburn 
 
 The wind blows down the street, 
 
 A shutter bangs somewhere, 
 While twilight falls as softly as 
 
 A woman's flowing hair. 
 
 Within a quiet room, 
 
 Adventurers at rest, 
 A mother holds her newborn son, 
 
 Safe, now, upon her breast ! 
 
 For out of Night and Pain, 
 
 The womb of mystery, 
 Is sprung this miracle of Life 
 
 That she can touch and see. 
 
 No seer's prophetic dream, 
 
 No star in all the skies 
 Burns with a lustre half so bright 
 
 As happy mother eyes. 
 
 No quester for the Grail, 
 
 No searcher for the Truth, 
 Counts more than those who bear and rear 
 
 And love and nurture Youth ! 
 
 Within her curving arm, 
 
 All safe and warm he lies. 
 The heir of all that Man has won 
 
 Down countless centuries ! 
 
 * Written especially for this book. 
 
PART V 
 The Young Mother 
 
 CHAPTEE XIV. THE PUERPERIUM. Physiology. Involution. After 
 pains. Lochia. Loss of Weight. Menstruation. Lactation. Ab- 
 dominal Wall. Digestive Tract. Temperature. Pulse. Skin. Urine. 
 
 CHAPTER XV. ROUTINE NURSING CARE DURING THE PUER- 
 PERIUM. Complications to be Guarded against. General Treat- 
 ment of the Patient. Nursing Care. Position in Bed. Sitting up. 
 The Daily Bath. Diet. The Bowels. The Bladder. Catheterization. 
 Temperature, Pulse, and Respiration. Care of the Perineum. Care 
 of the Breasts. Lactation. Stripping. Abdominal Binders and 
 Bed Exercises. 
 
 CHAPTER XVI. THE NURSING MOTHER. Normal Routine. The 
 Establishment of Breast Feeding. The Mother's Frame of Mind 
 and State of Nutrition. Method of Nursing. The Nursing Schedule. 
 Personal Hygiene of the Nursing Mother. Diet. Bowels. Rest 
 and Exercise. Recreation. Weaning. Drying up the Breasts. 
 
 CHAPTER XVII. NUTRITION OF THE MOTHER AND HER BABY. 
 Importance of Adequate Nutrition in First Weeks of Life. Neces- 
 sary Elements of an Adequate Dietary. "Vitamines. " Danger of 
 Deficiency Diseases. Danger of Conditions Approaching Recognizable 
 Disease. The Deficiency Diseases. Scurvy. Infantile Scurvy, Cor- 
 rective Diet. Beriberi. Xeropthalmia. Pellagra. Rickets. Cor- 
 rective Diet. Application of Principles of Nutrition to the Diet of 
 the Nursing Mother. 
 
 CHAPTER XVIII. COMPLICATIONS OF THE PUERPERIUM. Post- 
 partum Hemorrhage. Causes, Treatment and Nursing Care. Puer- 
 peral Infection. History of Disease. Prevention. Symptoms, Treat- 
 ment and Nursing Care. Phlegmasia alba dolens, or ' ' Milk leg. ' ' 
 Puerperal Mania. 
 
CHAPTER XIV 
 THE PHYSIOLOGY OF THE PUERPERIUM 
 
 The puerperium ^ is ordinarily regarded as comprising the 
 five or six weeks immediately following delivery. During this 
 period the mother's body undergoes various changes which re- 
 store it very nearly to its pre-pregnant state, leaving the patient 
 in a normal, healthy condition. The most important of these 
 changes are involution of the uterus, loss of weight and improve- 
 ment in tone of the abdominal and perineal muscles. The altera- 
 tions which produce this restoration are normal physiological 
 processes, but mismanagement or lack of care while they are 
 taking place may result in serious complications; these may be 
 immediate or remote, such as hemorrhage and infection or 
 chronic invalidism. 
 
 Recognition of these dangers, and the possibility of prevent- 
 ing them, is responsible for the present custom of obstetricians 
 to watch over their patients during the puerperium. This is in 
 sharp contrast to the old practice of the doctor's visiting the 
 puerperal woman only when there was a complication so ap- 
 parent that he was summoned. 
 
 The precautions and the care which the doctor takes of his 
 patient after delivery involve intelligent and watchful nursing. 
 In order to give this the nurse must understand something of 
 the normal physiology of the puerperium, just as she did in 
 pregnancy and labor. Otherwise she may not be able to dis- 
 tinguish evidences of normal changes from symptoms of com- 
 plications. 
 
 Involution. Considerable attention is centred in the re- 
 markable atrophic changes that take place in the uterus during 
 the puerperium, for it is upon their being normal that the pa- 
 tient's recovery and future well-being so largely depend. Im- 
 
 * From pu^r, child, and parere, to bring forth. 
 
 317 
 
318 OBSTETRICAL NURSING 
 
 mediately after delivery the uterus weighs about two pounds ; is 
 from seven to eight inches high ; about five inches across and 
 four inches thick. The top of the fundus may be felt above the 
 umbilicus, and the inner surface, wiiere the placenta was at- 
 tached, is raw and bleeding. At the end of six or eight weeks the 
 uterus has descended into the pelvic cavity and resumed ap- 
 proximately its original position and size, and its former weight 
 of two ounces ; a new lining has developed from the few glands 
 which have not been cast off in the discharges. 
 
 This rapid diminution in the size of the uterus is termed 
 involution and is accomplished by means of a process of self- 
 digestion or autolysis. The protein material in the uterine walls 
 is broken down into simpler components which are absorbed and 
 eventually cast off largely through the urine. This change and 
 absorption of uterine tissues is similar to the resolution that 
 takes place in a consolidated lung in pneumonia. 
 
 Since satisfactory involution is necessary to the patient's 
 future health, its progress should be watched with deep concern 
 and interest, and all possible effort made to promote it ; firm con- 
 sistency of the uterus and a steady descent into the pelvis and 
 normal lochia being the chief evidences of satisfactory involu- 
 tion. There is evidently a close relation between the functions 
 of the breasts and of the uterus during the puerperium, and as a 
 rule involution accordingly progresses more normally in women 
 who nurse their babies than in those wdio do not. 
 
 The so-called "after-pains" are also affected by nursing, be- 
 ing more severe as a rule Avhen the baby is at the breast than at 
 other times. These pains are caused by the alternate contrac- 
 tions and relaxations of the uterine muscles and are more com- 
 mon in multiparae, than in primipar^e, because the muscles of 
 the former have somewhat less tone than the latter and therefore 
 tend to relax, and then contract, whereas the better muscle tone 
 of the primipara tends to keep the uterus steadily contracted. 
 
 These after pains usually subside after the first twenty-four 
 hours, though they may persist for three or four days. They 
 may amount to little more than discomfort, but not infrequently 
 are so severe as to require the administration of sedatives. Per- 
 sistent after pains may be due to retained clots. 
 
 The cervix, vagina and perineum which have become stretched 
 
THE PHYSIOLOGY OP THE PUERPERIUM 319 
 
 and swollen during: labor, gradually regain their tone during 
 the puerperiuni, and the stretched uterine ligaments become 
 shorter as they ret-over their tune, finally regaining their former 
 state. Until the ligaments and the pelvic floor and abdominal 
 wall are restored to normal tonicity the uterus is not adequately 
 supported and tiierefore may be easily displaced. 
 
 The lochia c(msists of the uterine and vaginal secretions and 
 the blood and uterine lining which are cast off during the puer- 
 periuni. During the first three or four days tliis discharge is 
 bright red, consisting almost entirely of blood, and is termed 
 the lochia rubra. As the color gradually fades and becomes 
 brownish it is called the lochia serosa. After about the tenth day, 
 if involution is normal, the discharge is whitish or yellowish and 
 is designated as the lochia alba. The total amount of the lochial 
 discharge has been variously estimated at from one to three pints, 
 being more profuse in multiparsB than primiparae, and in 
 women who do not nurse their babies. Under normal conditions 
 the discharge is profuse at first, gradually diminishing until it 
 entirely disappears by the end of the puerperium. There may 
 be small amounts of blood retained during the first day or two 
 and expelled later as clots, without any serious significance, and 
 there may be a pinkish discharge after the patient gets up for 
 the first time, but if the lochia is persistently blood-tinged it 
 may be taken as an indication that the uterus is not involuting 
 as it should. 
 
 The normal characteristic odor is flat and stale. A foul odor, 
 no odor at all or a marked decrease in the amount of the dis- 
 charge is suggestive of infection. 
 
 Loss of Weight. One of the striking changes during the 
 puerperium is the loss in weight, due largely to three factors: 
 the elimination of fluids from the edematous tissues; the de- 
 crease in the size of the uterus and the escape of vaginal and 
 uterine secretions, termed the lochia. The smaller amount of 
 food taken during the first few days post-partum also may be 
 a factor. 
 
 This loss in weight is extremely variable, fat women natu- 
 rally losing more than thin women and those who nurse their 
 babies losing more than those who do not. 
 
 Dr. Edgar estimates that the loss through the lochia amounts 
 
320 OBSTETRICAL NURSING 
 
 to something over three pounds, and the loss through fluids from 
 the tissues, from nine to ten pounds. According to Dr. Slemons, 
 the loss in fluids equals about 1/lOth of the patient's weight at 
 the beginning of the puerperium, while all agree that the uterus 
 decreases about two pounds in weight. All told, then, the patient 
 may normally lose from twelve to fifteen pounds during the 
 puerperium. This loss may be somewhat controlled, however, by 
 a suitable diet, and under most conditions the patient should re- 
 turn to not less than her pre-pregnant weight by the end of the 
 sixth or eighth week. 
 
 Menstruation. Although in the ideal course of events, the 
 mother does not menstruate while nursing her baby, that is, for 
 eight to ten months. Dr. Slemons estimates that about one-third 
 of all nursing mothers begin to menstruate about two months 
 after delivery, while according to Dr. Edgar one-half of those 
 who do not nurse their babies begin to menstruate in six weeks 
 after delivery. 
 
 Menstruation is more likely to return early in primiparae 
 than in multipai'aB. Patients sometimes wonder whether this 
 early discharge is menstrual or lochial, and though they can not 
 tell, a physician can easily decide by examination, and it is im- 
 portant that he be given the opportunity to do so. A nursing 
 mother may menstruate once and then not again for several 
 months or a year; or she may menstruate regularly and nurse 
 her baby satisfactorily at the same time, though menstruation is 
 usually regarded as unfavorable to lactation. 
 
 Lactation. During the first two or three days after the 
 baby is born, the breasts secrete a small amount of yellowish 
 fluid called colostrum, which differs from milk chiefly in that 
 it contains less fat and more salts and serum-albumen than milk 
 and in the fact that it coagulates upon boiling. About the third 
 day after delivery, the meagre amount of colostrum is replaced 
 by milk and as it increases rapidly in amount, the breasts usually 
 become tense and swollen at this juncture, and sometimes very 
 painful; but this turgidity usually subsides after a day or two. 
 
 The function of the breasts, that of secreting milk, is defi- 
 nitely stimulated by the baby's suckling and will not continue 
 for more than a few days without this stimulation, a fact to be 
 remembered if it is desirable for any reason to dry up the breasts. 
 
THE PHYSIOLOGY OF THE FUERPERIUM 321 
 
 The ideal condition is for the breasts to secrete a quantity 
 and quality of milk which will adequately nourish the baby for 
 eight or ten months. The reverse of this condition is sometimes 
 found in very young or in elderly women, or in very fat or frail, 
 undernourished women. 
 
 Ovulation is usually suspended during lactation, but a mother 
 may become pregnant a few weeks after delivery even while 
 nursing her baby, though the quality of her milk is likely to be 
 unfavorably affected by the pregnancy. But, as has been ex- 
 plained, the return of menstruation does not necessarily exert 
 as unfavorable an influence upon lactation as was formerly be- 
 lieved. 
 
 Abdominal Wall. The abdominal wall is usually over- 
 stretched during pregnancy, and immediately after labor when 
 the tension is removed, the skin lies in folds and the entire wall 
 is soft and flabby. The normal and desirable course is for the 
 muscles gradually to regain their tone ; for the excess of fat to 
 be absorbed and the walls to approach their original state in the 
 course of a few weeks. The striae usually remain, and the 
 muscles sometimes fail to regain their tone, as for example when 
 pregnancies follow each other in rapid succession or when there 
 has been excessive distension. In such cases there is likely to be 
 the pendulous abdomen so often seen in multiparae, and a dias- 
 tasis, or separation of the rectus muscles. 
 
 Digestive Tract. During the first day or two after delivery 
 the mother may have very little appetite but she is usually very 
 thirsty. She will almost inevitably be constipated, because of 
 the loss of intra-abdominal pressure ; the sluggishness of the in- 
 testines acquired during pregnancy ; her recumbent position, lack 
 of exercise and the fact that she is taking relatively less food than 
 usual and that her bowels were freely evacuated at the onset of 
 labor. 
 
 Temperature. The temperature often rises to about 99° F. 
 immediately after labor but it should drop to normal in a few 
 hours and practically remain so. For various causes, some of 
 which are unexplained, the temperature will not infrequently 
 be slightly above normal at times during the first few days of 
 the puerperium, without the patient's seeming to suffer any ill 
 effects. But the fairly general agreement among obstetricians 
 
322 OBSTETRICAL NURSING 
 
 seems to be that a temperature of 100.4° F. is the upper limit of 
 normality and that infection is to be suspected if it reaches 
 that point and remains there for twenty -four hours. 
 
 Pulse. The normal pulse rate is usually slower during the 
 puerperium, being about 60 or 70 beats to the minute, and is re- 
 ferred to as puerperal bradycardia. It is thought that this is 
 due to the absolute rest in bed and the decreased strain upon 
 the heart after the birth of the baby. 
 
 Skin. There is usually profuse perspiration during the first 
 few days, while the elimination of fluids is most active, but it 
 gradually subsides and becomes normal by the end of a week. 
 The perspiration sometimes has a strong odor and there is not 
 infrequently an appreciable amount of desquamation. 
 
 Urine. Many patients find it difficult, even impossible, to 
 void urine during the first several hours after delivery because 
 of the removal of intra-abdominal pressure ; the recumbent posi- 
 tion and the swelling and bruised state of the tissues about the 
 urethra. The bladder is likely to be less sensitive than usual 
 and the patient will be able to retain an abnormally large amount 
 of urine for several hours without discomfort, or desire to void. 
 
 The output of urine during the first few days is greater than 
 normal, and there is also a considerable increase in the amount 
 of nitrogen excreted, beginning two or three days after delivery. 
 This is evidently derived from the broken down proteins in the 
 uterine wall, and the excess gradually subsides as involution 
 progresses, and disappears by the time the uterus descends into 
 the pelvis. 
 
 When one considers the severe ordeal that the young mother 
 has just passed through, her recovery and return to a normal 
 state are surprisingly rapid, when she is given good care. 
 
CHAPTER XV 
 NURSING CARE DURING THE NORMAL PUERPERIUM 
 
 In general, the nursing care during the puerperium is much 
 the same as that which is given to a surgical patient, with special 
 attention to the breasts and perineum and a sustained effort to 
 prevent complications and restore the mother to a normal state 
 of health in due time. 
 
 As the nurse doubtless realizes by this time, the principal 
 complications to guard against during the puerperium are hemor- 
 rhage from the still raw area, Avhere the placenta was attached 
 to the inner surface of the uterus ; infection of the birth canal ; 
 breast abscesses; displacement of the uterus and subinvolution, 
 or failure of the uterus to return to its normal size and condition 
 in the usual length of time. 
 
 In addition to guarding against these definite complications, 
 the nurse must help to save her patient from the less tangible, 
 but perhaps equally injurious effects of fatigue of mind and 
 body. As many young mothers are in a more or less unstable, 
 excitable condition after the baby's birth, the beneficial effect 
 of promoting a tranquil and contented state of mind can scarcely 
 be overestimated. 
 
 The doctor may be ever so tactful and cheering and sustain- 
 ing, but his contacts with the patient are short and infrequent 
 as compared with the nurse's constant companionship. She can, 
 therefore, by her attitude, manner and conduct practically create 
 or destroy the atmosphere that is necessarj^ to her patient's wel- 
 fare. 
 
 In order to give the best and most helpful service the nurse 
 must try from the very beginning to understand her patient as 
 an individual and adapt herself to the patient's temperament. 
 Some women are rested and soothed by being talked with, read 
 to, diverted and amused in one way or another, during most of 
 
 323 
 
324 OBSTETRICAL NURSING 
 
 the time, and will grow nervous and depressed if left to their own 
 devices. Others, who have greater resources within themselves 
 are happier and better off when left to themselves a good deal, 
 and given an opportunity to think things over. Some women 
 are much subdued as the consciousness of their motherhood 
 grows upon them, and they feel a kind of awe and wonder about 
 this baby that they begin to realize is their own. It is a big ex- 
 perience, this one of motherhood, full of promise and responsi- 
 bilities, and the young mother herself very often wants to think 
 it out. She will enjoy talking when she wants to talk, but may 
 be irritated and exhausted by a nurse who tries to entertain her 
 all of the time. 
 
 For this reason, the most conscientious and painstaking nurse 
 imaginable may destroy her usefulness, by adopting the wrong 
 attitude toward her patient during this period of enforced in- 
 timacy. Some women want, and even need to be indulged and 
 petted ; but, on the other hand, a certain type of reserved and 
 dignified woman is affronted by such attention or by the easy 
 air of familiarity that another courts; one patient is exhausted 
 by the unvarying punctuality and precision of a conscientious, 
 but unadaptable nurse, while that very punctuality and preci- 
 sion is satisfying and restful to another. 
 
 It is not a simple matter to sound the depths of a patient's 
 personality, for they are all complex and each one is peculiar to 
 herself. That fact must not be overlooked for each patient is 
 an entirely new and different problem and not like any other 
 that the nurse has had before. But the nurse who is sincere and 
 sympathetic and who earnestly tries to put herself in her pa- 
 tient's place and see things from her standpoint, will, by virtue 
 of that very attitude, accomplish much toward sensing the pa- 
 tient's temperament and establishing harmonious relations. 
 Moreover, the patient, herself, will all unconsciously make some- 
 thing of an adjustment to the nurse when she feels the nurse's 
 sincerity and her eagerness to be of service. 
 
 One factor in shaping the young mother's state of mind, 
 which the nurse must take into account is that the entire scheme 
 and purpose of her patient's life have been changed. She has 
 been plunged very suddenly into a wholly new condition and 
 
CARE DURING THE NORMAL PUERPERIUM 325 
 
 her reaction to this change will depend upon her temperament, 
 disposition and habits of adjustment. 
 
 She has spent nine months looking forward to an event that 
 has been consummated ; she has spent nine months in a state of 
 more or less apprehension and suspense that have been abruptly 
 ended, and we know that it is quite natural for any one to ex- 
 perience a letting down, or something akin to collapse, when 
 long-continued uncertainty is ended, even though it ends hap- 
 pily. 
 
 And as recovery progresses the patient becomes aware, per- 
 haps only vaguely, of another change which is not always a wel- 
 come one. For nine months she has been the centre of interest 
 in her immediate circle ; she has been the object of unremitting 
 concern and solicitude, and much as she and her family may 
 have tried to keep her life normal, she and her needs have con- 
 stantly been given the first consideration. The very mystery of 
 the child developing within her has created an attitude of re- 
 spect, almost of reverence, which was never her portion before. 
 In every way she has been shielded, protected and cared for, and 
 all eyes, including her own, have steadily looked forward to the 
 event for which this care has been preparing her — her ordeal 
 of childbirth and the coming of her baby. 
 
 And now her ordeal is over. Her baby is here. Every one 
 may be said to be breathing easily at last and they are no longer 
 apprehensive and absorbingly interested in her. As a result the 
 young mother will soon become simply one of the family and 
 the community, and will cease to be the centre of reverential in- 
 terest and solicitude. 
 
 It is scarcely human to welcome such a change in one 's state, 
 and though in all probability very few mothers are conscious 
 of resenting it, very many actually do. And for this reason very 
 many unwittingly cling to a role of semi-invalidism. It is en- 
 tirely unconscious on their part and it is also very human and 
 natural. 
 
 To aid in the process of bracing up such a young woman to 
 resume her former life and to meet the demands which it im- 
 poses : or to protect another patient of the eager, buoyant type 
 from exposing herself too early to the onslaughts made by 
 
326 OBSTETRICAL NURSING 
 
 everyday life, is far from beiug a simple task, and to meet it no 
 one rule can be laid down. There are all of the variations and 
 degrees between the timid or self-indulgent woman, who must 
 be encouraged and spurred on, and the too active, ambitious pa- 
 tient, who must be steadied and held back for a time. 
 
 But here, again, this is simply a part of the nurse's duty; 
 one aspect which makes nursing the gratifying service that it is». 
 
 Fortunately the majority of young mothers are happy and 
 normal in their outlook and may be kept so by the exercise of 
 an average amount of tact and amiability on the part of the 
 nurse. The actual physical care of the patient during the puer- 
 perium is a fairly simple matter for the well trained nurse. She 
 will find, however, that in hospitals, private practice and pub- 
 lic-health work alike there will be wide differences in the treat- 
 ment given by different doctors, during this period, just as 
 there were during pregnancy and labor, and she will have to 
 carry out the prescribed directions enthusiastically and loyally 
 no matter how they vary from those of the doctors who helped 
 in her training. 
 
 The details of the care will be indicated by the individual 
 doctor, but the general, underljdng principles — cleanliness, 
 watchfulness, adaptability and sympathetic understanding will 
 apply to the nursing of all patients. The most notable differ- 
 ences of opinion relate to the care of the breasts, the perineum 
 and the use of abdominal binders, the accepted routine for the 
 general nursing of average, normal cases being fairly uniform 
 the country over. 
 
 NURSING CARE 
 
 As has been stated, the general nursing care of the puerperal 
 patient is much the same as that given to any surgical patient, 
 with such adaptations as are indicated by the condition and 
 needs of the young mother. 
 
 Position in Bed. The question of the patient's position In 
 bed is probably the first one that presents itself to the nurse 
 after that first hour when the patient must be kept flat on her 
 back and the fundus closely watched. She should continue to 
 lie quietly on her back for a few hours, with only a small pillow 
 
CARE DURING THE NORMAL PUERPERIUM 327 
 
 under her head, as moving about may cause hemorrhage. Some 
 doctors permit the patient to turn from side to side at will after 
 a few hours of quiet, while others do not allow this for two 
 or three days particularly if the patient has perineal stitches, 
 unless her knees are tightly bound together. Their reason for 
 this precaution is fear that the stitches may be torn out if the 
 thighs are separated and also that air may gain access to the 
 
 Fig. 116. — Height of fundus on each of tlie first ten days after delivery. 
 
 uterine vessels, through the relaxed and gaping birth canal, and 
 produce air embolism. It is a routine in some hospitals to keep 
 the head of the patient's bed elevated during the first week, to 
 promote drainage, but as a rule it is in the usual position. 
 
 Quite commonly the patient is encouraged to lie first on one 
 side and then on the other, after she begins to move about in 
 bed unassisted, and then face downward ut intervals, in order 
 to change the position of the uterus and thus tend to prevent 
 backward displacement 
 
328 OBSTETRICAL NURSING 
 
 In many hospitals, it is part of the daily routine to measure 
 and record the height of the fundus (Fig. 116) above the sym- 
 physis, in addition to noting the character, amount and odor of 
 the lochia, in order to judge if involution is progressing nor- 
 mally. A uterus that does not remain firm and does not steadily 
 shrink in size and descend into the pelvis is not involuting prop- 
 erlj^, and the usual remedy is more rest and a longer stay in 
 bed, with an icecap over the fundus. 
 
 Sitting Up. Except when there are perineal stitches or the 
 temperature has been elevated at some time following delivery, 
 the patient is ordinarily allowed to sit up in bed about the sixth 
 or eighth day. If the lochia is normal, the uterus firm and in the 
 proper position in the abdomen and her general condition sat- 
 isfactory, she is allowed to sit up in a chair for a little while 
 about the ninth or tenth day. Some patients are able to sit up 
 for an hour the first time without being tired, but it is often 
 better for them to sit up for a few moments morning and after- 
 noon on the first day, than for a longer time at one stretch. The 
 patient is usually allowed to sit up an hour longer on each suc- 
 cessive day and to walk a few steps on the third or fourth day 
 after getting up. 
 
 A patient with stitches does not usually sit up in bed until 
 the ninth or tenth day, when the stitches are removed, sitting up 
 in a chair for an hour, two or three days later. If she has had 
 fever, the time at which she may sit up will of necessity depend 
 upon her condition. 
 
 The return to normal life must be very gradual and this also 
 must be regulated by the patient's general condition and her re- 
 cuperative powers. A pinkish or red discharge or backache 
 should be taken as warnings against standing or walking or 
 working. The possible consequences of ignoring these warnings 
 and being up and about too soon, may be displacement, even pro- 
 lapse of the uterus; hemorrhage, from dislodgment of clots in 
 the uterine vessels; metritis or endometritis. 
 
 It is not a good plan, as a rule, for the patient to go up and 
 down stairs until the baby is about four weeks old, nor wholly 
 to resume her normal activities within six or eight weeks after 
 delivery. 
 
CARE DURING THE NORMAL PUERPERIUM 329 
 
 In addition to this sustained, general care, it is a customary 
 preventive measure for the doctor to make a thorough pelvic ex- 
 amination from four to six weeks after delivery. A slight ab- 
 normality, if detected at this time may usually be corrected with 
 little difficulty, but if allowed to persist may result in chronic 
 invalidism or necessitate an operation. If the uterus is not prop- 
 erly involuted, for example, or the perineum is found to be 
 flabby, more rest in bed is indicated; while a uterine displace- 
 ment, which seems to be present in about a third of all cases, 
 usually may be corrected by the adjustment of a pessary. 
 
 The time of sitting up, of getting up and of walking about 
 varies so with the individual, therefore, that it is not possible to 
 describe a definite routine, for some patients recover slowly and 
 would be injured by getting up and about at a period which 
 would be entirely safe and normal for the majority. It must be 
 determined in each case by the condition of the uterus, the ap- 
 pearance and amount of the lochia and the patient 's general con- 
 dition. 
 
 Quite evidently, then, much ill health and many gyneco- 
 logical operations may be prevented by caution, prudence and 
 good care during the first few days and weeks after the baby's 
 birth, while the patient returns to a normal mode of living. 
 
 The Daily Bath. During the first week or two the patient's 
 skin must aid in excreting fluids from the edematous tissues 
 throughout the body and broken down products from the invo- 
 luting uterus. Therefore she should have a bath of warm water 
 and soap every day, to remove material already on the surface 
 and stimulate the skin to further activity, and an alcohol rub at 
 night, if possible. It is important for the nurse to remember, 
 while bathing her patient, that she is perspiring freely and there- 
 fore may be easily chilled if not well protected. 
 
 It is often a good plan to have the patient, without stitches, 
 begin to bathe herself in bed, after the third or fourth day, for 
 the sake of the exercise, and also the encouragement that it of- 
 fers. When all is going well, tub-bathing is usually resumed by 
 the third or fourth week. 
 
 Diet. Opinions as to diet vary slightly with different doctors 
 and in different hospitals, but in general, a patient in good 
 
330 • OBSTETRICAL NURSING 
 
 condition is given liquid food during the first twelve to twenty- 
 four hours after delivery; then a soft diet for a day or two, a 
 nourishing, light diet being resumed by the third or fourth day. 
 or after the bowels have moved freely. 
 
 The patient will usually have little appetite, at first, and will 
 have to be tempted by small amounts of invitingly served food. 
 The factors which the nurse must bear in mind when arranging 
 the patient 's dietary are the general nutrition of the mother ; the 
 desirability of minimizing her loss of weight during the puer- 
 perium; increasing her strength and, particularly, of promoting 
 the function of her breasts, in order to produce milk of a quality 
 and quantity adequate to nourish the baby. 
 
 The best producer of such milk is a diet consisting largely 
 of milk, eggs, leafy vegetables and fresh fruits, taken with an 
 appetite that is made keen by constant fresh air. The nurse 
 will do well to convince her patient of this, in addition to bearing 
 it in mind herself, and to place little reliance on so-called milk 
 producing foods. 
 
 The young mother's dietary may well be made up from the 
 groups of foods that are suitable for the expectant mother. (See 
 Chapter VI). At this time, as during pregnancy, she must 
 avoid all food which may produce any form of indigestion, but 
 for the baby's sake, now, as well as her own. While it is not 
 generally believed, to-day, that there are many, if any articles 
 of diet which in themselves affect the mother 's milk unfavorably, 
 it is generally conceded that a derangement of her digestion may, 
 and usually does, have a deleterious effect upon her milk, and 
 therefore upon the baby. 
 
 The old, and widespread, belief that certain substances from 
 such highly flavored vegetables as onions, cabbage, turnips and 
 garlic are excreted through the milk, to the baby's detriment, is 
 not given general credence to-day. On the other hand, it is 
 known, however, that certain protective substances in certain 
 foods are excreted through the milk, to the baby's distinct ad- 
 vantage, and it is therefore, important that the mother's diet 
 should regularly contain those articles of food which contain 
 them. These foods are milk; egg yolk; glandular organs, such 
 as sweet-breads, kidneys and liver; the green salads, such as 
 
CARE DURING THE NORMAL PUERPERIUM 331 
 
 lettuce, romaine, endive and cress and the citrous fruits, or 
 oranges, grapefruit and lemons. 
 
 These are called "protective foods" because they protect the 
 body against the so-called deficiency diseases known as scurvy, 
 beri-beri, xerophthalmia, \vhi(;h with rickets and pellagra are 
 discussed in the chapter on Nutrition. It is possible for a baby 
 who nurses at the breast of a woman whose diet is poor in pro- 
 tective foods, to be so insufficiently nourished, in some particu- 
 lar, as to be on the border line of one of these diseases, or even 
 to develop the disease itself. This is one reason for the state- 
 ment that the nursing mother must "eat for two." 
 
 Certain drugs are excreted through the milk and may affect 
 the baby in the same way as though they were administered di- 
 rectly, for example : salicylic acid, potassium iodid, lead, mer- 
 cury, iron, arsenic, atropin, chloral, alcohol and opium.^ 
 
 In addition to her food the nursing mother should have an 
 abundance of water to drink, and to facilitate this it is a good 
 plan to keep a pitcher or thermos bottle of water on the bedside 
 table, and replenish it regularly, every four hours. 
 
 In general, the young mother should have light, nourishing, 
 easily digestible food, with little, if any meat; an abundance of 
 cereals, creamed dishes, creamed soups, eggs, salads and the fresh 
 fruits and vegetables which ordinarily agree with her ; at least a 
 quart of milk, daily, in addition to that which is used in prepar- 
 ing her meals, and an abundance of water to drink. 
 
 The Bowels. The puerperal patient is almost always con- 
 stipated, and needs assistance in regaining regularity in the 
 movements of her bowels. 
 
 The routine use of cathartics and enemata varies, but it is 
 very common to give an enema on the second morning after 
 delivery or castor oil or Rochelle salts, followed by an enema if 
 necessary. After this, a mild cathartic or a low enema is given 
 often enough to produce a daily movement when this is not 
 accomplished by means of the diet. 
 
 Some doctors, however, prefer that the bowels shall not move 
 for four or five days after delivery, believing that this delay re- 
 
 »"The Practice of Obstetrics," by J. Clifton Edgar. 
 
332 OBSTETRICAL NURSING 
 
 duces the danger of infection from the intestinal contents, which 
 are swarming with organisms, particularly the colon bacillus. 
 
 In cases of third degi'ee tears, catharsis is practically always 
 delayed for four to six days in order that the torn edges of the 
 rectal sphincter may become well united before being strained 
 by a bowel movement. In these cases an enema of six or eight 
 ounces of warm olive oil is often given and the patient encour- 
 aged to retain it over night, in order to soften the contents of 
 the rectum and lessen the strain and irritation of evacuation. 
 
 The Bladder. The question of helping the patient to void 
 after delivery is one of extreme importance, because she will al- 
 most certainly have difficulty in emptying her bladder, and yet 
 catheterization is not to be resorted to unless absolutely neces- 
 sary. As a rule the patient should be encouraged to try to void 
 from four to eight hours after delivery. If she is unable to do 
 so at first there are several aids which the nurse should employ 
 before admitting the patient's inability to empty her bladder. 
 Inducing her to drink copious amounts of hot fluids is the first 
 step. Very often she will then void if placed upon a bedpan 
 containing water hot enough to give off steam, and more warm, 
 sterile water is poured directly upon the urethral outlet ; or hot 
 and cold sterile water may be dashed, alternately, upon the 
 meatus. 
 
 The sound of running water is often helpful as well as the ap- 
 plication of hot stupes over the supra-pubic region. When every- 
 thing else fails, success frequently follows the application of a 
 partly filled hot-water bottle over the bladder, held in place by 
 a tight binder, particularly if the patient" rests upon a pan of 
 steaming water at the same time. 
 
 The danger of infecting the bladder, by carrying lochia into 
 it upon the catheter, is so great that some doctors choose what 
 they regard as the lesser of two evils, and allow the patient to 
 be assisted to the sitting position, if she has not a serious tear. 
 Not infrequently the patient's inability to void is due to the 
 fact that she is unaccustomed to using a bedpan, and would have 
 difficulty in using one under any conditions, but is able to void 
 while sitting up. As the danger of infection is greater two or 
 three days after delivery than at first, because of the beginning 
 
CARE DURING THE NORMAL PUERPERIUM 333 
 
 decomposition of the lochia, it is very evidently important to 
 help the patient to establish the habit of voiding from the be- 
 ginning, for if she is catheterized once there is great likelihood 
 that she will need to have it continued for some days. 
 
 If the first attempts are unsuccessful, therefore, but the pa- 
 tient thinks that slie may be able to void later, if the efforts are 
 repeated, catheterization is sometimes delayed for as long as 
 sixteen to eighteen hours after delivery in the hope that it may 
 be avoided altogether. 
 
 When the most persistent and painstaking efforts fail, and 
 catheterization is necessary, the nurse must remember the ex- 
 treme gravity of her responsibility and preserve asepsis through- 
 out the procedure. Although there is extreme danger of infec- 
 tion, it can be prevented as a rule, and its occurrence is there- 
 fore regarded as almost inexcusable. 
 
 In preparing for catheterization, the nurse should drape the 
 patient as for a vaginal examination, making sure that she is 
 warmly covered, and place her on a sterile douche- or bedpan. 
 If it is done at night she should place the light in a position at 
 once safe and advantageous. She should have at hand on a 
 tray: sterile forceps; cotton pledgets; two glass catheters (in 
 case one should be broken or become contaminated) ; a disinfect- 
 ing solution such as bichlorid, 1-4,000 or lysol 1 per cent. ; a 
 sterile receptacle in which to receive the urine ; sterile towels 
 and a dressing basin or paper bag for the used pledgets. 
 
 The preparation of the nurse's hands, at this point, varies 
 in different hospitals, but always the greatest care is taken to 
 bring nothing unsterile in contact with the vulva and meatus. 
 
 According to one method, the nurse scrubs her hands for 
 three minutes and prepares the patient as for a vaginal exam- 
 ination, removes the douche pan and places a sterile towel over 
 the vulva. She then scrubs and soaks her hands as described in 
 Chapter XII, puts on sterile gloves, places a sterile towel over 
 the patient's abdomen and slips one under her hips. She should 
 then separate the labia with the gloved fingers of the left hand, 
 drawing the fingers upward a little to make the meatus more 
 prominent. The inner surface of the labia is then bathed with 
 pledgets soaked with the disinfecting solution, with downward 
 
334 OBSTETRICAL NURSING 
 
 strokes, each pledget being used but once. Five or six pledgets 
 should be used, one after the other, to sponge the meatus, each 
 pledget being placed squarely against the orifice, without touch- 
 ing the adjacent tissues, and given a slight, downward twisting 
 motion and discarded. The bowl may then be placed in position 
 to receive the urine, and the catheter picked up with the fingers, 
 by its open end. The rounded end must be carefully inspected 
 to insure against using one that is cracked or broken, after which 
 it is slowly and gently introduced into the urethra for two or 
 three inches. If the urine does not flow freely the catheter may 
 be slightly withdrawn and light pressure made upon the bladder. 
 
 Before removing the catheter the nurse must locate the fun- 
 dus and assure herself that it is in a proper position. If it is 
 pushed up or to one side she will know that the bladder is still 
 distended, and that more urine must be withdrawn. After the 
 bladder has been emptied the nurse should place one finger over 
 the open end of the catheter and remove it slowly. 
 
 Another method of catheterization differs from the one just 
 described, in the preparation of the nurse's hands. In this in- 
 stance she simply washes her hands well with soap and hot 
 water and wears neither gloves nor finger cots. 
 
 She bathes the vulva with pledgets and an antiseptic solu- 
 tion, using forceps, and then separates the labia with two dry 
 pledgets, one each under forefinger and thumb of the left hand, 
 and proceeds as above. It will be observed that the nurse avoids 
 touching the inner surface of the labia or the meatus with any- 
 thing but sterile pledgets and the sterile catheter. The advan- 
 tage of this procedure is that it is accomplished quickly and with 
 the minimum of disturbance to the patient. 
 
 A distended bladder may so easily occur unless the patient 
 is carefully observed during the puerperium that the nurse 
 should charge herself to watch for this complication. She should 
 give the patient a bedpan every four hours, note the contour of 
 the abdomen and measure the urine during the first week, re- 
 membering that the patient should void considerably more than 
 the average amount, both because of the amount of milk and 
 water that she is taking, and the fluid which she is eliminating 
 from her tissues. The importance of measuring the urine lies 
 
CARE DURING THE NORMAL PUERPERIUM 335 
 
 in the fact that though the patient may void fairly regularly she 
 may not empty her bladder, and thus enough urine may accumu- 
 late to distend it. 
 
 The temperature, pulse and respirations are usually taken 
 and recorded every four hours for the first five or six days and 
 then two or three times daily, if normal. If the temperature is 
 above normal at any time, the nurse should take it every two 
 hours until it becomes normal and notify the doctor immediately 
 if it goes as high as 100.4° F., or if the pulse reaches 100. 
 
 Care of the Perineum. The best way of caring for the peri- 
 neum, during the first week or ten days after delivery, is a moot 
 question, and the nurse may find herself sorely perplexed by the 
 widely divergent instructions of different doctors who have 
 excellent results, unless she goes back of the details themselves 
 and recognizes their purpose. She will then see that there is 
 entire agreement about the importance of protecting the patient 
 against infection, at this time, when infection may so easily 
 occur. And so far as the nurse is concerned, this means clean- 
 liness as to methods and appliances, when making perineal 
 dressings, and extreme precaution against conveying infection 
 to her patient. The minimum requisites for this are that the bed- 
 pan shall be sterilized, by steam or boiling, at least once a day, 
 and well scrubbed and scalded after each time that it is used, and 
 that the nurse shall at least scrub her hands with soap and hot 
 water before making each perineal dressing, and apply only ster- 
 ile pads. 
 
 After the perineum is bathed, immediately following deliv- 
 ery, the usual practice is to apply a sterile pad, after which a 
 fresh one is applied as often as necessary at first, every four 
 hours during the first week and subsequently every eight hours. 
 When the dressing is changed, and after each voiding and defeca- 
 tion, the perineum is bathed with sterile pledgets and some such 
 antiseptic solution as bichlorid 1-2,000 or lysol i/o per cent, or 
 1 per cent. (Figs. 117 and 118.) The soiled pad must always 
 be removed from above downward and the bathing also directed 
 toward the rectum, each pledget being used for one stroke only. 
 The rectum is bathed last, a fresh sterile pad applied and the 
 patient's hips and back thoroughly dried. 
 
836 
 
 OBSTETRICAL NURSING 
 
 The nurse may be required to scrub and soak her hands, 
 wear sterile gloves and hold the pledgets in forceps when bathing 
 the perineum, the object of such precautions being, quite clearly, 
 to avoid infecting the patient from without, for the inner surface 
 of the uterus is still regarded as an open wound. 
 
 PiQ. 117.— Preparation and draping of patient for post-partum dress- 
 ing Note rack of equipment on table; bag of dry, sterile pledgets at 
 head of bed; paper bag on floor for used pledgets. The nurse has 
 scrubbed her hands. (From photograph taken at The Manhattan Maternity 
 Hospital.) 
 
 Some obstetricians believe that the perineal pad is a menace, 
 since it slips and moves about, and thus may transfer infective 
 material from the anus to the vagina. Accordingly, they forbid 
 
CARE DURING THE NORMAL PUERPERIUM 337 
 
 the use of all perineal dressings and instead have large, sterile, 
 absorbent pads slipped under the patient's hips to receive the 
 lochia, the pads being changed as often as necessary. This is 
 the practice at the Brooklyn Hospital, for example, where the 
 nurse bathes the vulva with lysol 1 per cent, placing the patient 
 on a sterile bedpan, using sterile forceps and cotton swabs and 
 wearing sterile gloves while making the dressing. 
 
 Another method is to place the patient on a sterile bedpan, 
 remove the pad and wdth gloved hands pour from a sterile pitcher 
 a warm antiseptic solution over the groin and outside of the 
 
 Tig. 118. — Equipment, in rack, used at The Manhattan Maternity 
 Hospital in bathing perineum. A, pitcher of lysol, 1%. B, basin of pled- 
 gets in lysol. C, sponge-sticks in alcohol. 
 
 vulva ; then to separate the labia and pour the solution between 
 them, in some instances pressing a dry, sterile pledget to the 
 vaginal orifice during the irrigation. 
 
 When the urine is being measured, as it frequently is during 
 the first week, the solution which is used for irrigating the vulva 
 should be measured beforehand and the contents of the bedpan 
 measured after the dressing, in order that the amount of urine 
 passed, if any, may be ascertained. 
 
 Another method of bathing the perineum, that employed at 
 Johns Hopkins Hospital, is simply to bathe the perineum with 
 
338 OBSTETRICAL NURSING 
 
 soap and warm water, without separating the labia, using a clean 
 wash cloth and afterwards applying a sterile pad, the pads being 
 changed every four hours, or oftener if necessary. The theory 
 upon which this procedure is based is that the steady outward 
 flow of the lochia constantly carries material, infective and 
 otherwise, away from the generative tract, and that if nothing 
 is introduced between the labia or into the vagina the patient 
 will not be infected. 
 
 In caring for the perineum, the nurse must remember also 
 the real danger of the patient infecting herself with her own 
 fingers and should caution her against taking this risk. The 
 patient should be told that if she feels uncomfortable, or thinks 
 she is bleeding, she must lie quietly and summon a nurse, but on 
 no account to try to find out for herself what is wrong. There 
 is little doubt that cases of severe infection have been caused 
 by the introduction of organisms into the vagina by means of 
 the patient's own fingers, after the most scrupulous precautions 
 had been taken by doctors and nurses to avoid that very disaster. 
 
 In most instances the care of the perineum is the same 
 whether or not there are stitches, and in any case the method em- 
 ployed will be specified by the doctor. The nurse 's responsibility 
 is to appreciate the object of the care, whatever form it may 
 take, and bring intelligence to bear in giving it. 
 
 When there are perineal stitches, it is a wise and harmless 
 precaution to fasten a towel or bandage about the patient 's knees 
 for a few days, to prevent her pulling apart the uniting edges 
 of the tear as she moves about in bed. 
 
 Douches. In connection with perineal dressings, it may be 
 well to caution the nurse against giving douches without explicit 
 orders. Douches are seldom given early in the puerperium, for 
 fear of carrying infective material up into the uterus, except 
 occasionally in cases of hemorrhage, in which case they are given 
 by the doctor. 
 
 Sometimes, however, a low vaginal douche is given daily for 
 some time after the patient gets up, with the idea of increasing 
 her comfort and promoting involution. About two quarts of 
 some weak antiseptic solution at 110° F. is given with the nozzle 
 introduced just within the vaginal outlet, and the container of 
 
CARE DURING THE NORMAL PUERPERTT^M 339 
 
 the solution placed only slightly above the level of the patient's 
 hips, in order that the stream may be very gentle. 
 
 The Care of the Breasts. There is a wide difFerenee of 
 opinion about the proper care of the breasts, also, but here again, 
 
 Fig. 119. — Sterile g:auze held in place over nipples by means of adhesive 
 strips and tapes. (From photograph taken at Bellevue Hospital.) 
 
 although the details vary, the ultimate objects of the care are 
 always the same, namely: to facilitate the baby's nursing, pro- 
 mote the mother's comfort and prevent breast abscesses. These 
 
340 OBSTETRICAL NURSING 
 
 ends are usually accomplished by keeping the nipples clean and 
 intact and by giving support and rest to heavy, painful breasts. 
 
 The patient who has cared for her nipples during the latter 
 part of pregnancy will usually have little or no trouble with 
 them during the period of lactation, if the care is continued. 
 But this attention is imperative. 
 
 It is very generally customary to have the nipples bathed be- 
 fore and after each nursing with a saturated solution of boracic 
 acid, in either water or alcohol, using sterile pledgets and for- 
 ceps, and to keep them clean between nursings by applying ster- 
 ile gauze. This gauze may be held in place by means of a breast 
 binder or by tapes tied through the ends of narrow strips of 
 adhesive plaster, four being applied to each breast. (Fig. 
 119.) Strips of adhesive plaster about five inches long are folded 
 over at one end, two adhesive surfaces being in contact for about 
 an inch. Through a hole in the folded end a narrow tape or 
 bobbin is tied and the strips applied to the breast, beginning at 
 the margin of the areola and extending outward. The free ends 
 of the tapes are tied over squares of sterile gauze, between nurs- 
 ings, and untied to expose the nipple at nursing time. 
 
 Lead shields are sometimes used to protect the healthy nipple 
 and not infrequently are applied to cracked nipples, being held 
 in pface by means of a breast binder. The secretion of milk 
 which escapes into the shield is acted upon by the metal and the 
 result is a lead wash which continuously bathes the nipple. The 
 shields should be scrubbed with sapolio and boiled once daily. 
 
 Another method, and one widely employed, is to anoint the 
 nipple after nursing with sterile albolene or a paste of sterile 
 bismuth and castor oil, and apply squares of sterile paraffin 
 paper. These bits of paper are pressed into place and held for 
 a moment by the nurse 's hand, the warmth of which softens and 
 moulds them to the breast after which they remain in place. 
 In some instances the bismuth and castor oil paste is wiped off, 
 with a sterile pledget, before nursing and in others it is not. 
 
 In some hospitals, neither gauze nor paper is used, the nip- 
 ples being protected by putting sterile night-gowns on the pa- 
 tients. 
 
 The purpose of all of these methods is to keep the nipples 
 
CARE DURING THE NORMAL PUERFERIUM 341 
 
 clean, and here again the patient must be cautioned against in- 
 fecting herself. No amount of care on the nurse's part will 
 protect the patient if she touches her nipples with her jSngers. 
 
 The nurse will appreciate the reason for all of this pains- 
 taking care if she calls to mind the fact that the breast tissues 
 are highly vascular and excessively active at this time and 
 therefore very susceptible to infection, and also that the baby's 
 suckling is often very vigorous and accompanied by a good deal 
 of chewing and gnawing of the nipples. Unless the nipples have 
 
 Fig. 120. — Protecting cracked nipples by having the baby nurse through 
 a shield. (From photograph taken at Johns Hopkins Hospital.) 
 
 been toughened, and sometimes even when they have, the skin 
 becomes abraded or cracked as a result of the baby's suckling, 
 thus creating a portal of entry for infecting organisms, in addi- 
 tion to the milk ducts which lead back into the breast tissues. 
 Unless the nipples are kept clean, constantly, they may become 
 infected by organisms from the baby's mouth or on the patient's 
 hands, bedding or gown with a breast abscess as a result. The 
 important thing, then, is to keep the nipples clean and not allow 
 anything unsterile, excepting the baby's mouth, to come in con- 
 tact with them at any time. 
 
 It is sometimes the practice to swab the baby's mouth with 
 
342 OBSTETRICAL NURSING 
 
 boric soaked cotton or gauze before each nursing, but many 
 doctors hold that this is injurious to the delicate mucous lining 
 of the baby's mouth. The opinions for and against this routine 
 seem to be about equally prevalent. 
 
 If the nipples become painful or cracked, one can easily 
 understand that continued suckling would only aggravate the 
 condition and increase the danger of infection. But the baby 
 must nurse, if possible, and so in the majority of cases a nipple 
 shield is used (Figs. 120-121) as a protection, and after nursing 
 the fissures or abraded areas are painted with bismuth and cas- 
 tor oil paste ; compound tincture of benzoin ; 
 balsam of Peru ; argyrol, silver nitrate or 
 sometimes only alcohol. The application is 
 made with sterile swabs prepared by tAvisting 
 a wisp of cotton about the end of a toothpick. 
 If the crack or abrasion is extensive enough 
 to cause bleeding, even nursing through a 
 shield is sometimes, but not necessarily dis- 
 continued, while the other treatment is the 
 
 Fig. 121. — Nipple same as for a nipple that does not bleed. 
 
 shield used in Fig. „ , • • j • i xi ^ u 
 
 "1^20 bound, uninjured nipples, then, are to be 
 
 kept clean and protected from infection and 
 those which are abraded or cracked are to be kept clean and also 
 protected against further injury. 
 
 Lactation. About the third or fourth day after delivery, 
 when milk replaces colostrum, the breasts become swollen, en- 
 gorged and often very painful, and not infrequently, a hard, 
 sensitive lump or "cake" may be felt. The growing tendency, 
 now, is merely to support these heavy breasts by means of a 
 binder which has straps passing over the shoulders, in order to 
 hold them up without making pressure (Fig. 122) and to apply 
 ice caps or hot compresses to the painful areas. It used to be 
 customary to massage and pump caked breasts, to apply pressure 
 and various kinds of lotions or ointments. Though one, or all of 
 these measures are still employed, in some eases, the general prac- 
 tice is to avoid manipulating the breasts but to empty them reg- 
 ularly by the baby 's nursing ; support them and allow Nature to 
 make an adjustment between the amount secreted and the 
 amount withdrawn. 
 
CARE DURING THE NORMAL I'UEHI'ERIUM 343 
 
 Free purging is sometimes employed and tlie amount of 
 fluids reduced until the engorgement and discomfort subside. 
 
 Fig. 122. — A simple method of supporting heavy breasts by means of 
 three folded towels; one fastened about the waist, one over each shoulder, 
 crossing front and back. 
 
 This happy issue is practically always reached if the baby nurses 
 regularly and satisfactorily, as there is a spontaneous adjustment 
 between the amount secreted by the mother and that withdrawn 
 
344 
 
 OBSTETRICAL NURSING 
 
 by the baby. But as abscesses may follow in the Avake of caked 
 breasts, particularly if the nipples are sore, it is of great im- 
 portance that the nurse watch closely for the first evidence of 
 painful lumps. The prompt application of a supporting bandage 
 and. ice bags (Fig. 123) or hot corapresses will, in the majority 
 
 Fig. 123. — Ice caps held in place on painful breasts by straight binder 
 with darts pinned in under breasts and supported by shoulder straps of 
 muslin bandage. 
 
 of cases, give speedy and complete relief. So widely is this be- 
 lieved that many doctors regard the care of the breasts, including 
 the prevention of breast abscesses, as a nursing question, entirely, 
 and conversely are likely to regard the occurrence of a breast 
 abscess as an evidence of careless nursing. 
 
 Certain it is that breast abscesses are almost never seen where 
 
CARE DURING THE NORMAL PUERPERIUM 345 
 
 the nurses have this sense of responsibility, and habitually 
 watch the breasts closely and promptly use support and either 
 heat or cold when the breasts become heavy and sensitive. 
 
 There are innumerable bandages and methods for supporting 
 heavy breasts, any one of which is efficacious so long as it meets 
 the two chief requirements: to lift the breasts, suspending their 
 weight from the shoulders, and, while fitting snugly below to 
 avoid making pressure at any point, particularly over the nipples. 
 One of the most satisfactory and widely used supports is the Y- 
 
 FiG. 124. — Modified Richardson "Y" binder made of two strips of 
 soft muslin, full width of material and 44 inches lon<i, folded into strips 
 of same width as distance from margin of patient 's breast to outer part 
 of areola. One strip is folded in the middle at right angles and pinned to 
 one end of the other strip as indicated. (Figs. 124, 125, 126, with captions, 
 are from The Maternity Hospital, Cleveland, by courtesy of Miss Calvin 
 MacDonald.) 
 
 bandage, (Figs. 124, 125, 126), another, the Indian binder (Fig. 
 127.) 
 
 The nurse must on no account massage or pump engorged 
 breasts on her own responsibility, for tliere is a good deal of evi- 
 dence to show that any such manipulation tends to increase the 
 amount of the secretion and this in turn increases the engorge- 
 ment and pain. It is possible, too, that massage may bruise the 
 breasts and thus make them more susceptible to infection. 
 
 Mastitis. When infection occurs, the swollen, painful 
 
346 
 
 OBSTETRICAL NURSING 
 
 breasts may groAV hot and red, the patient may complain of chil- 
 liness and have a slight fever, with or without there being an 
 abscess. Even then the general treatment is most frequently 
 
 Fig. 125. — Bandage in Fig, 124 applied. The long arm of binder is 
 placed under patient 's shoulders, one end of the Y being brought around 
 the top of the breasts and the other around the lower part, toward the 
 nurse, crossed at right angles under the arm and pinned to long arm of 
 liandage as indicated in F?g. 126. The nip])les are covered with sterile 
 gauze and the upper and lower parts of the Y fastened with a safety pin 
 between the breasts. The remaining length of the long arm is brought 
 across the breasts and fastened with a safety-pin to the opposite side. 
 When the baby nurses this pin is removed as Avell as the one between the 
 breasts. The entire binder should be snug and held in place by means of 
 shoulder straps, pinned front and back. 
 
 found to consist of support ; ice or heat ; catharsis and restricted 
 fluids, though in some cases the breasts are pumped and nursing 
 is discontinued. 
 
 AVhen the inflammation so far progresses as to require that 
 
CARE DURING THE NORMAL PUERPERIUM 347 
 
 the breast be opened and drained, the subsequent nursing care 
 will be outlined by the doctor to meet the needs of each case. It 
 is a painful operation and often a serious one, for the destruc- 
 
 FlG. 126. — Y bandage in Fig. 125 seen from the opposite side. 
 
 tion of breast tissue may be extensive enough to render the 
 breasts valueless as milk-producing organs. The healing is slow 
 and altogether the occurrence is a most lamentable one. 
 
 The nurse's part in preventing this complication is cleanli- 
 ness and gentleness in her attentions ; unremitting watchfulness ; 
 immediate application of a suspensory bandage and either heat or 
 
 Fig. 127. — Indian Binder used at The Montreal Maternity Hospital for 
 supporting heavy breasts. The tapering ends tie in a knot in front. 
 
 cold, upon the first sign of engorgement and prompt reporting 
 to the doctor. 
 
 If the patient 's nipples have not been toughened during preg- 
 
348 
 
 OBSTETRICAL NURSING 
 
 nancy or if flat or retracted nipples have not been satisfactorily 
 brought out, it may be necessary for the nurse to employ the 
 treatment to these ends which were described in the chapter on 
 pre-natal care. In the meantime the baby may have to nurse 
 through a shield until the nipple is brought out prominently 
 enough for him to grasp it well. 
 
 Stripping. Sometimes in cases of depressed nipples, which 
 the baby cannot grasp, or when the baby is too feeble, to nurse 
 at the breast, milk is withdrawn from the breast by means of so- 
 called ** stripping." The nurse should scrub her hands thor- 
 oughly with hot water and soap and dry them on a sterile towel 
 
 Pig. 128. — Position of thumb and finger below nipple on areola, in 
 stripping breasts. (From photograph taken at The Long Island College 
 Hospital.) 
 
 before beginning. The breast is grasped by placing the thumb 
 and forefinger of the right hand on the areola on opposite sides of 
 the nipple but well below it. The nipple is then raised from 
 the breast by a quick, lifting and rolling motion of the thumb 
 and finger, accompanied by slight pressure. A sterile medicine 
 glass should be held in position to receive the milk which spurts 
 from the nipple, but the glass should not touch the breast. (Fig. 
 128.) 
 
 There is a knack about stripping and it requires practice, but 
 those doctors who advocate it feel that it empties the breast, 
 when this is necessary, with less disturbance than that caused 
 by pumping, and as the milk is projected directly from the nip- 
 
CARE DURING THE NORMAL PUERPBRIUM 349 
 
 pie into the sterile glass, without any of it running over the 
 nipple or breast as may happen in pumping, it has the additional 
 advantage of always being sterile. 
 
 Extreme gentleness must be used; the openings of the milk 
 ducts must not be touched by the fingers, and the thumb and 
 finger must not press deeply enough to reach the glandular tis- 
 sue itself. If done properly stripping neither stimulates nor 
 bruises the breast tissue nor does it cause the patient even tem- 
 porary discomfort. 
 
 Abdominal Binders and Bed Exercises. There is consid- 
 erable dififercnee of oi)inion about the advantage of using ab- 
 dominal binders upon the puerperal patient while she is in bed, 
 and the nurse Avill accordingly care for the patients of some 
 doctors who use them and for those of others who do not. 
 
 The application of a moderately snug binder for the first day 
 or two is a fairly common practice, for multi parse, particularly, 
 are often made very uncomfortable by the sudden release of ten- 
 sion on their flabby abdominal walls ; a discomfort which a binder 
 will relieve. And during the first few days after the patient gets 
 up and walks about, she is sometimes given great comfort by a 
 binder that is put on as she lies on her back, and is adjusted 
 snugly about her hips and the lower part of her abdomen. 
 
 But the continued use of a binder after the first day or two, 
 while the patient is still in bed, is not as general as it formerly 
 was. Many women ask for binders in the belief that they help 
 to ''get the figure back" to its original outline, and some doctors 
 feel that the use of the binder is helpful in restoring the tone 
 to the abdominal muscles, which amounts to about the same 
 thing. Both the straiglit swathe and the Scultetus binder are 
 used for this purpose and they are put on in the usual manner; 
 snugly and with even pressure, but not tight enough to bind. 
 
 Those doctors who disapprove of the binder believe that it 
 interferes with involution and, by making pressure, tends to 
 push the uterus back and cause a retro-position, in addition to 
 retarding instead of promoting a return of normal tone to the 
 abdominal muscles. 
 
 Accordingly, they instruct their patients to take exercises, in- 
 stead of wearing binders, and they have these exercises started 
 
350 
 
 OBSTETRICAL NURSING 
 
 while the patient is still in bed. Their adoption, and the rate 
 at which they are increased, are entirely dependent upon the 
 individual patient 's condition, for they must never be continued 
 to the point of fatigue. There are, therefore, no definite rules 
 laid down, concerning these exercises, beyond a description of 
 the positions and movements themselves, and their sequence. 
 
 Those which are taught to the patients at the Long Island 
 College Hospital are so simple, and evidently productive of such 
 happy results that they offer excellent examples of this form of 
 treatment. They are, of course, taken only by the doctor 's order, 
 
 Fig. 129. 
 
 Figs. 129 to 135, inclusive, are bed exercises taken during the ptier- 
 perium. For description see text. (From photographs taken at The Long 
 Island College Hospital.) 
 
 but the nurse's intelligent supervision increases their effective- 
 ness. 
 
 The general purpose of tliese exercises is to strengthen the 
 abdominal muscles, thus helping to prevent a large, pendulous 
 abdomen; to increase the patient's general strength and tone, 
 just as exercise benefits the average person ; to promote involu- 
 tion; to prevent retro-version and in a measure, increase intes- 
 tinal tone and thus relieve constipation. To accomplish these 
 much to be desired ends the exercises must be taken with modera- 
 tion and judgment; started slowly; increased very gradually 
 and constantly adapted to the strengtisof the individual patient. 
 Otherwise they may do more harm than good. In the average, 
 uncomplicated case in which the patient is doing well, she usu- 
 
CARE DURING THE NORMAL PUERPERIUM 351 
 
 ally starts the chin-to-chest exercise from twelve to twenty -four 
 hours after delivery. She should lie flat on her back and raise 
 her head until her chin rests upon her chest. (Fig. 129.) If 
 she rests her hand upon her abdomen, she will feel for herself 
 that the abdominal muscles contract, and accordingly will be 
 
 
 ^^^K'VJr^ 
 
 ^1 
 
 :7f ?l 
 
 ■i 
 
 
 '1 
 
 
 
 '1 
 
 "' .^"-''^v^ 
 
 *.- . ,J 
 
 iflJillk_£L 
 
 '^t^l 
 
 Fig. 130. 
 
 disposed to continue the exercises with more interest and confi- 
 dence than she otherwise might. The movement is repeated 
 twenty-five times, morning and evening, every day, and con- 
 tinued as long as the patient is in bed. 
 
 The familiar, deep-breathing exercise is ordinarily started 
 
 Fig. 131. 
 
352 
 
 OBSTETRICAL NURSING 
 
 on the third or fourth day. The patient should lie flat, with her 
 arms at her sides, then extend them straight out from the 
 shoulders (Fig. 130), raise them above her head (Fig. 131) and 
 return them to the original position. This is repeated ten times 
 morning and evening, daily, as long as the patient is in bed. 
 
 Fig. 132. 
 
 The one-leg-flexion exercises are not done by patients Avith 
 perineal stitches, but in other cases they are usually started 
 about the fifth day. The thigh is flexed sharply on the abdomen 
 and leg on thigh (Fig. 132), then extended and lowered to the 
 bed. This is repeated ten times, with each leg, morning and 
 evening for one, or possibly two days. 
 
 The next exercise replaces the one-leg-flexion and is started 
 after the latter has been done for one or two days, according to 
 
 Fig. 133. 
 
 the strength of the patient, and it in turn is continued for only 
 one or two days. Both thighs are sharply flexed on abdomen 
 and legs on thighs (Fig. 133), then extended and lowered but 
 not far enough for the heels to rest upon the bed before being 
 flexed again. This is repeated ten times morning and evening. 
 
CARE DURING THE NORMAL PUERPERTUM 353 
 
 Next is the exercise for which the leg-flexion exercises pre- 
 pare the patient, and which are discontinued when this one is 
 adopted. It is started, as a rule, about the seventh day, or three 
 or four days before the patient gets up. Both legs are slowly 
 lifted to a position at right angles to the body (Fig. 134) and 
 
 ^ 
 
 Fig, 134. 
 
 slowly lowered, but not far enough for the heels to touch the 
 bed (Fig. 135), and the movement repeated. As this exercise re- 
 quires a good deal of effort, it must be taken up very gradually, 
 as follows : The legs should be raised on the first day, once in the 
 morning and twice in the evening; second day, three times in 
 
 Fig. 135. 
 
 the morning and four times in the evening; third day, five times 
 in the morning and six times in the evening and so on, if the pa- 
 tient is not fatigued, until the exercise is repeated ten times each 
 morning and evening. It is continued for several months. 
 
 The knee chest position (Fig. 136) is intended to counteract 
 
354 
 
 OBSTETRICAL NURSING 
 
 the tendency toward retroversion, from which so many women 
 suffer after childbirth. It is usually started about the seventh 
 day and the patient begins by remaining in that position for 
 
 Fig. 136. — Knee chest position. 
 
 a moment or two, gradually lengthening the time to about five 
 minutes each morning and evening for about two months. 
 
 "Walking on all fours is violent exercise and has to be taken 
 up very gradually. Some patients are able to attempt it on 
 the first day out of bed, if they have been taking the other 
 
 Fig. 137. — Walking on all fours. (From a photograph taken at the 
 Long Island College Hospital.) 
 
 exercises, but as a rule it is not started until the second or third 
 day. The patient 's clothes should be free from all constrictions ; 
 the knees should be held stiff and straight with the feet widely 
 
CARE DURING THE NORMAL PUERPERIUM 355 
 
 separated, to allow a rush of air into the vagina, and the entire 
 palmar surface of the hands should rest flat on the floor. (Fig. 
 137.) The patient should start by taking only a few steps each 
 morning and evening, gradually lengthening the walk to five 
 minutes twice daily and continuing it for about two months. 
 
 It is believed that as the patient walks in this position the 
 uterus and rectum rub against each other producing something 
 the same result as would be obtained by massage. The effect of 
 the exercise is to promote involution and diminish the tendency 
 toward constipation and retroversion, apparently preventing 
 malposition entirely in a large percentage of eases. Though not 
 widely used, its beneficial effects are unquestioned by those doc- 
 tors who employ it. 
 
 In taking a general survey of the young mother and her needs, 
 we realize that in a broad sense she is not ill, in so far as no 
 pathological condition exists. But she is in a transitional state 
 and may become acutely or chronically ill if not carefully watched 
 and nursed. In general her mental, physical and nervous forces 
 must be conserved and increased, and this requires thoughtful 
 and devoted attention from the nurse. She must be scrupulously 
 clean in her care of the nipples and perineum, and in order to be 
 able promptly to inform the doctor of any departure from the 
 normal in the patient's condition, the nurse's watchfulness 
 should embrace regular observations upon the following : 
 
 1. The patient's general condition ; the amount and character of 
 her sleep; her appetite; her nervous and mental condition. 
 
 2. The temperature, pulse and respiration. 
 
 3. The height and consistency of the fundus. 
 
 4. The quantity, color and odor of the lochia. 
 
 5. The persistence and severity of the after-pains. 
 
 6. The condition of the perineum. 
 
 7. The condition of the nipples and breasts. 
 
 8. The functions of the bladder and bowels. 
 
 If all goes well and there are no complications, the patient 
 will usually be able to assume full charge of her baby by the 
 sixth or eighth week, and practically return to her customary 
 mode of living, with the difference that she now has the care of 
 a baby which she did not have before. The care of that baby 
 
356 OBSTETRICAL NURSING 
 
 requires certain, definite care of herself, as a nursing mother, 
 which will be described in detail in the next chapter. 
 
 To sum up the general principles of nursing the young mother 
 during the puerperium, we find that just as during pregnancy 
 and labor, the nurse must first be familiar with the normal 
 changes that occur in order that she may recognize the abnor- 
 mal. Then, as before, the nurse's care of the individual patient 
 must rest unfailingly upon a foundation of cleanliness in order 
 to prevent infection; watchfulness, which implies ability to 
 recognize normal changes and unfavorable symptoms; adjust- 
 ment to the methods of the attending physician and to all of 
 the circumstances surrounding the patient, and the wisest and 
 tenderest consideration for her patient as an individual 
 
CHAPTER XVI 
 
 THE NURSING MOTHER 
 
 Not infrequently tlie nurse remains with her patient after 
 the end of the puerperium, and therefore she may have the care 
 of the mother and baby for several weeks, or even months. The 
 most valuable single service which she can perform in this 
 capacity is to help in making it possible for the mother to nurse 
 her baby at the breast. For both the nurse and the mother must 
 realize that the breast-fed baby is much more likely to live 
 through the difficult first year, and is markedly less susceptible 
 to disease and infection than is the bottle-fed baby. 
 
 The first step is to convince the young mother of what it 
 means to her baby and her obligation to try to nurse him, since, 
 excepting under very rare and unusual conditions, she can nurse 
 him if she wants to enough to make the necessary effort and 
 sacrifice. 
 
 The important contra-indications for attempting breast-feed- 
 ing are retracted nipples, tuberculosis, eclampsia, severe heart 
 or kidney disease and certain acute infectious diseases such as 
 typhoid fever. 
 
 It seldom happens that the mother who has had average pre- 
 natal care, followed by good care during and after delivery, is 
 unable to nurse her baby if she orders her life in the way that is 
 known to be necessary to promote and maintain lactation. The 
 first essential is her real desire to nurse her baby ; next, her 
 appreciation of the continuous care of herself that is necessary 
 and third, her whole-hearted willingness to take this care for 
 her baby's sake. 
 
 It is safe to say that if the doctor and the nurse and the pa- 
 tient all want the baby to nurse at the breast, and all do every- 
 thing in their power to make this possible, they will almost in- 
 variably succeed. This assertion can scarcely "be made too posi- 
 
 367 
 
358 OBSTETRICAL NURSING 
 
 tively, ?nd the nurse should never lose sight of the fact that if 
 the baby is not breast-fed he is being defrauded, and in the vast 
 majority of cases, because of insufficient effort on the part of 
 the doctor, nurse or patient, or all three. 
 
 A favorable frame of mind and state of good nutrition in 
 the mother are the two indispensable factors in establishing 
 breast-feeding and in maintaining the secretion of an adequate 
 supply of breast-milk. These conditions, in turn, are both af- 
 fected by her general mode of living, as long as the baby nurses. 
 
 Women with happy, cheerful dispositions usually nurse their 
 babies satisfactorily, while those who worry and fret are likely 
 to have an insufficient supply of milk, or milk of a poor quality. 
 And in addition to this sustained influence, the temporary effect 
 of a fit of temper; of fright; grief; anxiety or any marked emo- 
 tional disturbance is frequently injurious to the quality of milk 
 that previously has been satisfactory. Actual poisons are created 
 by such emotions and may affect the baby so unfavorably as to 
 make it advisable to give him artificial food, for the time being, 
 and empty the breasts by stripping or pumping, before he re- 
 sumes breast feeding. 
 
 A mother's lack of faith in her ability to nurse is so detri- 
 mental in its effect that she must be assured over and over, that 
 she can nurse her baby if she will persevere. If the nursing does 
 not go well at first she must not give up, but must continue to put 
 the baby to the breasts regularly, as this is the best means of 
 stimulating them to activity. His feeding should be supple- 
 mented with modified cow 's milk, if the breast milk is inadequate 
 either in amount or quality. 
 
 Method of Nursing. The baby should be put to the breast 
 for the first time between eight and twelve hours after he is born. 
 This gives the tired mother an opportunity to rest and sleep, and 
 the baby, too, is benefited by being kept warm and quiet during 
 this interval. His need for food is not great as j'^et, nor is there 
 much if any nourishment available for him. 
 
 In preparing to nurse her baby, the mother should turn 
 slightly to one side, and hold the baby in the curve of her arm 
 so that he may easily grasp the nipple on that side. She should 
 hold her breast from the baby 's face with her free hand by plac- 
 
THE NURSING MOTHER 
 
 359 
 
 ing the thumb above and fingers below the nipple, thus leaving 
 his nose uncovered, to permit his breathing freely. (Fig. 138.) 
 The mother and baby should lie in such positions that both will 
 be comfortable and relaxed, and the baby will be able to take into 
 h^ mouth, not only the nipple but the areola as well, so as to 
 
 Fig. 138. — Position of mother and baby for nursing in bed. 
 
 compress the base of the nipple with his jaws as he extracts the 
 milk by suction. 
 
 The nurse may have to resort to a number of expedients in 
 persuading the baby to begin to nurse, for he does not always 
 take the breast eagerly at first. He must be kept awake and 
 sometimes suckling will be encouraged by patting or stroking 
 his cheek. Or if his head is drawn away from the breast, a little, 
 he will sometimes take a firmer hold a)Kl begin to nurse. Moisten- 
 ing the nipple by expressing a few drops of colostrum or with 
 
360 OBSTETRICAL NURSING 
 
 sweetened water may stimulate the baby's appetite and thus 
 prompt him to nurse. 
 
 The young mother must be prepared to find very discour- 
 aging the early attempts to induce the baby to nurse, but if 
 the nurse will help her to persevere in making regular attempts 
 she will almost certainly succeed. 
 
 During the first two or three days the baby obtains only 
 colostrum, while nursing, but the regular suckling is extremely 
 important, not alone for the sake of getting him into the habit 
 of nursing but for the sake of stimulating the breasts to secrete 
 milk. 
 
 Moreover, the irritation of the nipples so definitely promotes 
 involution of the uterus that this process goes on more rapidly 
 in women who nurse their babies than in those who do not. If 
 the nipples are not sufficiently prominent for the baby to grasp 
 them, a shield will have to be used while they are being brought 
 out. But the shield should be discarded as soon as possible for 
 it is the baby's suckling that produces the physiological effects. 
 If a shield is used, it should be washed and boiled after each 
 use and kept, between nursings, in a sterile jar or a solution 
 of boracic acid. 
 
 The length of the nursing periods and the intervals between 
 them have to be adjusted to the needs and condition of each 
 baby; his weight, vigor, the rapidity with which he nurses, the 
 character of his stools and his general condition, all of which 
 will be considered in connection with the care of the baby. The 
 intervals between nursings are measured from the beginning of 
 one feeding to the beginning of the next, and are fairly uniform 
 for babies of the same age and weight. The length of the nurs- 
 ing period itself is usually from ten to twenty minutes. 
 
 The average baby nurses about every six hours during the 
 first two days, or four times in twenty-four hours. According 
 to one schedule he will nurse every three hours during the day 
 for about three months, beginning with the third day, and at 
 10 p.m. and 2 a.m., or seven times in twenty four hours. From 
 the third to the sixth month he nurses every three hours during 
 the day and at ten o'clock at night, or six times in twenty- four 
 hours, and from that time until he is weaned he should nurse at 
 
THE NURSING MOTHER 
 
 361 
 
 Fig. 139. — The Nursing Mother. (By permission from a pastel by 
 Gari Melchers.) 
 
362 
 
 OBSTETRICAL NURSING 
 
 four hour intervals during the day and at ten o'clock at night, 
 or five times daily, as follows : 
 
 First and second days. 
 First three months.... 
 Third to sixth month. 
 After the sixth month 
 
 Day 
 
 6.. 12.. G 
 6.. 9. .12. .3. .6 
 6.. 9..12..3..b 
 6. .10.. 2. .6 
 
 Night 
 
 12 
 
 10.. 2 a.m. 
 
 10. 
 
 10. 
 
 It is becoming more and more common to omit night feed- 
 ings after 10 p.m., even during the first three months, with the 
 average baby who is in good condition. When this practice is 
 adopted the baby not only seems to do as well as he normally 
 should, but to benefit by the long digestive rest during the night. 
 Certainly the mother profits by the unbroken sleep which this 
 makes possible. 
 
 As a rule the baby should nurse from one side, only, at each 
 nursing, emptying the breasts alternately, but if there is not 
 enough milk in one breast for a complete feeding both breasts 
 may be used at one nursing. Neither the mother nor the baby 
 should be permitted to sleep while he is at the breast, but he 
 should pause every four or five minutes to keep from feeding 
 too rapidly. 
 
 After the mother sits up, she may occupy a low, comfortable 
 chair while nursing the baby. She should lean slightly forward 
 and raise the knee upon which the baby rests by placing her 
 foot on a stool, supporting his head in the curve of her arm, and 
 holding her breast from his face, just as she did while in bed. 
 (Fig. 139.) She should nurse him in a quiet room where she 
 will not be disturbed nor interrupted and where the baby and 
 her breasts will be protected from drafts or from being chilled. 
 Many women prefer always to lie down when nursing the 
 baby. 
 
 Before the nurse leaves her patient she should teach her how 
 to care for her nipples, including the preparation of boric solu- 
 tion ; the importance of washing her hands before bathing her 
 nipples, and of keeping the breasts covered with clean gauze 
 between nursings. 
 
THE NURSING MOTHER 363 
 
 PERSONAL HYGIENE OF THE NURSING MOTHER 
 
 The personal hygiene of llie nursing mother slioukl be 
 virtually a continuation of that which is advisable during the 
 latter part of the puerperium; a normal, tranquil kind of life 
 which is unfailingly regular in its daily routine. 
 
 But this is not quite as easy as it sounds, for during the puer- 
 perium the young mother is still something of a patient and is 
 regarded as such, while during the months that follow she is 
 simply a nursing mother, who must live sanely and moderately 
 for her baby's sake, and at the same time take her place among 
 people who are not under compulsion to place any special re- 
 strictions upon their daily lives. It is much easier to take pre- 
 cautions and follow directions for a few days or weeks, while 
 the situation is novel, than it is to persist month after month 
 without help or encouragement. The young mother's family 
 often fails to appreciate the difficulty of her problem and for this 
 reason she is sometimes unable to care for herself, as she should, 
 with the result that she cannot nurse her baby successfully. 
 
 As long as the nurse remains with her patient, therefore, 
 she must try to impress upon both the patient and the members 
 of her household that the most important single factor in the 
 care of the new baby is the sustained and regular care which 
 the nursing mother should take of herself. For it must be re- 
 membered constantly that it is not alone breast feeding, but 
 satisfactory breast feeding that nourishes and builds and pro- 
 tects the baby. Unsatisfactory breast milk may be positively 
 injurious, and irregularity and thoughtlessness in the mother's 
 mode of living will usually produce milk of this character. 
 
 Therefore, for ten or twelve months after the baby is born, 
 the mother should discharge her responsibility and obligation to 
 him by regulating her own life to meet his needs. 
 
 Diet. Throughout the entire nursing period the mother's 
 diet must be such that it will nourish her and also aid in pro- 
 ducing milk which will meet the baby's needs. His needs are 
 that the daily demands of his growing body shall be supplied 
 and that he shall be given those materials which will build a 
 sound body, with resistance against disease and infection. 
 
364 OBSTETRICAL NURSING 
 
 So important is this matter of nutrition, and the principles 
 upon which it rests, that it is discussed at considerable length 
 in the succeeding chapter. At this point, however, it may be 
 stated briefly that the most valuable article in the nursing 
 mother's dietary is milk, and that to this should be added eggs 
 and the vegetables which are designated as ''leafy," and fresh 
 fruits, particularly oranges. These foods are rich in the mate- 
 rials which are essential to the baby's nutrition, good health, 
 and resistance. 
 
 She should have a generous, simple, nourishing mixed diet, 
 then, consisting largely of milk, eggs, and leafy vegetables. She 
 must steadily guard against indigestion for if her digestion is 
 deranged the baby is almost sure to suffer. Rich and highly 
 seasoned foods must be avoided, as well as alcohol, strong tea and 
 coffee or any articles of food or drink that might upset her. 
 
 It becomes apparent that although the expectant mother does 
 not have to "eat for two," the nursing mother does, in certain 
 respects. She should augment the nourishment provided by 
 her three regular meals, by taking a glass of milk, cocoa or some 
 beverage made of milk, during the morning, afternoon and be- 
 fore retiring. 
 
 The morning and afternoon lunches had better be taken about 
 an hour and a half after breakfast and luncheon, respectively, 
 in order not to impair the appetite for the meals which follow. 
 
 It is very important that the nursing mother shall take her 
 meals with clock-like regularity and enjoy them, but at the same 
 time she must guard against overeating, for fear of deranging 
 her digestion. She must drink water freely, partly for the sake 
 of promoting intestinal activity. 
 
 Bowels. The nursing mother's bowels must move freely 
 and regularly every day, but she should not take cathartics nor 
 even enemata without a doctor's order. 
 
 She will usually be able to establish the habit of a daily 
 movement by taking exercise, eating bulky fruit and vegetables, 
 drinking an abundance of water and regularly attempting to 
 empty her bowels, every day, preferably immediately after break- 
 fast. 
 
 Rest and Exercise. The nursing mother will not thrive, 
 
THE NURSING MOTHER 365 
 
 nor will the baby, unless she has adequate rest and sleep and 
 takes at least a moderate amount of daily exercise in the open 
 air. She should have eight hours sleep, out of the twenty-four, 
 in a room with open windows, and as fatigue has an injurious 
 effect upon the character of the milk, the average mother should 
 lie down for a while every afternoon. 
 
 Her exercise will have to be adjusted to her tastes, customary 
 habits, circumstances and physical endurance, for it must always 
 be stopped before she is tired. Walking is often the best form 
 of exercise that the nursing mother can take, though she may 
 engage in any mild sports that she enjoys. Violent exercise is 
 inadvisable because of the exhaustion that may follow. 
 
 Recreation. Part of the value of exercise lies in the pleas- 
 ure and diversion which it gives, for a happy, contented frame 
 of mind is practically indispensable to the production of good 
 milk. In addition to some regular and enjoyable exercise, there- 
 fore, the mother needs a certain amount of recreation and change 
 of thought and environment. If her life is monotonous and 
 colorless, the average woman is likely to become irritable and 
 depressed ; to lose her poise and perspective ; to worry and fret, 
 and then, no matter what she eats nor how much she sleeps, her 
 digestion will suffer, her milk will be affected and the baby will 
 pay. This, of course, goes back to the question of her mental 
 state and the condition of her nerves as being determining 
 factors in the young mother's ability to nurse her baby success- 
 fully. 
 
 For the sake of giving her an opportunity to go out, mingle 
 with her friends or enjoy some music or a play, it is often a very 
 good plan to replace one breast feeding, some time in the course 
 of each day, with a bottle feeding. The freedom which this long 
 interval between two nursings gives the mother for diversion 
 and amusement, will usually affect her general condition so 
 favorably that the quality of her milk is better than it other- 
 wise would be, and the baby is benefited as a result. This single 
 supplementary feeding cannot be regarded lightly, however, for 
 it must be prepared with the same cleanliness and accuracy as 
 an artificial diet. 
 
 Weaning. One advantage in giving the baby a supplemen- 
 
366 OBSTETRICAL NURSING 
 
 tary bottle, once a day, is that it paves the way for -weaning, 
 when the time comes to make this change. Under ordinary con- 
 ditions, the mother begins to wean her baby about the eighth or 
 tentli month. Having started by replacing one breast feeding, 
 daily, with a bottle feeding, she should gradually increase the 
 number of daily artificial feedings until all of the breast feed- 
 ings are discontinued by the time the baby is eleven or twelve 
 months old. There are exceptions to this general rule, of course, 
 and under any conditions the weaning should always be directed 
 by a doctor, for the baby will suffer unless it is skillfully done. 
 
 If the mother's milk is satisfactory and the baby is doing 
 well, it is often considered wiser not to discontinue the breast 
 feeding entirely, during the hot summer months, even though 
 the weaning falls due at this time. 
 
 It was formerly deemed advisable to wean the baby for any 
 one of several reasons, but at present the only indications for 
 this step which are generally accepted by the medical profes- 
 sion, are : pulmonary tuberculosis, acute infectious diseases in 
 the mother, and pregnancy. Menstruation, which is normally 
 suspended during lactation, was long regarded as incompatible 
 with satisfactory nursing, but it is now known that if the mother 
 is taking proper care of herself and is in generally good condi- 
 tion, the effect of menstruation upon the milk is usually for the 
 duration of the periods only. It may be necessary to supple- 
 ment the breast feeding with suitably modified cow's milk dur- 
 ing menstruation, but the baby should be put to the breast regu- 
 larly, just the same, for if the stimulation of the baby's suckling 
 is discontinued, the temporary reduction in the amount of milk 
 secreted will probably be permanent. 
 
 The state of pregnancy, however, is different, for though 
 some women nurse the baby satisfactorily for some months after 
 becoming pregnant, it is not considered advisable to subject a 
 woman to the combined strain of pregnancy and nursing. 
 Moreover, the mother's milk is usually impoverished during 
 pregnancy and the nursing baby suffers in consequence. 
 
 Drying up the Breasts used to be a great bugbear. Lotions, 
 ointments and binders were employed and often a breast pump 
 as well. Various drugs were given by mouth and the patient 
 
THE NURSING MOTHER 367 
 
 was more or less rigidly dieted. It is true that some of these 
 measures are still employed and are followed by a disappeararice 
 of the milk. But at the same time, the breasts dry up quite as 
 satisfactorily when none of these things is done, provided the 
 baby does not nurse. It is not known what starts the secretion of 
 milk in the mother's breasts but certain it is that absence of the 
 baby's suckling prevents it. 
 
 If the drying up of the breasts is left to the nurse, as it so 
 frequently is, her wisest course will be to do nothing beyond 
 applying a supporting bandage if the breasts are heavy enough 
 to be uncomfortable. She may rely absolutely upon the fact 
 that the baby's suckling is the most important stimulation in 
 promoting the activity of the breasts and if this stimulation is 
 not given, or is removed, the secretion of milk will invariably 
 subside in the course of a few days. It is true, that the breasts 
 may be engorged and very uncomfortable for a day or two, and in 
 addition to a supporting bandage the doctor may order sedatives, 
 but the discomfort subsides as the secretion disappears. This 
 is true whether the reason for drying up the breasts is that the 
 baby is still born or has died, or a live baby 's nursing is discon- 
 tinued. 
 
 Naturally, the nurse will not press her patient to drink an 
 extra amount of milk if it is not desirable to promote the activity 
 of the breasts, but, unless otherwise ordered, there is no neces- 
 sity for placing any other restrictions upon her patient 's diet. 
 
 In thinking over the period of lactation, as a whole, it is 
 apparent that the most valuable service which the nurse can 
 offer to the nursing mother, is assistance in planning and living 
 a simple, normal, tranquil life ; helping her to eat, sleep, bathe, 
 and exercise and to nurse lier baliy with unfailing regularity 
 — all for the sake of providing her baby with adequate nourish- 
 ment. This must be the chief end and aim of her existence. 
 
 Normal breast-milk is the ideal baby food and there is no 
 entirely satisfactory substitute. It greatly increases the baby's 
 chances of living through the first year, and protects him from 
 many diseases. 
 
 Quite evidently, breast-feeding is every baby's right and the 
 nurse can and should help him to secure it. 
 
CHAPTER XVII 
 NUTRITION OF THE MOTHER AND HER BABY 
 
 The importance of providing the expectant and nursing 
 mother with suitable food has been stressed so insistently in the 
 preceding pages, that it is advisable to explain to the nurse the 
 reason for these recommendations, in regard to certain groups of 
 foods, and thus make clear why a young mother may eat a large 
 amount of food and have an adequate amount of breast milk, and 
 yet fail to nourish her baby satisfactorily. 
 
 The following material is available in these pages through 
 the interest and generosity of Dr. E. V. McCollum and Miss 
 Nina Simmonds, Professor and Assistant Professor of Chemical 
 Hygiene, School of Hygiene and Public Health, Johns Hopkins 
 University. This information is the result of many years of re- 
 search and experimentation on many thousands of laboratory 
 animals and of observations upon human beings as well. Dr. 
 McCollum and Miss Simmonds offer the fruits of their labors 
 to obstetrical nurses, in the belief that they are in a peculiarly 
 favorable position to aid in improving the nutritional state of 
 the coming generation. 
 
 In order that such a discussion may not seem irrelevant to 
 obstetrical nursing, the nurse must remind herself anew, that 
 the object of obstetrics to-day is not only to carry a woman safely 
 through childbirth, but to give her such care from the begin- 
 ning of pregnancy that she and the baby shall emerge from 
 this experience, not merely alive, but well and vigorous and with 
 every prospect of continuing to be so. 
 
 It is the acknowledged obligation of those engaged in obstet- 
 rical work to strive toward improving the health of the race 
 at its source — the health of the mothers and babies. Malnour- 
 ished mothers and malnourished babies do not develop a hardy 
 
 race. 
 
 368 
 
NUTRITION OF THE MOTHER AND HER BABY 369 
 
 It is probably safe to say that the two most influential factors 
 in creating and maintaining a satisfactory state of health are 
 suitable nutrition and prevention of infection ; and although 
 we shall concern ourselves solely with nutrition in this chapter, 
 it should be stated in passing that a state of good nutrition goes 
 far toward protecting the individual from infection. 
 
 It will help in clarifying the subject to explain in the begin- 
 ning that a state of good nutrition is not necessarily evidenced 
 by one's being tall nor by being fat. But it is evidenced by nor- 
 mal size and development ; sound teeth and bones ; hair and skin 
 of normal color and texture ; blood of the normal composition ; 
 stable nerves ; vigor both mental and physical ; normally func- 
 tioning organs and resistance to disease, and above all that in- 
 describable condition which is summed up as a state of general 
 well-being. 
 
 That this degree of nutritional stability is not as prevalent 
 in this country as might be desired is disclosed by reports upon 
 findings of the examining boards for army service, over a period 
 of three years and physical examinations of various groups of 
 school children throughout the country. It was found in the 
 first case, that about sixteen per cent, of the apparently normal 
 young men who were inspected for military service, were under- 
 nourished in some degree, and according to Dr. Thomas W. 
 "Wood, Professor of Physical Education, Columbia University, 
 "Five million children in the United States are suffering from 
 malnutrition." This army of undernourished children, which 
 represents about one-third of the children of the country, is on 
 the broad highway to ill health, invalidism of various kinds and 
 degrees, instability and inefficiency. They are certainly not 
 developing into the clear-eyed, alert, buoyant individuals that 
 go to make up good citizenry. 
 
 The tragic aspect of this state of undernourishment is that 
 though a great deal can be done to nourish and build up the 
 malnourished eliild or adult, a certain amount of damage that 
 results from inadequate nourishment during the early, forma- 
 tive weeks and months cannot be entirely repaired later on in 
 life. 
 
 As the baby grows and develops, certain substances are 
 
370 ■ OBSTETRICAL NURSING 
 
 needed at the various stages of its progress, and if these are 
 not supplied at these stages, there will always be some degree 
 of inadequacy in the adult make up. It is much like the futility, 
 when building a house, of using bricks without straw for the 
 foundation instead of firm, dural)le rock, and then trying to 
 make it substantial and secure later on by using good materials 
 when constructing the upper stories. 
 
 The solid foundation and substantial beams and girders for 
 men and women are put in during infancy and early childhood 
 in the shape of good material that forms good nerves, muscles, 
 bones, teeth and general physical stability. It is practically 
 impossible to make up to the older child or adult for damage 
 caused by failure to supply sufficient nourishment to the grow- 
 ing, developing, infant body. 
 
 "The moving finger writes; and, having writ, 
 Moves on ; nor all thy piety nor wit 
 Shall lure it back to cancel half a line, 
 Nor all thy tears wash out a word of it." 
 
 We see all about us the results of this form of neglect of 
 babies, in the bow-legged, knock-kneed, undersized, misshapen, 
 chicken-breasted adults and in those who are nervous and below 
 par in endurance ; are susceptible to colds and other infections 
 and may be summed up as being "not strong." 
 
 The reasons for much of the undernourishment among peo- 
 ple in this country to-day are to be found in certain widespread 
 misconceptions of long standing as to what constitutes a state 
 of good nutrition or malnutrition and the value and purposes of 
 different foodstuffs. For malnutrition does not necessarily de- 
 scribe a simple condition due to an insufficient amount of food, 
 but to any one of several complex conditions due to a lack in 
 the food of one or more essential substances. 
 
 One may eat a large amount of food and even have a well- 
 padded body and yet be seriously in need of certain food factors 
 — in other words, be incompletely nourished in some particular. 
 
 That was possibly the first misconception — the belief that one 
 simply needed enough food, and accordingly was well nourished 
 if three large meals were eaten daily, irrespective of the com- 
 position of those meals. A step forward was taken when house- 
 
NUTRITION OF THE MOTHER AND HER BABY 371 
 
 wives and people generally accepted the fact that quantity alone 
 was not enough to consider in providing food, but that the dietary 
 should consist of balanced amounts of the five food materials: 
 fats, carbohydrates, proteins, minerals and water, in order to 
 build and maintain the body in a state of health. 
 
 But this, too, was found to be an error, in so far as it was 
 only a part of the truth, for it was next ascertained that even 
 provision for a suitable balance of the five food groups was not 
 enough to nourish us, but that we must consider the heat and 
 energy producing properties of these component parts, as meas- 
 ured by the caloric unit, and each must daily take in the requisite 
 number of calories if we would keep our engines going. 
 
 It is now known that even this is not enough, for we may 
 eat food in ample quantities, consisting of the properly balanced 
 fats, proteids, carbohydrates, minerals and water, and it may 
 daily yield the required number of calories, and still we may 
 suffer from seriously faulty nutrition. 
 
 Hess and Unger state in this connection, that, **in framing 
 dietaries for children and adults, our minds are still focused on 
 insuring a sufficient supply of calories in the food, and we have 
 not j^et reacted in practice to the newer knowledge that ample 
 carbohydrates, fats and proteins may constitute a dangerously 
 deficient diet." ^ 
 
 "We find an explanation for this fact in the comparatively 
 recent recognition of three substances, as yet not clearly under- 
 stood, which are contained in a certain few articles of food, each 
 one of which is essential to growth and normal health and well- 
 being, though not necessarily concerned in the production of 
 heat or energy. Various terms have been applied to these mys- 
 terious, but necessary substances, such as vitamines, accessory 
 food substances as applied to all, or fat-soluble A, water-soluble 
 B and water-soluble C to designate them separately. 
 
 A surprisingly small amount of each of these substances is 
 sufficient to meet the needs of an individual, but no one of these, 
 even in this small amount, can be safely dispensed with, for if 
 the diet is deficient, or lacking in one or more of them some 
 
 ^ Alfred F. Hess, M.D., and Lester J. Unger, American Journal of Dis- 
 eases of Children, April, 1919. 
 
372 OBSTETRICAL NURSING 
 
 form of nutritional disturbance will result. It may be severe 
 enough to be diagnosed as a disease, or it may be only enough 
 to keep the individual below a normal state of health. 
 
 When the disturbance is profound enough to produce a defi- 
 nite, recognizable condition, it is designated as a deficiency dis- 
 ease, of which there are three : scurvy, beri-beri and xerophthal- 
 mia. With these are sometimes included rickets and pellagra. 
 The exact cause of the two latter disorders is not definitely 
 known but both are associated with faulty nutrition. Poor 
 hygienic conditions may enter into the causation of rickets, and 
 infection may be a factor in the occurrence of pellagra, but 
 neither disease appears among those who are suitably fed while 
 both diseases may be produced by faulty diet and both may be 
 cured with suitable food. 
 
 But probably of graver importance to the public welfare than 
 the well defined nutritional disturbances, themselves, is the fact 
 that between a state of good health and the level upon which a 
 disease is recognizable is a long scale, along which are ranged 
 an uncounted army of under-par, half-sick people. These are 
 the ones who are tired, nervous, susceptible to infections, with 
 feeble recuperative powers, and in general are more or less in- 
 effective in the business of life. 
 
 It is this borderline state, or as Dr. Goldberger terms it, * * the 
 twilight zone," which cannot quite be called disease but is not 
 health, that is serious to the masses, for diagnosed disease is 
 given treatment, but nervousness, lack of energy and endurance, 
 weakness and inefficiency are not treated; they are merely 
 tolerated, as a rule. The sufferers fail to reach their highest 
 possible development and they fail to be of highest value to 
 society. 
 
 This is the condition which can be so largely prevented by 
 giving the baby a good nutritional foundation ; this must be 
 started during its prenatal life, carried through the nursing 
 period and then continued throughout the rest of his life. Since 
 the nurse is very likely to be entrusted with the arrangement of 
 the patient's dietary, being told merely to give a liquid, soft 
 or light diet and possibly to avoid certain articles, it will mean 
 much to the coming generation if nurses at large are able so to 
 
NUTRITION OF THE MOTHER AND HER BABY 373 
 
 compose the various diets for the expectant and nursing mother, 
 that they will provide not only the requisite fats, proteids, 
 carbohydrates, minerals and water and yield the necessary 
 calories, but also contain all three protective substances : fat- 
 soluble A, water-soluble B and water-soluble C. It can be 
 demonstrated that when these food factors are not present in 
 the mother's diet, they will not appear in her milk, and accord- 
 ingly will not be supplied to her baby. 
 
 This is the crux of the whole matter. If the mother's diet is 
 faulty, her milk will be faulty in the same respect and the baby 
 will start life with tissues which contain an inadequate amount 
 of the substances that are necessary to make them sound and 
 promote health. 
 
 That is what we have in mind when we say that the mother's 
 milk must be satisfactory not alone in quantity but in quality 
 as well. 
 
 In order to make quite clear how damaging are the results 
 of diets which are deficient or lacking in these protective sub- 
 stances, we shall take up, briefly, the deficiency diseases in turn. 
 
 Scurvy (scorbutus) is caused by a lack or deficiency of the 
 substance called water-soluble C, the most unstable of all the 
 protective substances, being easily impaired or destroyed by 
 heating, drying or aging. This anti-scorbutic substance is pres- 
 ent in fresh milk, potatoes, oranges, lemons, onions, and such 
 fresh vegetables as lettuce, raw cabbage and celery and in apples, 
 pears, peaches, bananas and cantaloupe. Tomatoes are rich 
 in the anti-scorbutic substance and, moreover, this form is but 
 slightly injured by heating or aging, for which reason canned 
 tomatoes are frequently used both to prevent and to cure scurvy. 
 
 Scurvy is a disease which develops slowly. The patient loses 
 weight, is anemic, pale, weak and short of breath. The gums 
 become swollen, bleed easily and frequently ulcerate; the teeth 
 loosen and often drop out. Necrotic areas in the bones may 
 result. Hemorrhages into the mucous membranes and the skin 
 are characteristic. Large black and blue spots develop in the 
 skin, after trivial injury, or even spontaneously. The ankles 
 become edematous and in severe cases a hard, board-like con- 
 dition of the skin and subcutaneous tissues develops. There, is 
 
374 OBSTETRICAL NURSING 
 
 sometimes severe headache and in the later stages there may be 
 convulsions and delirium. 
 
 Although scurvy has been known to exist for centuries, -well 
 developed cases are not often seen among adults to-day, because 
 experience has taught the importance of including some fresh 
 food in the dietary, and present transportation facilities make 
 this a fairly simple matter for most people. The disease was 
 doubtless limited almost entirely to soldiers and pioneers until 
 after the discovery of America. This event marked the begin- 
 ning of long sailing voyages, with diets of dried and otherwise 
 preserved foods, and scur-vy began to take a heavj^ toll of life 
 among the mariners. It became known as "the calamity of 
 sailors" because of its frequency on shipboard. A notable in- 
 stance in the history of the disease was the voyage of Jacques 
 Cartier, in 1536, when he lost twenty-six of his party from 
 scurvy, and only saved the remainder by the use of an infusion 
 of pine needles. The efficacy of fresh fruits and vegetables in 
 the prevention and cure of scurvy was discovered by common 
 experience ; when it became customary to administer lime- or 
 lemon- juice to all sailors, scurvy practically disappeared from 
 the service. 
 
 Although we seldom see actual cases of the disease among 
 adults to-day, it is believed that there are large numbers of bor- 
 der-line eases among people who subsist largely on meats, canned 
 and dried vegetables and canned fruits, the meat-bread-and- 
 potato type of diet, for several months at a time, as during 
 the winter season. 
 
 ''Every individual requires a certain amount of anti-scor- 
 butic substance in his dietary, or to put this statement in a 
 broader way, every nation has need for a per capita quota of 
 foodstuffs containing this necessary food factor, if scurvy is to 
 be avoided." ^ 
 
 Infantile scurvy is seen among babies who are fed solely on 
 milk that has been heated, boiled, pasteurized or canned, since 
 the anti-scorbutic substance in milk is practically destroyed 
 by heating or aging. The disease is characterized by malnutri- 
 
 ^ Alfred P. Hess, M.D., The Journal of the American Medical Association, 
 Sept. 21, 1918. 
 
NUTRITION OF THE MOTHER AND HER BABY 375 
 
 tion, pain, typical changes in the structure of the bones and 
 hemorrhage in various parts of the body, most frequently in the 
 gums and beneath the periosteum. The disease develops slowly, 
 the first symptoms appearing between the seventh and tenth 
 months. Tenderness or pain in the legs is perhaps the most 
 common symptom and may be detected first by the baby 's crying 
 when its diaper is changed or its stockings are put on. And a 
 baby that previously has been cheerful, playful and active will 
 prefer to lie quietly and will cry whenever it is touched. He 
 grows pale, listless and weak and fails to gain in weight or 
 length. The large joints are likely to be swollen and tender; 
 the swollen gums may bleed; the urine may be diminished in 
 amount and contain blood and there also may be edema. But 
 it is quite possible for a baby to be in serious need of an anti- 
 scorbutic and still not present well defined symptoms of seur\'y, 
 or it may suffer from the latent or subacute type of the disease. 
 In the latter case there may be stationary weight ; fretfulness ; 
 a muddy complexion ; rapid pulse and respirations ; edema over 
 the tibise with perhaps tenderness of the bones and tiny hemor- 
 rhagic areas over the body. 
 
 Scurvy may be both prevented and cured by giving orange 
 juice, potato water, or tomato juice to a baby whose diet con- 
 sists of milk that has been heated and is therefore lacking in 
 water-soluble C. Many doctors believe that an anti-scorbutic 
 should be started as early as the end of the first month, with 
 babies fed on pasteurized milk, for the disease develops so slowly 
 that severe damage may be done if the administration of this 
 material is delayed until symptoms appear. 
 
 Scurvy, itself, does not often cause death among babies, but 
 its occurrence is serious since it renders the infants very sus- 
 ceptible to infection, particularly nasal diphtheria and "grip." 
 Recovery from even severe attacks is amazingly rapid, sometimes 
 being complete in a week or ten days as a sole result of giving 
 orange juice. 
 
 It is sometimes recommended that modified milk, for infant 
 feeding, be made up with potato water, instead of barley water, 
 since the latter has no anti-scorbutic properties, while potatoes 
 are somewhat protective even after being cooked. 
 
376 OBSTETRICAL NURSING 
 
 Spinach water is sometimes given, but there is doubt in some 
 minds about its anti-scorbutic value, which seems to be more 
 damaged by heat than that of potatoes and tomatoes. 
 
 Canned tomatoes are valuable because of being inexpensive 
 and preserving their anti-scorbutic properties, even after heat- 
 ing. It is the opinion of many pediatricians that babies tolerate 
 canned tomatoes very well, and in some cases may be given as 
 much as four, six, or even eight ounces daily, without causing 
 trouble. 
 
 Infusion of orange peel also is used in the prevention and 
 treatment of scurvy and has the advantage of being inexpensive 
 since the orange itself may be used for other purposes. 
 
 But orange juice and lemon juice are generally accepted as 
 being the most valuable of all anti-scorbutics. Orange juice 
 may be started early, and to be of value as a preventive, must 
 be started early or scurvy will have started to develop. The 
 common practice is to give a dram, daily, at three months, in- 
 crease it to an ounce by the sixth month and two ounces when 
 the baby is a year old. It should be diluted with water and 
 given in two doses, midway between two morning and afternoon 
 feedings. 
 
 To sum up : Scurvy in infants or adults is the result of a diet 
 which is deficient or lacking in the anti-scorbutic substance, 
 called water-soluble C, and may be prevented or cured by adding 
 to the faulty diet those articles of food which contain this sub- 
 stance, namely, fresh milk, oranges, leafy, green vegetables, cab- 
 bage, onions, potatoes or tomatoes. Although scurvy is seldom 
 seen in breast-fed babies it is believed that an infant nursing 
 at the breast of a woman whose diet is poor or lacking in the anti- 
 scorbutic substance may suffer a certain degree of starvation for 
 this food factor. 
 
 Recent work at the University of Minnesota has shown that 
 milk from cows on dry feeds is very much lower in anti-seorbutie 
 properties than milk from cows on green pasture. This provides 
 a strong argument for giving orange juice to all artificially fed 
 babies, for one cannot always know how the cows, from which 
 the milk is obtained, are fed. 
 
 Beri-beri is a deficiency disease, chiefly characterized by 
 
NUTRITION OF THE MOTHER AND HER BABY 377 
 
 paralysis and caused by a diet which is lacking or poor in water- 
 soluble B. The foods which entirely lack this substance are 
 polished rice, starch, sugar, glucose, and the fats and oils from 
 both animal and vegetable sources, while those which are poor 
 in it are the products of degerminated cereal grains, such as 
 tapioca, hominy, cornmeal, macaroni, spaghetti and the muscle 
 cuts of meat, such as steak, roast, chops, ham and fish and fowl 
 muscle. Foods which are rich in water-soluble B are beans, peas, 
 the root vegetables as beets, carrots, white and sweet potatoes, 
 leafy vegetables, fruits, milks, eggs and the glandular organs 
 such as liver, kidneys and sweet breads. 
 
 The early symptoms of beri-beri are fatigue and depression ; 
 numbness and stiffness in the legs; more or less edema of the 
 ankles and face, followed by tenderness of the calf muscles, and 
 tingling or burning sensations in the feet, legs and arms. There 
 are two types of the disease, the dry and the wet. In the dry 
 tj'^pe, wasting anesthesia and paralysis are the chief symptoms, 
 while the most marked evidences of the wet type are the edema, 
 which may be excessive, affecting the entire body. The death 
 rate from beri-beri is usually high. 
 
 We are accustomed to thinking of this disease as occurring 
 chiefly among the Orientals, for it was long confined to Southern 
 China, Japan, the Dutch East Indies and the Malay Peninsula. 
 But it may occur among any people whose diet is poor in those 
 foods containing the particular substance which protects against 
 it. It is common in Newfoundland and Labrador and certain 
 parts of South America and among people who eat little aside 
 from staple, non-perishable, cereal products, wheat bread made 
 from bolted flour, fish and salt meats. An evidence of this near 
 at home was an outbreak of typical beri-beri, in the jail at Eliza- 
 beth, N. J., in 1914, caused by the faulty diet of the inmates. 
 
 The disease may be prevented or cured only by including in 
 the diet such food as milk, eggs, fresh fruit and vegetables. 
 
 Xerophthalmia is a deficiency disease characterized by eye 
 lesions and due to a lack of, or deficiency in the diet of the pro- 
 tective substance which has been designated as fat-soluble A. 
 This substance is absent in polished rice, and present in but small 
 amounts in barley and other cereals ; in muscle cuts of meat ; in 
 
378 OBSTETRICAL NURSING 
 
 peas, beans and other vegetables excepting those described as 
 "leafy." It is contained in cod-liver oil, butter, cream, egg 
 yolk, liver, kidneys and the leafy vegetables. 
 
 In the early stages of the disease the eyes are inflamed and 
 the lids badly swollen. If the diet is wholly lacking in fat- 
 soluble A, the disease progresses rapidly, the eye balls frequently 
 
 
 HBhC-V 
 
 ^^V1 
 
 II 
 
 i'H.fll 
 
 
 
 '^•esi^Mli^. a^B 
 
 
 
 ^^- 
 
 ;tf% ■ 
 
 P^^^tt^^ 
 
 
 
 
 Fig. 140. — This baby is totally blind in the left eye as a result of 
 ulcers, due to a long continued diet of cereals with a little skimmed milk; 
 in other words, a diet poor in fat-soluble A. The right eye became in- 
 volved but administration of cod-liver oil was followed by speedy recovery 
 and partial vision was saved. There is little doubt but that the baby 
 would have been totally blind had the faulty diet been continued. (From 
 the Newer Knowledge of Nutrition, by E. V. McCoUum.) 
 
 rupture and the lens and vitreous humor are expelled, with 
 total and permanent blindness as the tragic result. On the other 
 hand, the malady clears up in a very spectacular manner if, in 
 the early stages, the patient is fed those foods which contain 
 the mysterious, but indispensable fat-soluble A. 
 
 Well developed xerophthalmia is not common in this country 
 
NUTRITION OF THE MOTHER AND HER BABY 379 
 
 but one sees inflamed eyes and corneal ulcers in young chil- 
 dren which clear up with little local treatment after a mother 
 has been persuaded to give the patient more fresh milk, butter 
 and green vegetables. 
 
 Mori reports upon about 1500 cases occurring in Japan, in 
 1905, among children between the ages of two and five years. 
 He states that the disease does not occur among the fisher folk 
 but among people whose diet is largely composed of rice, barley, 
 cereals, beans and "other vegetables," but he does not state 
 what the other vegetables are. Prompt relief of the eye symp- 
 toms was observed when cod-liver oil, chicken livers and eel fat 
 were administered. 
 
 Bloch describes cases of xerophthalmia among infants under 
 one year of age, in the vicinity of Copenhagen, during the years 
 of 1912 and 1916. (Fig. 140.) The babies were also suffering 
 from malnutrition and the skin was dry, shrivelled and scaly. 
 Their diet consisted largely of separator skimmed milk, which 
 was, therefore, practically fat-free, oatmeal gruel and barley 
 soup. The milk was pasteurized and then cooked in the home 
 before being fed to the babies. Such i. diet was so faulty that 
 the infants in question may well have been border-line cases of 
 scurvy and beri-beri, as well as developed cases of xerophthalmia. 
 It is also evident that the children were unquestionably suffer- 
 ing from rickets. 
 
 It is believed that the condition known as night-blindness is 
 related to, or a mild or early form of xerophthalmia. It occurs 
 in Newfoundland and Labrador, among men in lumber 
 camps and elsewhere, whose diet consists chiefly of wheat flour, 
 beans, meat, fish, molasses, raisins and coffee. Such a diet is 
 made up of those parts of the plant or animal which have good 
 keeping qualities, but these qualities do not compensate for the 
 poverty of the protective substance. 
 
 Dr. Anna Strong, who has had experience as a medical mis- 
 sionary in India, observes that night-blindness is common in the 
 vicinity of Calcutta, and it is said to occur frequently in Russia 
 during the Lenten fasts. The popular treatment for this con- 
 dition consists of poulticing the eyes with fresh goat 's liver and 
 giving the liver as a food as well; while in Japan the efficacy 
 
380 OBSTETRICAL NURSING 
 
 of eating liver to cure night-blindness lias been recognized from 
 early times. 
 
 Pellagra is a disease of obscure origin, associated with faulty 
 nutrition, which involves the nervous and digestive systems and 
 the skin. Usually one of the first symptoms is soreness and in- 
 flammation of the mouth, then a remarkable, symmetrical erup- 
 tion appears on parts of the body, which, with weakness, nerv- 
 ousness and indigestion form the most characteristic picture of 
 the disease. 
 
 There are some indications that infection may be the imme- 
 diate cause, but the strong evidence is that a faulty diet is the 
 chief predisposing cause of the disease. Certain it is that 
 pellagra is both prevented and cured by a diet containing liberal 
 amounts of milk, eggs and leafy vegetables. On the other hand, 
 those who live during the winter months on a diet chiefly de- 
 rived from bolted white flour, degerminated cornmeal, polished 
 rice, starch, sugar, molasses and fat pork, furnish the victims 
 of this dreaded disease in the spring. 
 
 Pellagra was discovered in Northern Spain, by Cassal, in 
 1735, but for many years it had been of common occurrence 
 in parts of Italy, and during the last century has been prevalent 
 in parts of France, the Balkans, especially Roumania, and for 
 a lesser time, in Egypt. In America the disease was not recog- 
 nized with certainty until 1908, but from that year its incidence 
 apparently increased, until by 1917 there were 170,000 cases of 
 pellagra recorded in the United States, principally located in 
 the Southern States. 
 
 In 1914, Dr. Joseph Goldberger, of the United States Public 
 Health Service, began an investigation of the factors concerned . 
 in causing pellagra. After he had studied its prevalence in vari- 
 ous orphanages in the South, and had relieved the situation by 
 improving the diet with milk, fresh vegetables and meat, he was 
 anxious to know whether the disease could be produced by^ a 
 faulty dietary, of the type common among pellagrins. He 
 planned an experiment to this end, which would restrict men to 
 a diet similar to that which had been supplied in the institutions 
 where pellagra had been endemic, and where it had been relieved 
 by the improvements in the food supply which have been men- 
 
NUTRITION OF THE MOTHER AND HER BABY 381 
 
 tioned. This type of diet was also very characteristic of that used 
 in the homes of the cotton mill workers throughout the South, 
 where pellagra was so common. The Governor of Mississippi 
 offered pardon to any of the healthy white men in the state prison 
 who would submit themselves as subjects for the experiment, and 
 eleven actually underwent the test. 
 
 The men were put upon a diet consisting of articles made 
 from white, wheat flour, degerminated cornmeal (maize), pol- 
 ished rice, starch, sugar, molasses, pork fat, sweet potatoes, coffee 
 and very small quantities of collards and turnip greens — so small 
 
 Fig. 141. — Eachitic baby and normal baby of the same age, showing 
 dwarfism and deformities caused by rickets. (By courtesy of Dr. Leonard 
 Findlay, Glasgow, Scotland.) 
 
 as to furnish inadequate protection against a certain degree of 
 undernourishment. At the end of five and a half months six of 
 the eleven men developed the skin lesions characteristic of in- 
 cipient pellagra. 
 
 As a result of his investigations. Dr. Goldberger points out 
 the important fact that when milk, eggs, meat, fresh fruit and 
 vegetables are included in the diet, pellagra does not develop, also 
 that the disease may be cured by giving these articles of food to 
 the afflicted person. 
 
 Rickets. The actual cause of rickets is not definitely known, 
 
382 OBSTETRICAL NURSING 
 
 but the disease apparently results from wrong proportions be- 
 tween calcium and phosphorus, and to unfavorable amounts of 
 these two substances in the food. Accordingly, it may be said 
 to be due to a faulty diet — one which is rich in carbohydrates 
 and poor in fats and possibly some substance as yet unrecognized 
 — and it may be both prevented and cured by what is now re- 
 garded as suitable feeding. 
 
 The chief characteristics of the disease are arrested growth 
 and softening of the bones, with dwarfism and deformities as a 
 result. (Fig, 141.) It is essentially a disease of infancy, oc- 
 curring as a rule, between the fourth and eighteenth months but 
 some of its unfavorable effects, such as bone deformities and 
 poor resistance to disease, may persist throughout life. 
 
 Although babies rarely die of rickets alone, it is one of the 
 most serious of all health problems and obstacles to normal de- 
 velopment and stability, since it predisposes to such diseases as 
 bronchitis, pneumonia, tuberculosis, measles, and whooping 
 cough and in general greatly enfeebles the powers of resistance 
 and recuperation. 
 
 It is common among babies who are fed solely or continu- 
 ously on heated milk, either boiled or canned, and on proprietary 
 foods and sweetened condensed milk. There has been some 
 speculation about the possible relation between rickets and fat- 
 soluble A, but no definite conclusions have yet been reached. 
 It is known, however, that rickets may develop among nursing 
 babies whose mothers are on faulty diets, and that the disease 
 may be prevented and cured by the administration of cod-liver 
 oil, which is rich in fat-soluble A. Sunshine, also, seems to have 
 a pronounced effect in preventing and in curing the disease. 
 
 Symptoms. The common symptoms of rickets which appear 
 early are irritability; restlessness particularly at night; a ten- 
 dency toward convulsions from very slight cause; digestive dis- 
 turbances and profuse perspiration about the head. The baby 
 may be fat, but is likely to be flabby and to have a characteris- 
 tically white, "pasty" color. The fontanelles are large and late 
 in closing ; the abdomen is large and the chest narrow ; dentition 
 is usually delayed and the teeth may be soft and decay early. 
 But the most conspicuous effect of rickets is upon the entire bony 
 
NUTRITION OF THE MOTHER AND HER BABY 383 
 
 skeleton, due to the inadequacy of the lime deposit. The bones 
 are soft, easily bent and broken and often misshapen. Their 
 growth is likely to be retarded and the ends of the long bones 
 may be enlarged, giving the familiar rwollen wrists and ankles, 
 while the nodules which form at the junction of the ribs and 
 
 Fig. 142. — Exterior of thorax of normal rat and rachitic rat of same 
 age. The latter shows dwarfism and deformities resembling pigeon breast 
 so frequently seen in human beings suffering from rickets. (From The 
 Newer Knowledge of Nutrition, by E. V. McCollum.) 
 
 sternum, produce the beaded appearance so commonly called a 
 "rickety rosary." The bones in the arms and legs may become 
 curved as the baby lies or sits in its crib, making him either bow- 
 legged or knock-kneed. The deformity is increased by walking 
 because the soft bones are easily bent by the weight of the body. 
 The spinal column may be curved or too weak to permit the baby 
 to sit straight or stand alone. The entire chest wall is often 
 
384 OBSTETRICAL NURSING 
 
 deformed (Figs. 142, 143) producing the familiar "chicken 
 breast," as well as a serious decrease in the size of the thoracic 
 cavity, and through loss of rigidity of the bony wall, the respira- 
 tory movements may be seriously impaired. The forehead is 
 prominent and the whole head looks square and larger than 
 normal, while the pelvic deformities in girl babies often give 
 rise to very serious obstetrical complications later in life, as has 
 been previously explained. 
 
 Although lack of fresh air and sunshine seem to be factors 
 in producing rickets, it has been observed that the disease does 
 
 / 
 
 (* 
 
 AttacfiWent ..-' 
 of Diaphragm*, 
 
 ^\.--- .:• 1 
 
 Fig. 143. — Interior of specimens in Fig. 142 showing nodules, due to 
 rickets, protruding into thoracic cavity and encroaching upon space occu- 
 pied by heart and lungs. This is a factor in the respiratory diseases which 
 frequently complicate rickets. 
 
 not develop in poor surroundings if the diet is suitable or if 
 cod-liver oil is given to babies fed artificially, or on unsatisfac- 
 tory breast milk ; but that it may occur in the presence of satis- 
 factory hygienic conditions if the diet is faulty in certain re- 
 spects. For children under a year old, the desirable food is 
 good breast milk, or, lacking that, fresh, certified cows' milk, 
 with fruit juices, scraped beef, eggs and strained vegetable 
 purees, started as early and increased as rapidly as the baby 
 can digest them. 
 
NUTRITION OF THE MOTHER AND HER BABY 385 
 
 Treatment. Cod-liver oil and sunshine, together with proper 
 food, are the essentials in treating rickets. When cod-liver oil 
 is given to a baby whose diet is faulty, it exerts a marked ten- 
 dency toward enabling the bones to develop satisfactorily even 
 when the mineral content of the food is unfavorable. The use 
 of sunshine, either by moving the baby from a dark to a light 
 house, or by exposing his body to the direct rays of the sun is 
 found to be of pronounced therapeutic value. These factors, 
 in addition to general good care constitute the treatment, but 
 it is a long slow process, taking from three to fifteen months, 
 and it is doubtful if the damage which the disease works can 
 ever be entirely repaired. 
 
 Rickets is more common during the cold months of the year, 
 winter and spring, than during the milder summer and autumn 
 seasons. A possible explanation for this lies in the higher value 
 of the cows' food during the warm months when green things 
 form the diets of animals. Since it is now recognized that milk 
 is not a constant product, but that its properties vary with the 
 food of the animals that produce it, cows' milk would be favor- 
 ably influenced by their being put to pasture. 
 
 Similar evidence of such an influence is seen in the fact that 
 although rickets is not seen among breast-fed babies whose 
 mothers are on satisfactory diets, it may and does occur in 
 breast-fed babies who are nourished by mothers who are, them- 
 selves, on dietaries which are poor in milk and fresh fruit and 
 vegetables. 
 
 Drs. Hess and Unger made a study of the occurrence of 
 rickets among colored babies in a section of New York City and 
 the value of cod-liver oil as a preventive of this disease. In com- 
 menting upon their findings, they state, "This tendency is so 
 marked that it may be safely stated that over ninety per cent, 
 of the colored babies have rickets, and that even a majority of 
 those that are breast-fed show some signs of this disorder." 
 They ascertained that the average diet of the mothers of these 
 rickety babies was largely made up of carbohydrates and pro- 
 teins, being poor in fats, although the diets yielded a daily quota 
 of calories which represented almost the requisite amount for 
 
386 OBSTETRICAL NURSING 
 
 their individual weights. But they took little fresh milk or 
 fresh fruit or vegetables, using canned and dried products freely. 
 
 It is important to note here that it is a diet of heated milk, 
 rich in carbohydrates but poor in fats, that produces rickets in 
 a bottle-fed baby — almost the same type of diet which in a 
 nursing mother results in rickets in a breast-fed baby. 
 
 In an endeavor to prevent rickets among these incompletely 
 nourished babies, Drs. Hess and Unger carried on a definitely 
 organized experiment. "Our plan," they report, "was to give 
 infants under six months one-half teaspoonful of oil three times 
 daily and older infants twice this amount. It was found that 
 almost all babies can take cod-liver oil, although it may disagree 
 temporarily and may have to be discontinued for short intervals 
 when there is digestive disturbance. Infants of from two to 
 three months tolerate the oil in half-teaspoonful doses, and 
 younger ones may be given still smaller amounts." In com- 
 menting upon the tabulated results of this interesting study they 
 say: "It is seen that we were able to prevent the development 
 of rickets in more than four-fifths of the infants who received 
 the oil for six months, and in more than half of those who were 
 given it for four months. This result must be considered satis- 
 factory when we note that, of the sixteen infants who did not 
 receive the oil, fifteen showed signs of rickets, though all of them 
 lived under the same conditions and many in the very same 
 families. No other treatment was given, nor was a change of 
 diet or mode of life attempted which could account for the dif- 
 ference in the results between the two groups of cases." The 
 poor quality of the breast milk of these inadequately nourished 
 mothers is suggested by the further statement: "Table two 
 shows that the cod-liver oil proved to be a more potent factor than 
 breast feeding in warding oif rickets, and that almost all the 
 colored babies developed rickets even though nursed." 
 
 It may seem like a far cry from scurvy among sailors, on 
 shipboard, xerophthalmia among lumbermen in Labrador, and 
 beri-beri among the Orientals to the nursing mother and her 
 baby in our care. 
 
 But when we gather all of these apparently unrelated threads 
 together and consider them in their possible relation to this same 
 
NUTRITION OF THE MOTHER AND HER BABY 387 
 
 nursing mother and her baby, right here at hand, the following 
 facts stand ont as being of insistent importance to their well- 
 being : 
 
 1. There are five recognized diseases resulting from faulty nutri- 
 tion, which may be both prevented and cured by a diet which 
 contains the protective substances which are now regarded as 
 essential to normal growth, development and well-being. 
 
 2. These essential substances are not necessarily provided in ade- 
 quate amounts by a diet that is satisfactory in bulk or in its 
 balance of fats, carbohydrates, proteins, salts and water or that 
 yields the requisite number of calories. The familiar diet of 
 meat, potatoes, peas, beans, bread, pie and coffee is so far from 
 providing complete nourishment that those who are limited to 
 it are in a state of partial starvation, 
 
 3. The diseases resulting from a lack or deficiency of the protective 
 substances, fat-soluble A, water-soluble B and water-soluble C, 
 respectively, are xerophthalmia, beri-beri and scurvy. With 
 these are often included pellagra and rickets, the causes of which 
 are not definitely known but result from diets that are poor in 
 certain respects. The serious aspect of the deficiency diseases, 
 however, does not lie entirely in those conditions which are well 
 enough developed to be recognizable, thus prompting treatment; 
 but also in the wide prevalence of malnutrition, of some form, 
 which is not severe enough to be diagnosed as disease, and 
 which is caused by a sustained diet that is poor in one or more 
 essential food factors. This condition is serious because it pro- 
 duces a legion of individuals who are spoken of as being "not 
 strong." They are tired, nervous, susceptible to infections, have 
 poor recuperative powers and in general fall short of a normal 
 state of health and efficiency. 
 
 4. Although the breast tissues are capable of converting into milk 
 certain substances which they extract from the blood, and may, 
 for example, convert poor proteins into proteins of higher 
 value, they cannot create the protective substances which we 
 have been considering. They can merely excrete these substances 
 if they are contained in the mother's diet. The absence, or 
 shortage of these food essentials in the mother's diet, and there- 
 fore in her milk, may result in rickets or other malnourished 
 conditions in the baby, or in a degree of faulty nutrition which 
 is not marked enough to be diagnosed, but enough to keep 
 him frail. Enough to give him the poor start that is so likely 
 to put him, ultimately, in the class of those adults who are more 
 or less unfit, though not actually ill. 
 
 We must see to it, therefore, that our selection of food for 
 
388 OBSTETRICAL NURSING 
 
 the expectant and nursing mother provides those substances 
 which are necessary to promote growth and development and 
 preserve health, if we are to live up to our claim that the aim 
 of obstetrical nursing is to aid in building a strong, vigorous and 
 buoyant race. 
 
 The nurse may find herself feeling a bit dismayed at the pros- 
 pect of trying to remember at all times which foods contain fat- 
 soluble A, for example, and which are poor in water-soluble C, 
 but she can remember in general, that milk and leafy vegetables 
 are the great protective foods and that any diet which is poor in 
 these is incapable of nourishing satisfactorily ; and by calling to 
 mind the deficiency diseases, previously described, she will be 
 impressed anew by the seriousness of faulty nutrition. 
 
 By milk we mean, in addition to fresh milk, cream, butter, 
 butter-milk, cream-soups and sauces, custards, ice-cream and all 
 dishes and beverages made of milk. 
 
 By leafy vegetables we mean lettuce, romaine, endive, cress, 
 celery, cabbage, spinach, onions, string beans, asparagus, cauli- 
 flower, Brussels sprouts, artichokes, beet greens, dandelions, 
 turnip tops and the like. 
 
 Other foods which are rich in protective substances are fresh 
 fruit, egg-yolks and glandular organs. 
 
 Nearly all of the common foods are deficient in some respect, 
 but as the shortcomings of the various groups are different, we 
 can arrange entirely satisfactory diets by combining foods which 
 supplement each other's deficiencies. This explains to us why 
 the meat-potato-peas-beans-bread-and-pie type of meals fails to 
 supply adequate nourishment. These foods belong in the same 
 general group and are deficient in about the same kind of food 
 factors, thus tending to duplicate, rather than supplement each 
 other. 
 
 If such a fare is enriched by the addition of the protective 
 foods, milk and leafy vegetables, we have a well rounded diet 
 in which the deficiencies of one group of foods are supplied by 
 the properties of the other groups. In fact, it is only by such 
 a supplementing combination that an entirely satisfactory diet 
 can be secured. 
 
 Dr. McCollum points out that the mother on a faulty diet 
 
NUTRITION OF THE MOTHER AND HER BABY 389 
 
 cannot nurse her baby to his advantage. * ' The mammary gland,'* 
 he says, "picks up from the blood both of the chemically un- 
 identified food essentials, fat-soluble A and water-soluble B, and 
 passes these into the milk, but it is unable to produce either of 
 these substances anew. When one or the other of these is absent 
 from the mother's diet it is not found in the milk. We have 
 shown the possibility of producing milk, poor or lacking in each 
 of these substances and therefore not capable of inducing 
 growth. ' ' ^ 
 
 Dr. W. E. Musgrave gives dramatic accounts of the effect 
 upon nursing babies of faulty nutrition among mothers in the 
 Philippines, as follows: "Infant mortality in Manila," he 
 writes, "is greater than it is in any other city from which we 
 have records. The underdeveloped and undernourished condi- 
 tion of the great masses of the Filipino people is due to a num- 
 ber of causes, the principal one being insufficient quantity and 
 injudicious variety of foodstuffs employed. The cause of the 
 enormous influence of the faulty nutrition of the mothers upon 
 infant mortality directly and indirectly is one of the most im- 
 portant subjects within the scope of any investigation of this 
 character. The mortality in breast-fed children is higher than 
 it is among children artificially fed. This condition so far as 
 we know is peculiar to the Philippines. The logical, and we 
 believe, the correct explanation of this is the deficiency in quality 
 and quantity of the mother's milk. There are not in history 
 more pathetic examples of unavailing self-sacrifice than are daily 
 seen in our large clinics of poor, half-starved, undernourished 
 mothers attempting to supply from their breasts food enough 
 for one or more children, when their own metabolisms are in a 
 starved condition. When asked the direct question as to the 
 supply of foodstuffs these mothers almost invariably state that 
 they have plenty to eat and the pathetic part of the story is 
 that they believe that they are stating facts. These abnormal 
 premises are the result of a peculiar unexplainable psychology 
 that is of very wide application in this country that the ad- 
 
 *"The Nursing Mother as a Factor of Safety in the Nutrition of the 
 Young." E. V. McCollum and N. Sinimonds, The American Journal of 
 Physiology, June, 1918. 
 
390 OBSTETRICAL NURSING 
 
 ministration of food is more to satisfy hunger than to produce 
 flesh and blood, and that the cheapest way in which hunger 
 may be satisfied produces a satisfactory form of existence." 
 
 It is generally agreed that the two big problems of babyhood 
 are proper nutrition and the prevention of infection, but nutri- 
 tion is perhaps the greater problem, since any form or degree 
 of malnutrition lessens the baby 's powers to resist and to recover 
 from infection. Whether breast-fed or bottle-fed, therefore, it 
 is imperative that the baby be nourished in the complete sense 
 of being given all of the food materials which are essential to 
 normal growth, development and protection against disease. 
 
 If the baby is artificially fed on milk that has been heated, 
 his diet needs to be augmented by such protectives as cod-liver 
 oil and orange juice, since the protective properties of milk are 
 impaired by heating. If he is breast-fed, the mother will be 
 able to supply to her baby the requisite nourishment and pro- 
 tective substances only if she, herself, is adequately nourished 
 and in good condition. 
 
 That is the point of this entire discussion: The nursing 
 mother must be on a satisfactory diet or she cannot satisfac- 
 torily nurse her baby. And by satisfactorily nursing her baby 
 we mean, to give him from the beginning, through her milk, the 
 materials necessary to build well and firmly that temple, in the 
 shape of his body, which he will occupy throughout life ; a struc- 
 ture so securely built, from the foundation up through each 
 stage, that it will be able to withstand the attacks of disease and 
 weather the inevitable storm and stress of life. 
 
 BIBLIOGRAPHY 
 
 McCoUum. The Newer Knowledge of Nutrition, 2nd edition. New 
 
 York, 1918. 
 MeCollum and Simmonds. The American Home Diet, Detroit, 1919. 
 McCollum. Newer Aspects of Nutrition, Proceedings of the Institute 
 
 of Medicine of Chicago, 1920, iii, 13. 
 Musgrave, W. E. The Philippine Jour, of Science, Series B, vol. 8, 
 
 1913, 459. 
 Goldberger, J. Jour. Amer. Med. Assoc, 1916, Ixvi, 471. 
 Hess, A. F. and Unger, L. J. Prophylactic Therapy for Rickets in a 
 
 Negro Community. 
 
CHAPTER XVIII 
 COMPLICATIONS OF THE PUERPERIUM 
 
 The most important of the complications of the puerperium 
 are subinvolution and malpositions of the uterus; breast 
 abscesses; hemorrhage and infection. 
 
 The importance of these to the nurse lies in their prevent- 
 ability, by means of the clean and efficient care which she helps 
 to give during pregnancy, labor and the early weeks after the 
 baby is born. 
 
 The nurse's part in prevention and treatment of subinvolu- 
 tion, malpositions of the uterus and breast abscesses is so bound 
 up in the daily care of the young mother that it was described 
 in the preceding chapter. 
 
 Hemorrhage. Under ordinary conditions, a patient may lose 
 as much as 500 cubic centimetres of blood during or immediately 
 after labor, without serious results, but a loss of 600 cubic centi- 
 metres or more is regarded as a hemorrhage and as requiring 
 speedy attention. 
 
 According to Dr. Williams, severe hemorrhage occurs only 
 once in every few hundred labors, and with proper treatment, 
 should not result fatally in more than one out of every 2000 or 
 2500 cases. 
 
 The severe hemorrhage due to a partially separated placenta 
 occurs during the third stage of labor and was discussed in that 
 connection. As the danger of hemorrhage, after labor is com- 
 pleted, is greatest during that critical hour immediately follow- 
 ing, it is practically routine the country over to watch the pa- 
 tient closely during this period, both for the sake of preventing 
 bleeding and detecting its early evidence, should hemorrhage 
 occur, thus making prompt treatment possible. 
 
 The causes of post-partum hemorrhage are : Deep cervical 
 tears, retained portions of the placenta, and atony of the uterus. 
 
 391 
 
392 OBSTETRICAL NURSING 
 
 The treatment of hemorrhage due to tears of the generative 
 tract is suturing the torn edges. 
 
 Since the retention of even a small piece of placental tissue 
 will prevent the uterus from contracting firmly, the treatment 
 of hemorrhage from this cause is immediate removal of the 
 retained fragment. It is to obviate this occurrence that the 
 placenta is carefully inspected after its expulsion. If it is not 
 intact, the obstetrician may introduce his finger and remove the 
 retained portion, thus making it possible for the uterus to con- 
 tract properly and close off the open blood vessels. 
 
 Atony, or impaired tone of the uterine muscles, may result in 
 hemorrhage because of failure of the muscle fibres to constrict 
 the vessels. Quite evidently, the first step toward controlling 
 hemorrhage from this cause is to stimulate the muscles to con- 
 tract ; this is done by means of massage and the administration of 
 pituitrin and ergot. Elevation of the foot of the bed and appli- 
 cation of ice-bag to the abdomen are also employed. 
 
 In severe cases, the doctor may give an intra-uterine douche 
 of hot, sterile salt solution and if this fails he may pack the uterus 
 tightly with sterile gauze. The douche and pack represent opera- 
 tive maneuvers and, therefore, are never to be undertaken by 
 the nurse. Her assistance is important, however, as strictest 
 asepsis is imperative and she will have to prepare the patient 
 and the necessary articles with the greatest care. 
 
 Should bleeding become profuse during the doctor's absence 
 the nurse must stay with the patient and massage the fundus 
 and have some one else elevate the foot of the bed on the seat 
 of a straight chair or upon firm blocks and summon the doctor. 
 In anticipation of such an emergency the nurse must always 
 have an understanding with the doctor about the administration 
 of pituitrin and ergot. If there has been no understanding, and 
 the doctor is delayed or the bleeding becomes alarmingly profuse, 
 the nurse will usually be upheld if she gives 1 cubic centimetre 
 of pituitrin, hypodermically and a dram of ergot by mouth. 
 
 It is, of course, definitely understood that nurses do not 
 give medicines without orders, but a single dose of pituitrin 
 and ergot upon the occurrence of a profuse hemorrhage can 
 scarcely do harm and may actually save the patient 's life. Such 
 
COMPLICATIONS OF THE PUERPERIUM 393 
 
 a situation is an emergency fortunately a rare one, and the 
 nurse will have to be quick-witted and use the best judgment 
 she is capable of. 
 
 The patient is usually more or less shocked by the time the 
 bleeding has been controlled and needs the rest, quiet and stimu- 
 lation that are ordinarily employed in such cases. She should 
 be well wrapped in blankets and surrounded with hot water bot- 
 tles placed outride the blankets, watched constantly and moved 
 frequently; salt solution or strong coffee are sometimes given 
 by enema, or saline infusions or intra-venous injections may be 
 given. The patient must be kept warm and quiet and pressed 
 to drink large amounts of fluids. 
 
 But above all the nurse must remember that severe hemor- 
 rhage from a relaxed uterus can almost always be prevented if 
 the fundus is kept hard, by massage when necessary, during the 
 first hour or so after delivery. 
 
 Puerperal infection is usually regarded as a condition 
 which results from the entrance of infective bacteria into the 
 female generative tract during labor or the puerperium, to dis- 
 tinguish it from other infections which may occur coincidently 
 with the puerperal state, but not necessarily be related to it. 
 
 Puerperal infection is one of the most destructive and most 
 dreaded of the complications which may overtake the obstetrical 
 patient, and has evidently been so considered since the days of 
 Hippocrates. Until recent years this veritable scourge was so 
 utterly baffling that it was regarded as more or less of a dis- 
 pensation of a Divine Providence and therefore to be accepted 
 with the same philosophical resignation as earthquakes and 
 cyclones. 
 
 In dramatic contrast to this unresisting attitude is the pres- 
 ent knowledge concerning the cause and prevention of this dis- 
 ease, and the general belief that it is a wound infection and 
 therefore practically preventible; that it is to be ascribed to 
 the carelessness of mankind rather than to the indifference of 
 Providence. 
 
 This change is due very largely to the devoted work of three 
 men who were deeply stirred by the tragic frequency with which 
 young women laid down their lives in so-called ' * child bed fever." 
 
394 OBSTETRICAL NURSING 
 
 These men were Ignaz Semmelweiss, Oliver "Wendell Holmes, 
 better known to Americans as poet and humorist, and Louis 
 Pasteur, each contributing his own special observations to the 
 sum of knowledge which was to mean so much to mothers of 
 the future. Also the theories of Lister concerning antisepsis 
 and the inauguration of the use of sterile rubber gloves by Dr. 
 Halsted, of Johns Hopkins Hospital, has had the same life-saving 
 effect upon obstetrical patients as upon all surgical patients. 
 
 In 1843, Oliver Wendell Holmes read a paper before the 
 Boston Society for Medical Improvement, entitled "The Con- 
 tagiousness of Puerperal Fever." In this paper he presented 
 striking evidence that in many instances, something was con- 
 veyed by doctor or nurse, from an ill person to a maternity 
 patient with puerperal fever as a result. He was attacked and 
 ridiculed for his theories and some of the leading obstetricians 
 declared that it was an insult to their intelligence to expect them 
 to believe that creatures too small to be seen by the naked eye 
 could work such havoc. 
 
 In 1847 Ignaz Semmelweiss, of the Vienna Lying-in Hos- 
 pital, decided as a result of some of his investigations that puer- 
 peral infection was a wound infection, and that the infecting 
 organisms were introduced into the birth canal on the examining 
 finger of the doctor or nurse, after contact with an infected pa- 
 tient or cadaver. Accordingly he required that all vaginal ex- 
 aminations be preceded by washing the hands in chlorid of 
 lime, after which precautions the mortality from infection 
 dropped from 10 per cent, to less than 1 per cent. In 1867 
 Semmelweiss offered his theories and conclusions in a masterly 
 work on this subject, the title of which may be translated as 
 "The Etiology, Conception and Prophylaxis of Child-Bed 
 Fever, ' ' but the actual cause of the disease was still unknown. 
 
 But about 1879 Pasteur demonstrated what is now known 
 as the streptococcus, in certain patients suffering from puerperal 
 fever. 
 
 "Pasteur," wrote M. Roux, "does not hesitate to declare that that 
 microscopic organism (a microbe in the shape of a chain or ehaplet) 
 is the most frequent cause of infection in recently delivered women. 
 One day, in a discussion on puerperal fever at the Academy, one of 
 
COMPLICATIONS OF THE PUERPERIUM 395 
 
 his most weighty colleagues was eloquently enlarging upon the causes 
 of epidemics in lying-in hospitals; Pasteur interrupted him from his 
 place. 'None of those things cause the epidemic; it is the nursing and 
 medical staff who carrj^ the microbe from an infected woman to a 
 healthy one.' And as the orator replied that he feared that microbe 
 would never be found, Pasteur went to the blackboard and drew a 
 diagram of the chain-like organism, saying: 'There, that is what it is 
 like!' His conviction was so deep that he could not help expressing 
 it forcibly. It would be impossible now to picture the state of surprise 
 and stupefaction into which he would send the students and doctors in 
 hospitals, when, with an assurance and simplicity almost disconcerting 
 in a man who was entering a lying-in ward for the first time, he criti- 
 cised the appliances, and declared that the linen should be put into a 
 sterilizing stove." ^ 
 
 Slowly, but very slowly, the teachings of these earnest men 
 were adopted by the medical profession, with the result that in 
 well-conducted, modern hospitals the precautions which have 
 been described in preceding chapters are rigidly observed. And 
 to-day, one woman in about 1,000 in such hospitals dies of puer- 
 peral infection, instead of one in ten, as in the early days. In 
 the year 1864, 23 per cent, of the patients at the Maternite, in 
 Paris, died of puerperal infection. 
 
 But unhappily, the decline in the occurrence of puerperal 
 infection, in this country is largely confined to the hospitals, for 
 in the homes throughout the land the disease is almost as com- 
 mon as it was in the days of our fathers, or even grandfathers. 
 Of approximately 20,000 deaths from childbirth in this country 
 during 1920, about one-half, or possibly 10,000 were from puer- 
 peral infection. 
 
 To the nurse there is considerable significance in Pasteur's 
 cJiaracterization of the infected young mother as an "invaded 
 patient," for the nurse's preparation for labor and her care 
 of the patient during the puerperium should be enormously influ- 
 ential in preventing this "invasion." In this connection she 
 may well ponder Miss Nightingale's assertion that "The fear 
 of dirt is the beginning of good nursing. ' ' Certainly the obstet- 
 rical patient cannot be well cared for unless the nurse has this 
 fear in her heart. 
 
 ' ' ' The Life of Pasteur, ' ' by Vallery Eadot. 
 
396 OBSTETRICAL NURSING 
 
 Puerperal infection, then, in the light of present informa- 
 tion, is regarded as a wound infection caused by the strepto- 
 coccus, gonococcus, colon bacillus, gas bacillus or any other pus 
 producing organism. Of these, the streptococcus infection is 
 the most frequently seen and is also the most serious, about 10 
 per cent, of such infections resulting fatally; while the gon- 
 orrheal infection, though seldom ending in death, usually causes 
 sterility. 
 
 Infection during the puerperium occurs most often in the 
 uterus, and, if mild, may amount to nothing more than endome- 
 tritis, or inflammation of the uterine lining. In more serious 
 cases, the inflammation may spread to the tubes and ovaries; 
 may cause abscesses in the broad ligament and general perito- 
 nitis. A streptococcus infection may spread through the lym- 
 phatics and cause general septicemia. 
 
 Infection of the raw and bleeding placental site may occur 
 at any time during labor or the ten days following, though the 
 danger of infection decreases steadily after the first day post- 
 partum. 
 
 S3nnptoins. The symptoms vary greatly according to the 
 infecting organism and according to the site and extent of the 
 inflammation. In mild types of infection, the patient may be 
 entirely normal for the first three or four days and then com- 
 plain of chilliness or even have a chill ; her temperature will be 
 slightly above normal, finally reaching about 101° F., where it 
 hovers for ten days or two weeks, after which it drops again 
 to normal and the patient recovers. 
 
 The severe type, which is so dreaded, is the one in which the 
 patient is normal until the third or fourth day when she com- 
 plains of tenderness, chilliness, weariness, and of being gen- 
 erally wretched. She may complain of chilliness but more often 
 has a chill. 
 
 The pulse is usually rapid and the temperature goes up 
 somewhat abruptly. (Chart 3.) The condition of the lochia 
 depends upon the infecting organism. In streptococcal infec- 
 tion the lochia is often greatly decreased in amount and almost 
 odorless, while in colon bacillus infections the lochia is profuse 
 and foul-smelling. The attack may be very acute and result 
 
COMPLICATIONS OF THE PUERPERIUM 397 
 
 fatally in a few days, or it may gradually subside and the 
 patient recover. 
 
 In gonorrheal infections the temperature does not go up until 
 later, from the sixth or to the tenth day, as a rule. (Chart 4.) 
 The patient is not usually very ill and generally recovers. But 
 the gonococcus is very likely to produce an inflammation of the 
 
 m>i 
 
 Name CLww VS^ \-» ©. W \^ v 
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 Chart No. 3. — Chart showing rise in temperature about 3rd day after 
 delivery in a streptococcus infection.. 
 
398 
 
 OBSTETRICAL NURSING 
 
 tubes and to close up the fimbriated opening. Thus it is im- 
 possible for ova thereafter to enter the tube and gain access to 
 the uterus and accordingly the patient cannot again become 
 pregnant. Unlike other infections, gonorrhea is not conveyed 
 to the patient during or soon after labor on instruments or 
 examining fingers, but is already present in the vulvo-vaginal 
 
 Name. 
 
 atQai&l 
 
 1 
 
 .^«?OUJ.. 
 
 Oct. 6, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19 
 
 Temp. 
 
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 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 i 1 1 1 i 1 1 1 
 
 
 Day of 
 
 1 
 
 2 
 
 3 
 
 4 
 
 5 
 
 6 
 
 7 
 
 8 
 
 9 
 
 10 
 
 11 
 
 12 
 
 13 
 
 14 
 
 1 
 
 5. 
 
 Chart No. 4. — Chart showing rise in temperature about 7th day after 
 delivery in gonorrheal infection. 
 
COMPLICATIONS OF THE PUERPERIUM 399 
 
 glands and from tlicm may travel to the uterine cavity and to 
 the tubes. 
 
 Treatment and Nursing Care. Preventive. There is so lit- 
 tle that i-aii l)e done toward curing a patient suffering from 
 puerperal infection that the greatest effort should be made to 
 prevent the disease. The nurse's part in preventing this com- 
 plication is an important one and consists of making such prep- 
 aration for labor that it may be conducted with absolute cleanli- 
 ness; maintaining the same asepsis during delivery as she would 
 throughout a major surgical operation and protecting the 
 perineum from infection after delivery. 
 
 Curative. The curative treatment for puerperal infection 
 resolves itself largely into good nursing care. The patient should 
 be kept warm and quiet and as comfortable as possible ; elimina- 
 tion is promoted, her strength is saved and her general resis- 
 tance increased in everj' way possible. The head of the bed is 
 frequently elevated, to promote drainage ; the windows are kept 
 open to provide plenty of fresh air ; the diet is light and nourish- 
 ing and the patient is encouraged to drink an abundance of 
 water. Ice caps to the head and abdomen are frequently used 
 to make the patient more comfortable; also cold sponge baths 
 when the temperature is high. 
 
 A patient suffering from puerperal infection should be con- 
 scientiously isolated. If the nurse who cares for her is forced 
 to come in contact with other patients, she should wear gloves 
 and a gown while attending the infected woman and thoroughly 
 scrub and soak her hands after each attention. 
 
 It was formerly the practice to curette the patient suffering 
 from puerperal infection, and give intra-uterine douches, but 
 it is now pretty generally believed that neither of these pro- 
 cedures does any appreciable good, but on the other hand may 
 do harm. The objection to curettage is on the ground that by 
 this means the protective w^all which Nature has developed to 
 prevent the further invasion of bacteria into the uterine tissues, 
 is removed and a new bleeding area is provided for further and 
 easy development of the inflammation. 
 
 Antiseptic douches seem to be useless, for if they are strong 
 enough to be germicidal they are likely to injure the tissues and 
 
400 OBSTETRICAL NURSING 
 
 also do harm by being absorbed into the system; while weaker 
 solutions will not destroy the organisms but are likely to carry 
 more infective material up into the uterus. In cases of putrid 
 endometritis, however, if the doctor cleans out the uterus with 
 his finger, a douche of sterile salt solution is often given for 
 the purpose of removing any putrefactive material which may 
 "have been left behind. 
 
 Phlegmasia alba dolens or "milk leg." In some cases 
 of puerperal infection, thrombi are formed in the veins of the 
 pelvis, from which particles may be broken off and carried to 
 various parts of the body and cause phlebitis or even abscesses. 
 If thrombi lodge in the large vessels of the thigh, the interfer- 
 ence of the venous circulation results in swelling and tenderness 
 of the leg which is often referred to as "milk leg." This con- 
 dition is rather rare and does not usually appear until the second 
 or third week after delivery. 
 
 The swelling ordinarily starts at the foot and gradually 
 extends up to the thigh. The patient complains of pain in the 
 calf of her leg and she may have an elevated temperature, rapid 
 pulse and the general wretchedness associated with an infection. 
 
 The main feature of the treatment is rest in bed ; the patient 
 should be kept there for at least a week after her temperature 
 becomes normal ; her leg should be elevated, wrapped in cotton 
 batting and the bedclothes held from it by means of a bed cradle 
 or some sort of a light frame. The nurse should never rub the 
 affected leg, and the patient should also be cautioned against 
 this for fear of dislodging a particle of the thrombus and causing 
 an embolism elsewhere, possibly in the lungs. For the same 
 reason, the patient must be warned not to make sudden or vio- 
 lent movements for some time after she is allowed to be up and 
 about, but to walk and move rather slowly. The swelling and 
 discomfort may subside in a few weeks or they may persist for 
 months. 
 
 Puerperal Mania. A word about extreme mental unbalance 
 during the puerperium is worth while at this point because the 
 nurse will frequently hear of this distressing condition, and 
 will almost inevitably come in contact with it at some time. It 
 was formerly believed that there were certain mental disorders 
 
COMPLICATIONS OF THE PUERPERIUM 401 
 
 which were peculiar to pregnancy and the puerperium, but this 
 belief has given way before the present knowledge of psychiatry. 
 
 The puerperal patient is sometimes delirious and violent for 
 longer or shorter periods of time, but apparently these condi- 
 tions are due to toxemia or fever, or a mental unbalance has 
 resulted from her reaction to the idea of motherhood, just as 
 it would have resulted from an equal strain of some other char- 
 acter. 
 
 In other words, the young mother may suffer mental derange- 
 ment from the same causes that would produce this state in 
 any other person, but not from causes or conditions which are 
 peculiar to the puerperium. 
 
 If the excitement or delirium are due to a toxemia, they are 
 relieved by treating the cause, while from the nurse 's standpoint 
 the care would be the same as for any delirious patient. The 
 patient should not be left alone and she should be protected 
 against doing herself any injury. 
 
 A mental disturbance which is due to the patient's inability 
 to adjust herself to the state of motherhood, and all that that 
 implies to her, is a different matter, and is discussed in the chap- 
 ter on mental hygiene. 
 
"Sympathy with, interest in the poor so as to help them, 
 can onty be got by long and close intercourse in their own houses 
 — not patronizing — not 'talking down' to them — not 'prying 
 about' — sympathy which will grow in insight and love with 
 every visit." — Florence Nightingale. 
 
PART VI 
 THE MATERNITY PATIENT IN THE COMMUNITY 
 
 CHAPTER XIX. ORGANIZED PRENATAL WORK. Mortality in Child- 
 bearing. Aims of Prenatal Care. Difficulties: Educational, Eco- 
 nomic, Social, Professional. Prenatal Work in Other Countries. 
 Progress of Prenatal Work in this Country. The Women's Mu- 
 nicipal League of Boston. Maternity Centre Association of New 
 York. Routine and Methods. Results. The Situation in the Country 
 as a Whole. Prenatal Care in Rural Communities. Forms and 
 Routines used by Maternity Centre Association, New York City. 
 
 CHAPTER XX. HOME DELIVERIES AND CARE OF THE YOUNG 
 MOTHER BY VISITING NURSES. Forms and Routines of the 
 Philadelphia Visiting Nurse Society. 
 
CHAPTER XIX 
 ORGANIZED PRENATAL WORK 
 
 The foregoing discussions of prenatal care and the principal 
 complication h of pregnancy, and the dangers to which expectant 
 mothers, young mothers and their babies are exposed, bring us 
 sharply face to face with the questions, "What can be done 
 about it?" "What is being done about it?" and, "Is anything 
 more possible?" 
 
 We have considered the problem, and the remedy, at very 
 close range; that is, from the standpoint of the individual pa- 
 tient. We are now concerned to know whether or not the remedy, 
 in the shape of care and supervision during pregnancy, may be 
 extended in proportion to the enormous multiplication of the 
 problem, when instead of one patient we must think of millions. 
 In other words, is country-wide prenatal care, with all that it 
 implies, practicable? And if so, by what means or method? 
 
 Let us review the problem for a moment, and acknowledge 
 the pathos and tragedy of it. 
 
 Child-bearing is so dangerous, under present conditions in 
 this country, that it stands second only to tuberculosis as a cause 
 of death among women between the ages of 15 and 44. The 
 discharge of woman's supreme function is apparently very 
 hazardous. 
 
 Dr. Dublin summarizes as follows the rate at which mothers 
 die throughout the country at large : 
 
 1. ''More than seven women die from disorders of pregnancy or 
 childbirth out of each 1,000 confinements. This is equivalent 
 to one maternal death out of every 140 confinements. (About 
 20,000 in 1920.) 
 
 2. "Forty-five babies out of every 1,000 births, or one out of every 
 22, are born dead. (About 112,000 annually.) 
 
 3. "Forty babies out of every 1,000 born alive, die before they are 
 one month old. (About 100,000 annually.) 
 
 "Such ai'e the dangers to mother and infant at the present time." 
 
 405 
 
406 OBSTETRICAL NURSING 
 
 And then, as though in answer to our question, "What can 
 be done about it?" he states that, "among women who receive 
 prenatal and maternal care under skilled direction : 
 
 1. Only two women instead of seven die out of every 1,000 confine- 
 ments, 
 
 2. Only twelve babies, instead of 45, are still-born in every 1,000 
 births, 
 
 3. Only ten babies, instead of 40 per 1,000 born alive, die before 
 they are one month old. 
 
 Obviously, then, only a few — too few — American women are 
 receiving the minimum of care that makes child-bearing a rea- 
 sonably safe adventure. 
 
 Perhaps it will be w^ell for the nurse to pause just here for 
 a fresh reminder that the end really to be desired through pre- 
 natal care is not so much the mere prevention of death among 
 mothers and infants, as the promotion of health, as well; our 
 charges must be not only saved but saved to mental and physical 
 health, vigor and well-being, capable of being useful, productive 
 citizens. Happily, both life and health are conserved by the 
 same measures, and effort toward either end helps to accom- 
 plish both. 
 
 Although the inhabitants of a prosperous country like the 
 United States should be a hardy people, the results of medical 
 examinations by the draft boards, during the war, gave us a 
 rude awakening to the fact that they are not. 
 
 An appallingly large number of young men who were passing 
 in every day life as normal were found to be physically unfit for 
 military service. And we know that a large part of this unfitness 
 resulted from inadequate care, of some kind, during the weeks 
 and months that compi-ise the beginning of life. 
 
 It can scarcely be doubted that the most critical period in the 
 life history of the individual is the first ten months — the nine 
 months of intra-uterine life and the first month after birth. 
 Good care, then, during this critical period is indispensable in 
 the building of a healthy race. The difficulty in the way of 
 giving this care, at present, seems to be fourfold : educational, 
 economic, social and professional, and may be summed up some- 
 what as follows: 
 
ORGANIZED PRENATAL WORK 407 
 
 1. From the educational standpoint, almost universal ignorance 
 of the need of skilled obstetrical care. 
 
 2. From the economic standpoint, financial inability of the average 
 woman to afl'md such care. 
 
 3. From the social, or administrative, standpoint, a fairly general 
 failure on the part of public authorities to recognize the situa- 
 tion as one of grave national importance. 
 
 4. From the professional standi)oint, inadequacy of available 
 obstetrical service, both medical and nursing. 
 
 In many of the large cities women have access to excellent 
 obstetrical and prenatal care; both those who can pay for it 
 and also the poor woman who cannot, though very many in 
 both groups still fail to take advantage of the opportunities that 
 are open to them. 
 
 But the city women of moderate means, and those in small 
 towns and rural communities are in general unprovided for. 
 And it is their babies who grow up and later constitute the 
 backbone, w^eak or strong, of the nation. 
 
 Certain foreign countries which have evinced more concern 
 for the welfare of mothers and babies than has the United 
 States have demonstrated that widespread prenatal care is en- 
 tirely possible and practicable, and they regard it also as an 
 imperative measure toward promoting the national welfare. 
 
 The actual origin of this prenatal care is somewhat difficult 
 to locate. There are the consultations for pregnant women in- 
 stituted in Paris several years ago by Dr. Budin. But Dr. 
 Ballantyne, of Edinburgh, is generally regarded as the father 
 of the prenatal w^ork because of his work on abnormalities of 
 pregnancy and his insistence upon the importance of what might 
 be accomplished through intelligent care and supervision of all 
 women, not alone abnormal cases, throughout pregnancy. 
 
 In England for nearly twenty years the supervision and in- 
 stuction of expectant mothers has been an integral part of the 
 work of midwives who are trained, registered and controlled 
 by government authority. Of late the work among mothers and 
 babies has been so extended that during the war, always a de- 
 structive period for babies, the infant death rate was reduced 
 to the lowest figure in the country's history. This was accom- 
 plished partly through a maternity benefit which helped the 
 
408 OBSTETRICAL NURSING 
 
 mother to pay for obstetrical care, and partly through indirect 
 government aid, in the form of : compulsory notification of 
 births; a great increase in the number of "health visitors'' and 
 welfare centres, and government grants to local authorities which 
 defrayed half the expense of giving prenatal, natal and post- 
 natal care and of instructing mothers in the care of themselves 
 and their babies. Especial effort has been made to help the 
 mothers in rural sections ; more small hospitals being maintained, 
 more physicians being provided and assistance given in caring 
 for older children, during the mother's absence, if she was 
 obliged to go to a hospital at the time of delivery. 
 
 New Zealand also has made marked progress in its work of 
 saving the lives and promoting the health of its mothers and 
 babies, having at present the lowest infant death rate in the 
 world. This has been brought about largely through the efforts 
 of the "Society for the Health of Mothers and Children," an 
 organization employing visiting nurses, called Plunkett Nurses, 
 in honor of the family by that name which has greatly aided 
 the work. 
 
 The outstanding features of this work are educational and 
 preventive; the mothers being instructed from early in preg- 
 nancy about the care of themselves and the preparation for, 
 and subsequent care of their babies. Prenatal clinics are main- 
 tained and the facilities for hospital care are being steadily 
 increased and improved. 
 
 One is impressed by the spirit animating this organization, 
 as expressed in a statement of its "functions," one of which is 
 as follows : "To uphold the saeredness of the body and the duty 
 of health, to inculcate a lofty view of the responsibilities of ma- 
 ternity and the duty of every mother to fit herself for the per- 
 fect fulfillment of the natural calls of motherhood, both before 
 and after childbirth, and especially to advocate and promote the 
 breast feeding of infants." Work based upon such idealism 
 could not but be effective. 
 
 The New Zealand undertaking is regarded as patriotic, rather 
 than philanthropic, and mothers who are visited and cared for 
 are accordingly encouraged to pay for tliis service, if financially 
 able to do so. The Government supervises and warmly supports 
 
ORGANIZED PRENATAL WORK 409 
 
 the work of this Society and also aids by enforcing the most 
 perfect system of birth registration in the world, without which 
 the results of the work could not be accurately gauged. 
 
 England and New Zealand, as countries, have pointed the 
 way toward accomplishing a nation-wide reduction of maternal 
 and infant mortality and morbidity by making provision for 
 widely organized prenatal care. They recognize the problem 
 as one of public concern. They get at the heart of it : ignorance 
 on one hand and poor or inadequate care on the other. They 
 apply a practical solution, comprising a system of preventive, 
 instructive prenatal care, together with improved and increased 
 facilities for medical and nursing care at the time of delivery 
 and afterward. 
 
 This country has been strangely laggard in making wide- 
 spread, organized effort along these lines, to safeguard its mothers 
 and babies, through prenatal care. But sporadic, volunteer 
 effort has been made in certain cities, and has been crowned with 
 brilliant success. 
 
 The first of these attempts in this country was made in Bos- 
 ton, in 1909, with a maternity nurse working under the auspices 
 of the Women 's Municipal League. The work, which was estab- 
 lished by Mrs. William Lowell Putnam, was designed to show 
 what could be accomplished by intensive work in a small group 
 of city mothers, and suggest the feasibility of its extension to 
 larger numbers. 
 
 "The routine, which has been evolved through a five-year 
 experiment by the Prenatal Committee of the Women's Munici- 
 pal League, ' ' says Mrs. Putnam, ' ' has reduced the infant deaths, 
 among those cared for by a third to one-half, as compared with 
 cases not receiving this care. Still-births have been cut in half. 
 Premature births have been reduced to seven-tenths of one per 
 cent. These results were obtained by supervision during preg- 
 nancy only, and at a cost of less than $3.00 per patient ; an ex- 
 pense which the patients were always encouraged to meet if 
 possible. 
 
 * * The success of this venture proved to be so satisfactory that 
 the Boston workers have gone still further toward supplying 
 the needs of mothers and babies by adding to the prenatal care, 
 
410 OBSTETRICAL NURSING 
 
 care at the time of birth and afterwards until the mother is 
 again on her feet. Through the courtesy of one of the largest 
 Boston hospitals, a clinic is held weekly in its Out-Patient De- 
 partment. The hospital is in no way responsible for the clinic, 
 simply lending the room in which the clinics are held. The 
 medical care at the clinic and in the patients' homes is given by 
 obstetricians from the staff of the Boston Lying-in Hospital. 
 Medical examinations are made during pregnancy at the clinic, 
 and a nurse visits and instructs the patient during the period 
 of expectancy, always under the direction of a physician. The 
 delivery is performed in the home hy a physician connected with 
 the clinic, at which the nurse also is in attendance. She visits 
 the mother and baby twice daily for three days subsequent to 
 the delivery, gradual!}^ making her visits less frequent there- 
 after. The doctor pays from two to four postnatal visits, as 
 may be needed. For this prenatal, natal and postnatal, medical 
 and nursing care, $40.00 is the entire amount charged, and the 
 work is self-supporting with the nurse's time filled. Prenatal 
 care, alone, is given if desired by a physician and with visits at 
 the clinic included ; the charge for this service is $10.00. ' ' 
 
 I refer to the work in Boston, particularly, as its inaugura- 
 tion by Mrs. Putnam marked the beginning of this branch of 
 public-health work in this country, though to-day the same kind 
 of service is available to expectant mothers in many of the large, 
 and some of the smaller cities. Visiting nurse associations, the 
 country over are giving postnatal and infant care (in some in- 
 stances, excellent prenatal care, too), often providing for or 
 assisting with the deliveries, and effecting an enormous saving 
 of life and health by so doing. But the number of patients who 
 are cared for by each organization is relatively so small that 
 even the aggregate of the work done readies a pathetically 
 small proportion of the mothers and babies in the country as a 
 whole who need care. 
 
 The first comprehensive effort, in the United States, to meet 
 the need of all expectant mothers in an entire community, was 
 inaugurated in New York City, in 1918, by the Maternity Centre 
 Association, the chief function of the organization being to co- 
 ordinate the work of agencies already in existence. 
 
ORGANIZED PRENATAL WORK 411 
 
 This Association was formed as a result of the work of the 
 Maternity Protective Committee of the Women's City Club and 
 the Maternity Service Association of Physicians and Hospital 
 Superintendents. 
 
 The foi-ni of organization, purpose and methods of work of 
 this association may be studied with profit, for having been 
 started on a small scale as an experiment, it now constitutes a 
 demonstration of how, through co-ordinated effort, prenatal and 
 obstetrical care may be extended almost indefinitely to expectant 
 mothers in urban districts, and at a low cost. 
 
 The purpose and scope of the work are described by Miss 
 Anne Stevens, its former Director, who tells us "that it is the 
 aim of the Association to cover completely the need for maternity 
 care, prenatal, delivery and postnatal, in a given community, by 
 providing for every woman in that community, medical super- 
 vision and nursing care from the beginning of her pregnancy 
 until her bab}' is one month old. This is being attempted, not 
 by establishing another medical and nursing agency, but by estab- 
 lishing a centre through which the maternity work of every hos- 
 pital, private physician, midwife and nursing agency in the 
 community may be co-ordinated and developed to its fullest ex- 
 tent; a centre at which there will be a complete record of every 
 pregnancy in that district ; a centre from which the whole com- 
 munity may be educated to realize the need of and to demand 
 adequate medical supervision and nursing care for every woman 
 and her baby before and after birth. ' ' 
 
 It is not, then, an experiment in prenatal clinics, many of 
 which have been conducted, both in New York and elsewhere; 
 but it is an experiment in its attempt to provide adequate care 
 for every pregnant woman in the community from the begin- 
 ning of her pregnancy until her baby is a month old. 
 
 Standards for adequate prenatal care, upon which to base 
 the work, were formulated by the Maternity Service Association 
 of Physicians. The nurses worked with these standards as a 
 guide and gradually develoi)ed detailed i-outines, as a result of 
 frequent conferences over the difficulties and problems arising 
 in the course of their daily work among the patients. 
 
 These various adaptations were, of course, approved and 
 
412 OBSTETRICAL NURSING 
 
 authorized by the Medical Board of the Association. Because 
 these routines meet the doctor's requirements so satisfactorily, 
 and have been evolved out of the experience of many nurses, 
 concentrating their best efforts upon this Avork, they are copied 
 on pages 423 to 436 with the belief that they will be suggestive, 
 and perhaps save time and effort for those who may wish to inau- 
 gurate similar work. 
 
 Every effort is made by the Association to reach all of the 
 expectant mothers in the ten zones into which, for the purposes 
 of the work, the Borough of Manhattan was divided by the pre- 
 liminary committee ^ called by Dr. Haven Emerson, who at that 
 time was Commissioner of Health for New York City. This 
 Committee was called for the purpose of surveying the obstet- 
 rical facilities of Manhattan, and offering suggestions as to how 
 they might be utilized in an effort to decrease the persistently 
 high infant mortality. 
 
 Patients are reported for care by hospitals, dispensaries, 
 clinics, relief agencies, church clubs, settlements and the like 
 and are discovered in various ways by the nurses on their rounds. 
 
 The nurse 's first visit to a patient is little more than a friendly 
 one. In fact, she may have to make several such calls before she 
 is able to so far win the patient 's confidence and friendship that 
 she will consent to place herself under supervision. For in addi- 
 tion to obtaining her verbal consent, the establishment of this 
 sympathetic relationship is found to be necessary before the 
 nurse can feel sure that the patient will freely tell of her symp- 
 toms and follow the advice given. 
 
 Before making plans, or talking to the patient about pre- 
 natal care, the nurse ascertains what arrangements, if any, the 
 patient herself has made for care at the expected confinement. 
 She finds that the expectant mothers fall into four groups : 
 
 1. Those who have registered with a hospital, 
 
 2. Those who have arranged to be cared for by a physician. 
 
 3. Those who have arranged to be eared for by a midwife. 
 
 4. Those who have made no arrangements of any kind. 
 
 The nurse's relation to a patient registered with a hospital 
 
 * The Committee consisted of Drs. J. Clifton Edgar, Ralph Lobenstein 
 and Philip Van Ingea. 
 
ORGANIZED PRENATAL WORK 413 
 
 for delivery depends upon the scope of the work of that particu- 
 lar institution. Some hospitals will register patients early in 
 pregnancy, and assume the entire medical and nursing care and 
 supervision from that time until after the baby is born. The 
 Maternity Centre nurse, obviously, has no responsibility for 
 these patients. But she does give nursing care and instruction 
 to patients registered with hospitals which have not facilities 
 for prenatal clinics or visiting nurses to send into the patients' 
 homes. The hospital resident, in these cases, assumes responsi- 
 bility for medical supervision of the patients and receives a re- 
 port from the Maternity Centre upon each nursing visit ; and 
 the nurse in turn urges the patient to return to the hospital, 
 periodically, to see the doctor, in accordance with instructions 
 received from the hospital. 
 
 This form of co-operation has proved to be so satisfactory 
 that many hospitals now do not wait for the Maternity Centre 
 nurses to discover patients registered with them, but each day 
 notify the nurses of newly registered patients and ask that they 
 be given the routine nursing care and supervision by a Ma- 
 ternity Centre nurse. 
 
 When a nurse finds, upon her first visit to a patient, that 
 she has engaged a physician to attend her at the time of con- 
 finement, she gives no advice, but sends to the doctor a form 
 letter, prepared by the Medical Board, offering to nurse 
 that patient according to the routine of the Maternity 
 Centre Association if he wishes, and to report to him upon each 
 nursing visit. A very small percentage of physicians refuse this 
 offer of assistance, the majority accepting it with eagerness. 
 Patients who have engaged their own physician for delivery, 
 naturally, are not asked to go to the Maternity Centre clinics 
 for medical examination or advice, but are invited to go for the 
 nurse's instructions, and to attend the group conferences that 
 will be described later. 
 
 If the patient belongs to the third group, having engaged a 
 midwife, the nurse goes in person to see the midwife, as letters 
 are usually of little avail. She asks the midwife to bring her 
 patient to the clinic, explaining that, though midwives are taught 
 to conduct deliveries, they are not taught to make the examina- 
 
414 OBSTETRICAL NURSING 
 
 tions that are now known to be so important to the futnre wel- 
 fare of mothers and balnes, but that such examinations can be 
 made at the clinic by the doctor. If the initial examination dis- 
 closes any abnormality, this fact is explained to the midwife 
 and also that the rules governing her practice forbid her caring 
 for such a patient. The nurse, midwife and patient then plan 
 for adequate care at the time of delivery. In this way the nurses 
 win and retain the confidence and good wall of the midwives; 
 and since these women exert a powerful influence over their 
 patients and their families, their co-operation is of considerable 
 value in persuading the patients to accept more skilled care than 
 midwives can offer. 
 
 If, on the other hand, the initial examination does not dis- 
 close any abnormality, the midwife is simply asked to allow the 
 nurse to visit the patient at regular intervals, in a supervisory 
 way, and to have the patient report to the clinic doctor for his 
 periodic observations and advice. The intelligent midwives, 
 w'ho speak English, are usually co-operative, but the others are 
 sometimes suspicious and persuade their patients to refuse the 
 nurse's supervision. 
 
 For the patients in the fourth group, those who have made 
 no arrangement for care at the time of delivery, the nurse is even 
 more responsible. The plans for these patients include three 
 fundamental requirements : a complete physical examination ; 
 the correction of physical defects, so far as is possible, and a 
 study of the environment and social status of the patient; this 
 in order to adapt the care during pregnancy and at the time of 
 delivery to each individual's condition and circumstances. 
 
 From time to time the nurse explains to the patient, as much 
 as she can, about pregnancy and the changes that accompany it 
 and the reasons for the advice that is given, in order to secure 
 her intelligent co-operation. Experience has taught that it is 
 not enough to advise the patient to do thus-and-so because the 
 doctor thinks best. But if she understands that examination of 
 her urine, for example, may disclose conditions that can be cured, 
 but which if neglected may cause headaches, or convulsions, she 
 is much more likely to provide a specimen for examination than 
 if she is asked for one without explanation. 
 
ORGANIZED PRENATAL WORK 
 
 415 
 
 The care of each patient is a tactful adjustment of the pre- 
 scribed routine to the condition, habits and temperament of that 
 patient. It is carried on througli a combination of visits which 
 the nurse makes to the patient's home and visits which the pa- 
 tient makes to the nurse at the Maternity Centre in lier district. 
 The advantagfes of this combination of visits are, that the nurse 
 first knows the patient in her own home, and can help to plan 
 for the desired care with the conditions of this home in mind, 
 and perhaps evolve from tiu' patient's simpk^ belongings the 
 equipment needed for lier earc; also tliat at the Centre it is 
 possible to assemble the patients and give them a certain amount 
 
 Fig. 144. — Separate bed for the baby improvised from a market basket. 
 (By courtesy of the Maternity Centre Association.) 
 
 of informal group instruction. There is at each Centre a doll 
 model of a baby; a model of a baby's bed (Fig. 144), showing 
 that a box or a basket may be used with entire satisfaction ; a 
 model of the mother's bed, prepared for delivery at home and 
 protected with newspaper pads; a complete layette (Fig. 145) 
 to show the mothers how simple such an outfit can and should 
 be ; patterns for making each garment and some one to help 
 the women to make them; a brea.st tray (Fig. 146) and a baby's 
 toilet tray (Fig. 147), so complete and yet so simple that no 
 woman -with a few chipped or cracked cups to spare need be 
 dismayed. 
 
 In the course of this group instruction the women are taught 
 how to prepare for, and later care for their babies. One week, 
 
416 
 
 OBSTETRICAL NURSING 
 
 the nurse demonstrates to the group how to handle the baby, 
 dressing and undressing or bathing it ; or explains the reason 
 for making each article in the model layette, or the purpose and 
 use of each article on the toilet tray, and shows them how to 
 make boric acid solution and swabs. In short, each detail in 
 the care of the baby is gone over. Every alternate week the 
 
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 ■ '-- 
 
 ■ 
 
 1 ^x?^ 
 
 ■=iF 
 
 ^ 
 
 1 A »1 
 
 £ 
 
 1 
 
 ■ II 
 
 ■_..^IBI 
 
 ■ a 1 
 
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 1 
 
 Wfil- _^^t. 
 
 
 
 i 
 
 1 
 
 
 Fig. 145. — Layette recommended to patients by Maternity Centre As- 
 
 sociation : 
 
 A. Flannel binder. 
 
 B. Knitted band with straps 
 
 Shirt. 
 Petticoat. 
 
 E. Dress or nightgown, 
 
 F. Diaper. 
 
 Gr. Pad for basket-bed. 
 H. Flannel square. 
 
 mothers demonstrate to the nurse. They dress and undress the 
 doll model; explain and demonstrate how to make boric acid 
 solution; how to prepare sterile water and give it to the baby. 
 Many of the mothers attend the classes for several weeks in 
 succession, and frequently a mother returns with her three- 
 week-old baby to make sure that she has not forgotten any of 
 the details of infant care which the nurse tyied to teach her 
 before the baby came. 
 
ORGANIZED PRENATAL WORK 
 
 417 
 
 A patient is not asked to go to the Centre for any reason if 
 she seems very reluctant to go; or if her going is inadvisable 
 for physical reasons or if it would entail great hardship, be- 
 cause of young children who would have to be taken with her, or 
 
 Fig. 146. — Breast tray improvised from articles to be found in any 
 borne, contains : Jar of cotton pledgets ; bottle of liquid petrolatum ; soap 
 on saucer, covered with cup for water to bathe nipples. (By courtesy of the 
 Maternity Centre Association.) 
 
 left at home alone. But when they can go, it simplifies the work 
 and enables each nurse to supervise a larger number of patients 
 than if she did all of the traveling and visiting. 
 
 Fig. 147. — Baby's toilet tray equipped with jelly glasses, bottles, cellu- 
 loid hair receiver for cotton, and a soap dish, containing: 
 
 1. Safety pins sticking in cake 7. 
 of soap. 8. 
 
 2. Jar for sterile nipples. 9. 
 
 3. Jar of sterile water. 10. 
 
 4. Jar of boracic acid solution. 11. 
 
 5. Nursing bottle. 12. 
 
 6. Sterile water to drink. 
 
 (By courtesy of the Maternity Centre Association.) 
 
 Nursing bottle for water. 
 Small tooth pick swabs. 
 Liquid petrolatum. 
 Gauze mouth swabs. 
 Absorbent cotton. 
 Soap. 
 
418 OBSTETRICAL NURSING 
 
 Each patient is seen by a doctor or a nurse every two weeks 
 until the seventh month of pregnancy, and once a week after 
 the seventh month. At each visit the nurse follows as much of 
 the prescribed routine as is possible ; this routine consists of 
 testing for albumen in the urine ; taking the systolic blood pres- 
 sure ; listening to the fetal heart ; questioning the patient and 
 looking for the objective symptoms of complications. Dur- 
 ing these visits to the homes the nurses are able also to help 
 their patients assemble entirely satisfactory outfits for 
 the care of their nipples, consisting perhaps of jelly glasses, 
 cheese jars, or handleless cups. And they help to find a place 
 on the shelf where this little equipment may be kept undisturbed 
 and always ready for use. When it comes to the measuring of 
 urine, they explain that the regular size tomato can holds just 
 a quart, and is therefore quite as satisfactory for that purpose 
 as a costly graduated glass measure. 
 
 No patient is dismissed for failure to follow advice ; the nurse 
 continues her visits, unless the patient positively refuses to admit 
 her, and she continues to advise, adjusting and modifying the 
 ideal routine and persuading the patient to do as much as she 
 can, or will. 
 
 If abnormalities develop during pregnancy, the nurse ar- 
 ranges for immediate medical care, either at the patient's home 
 or in a hospital. If the clinic doctor feels that the patient should 
 have hospital care, but she will not or cannot go to a hospital, 
 she is persuaded to engage a doctor, and a nurse from the Centre 
 helps, as a visiting nurse, to take care of the patient in her own 
 home. 
 
 The next responsibility of the nurse is to advise the patient 
 in arranging for care at the time of delivery, this advice being 
 based upon the patient's physical condition, the circumstances 
 of her home life and the available facilities for care. Although 
 hospital care may be the ideal for all patients, from an obstet- 
 rical standpoint, the mother cannot always be removed from 
 her home with safety to the family circle. Her physical and 
 social conditions therefore are considered together; if there is 
 no complicating home problem, it is usual to advise hospital 
 care for primiparae and for all patients who have, or develop 
 
ORGANIZED PRENATAL WORK 419 
 
 abnormalities, or have a history of previous difficult labors, com- 
 plications or abnormalities. 
 
 Patients who, the doctors think, give promise of having com- 
 plicated labors and who prefer to remain at home are advised 
 to engage a doctor, and to arrange with the Henry Street Settle- 
 ment for nursing care at the time of delivery and during the 
 puerperium, as the Maternity Centre nurses do not perform this 
 service. 
 
 At one time, however, the Centre provided assistance to pa- 
 tients delivered at home, in the shape of a working housekeeper 
 to discharge the mother's household duties while she remained 
 in bed the necessary length of time after the baby was born, or 
 in some cases, while she took much needed rest during the latter 
 part of pregnancy. For this purpose the nurses had a list of 
 women who were good housekeepers and clean workers and whose 
 own children were partly grown. These women were glad of 
 an opportunity to do part time work and earn a little extra 
 money. They were paid thirty cents an hour, twenty-five 
 cents for lunch and whatever their carfare amounted to, the 
 patient paying whatever she could afford toward the fund, pro- 
 vided by the Women's City Club, from which these working 
 housekeepers were paid. This service, which in no wise replaced 
 the nurse's care, has been temporarily discontinued because of 
 lack of funds, but proved to be so valuable that it will be re- 
 sumed as soon as possible. 
 
 Supervisory postnatal visits are paid to patients, not under 
 the care of the visiting nurse service, who have been under Ma- 
 ternity Centre Association care during pregnancy, as well as to 
 those who have not had this care but are referred to the Centre, 
 by hospitals, upon their discharge. The nurse first visits to 
 satisfy herself that the mother is able to care for her baby and 
 to give any instructions that seem to be necessary. She then 
 visits the patient, or the patient visits the nurse, when she is 
 able, until the baby is a month old, when she is urged to register 
 the baby at a baby health station. 
 
 The importance and value of birth-registration is explained 
 to the mother and the nurse endeavors to have a copy of a birth 
 certificate in the mother 's hands before the case is dismissed. 
 
420 OBSTETRICAL NURSING 
 
 The importance of post-partum examinations, not later than 
 six weeks after delivery, is also impressed upon the patient. 
 Patients who are not to be examined by the doctors who de- 
 livered them are given a post-partum examination by a doctor 
 at the Maternity Centre, to make sure that they are dismissed 
 in good condition, or are referred to the proper agency for fur- 
 ther care, this being the first step in prenatal care for the next 
 baby. 
 
 Is all of this elaborate organization and detailed care worth 
 while ? 
 
 A recent statement issued by the Maternity Centre Associa- 
 tion replies convincingly that it is. It says that during 1920 
 among women in the Borough of Manhattan not under Maternity 
 Centre supervision : 
 
 1. One mother died for every 205 babies born, (One out of 140 
 for the rest of the country.) 
 
 2. One out of every 26 babies born, died under one month of age. 
 
 3. One out of every 21 babies was born dead. 
 
 Whereas, among women in Manhattan who were supervised 
 by the Association, during the same period: 
 
 1. One mother died for every 500 babies born. 
 
 2. One out of every 51 babies born, died under one month of age. 
 
 3. One out of every 42 babies was born dead. 
 
 The Association does not usurp nor supplant, but endeavors 
 to give impulse to public and private agencies alike in affording 
 the best possible supervision and care for expectant and par- 
 turient mothers and their babies. 
 
 Thus has the stupendous problem in New York been attacked 
 with courage and with gratifying results. Much might be accom- 
 plished in smaller and less complex communities with propor- 
 tionately less difficulty. 
 
 But all of the foregoing relates to city dwellers. What about 
 the expectant mothers in isolated and rural communities? 
 
 I wish we did not have to say. 
 
 Prenatal care is practically unknown among them and there 
 is scarcely any provision for obstetrical care, either. The nearest 
 physician may live miles away and even though one were near, 
 
ORGANIZED PRENATAL WORK 421 
 
 country women and their husbands do not always feel that the 
 expense of employing a doctor, for mere childbirth, is justifiable. 
 
 In certain Northern and Western communities, that were 
 considered fairly representative of those sections, conditions 
 have been studied at some length by agents of the Federal Chil- 
 dren 's Bureau. They found that about half of the mothers in 
 those communities had no medical attention whatever in child- 
 birth. Untrained women, friends or neighbors, frequently some- 
 one 's grandmother, were in attendance. Or husbands or work- 
 men were pressed into service. A few women were entirely alone 
 in their hour of trial. Scarcely a mother among them received 
 prenatal care and instruction worthy of the name. 
 
 In the Southern states, the proportion of w'omen delivered 
 by physicians seems to be even smaller than in the North and 
 West, and in some of the mountain regions the conditions are 
 distressing. From one such locality we learn that when a woman 
 goes into labor the first passing teamster is hailed, or perhaps 
 a member of the family hurries down the road for the nearest 
 tanner or blacksmith, or any one else, who in total ignorance 
 will fearlessly rush in to meet the great emergency. The results 
 of this practice — dismembered infants and badly injured or dead 
 mothers, — are too sickening to describe, but may be imagined 
 by any nurse who has seen good obstetrical work and appreciates 
 its value. 
 
 From another mountain region in the South comes the con- 
 trast in accounts of the work done by Miss Lydia Holman, 
 founder of the Holman Association, as evidence of what skill and 
 desire may accomplish. Something more than twenty years ago 
 this nurse started volunteer visiting nursing among the mountain 
 people, with no precedent to follow and no Board to direct or 
 advise. But there were sick people all about, people needing 
 care, and Miss Holman was not only trained but eager to nurse 
 them, and after all these qualifications are the chief requisites. 
 
 After all these years of self-sacrificing, pioneer work, of which 
 American nurses may justly be proud. Miss Holman has the 
 enviable satisfaction of knowing that she has lessened the perils 
 of childbirth for some 600 women and saved practically all of 
 their babies. Much of this in the simplest, most meagerly 
 
422 OBSTETRICAL NURSING 
 
 equipped mountain homes. She has even managed to have 
 some of the mothers taken to a nearby town for the repair of 
 lacerations which occurred during labor. And she has a little 
 hospital now up on the mountain top, with doctors and nurses, 
 not only caring for sick people, but, among other things, teaching 
 women and girls how to care for infants and children, 
 
 A complete maternity service for rural communities would 
 evidently include small hospitals for primiparas and abnormal 
 cases and to serve as centres from which nurses and doctors 
 would carry on prenatal supervision and instruction, and give 
 skilled attention at birth; followed by visiting nursing of the 
 young mother and her baby. The prenatal supervision in 
 sparsely settled districts might leave much to be desired, be- 
 cause of the impossibility of seeing each patient as often as is 
 wise. But even a little care would be an improvement upon 
 present conditions. In some localities, it has been found possible 
 to teach some of the more intelligent of these rural mothers a 
 good deal about their own supervision. One nurse tells of a very 
 isolated woman who could only be visited at long intervals whom 
 she taught to test her own urine for albumen, explaining its pos- 
 sible significance and seriousness. One day the report card that 
 came by mail indicated that the last test showed albumen. But 
 the card also carried the remark, *' Don't worry about this, I 
 am drinking lots of water, taking nothing but milk for food and 
 will be in to see the doctor on Tuesday, ' ' 
 
 This hints at some of the possible adjustments that must be 
 made in meeting the needs of the patient in unusual circum- 
 stances. For we are constantly facing the unalterable fact, that 
 no matter where she is, nor what conditions surround her, the 
 individual woman needs care and supervision, and though con- 
 ditions vary, the general needs of expectant mothers are the 
 same. 
 
 This survey of the situation in cities and rural communities 
 gives us a glimpse of what can be done about it — this problem 
 of mothers and babies who need care — and also what is being 
 done, and we begin to sense an answer to the question, "Is any- 
 thing more possible?" 
 
 It is clear that a wide extension of provisions for prenatal 
 
ORGANIZED PRENATAL WORK 423 
 
 care is necessary if all mothers are to be reached; rich, middle- 
 class and poor; in cities, small towns and rural districts alike. 
 We believe that it is possible; and we are sure that wherever 
 provision for prenatal care is made, the achievement of its fine 
 purpose will depend very largely upon the spirit of the indi- 
 vidual nurse. 
 
 What does it bring to the individual nurse — this survey of 
 the problem as a whole, with the suggestion for its possible solu- 
 tion? The appeal of not a few mothers and babies, only, but 
 of a legion, and of uncounted homes and family circles in danger 
 of being broken. And it l)rings a suggestion of the immeasur- 
 able comfort and influence which the maternity nurse may carry 
 into each home that she enters. For she helps to save lives and 
 health, and through them, homes and family groups, and these 
 are the building blocks of the nation. 
 
 For the nurse whose imagination is touched by this appeal, 
 it will exact much — the best and most that she has to give — 
 but in return she will find a deep and enduring satisfaction in 
 her work. 
 
 FORMS AND ROUTINES USED BY MATERNITY CENTRE 
 ASSOCIATION, N. Y. C. 
 
 ROUTINE FOR PRENATAL VISITS: 
 
 First Visit. — Get acquainted with the patient and get her confidence. 
 Learn if she has made any arrangements for her care at time of de- 
 livery. If a doctor or midwife has been engaged commnnieate with 
 him or her. If the patient is registered with a hosi:)ital, or is nnder 
 other nursing care, note that on your record, also on slip sent to 
 Central Office. Always ask to see patient's hospital or clinic card, 
 or any card which she may have been given by any nurse or other 
 visitor. Give patient pink card. 
 
 Explain simply the reason for an expectant mother seeing a doctor 
 and nurse early and regularly. Invite the patient to come to the Center. 
 Ask her in a general waj^ about herself, when the baby is expected, 
 other pregnancies and deliveries, and illnesses; other members of her 
 family. Direct your conversation so as to get as much data as possible 
 without asking a direct cjuestion. Do not attempt a full nursing visit 
 unless the patient meets you more than half way. Every patient is to 
 be encouraged to come to the Center for as much of the nursing care 
 as is possible for that individual woman. In the care of all patients it 
 is the nurse's responsibility to make every effort to solve (by working 
 
42€ OBSTETRICAL NURSING 
 
 with every existing agency) such home problems as might effect the 
 health of the mother or baby or disturb the mother's peace of mind. 
 
 Comjilete Nursing Visit. — Ask the patient about any aches, pains, 
 troubles of any kind, directing your questions to cover all items on 
 record. Select a table, chair, machine top, or end of mantel, to use 
 as work table, and place on it: 
 
 Newspaper for protection 
 
 Paper napkin as cover Bottle for specimen or 
 
 Nurse's soap, hand scrub and 
 
 towel fTest tube and holder 
 
 Watch 
 
 Fountai i pen 
 Maternity Record 
 Thermometer 
 Tycos 
 
 Urinometer 
 Litmus paper 
 Acetic Acid — 2% 
 Sterno 
 . Matches 
 
 Take temperature, pulse, respirations and blood pressure (to take 
 blood pressure adjust sleeve, get radial pulse, pump until obliterated, 
 let out air and read dial at moment pulse returns. See Tycos Manual, 
 sample No. 2, for full detail.) Wash thermometer thoroughly with 
 soap and water, dry and return to case. Scrub hands. Inspect or 
 demonstrate the care of nipples ; to be done daily after the fifth month, 
 not before. Use cotton ball (or soft toothbrush previously scalded 
 and kept for this purpose). Thoroughly scrub each nipple with warm 
 water and white soap and dry with a clean towel. Apply albolene, 
 pulling out the nipple. Do not handle breasts. Listen to the fetal 
 heart. If unable to hear make note on record n.h. If fetal movements 
 are felt by nurse put an "x"; if patient says she feels the baby move, 
 put "xx" in space on record for recording fetal heart rate. Look for 
 edema, varicose veins; do not take the patient's word for these symp- 
 toms. Apply bandage for varicose veins (patient to pay 70 cents for 
 bandage, or bandage to be lent to patient as long as needed, to be 
 washed and returned), and teach patient right-angle position. Get 
 specimen of urine, either to take to the station for examination or to 
 examine at once for specific gravity, reaction and albumen, in accord- 
 ance with instruction given on' page 30, Laboratory Technique — Wood, 
 Vogel and Famulener. Have the patient cleanse vulva before voiding, 
 and void in clean vessel. Teach patient proper disposal of urine, 
 emphasizing why kitchen sink is not to be used. If any abnormality 
 in amount, color, specific gravity, or trace of albumen, report to the 
 doctor, midwife or hospital in charge of the patient, if the patient has 
 engaged one; if not, use every effort to get the patient under care of 
 doctor. 
 
 Teach patient to measure amount of urine voided in 24 hours. Tell 
 her to void in toilet on getting up in A.M.; then for the rest of that 
 day and night and the following A.M. to void in a suitable vessel and 
 measure in a tomato can (if no suitable vessel, void in a tomato can) 
 and keep count of how many times she fiJls the can. 
 
ORGANIZED PRENATAL WORK 425 
 
 On an early visit examine teeth and show how to keep clean. Where 
 possible urge a visit to the dentist or dental clinic for prophj'lactic treat- 
 ment. Explain that it is not wise to have extractions done during 
 pregnancy without consulting a doctor, but that cleansing and tem- 
 porary fillings may be done with much saving of teeth. 
 
 On one visit, as early as possible, ask to see the layette, and advise 
 about it, going over the list of baby supplies. Urge the patient to 
 visit the center to see the model layette, and get help in the choice of 
 materials and patterns. Note on the record if layette is not complete by 
 the eighth month. Demonstrate the preparation of bed for the baby, 
 made from clothes basket, soap box, or in a baby carriage similar 
 to the model at the center. If the patient is to be delivered at home, 
 some time after the seventh month ask to see the mother's supplies, 
 going over the list. The patient should be advised against the use of 
 oilcloth from the kitchen table as a bed protector, and especially urged 
 to prepare newspaper pads like the model at the center. Note on the 
 report if the mother's supplies are not complete by the eighth month. 
 Advise about the arrangement of the room for delivery, and demon- 
 strate the preparation of the mother's bed like the model at the center. 
 
 No treatment or medicine to be advised except in accordance with 
 standing orders, private physician's orders, hospital orders and Ma- 
 ternity Centre Association routine (note on record which). 
 
 Form letter signed by the head of the medical board sent to 
 doctors who have been engaged by patients for delivery: 
 
 My dear Dr : 
 
 Mrs who has engaged you for her 
 
 care at delivery, has been referred to this association for nursing care. 
 
 In order to make the work of the nurses of this association of a 
 uniformly high standard, the Medical Board has adopted the enclosed 
 routine for the nurses to follow. 
 
 May we not have your cooperation in our effort to teach the women 
 of the community the need for, and value of, medical supervision 
 throughout their pregnancy? 
 
 May we have your permission to instruct our nurses to visit Mrs. 
 in accordance with our routine, and re- 
 port each visit to you? 
 
 A prompt reply on the enclosed slip will be greatly appreciated. 
 
 Cordially yours, 
 
426 OBSTETRICAL NURSING 
 
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ORGANIZED PRENATAL WORK 427 
 
 MATERNITY RECORD 
 
 The Maternity Record upon which a complete histoiy of each case 
 is recorded is divided into four parts, the first section for the social data 
 about the patient, the second for other pregnancies and observation of 
 patient during- this pregnancy, the third records deliveiy and post- 
 partum care, the fourth, post-natal care. (See insert for form.) 
 
 LEAFLET OF INSTRUCTIONS GIVEN TO PATIENTS 
 
 ADVICE FOR MOTHERS 
 
 Motherhood is natural and normal. If you do as the doctor and 
 nurse ask you to, you have no reason to worry about having your baby. 
 
 DIET 
 
 Eat the food you are used to. Do not eat what you know gives you 
 indigestion. Do not eat too much at any one meal. 
 
 Drink 8 glasses of water every day. 
 
 Drink all the milk you can. 
 
 Do not drink any beer, whiskey, wine or other alcohol. These hurt 
 the kidneys and thus may poison the baby. 
 
 Eat meat, meat-soup or eggs and drink tea or coffee only once a day. 
 
 SLEEP 
 At least 8 hours eveiy night with windows open. 
 
 EXERCISE 
 
 Do your regular house work, but lie down several times a day_ if 
 only for five minutes. If possible take a walk out of doors. Fresh air 
 is good for your baby. If you cannot get out, keep the windows open 
 while 3'ou work indoors. Do not do heavy work ; it will hurt your baby. 
 
 BATHING 
 Wash all over every day with warm (not hot) water, but do not 
 get into a tub after the seventh month. 
 
 GARTERS 
 Do not wear round garters or any tight bands. The nurse will show 
 you how to make suspender garters. 
 
 CONSTIPATION 
 
 If you are constipated, drink a cup of coffee (no cream or sugar) 
 before breakfast, hot milk (not boiled) with breakfast, go to the toilet 
 at the same time every day (after breakfast best). During the day 
 eat coarse bread, green vegetables, stewed fruit, drink no tea, but all 
 the water you can, at least 8 glasses, hot or cold. Cook 2 tablespoonfuls 
 of senna leaves with a pound of prunes and eat four to six prunes 
 every day. If you have hemorrhoids (piles) hold a cold compress to 
 
428 OBSTETRICAL NURSING 
 
 anus for five minutes after bowels move and do not let yourself get 
 constipated. Never take any cathartics unless your doctor, midwife, or 
 nurse tells you to. 
 
 IMPOST ANT 
 
 Do not have any sexual intercourse after the 8th month. If you 
 have severe headache, vomiting, spots before your eyes, if your face, 
 hands or feet swell, let your hospital, doctor or midwife and nurse 
 know at once. 
 
 Labor begins with pains in back or abdomen; with bleeding or 
 watery discharge. If you have any labor pains or bleeding before 
 the time you expect your baby, go to bed and send word to your hos- 
 pital, doctor or midwife and nui'se at once. 
 
 If you are going to the hospital, have ready after the 8th month 
 one set of baby clothes, to take with you to put on the baby when you 
 bring him home. Do not take anything else with you, the hospital will 
 supply all you need. As soon as labor begins, go to the hospital. 
 
 If you are to be confined at home, as soon as labor begins send for 
 the doctor or midwife. If the doctor is one of the hospital doctors, 
 follow the directions on your card from the clinic. 
 
 While waiting for the doctor, boil a large quantity of water in a 
 covered vessel and set aside to cool. Prepare your bed as the nurse 
 has shown you, take a warm sponge bath, braid your hair in two braids, 
 get out a set of baby clothes ready for the nurse to dress the baby. 
 Get out supplies needed for yourself. 
 
 mother's supplies 
 
 2 gowns. Cotton (absorbent). 
 
 1 pair white stockings. 2 wash-cloths. 
 
 4 sheets. 2 towels. 
 
 6 bed pads. 4 oz. lysol. 
 
 Vulva pads or supply of freshly 1 bedpan, 
 laundered old muslin. 
 
 The bed pads are made from 6 thicknesses of newspaper open to 
 full size and covered with freshly laundered old muslin tacked in place. 
 No other protection for bed is necessary. As a precaution, when possi- 
 ble, the entire mattress may be covered with oilcloth put on under the 
 bottom sheet. See model at center. All washable supplies for mother 
 and baby should be freshly laundered and put away in pillowcases or 
 clean, ironed paper until they are needed. 
 
 baby's supplies 
 
 The following is a list of the complete outfit of baby clothes and 
 toilet necessities. It may be modified as to material, quantity and 
 quality to suit the individual taste and pocketbook. 
 
ORGANIZED PRENATAL WORK 429 
 
 12 Diapers 18" x 18". 1 Felt pad or folded blanket for 
 
 3 Bands 6" x 27". mattress. 
 
 3 Shirts, size 2, cotton and wool i oilcloth case for mattress. 
 
 3 Petticoats. 2 Muslin pillow-cases for mat- 
 3 Slips. ^^^gg 
 
 2 Squares 36" x 36". 
 
 Note: The squares are used in- 2 Crib blankets, small size. 
 
 stead of coat and bonnet '- Towels. 
 
 until the baby is more than 2 Wash-cloths, old pieces of 
 
 2 months old. See model at linen. 
 
 the center. ^^ piece Castile soap. 
 
 1 Oilcloth or rubber 12" x 18". „ , . . , , 
 
 _„ , „ . 8 oz. bone acid powder, 
 
 12 large safety pms. 
 
 12 small safety pins. ^ P^^^^^^ absorbent cotton. 
 
 1 Basket or box for bed 15" x 1 Q^art oil— sweet or albolene. 
 
 30". 1 package toothpicks. 
 
 Tray— fitted with: 
 
 Glass jar for boric acid solution. 
 
 " " " nipple swabs. 
 
 " " " oil. 
 
 " " " small toothpick swabs. 
 Dish for soap. 
 
 Cake of soap to stick pins in instead of a pin cushion. 
 Hair receiver for absorbent cotton. 
 Newspaper cornucopias for waste. 
 Bottle and nipple for giving baby water. 
 Covered pail with borax water for soiled diapers. 
 Jars for tray may be empty cheese, candy or jelly jars. 
 
 CLINIC ROUTINE 
 
 The nurse is urged so to conduct her clinic as to assure privacy to 
 each patient examined, and the same treatment which the patient would 
 receive if she were the only patient in the office of one of our best 
 obstetricians. 
 
 Nurse is to wear her graduate uniform during clinic and during her 
 office hours. 
 
 Nurse's Duties 
 
 1 — Preparation of Clinic Room 
 
 Pads of doctor's record, return visit to doctor, post-partum examina- 
 tion; pencil; examining table; side tables; sterilizers; basins; instru- 
 ments; supply of clean dry gloves; Dejiartment of Health material for 
 taking Wassermanns, cultures and smears; cotton balls; tampons; 
 throat sticks; sheets; pillow cases; sounding towel; adequate supply 
 
430 OBSTETRICAL NURSING 
 
 of clinic drugs; solutions; thermometer, in glass of 50 per cent alcohol; 
 glass of ootton ; to be ready one-half hour before the time set for clinic. 
 
 2 — Preparation of Patients' Dressing Room 
 
 Screens or curtains arranged to form individual dressing rooms ; a 
 sufficient number of clean clinic gowns; separate chair provided for 
 each patient to leave clothes on, unless room is provided with racks or 
 hooks. 
 
 3 — Preparation for Urinalysis 
 
 Unless the urinalysis is made so near the toilet that the waste urine 
 may be thrown directly into the toilet, a covered pail is to be provided 
 one-fourth full of 1 per cent lysol solution. All waste urine and wash- 
 ings from the test tubes to be thrown into this pail, and under no circum- 
 stances is waste urine to be thrown into any sink or wash basin, even 
 though the basin is not used as a wash basin. 
 
 Test tubes, stemo, litmus, acetic acid, funnel, filter paper, test tube 
 holder, vessel for collecting specimen, basin of 1 per cent lysol solution 
 and cotton balls for patient to cleanse vulva before voiding, basin for 
 used cotton balls, pi'OAasion for patient to wash hands, to be in readi- 
 ness one-half hour before the time set for clinic. 
 
 4 — Preparation of the Patient for Examination 
 
 Each patient to completely undress, except her shoes and stockings, 
 and to put on clean gown supplied by the clinic. Her shoes to be 
 unfastened so that the doctor can examine her ankles for edema, her 
 temperature to be taken and a urinalysis made before the patient is 
 seen by the doctor. 
 
 5 — Assisting Doctor in Examining Room 
 
 Make notes on record pad at the doctor's dictation, reminding her 
 tactfully of anjf omissions made in her dictation. Conduct examina- 
 tion in the following order : Head, chest, breasts, blood pressure, abdom- 
 inal, fetal heart, measurements, ankles, vaginal, Wasseitnanns or 
 smears when necessary. 
 
 Note: Preparation for vaginal examination. Sponge vulva with 
 1 per cent lysol solution. Give doctor fresh gloves for each patient. 
 
 The nurse is responsible for the technique in the clinic room, not 
 the doctor. 
 
 If the doctor wishes to do a vaginal examination on a patient more 
 than eight months pregnant, or one who is bleeding, take same precau- 
 tion as though examining a patient in labor ; clip ; scrub with green soap 
 and water; then 1 per cent lysol; give doctor freshly boiled, sterile 
 gloves. 
 
 6 — Arrangement of Examining Room After Clinic 
 
 Soiled linen in laundry bags; fresh linen on tables, tables covered; 
 all used instruments to be washed, scrubbed when necessary, boiled five 
 
ORGANIZED PRENATAL WORK 431 
 
 minutes, dried and put away; all gloves used to be washed in cool 
 water and j^ieen suap and thoroughly rinsed, wrapped in towel, dropi)ed 
 .in boiling water and boiled for five minutes, then dried, powdered and 
 put away in a dean towel ready for use at next clinic; solution basins 
 to be emptied, washed and dried; all waste to be seciirely rolled up in 
 newspaper and put in a house garbage can; supply of drugs to be 
 cheeked up and replenished when necessary. 
 
 7 — Records 
 
 All "Doctor's Record" cards to be written up and filed; reports 
 mailed to the central ollice; reports on the condition of patient sent to 
 nursing agencies caring for the patient and other agencies working on 
 the case; maternity records to be tiled in date file before the nurse goes 
 off duty. 
 
 Doctor's Duties as Outlined on Doctor's Record 
 
 1. One complete physical examination including heart, lungs, 
 breast, blood pressure, abdominal examination, fetal heart, pelvic 
 measurements, vaginal examination and a Wassermann and G. C. 
 smear on all patients Avith a suspicious history. Notes on this 
 examination to be dictated to the nurse. 
 
 2. Blood pressure; abdominal; urinalysis; on return visits and pro- 
 vides space for notes on such other observations as she may wish 
 to make. 
 
 3. One post-partum examination on every patient ; including a 
 statement on general condition; examination of breasts; vaginal; 
 uterus; perineum; and note results of any intercurrent dis- 
 ease. 
 
 4. Eecording advice given to patient. 
 
 5. Instructing patients when to return to see the doctor. Note: 
 All patients not registered with a hospital or private doctor, to 
 be seen by the clinic doctor once a month up to the seventh 
 month, and once in two weeks, or oftener as the case demands, 
 thereafter. 
 
 8 — Duties of Clinic Assistants 
 
 At those clinics where a lay woman acts as assistant to the nurse, 
 the following duties (and no others without special permission) may 
 be assigned to the assistant : 
 
 1. Greeting patient; and from name on her pink card, getting 
 her maternity record from file and sending to nurse. 
 
 2. Taking temperature, a record of which is sent in to the nurse 
 on a scratch pad and copied by her on her clinic record. 
 
 3. Urinalysis. 
 
 4. Helping patient dress and undress. 
 
 5. Care of any children who maj* come with patient. 
 
432 
 
 OBSTETRICAL NURSING 
 
 6. See that patient understands when to return and has her pink 
 card so marked before she leaves. 
 
 CLINIC EQUIPMENT STANDARD 
 
 Requirements: 
 
 Room for examining, and dressing room, screens, running water, 
 gas, near a toilet, urinalysis facilities, good light, 
 
 Chair 
 
 Desk 
 
 Blotting pad 
 
 Blotter 
 
 Ink-well . . . , 
 
 1 
 
 1 
 
 1 
 
 1 
 
 1 
 
 Penholder 2 
 
 Office: 
 
 Clips 
 
 Ruler 1 
 
 Waste basket 2 
 
 Hand blotters 12 
 
 Ink, Red and Black 
 
 Charities Directory 1 
 
 Examining Room: 
 
 Table 1 
 
 Pad 1 
 
 Pillow 1 
 
 Foot bench 1 
 
 Shelves or side table for sup- 
 plies, etc 1 set 
 
 Garbage pail 1 
 
 Pelvimeter 1 
 
 Tape measure 1 
 
 Stethoscope 1 
 
 Tenaculum 1 
 
 Scissors 1 
 
 Bivalve speculum 1 
 
 Uterine Dressing Forceps. ... 1 
 Blood Pressure machine 
 
 (Tycos) 1 
 
 Thermometers 3 
 
 Thermometer Glasses (1 for 
 
 cotton) 2 
 
 Enamel jars for tampons and 
 
 pledgets 2 
 
 Large basin 1 
 
 Small basin 1 
 
 Erlemeyer flasks for green 
 
 soap and lysol 2 
 
 Medicine Glass 1 
 
 Hand Scrub 2 
 
 Rubber gloves, No. 71/2 6 pr. 
 
 Absorbent cotton 1 lb. 
 
 String Iball 
 
 Pens, 
 Erasers, 
 
 Ink 
 
 Pencil 
 
 Red Pencil . . , 
 Rubber bands 
 
 Map of Manhattan in Sani- 
 tary areas 1 
 
 Report on vital statistics 1 
 
 Babies' Welfare directory .... 1 
 Guide Cards Baby Health 
 
 Station 1 
 
 Spatulee 100 
 
 Hemoglobinometer (Tahl- 
 
 quist) 1 
 
 Needles (skin) 
 
 Wassermann Set from D. of H. 1 
 G. C. Smear Set from D, of H. 1 
 Culture tubes from D. of H. 
 
 Bandages (Ace) 6 
 
 Sterilizer 1 
 
 Sterilizer burner 1 
 
 Metal Shelf or table for Gas 
 sterilizer 
 
 Scott Tissue Towels 6 
 
 Urinalysis outfit 1 
 
 Test tube rack 1 
 
 Test Tubes 12 
 
 Test Tube holder 1 
 
 Urinometer 1 
 
 Sterno 
 Matches 
 
 Enamel Measure 1 
 
 Dish (Chamber) 1 
 
 Litmus 
 
 Acetic Acid 2% 
 
 Toilet paper 
 
 Funnel 1 
 
 Filter paper 
 Covered pail 
 
ORGANIZED PRENATAL WORK 
 
 433 
 
 Linen: 
 
 Sounding towels (for use in 
 
 listening to F. H.) 6 
 
 Sheets 6 
 
 Pillow cases 3 
 
 Doctor's gowns 2 
 
 Sewing Bag: 
 Cotton 70 
 Cotton 30 
 Needles, assorted 
 Thimble 
 
 Drugs: 
 K Y 
 
 Lysol 
 
 Green soap 
 Boro Glj'cerin 
 
 Breast Tray: 
 
 Castile soap in dish 
 Small bowl 
 Bottle of albolene 
 
 Dusters 
 
 Gowns for patients. 
 Covers for tables. . 
 
 Laundry bags 
 
 Towels 
 
 . 6 
 
 , 12 
 
 •a-s. 
 
 2 
 . 6 
 
 Tape measure 
 Tape 
 
 Safety Pins 
 Plain Pins 
 
 Alcohol 
 
 lodin 
 
 Albolene 
 
 Jar of cotton balls 
 Soft toothbrush 
 
 Exhibit on Table: 
 
 Patterns for baby clothes. 
 
 Complete layette. Slip and petticoat open in back. 
 
 Basket for baby bed. 
 
 Pad (of felt or hair mattress). 
 
 Rubber. 
 
 Pillow cases. 
 
 Blanket (crib). 
 
 Doll (baby) dressed. 
 
 Suspender garter for mother — abdominal support with garters. 
 
 Patient's bed prepared for time of delivery, newspaper pads. 
 
 Toilet Tray: 
 
 Jar of boiled water (for washing mother's nipples). 
 
 Jar of oil (mineral oil best). 
 
 Jar of boric acid— 2% for baby's eyes. 
 
 Jar of breast swabs. 
 
 Jar of small swabs. 
 
 Absorbent cotton in container (hair receiver). 
 
 Soap in dish. 
 
 Soa]> with safety pins, instead of pincushion.. 
 
 Jar for clean nipples. 
 
 Bottle and nipple, or cup and spoon for giving baby water. 
 
 Bottle of boiled water (day's supply boiled fresh each day) and 
 
 kept corked. 
 Newspaper cornucopia for waste. 
 
434 
 
 OBSTETRICAL NURSING 
 
 Contents of Nurse's Bag: 
 
 Any nurse may remove from her bag any article not necessary in 
 her district or for any one day's work, provided she makes note of 
 same on card, which is left in bag pocket, stating where removed 
 articles may be found. 
 
 1 mouth thermometer 
 
 1 Babies' Welfare Directory 
 
 1 rectal " 
 
 1 Board of Health Station card 
 
 1 baby scale 
 
 1 Sounding towel in envelope 
 
 Acetic acid — 2% 
 
 1 abs. cotton in envelope 
 
 1 test tube 
 
 1 scratch pad 
 
 1 test tube holder 
 
 Addressed postals 
 
 1 test tube brush 
 
 Advice to mothers 
 
 1 blue litmus 
 
 Letterhead memo pad and enve- 
 
 1 urinometer 
 
 lopes 
 
 1 sterno 
 
 Pink cards 
 
 1 matches 
 
 Maternity Records for patients to 
 
 2 specimen bottles 
 
 be visited 
 
 Paper napkins 
 
 Blank Maternity Records 
 
 Soap and hand scrub in bag 
 
 Prudential Ins. Co. Baby Primer 
 
 1 flashlight 
 
 1 Tycos Blood Pressure apparatus 
 
 1 fountain pen 
 
 3 Ace Bandages 
 
 
 1 Street directory 
 
 MATERNITY CENTRE STANDING ORDERS FOR NURSES 
 
 These standing orders may be used at the discretion of the nurses 
 when a patient is under no other medical supervision. When patients 
 are registered with a midwife, may be used with her consent. 
 Ante-Partum Orders 
 
 Cathartic ; 
 
 Heart Burn; 
 
 Binder: 
 Brassiere : 
 
 Toxemia : 
 
 After hygiene, diet, prunes and senna have 
 failed, use either 
 
 Caseara, grains 5, or, 
 
 Licorice Powder, beginning with drams 2 and 
 reducing dose gradually. 
 
 For neglected constipation use one-half pint 
 warm oil (sweet oil, albolene or olive oil) 
 enema, followed in one-half hour by soap 
 suds enema (this treatment to be given by 
 the nurse). 
 
 After advice as to diet, water, habits, constipa- 
 tion, use Soda Bicarbonate tablet, grains 10 
 (do not ad^dse or allow Baking Soda). 
 
 Abdominal binder like pattern P.R.N, for l>eavy 
 abdomen, backache. 
 
 Brassiere for breast support P.R.N. (Debevoise 
 tape best if patient can afford; if cannot 
 afford have patient make one like sample 
 support at Center). 
 
 Until medical attention can be secured ad^^se: 
 1. Mild — as much rest as possible; force 
 water 8 to 10 glasses a day. 
 Diet — milk, cereals, vegetables, stewed 
 fruits and oranges (no jieas or beans). 
 Eliminate all salt and condiments. 
 
ORGANIZED PRENATAL WORK 
 
 435 
 
 Post-Partum Orders: 
 Breasts : 
 
 Post-Natal Orders: 
 
 Thrush : 
 
 Constipation : 
 Cireumoision : 
 Excoriated Buttocks: 
 Oozing Umbilicus : 
 Protruding Umbilicus : 
 
 Severe — patient in bed. No vegetables; 
 
 diet of milk and cereals only. 
 With edema. Reduce water to 3 or 4 
 
 glasses for three days, after that force 
 
 water and follow 2. 
 
 For all cases instruct mothers to leave breasts 
 alone, no pumping, no massage. Supporting 
 binder P.R.N, (brassiere best). 
 
 For engorgement, follow preceding, and re- 
 strict so-called milk-making foods, but not 
 water. To dry up milk, follow preceding and 
 advise sodium phosphate daily in frequent 
 small doses (about drams 1). 
 
 For cracked nipples, apply paste of Bismiith 
 Subnitrate and Castor Oil, equal parts each. 
 Use nipple shield. If not healed report to 
 Central Office. 
 
 Cathartic, Cascara axains 5, or mineral oil 1/2 
 dram, or licorice powder drams 2. For 
 neglected constipation, use enema as described 
 for ante-partum patients. 
 
 Solution of Soda Bicarbonate (1 tablespoonful 
 to 1 glass of water) ; apply to spots with 
 swab before and after nursing. If not effec- 
 tive send baby to dispensary or doctor. 
 
 Olive Oil and Glycerin, equal parts of each, 
 minims 5-15 to dose. 
 
 If penis is not thoroughly healed, dress with' 
 Aristol powder. 
 
 Castor Oil and Bismuth Paste, equal parts of 
 each. 
 
 Cleanse with alcohol on swab, dust with Aristol 
 powder, apply dry sterile dressing. 
 
 If dry, strap with well covered button or coin, 
 using wide adhesive tape. 
 
 ROUTINE FOR POST-NATAL FOLLOW UP 
 
 Hospital Cases 
 
 See patient as soon after she is dismissed as possible, to make sure 
 she understands how to care for baby. Urge her to take baby to nearest 
 baby health station (see Blue Card) when baby is three weeks old. 
 Telephone health station to see if she does register. Urge her to bring 
 baby to your own station when one month old. At that time arrange 
 for post-partum examination : if it is the practice of the hospital, at 
 which the patient was delivered, to instruct patient to return for post- 
 partum examination, urge her to go at time set by hospital; if not, 
 urge her to come to your station for such examination. If siie fails 
 to come, visit her to learn condition of baby, and to urge post-partum 
 
436 OBSTETRICAL NURSING 
 
 examination. If during the post-natal follow-up work, any abnormality 
 is discovered in baby or mother, report that at once to the resident of 
 the hospital, where patient was delivered, and carry out his orders as 
 to whether patient is to return to him or be referred to gynecological 
 or baby clinic. 
 Patient Delivered at Home 
 
 Urge all pre-natal cases to send you post card when baby is born. 
 When postal is received, visit as soon as possible to see that everything 
 is all right; arrangements made for care of home and children so as 
 to keep mother in bed proper time, etc. If a Henry Street nurse is 
 doing post-partum bedside nursing, make no other visit but urge mother 
 to bring baby to see you at station when the baby is one month old. 
 If a practical nurse or a midwife case, visit every day or so, but do 
 not interfere with her conduct of the case. If you find it necessary 
 to report any irregularity to the Department of Health communicate 
 with the midwife before doing so. After she has dismissed the ease 
 follow the routine outlined above. Make special effort to get all mid- 
 wives' cases to come for post-partum examination, and also private 
 physicians' cases if they dismiss case before baby is six weeks old. 
 
CHAPTER XX 
 
 CARE OF THE MOTHER AND BABY BY VISITING 
 
 NURSES 
 
 The preventive value of post-partum care is now so gen- 
 erally recognized that maternity care by visiting nurses is given 
 not only in the larger cities, but is being extended even to rural 
 communities. The routine of the Visiting Nurse Society of 
 Philadelphia, under the direction of Miss Katharine Tucker, 
 may be taken as an example of effective post-partum care, in 
 which daily visits by a nurse bring to large numbers of patients 
 the minimum of necessary attention. As the same kind of work 
 is effective and possible in smaller communities, the routines 
 and instructions used by the Philadelphia Society are repro- 
 duced on pp. 439 to 445. These include 
 
 1. The equipment of the niu-se's bags. 
 
 2. Delivery routine. 
 
 3. Routine technique in caring- for mother and baby. 
 
 In normal maternity cases, a visit is made once a day for 
 eight days. After that time, if the mother is up and about and 
 the baby is in good condition, the nurse visits at least once a 
 week for supervision until the fifth week, when the case is trans- 
 ferred automatically to the Child Welfare Nurses under the 
 City. If, however, there is any complication with either the 
 mother or baby, the nurse continues daily visits or twice daily 
 as indicated by the condition, until both mother and baby are 
 normal. Instruction to the mother in the care of the baby is 
 one of the important phases of the maternity nurse's program. 
 
 The points observed and recorded on the bedside cards are : 
 condition of breasts, urination, condition of bowels, character 
 of lochia, position of uterus, T.P.R. or any abnormality. If 
 there is any rise in temperature or other abnormality noted, the 
 physician is called by telephone and the situation reported 
 
 437 
 
438 OBSTETRICAL NURSING 
 
 Any one can call the nurse — children, husband, neighbor, 
 doctor, social worker, — and a nurse is sent out on every call. A 
 doctor must be in charge of every case, and if one has not been 
 engaged when the nurse gets there, she sees to it that one is pro- 
 cured. The only exception is in cases delivered by midwives, in 
 which instances the nurse gives any necessary care and super- 
 vision, having it clearly understood that if any abnormality 
 occurs, she will first notify the midwife and then the midwife or 
 the nurse will immediately call a doctor. 
 
 The doctor ordinarily brings his own equipment for delivery. 
 The contents of the nurse's bag is the same for delivery as for 
 post-partum care, except for the addition of the nurse's gown, 
 extra towels and silver nitrate. Perineal pads, cotton, boric solu- 
 tion, etc., are supplied at cost, or free of charge if the patient is 
 unable to pay. Bed linen, nightgowns, layettes, etc., are pro- 
 vided for patients who cannot procure them. 
 
 The cost per visit to maternity patients averages one dollar 
 and the cost for services at the time of confinement averages five 
 dollars. Miss Tucker says of the maternity work: 
 
 "A eomplete maternity service which includes prenatal work, service 
 at time of confinement, post-partum care and subsequent supervision 
 of mother and baby is essential if adequate results are to be accom- 
 plished. Anything less than this complete service does not give full 
 protection to the life of the mother and the baby. The Philadelphia 
 Visiting Nurse Society has found that the inclusion of service at time 
 of confinement has given a tremendous stimulation to both their pre- 
 natal and postnatal service. In the branches where a delivery service 
 has been added, the prenatal service has increased fourfold. Both 
 doctors and patients are enthusiastic and see far more reason for in- 
 struction and supervision from a nurse who is going to see the case 
 through than from one who drops out at the crucial moment. It cer- 
 tainly has strengthened our whole maternity service, both as to results 
 accomplished and in our relationship to the doctor and to the com- 
 munity." 
 
CARE OP THE MOTHER AND BABY 439 
 
 FORMS AND ROUTINES FOR MATERNITY WORK, 
 
 VISITING NURSE SOCIETY 
 
 PHILADELPHIA 
 
 EQUIPMENT FOB BAGS 
 
 Bottles containing: 
 
 1. Alcohol. 
 
 2. Licreolisis. 
 
 3. Green soap. 
 
 4. Mouth wash. 
 
 Jar with boric acid crystals. 
 Jar with cord powder. 
 Jar containing- vaseline. 
 
 1. Hypodermic syringe. 
 
 2. Tongue depressors. 
 
 3. Two thermometers : rectal and mouth. 
 
 4. Toothpicks. 
 
 5. Adhesive plaster. 
 
 6. Fountain syringe or funnel and tube in linen bag. 
 
 7. Gauze and bandages in linen bag, cord dressing and cord tape. 
 
 8. Cotton and p.p. pads in linen bag. 
 
 9. Paper napkins on which to lay articles. 
 
 10. Granite pan. 
 
 11. Two towels. 
 
 12. One apron. 
 
 13. Handbrush. 
 Instrument case containing : 
 
 Scissors, forceps, 2 artery clamps, glass catheter, rubber catheter, 
 colon tube, connecting tube, glass nozzle, medicine dropper. 
 Folder containing: 
 Records. 
 Fee slips. 
 Literature. 
 
 ROUTINE TECHNIQUE 
 
 1. Uniforms. 
 
 Except in the case of substitutes during their first six months and 
 staff nurses during their probation period, all the nurses are required 
 to wear the uniform of the Society. 
 
 Prescribed hat and coat. 
 
 Sensible black shoes. 
 
 Plain dress of prescribed matei'ial. 
 
 2. Bags. 
 
 Lining to be changed once in two weeks. 
 Bottles to be kept neatly labelled. 
 
440 OBSTETRICAL NURSING 
 
 Lost articles to be replaced at *^lie expense of the nurse. 
 
 New equipment may be obtained only in exchange for the worn- 
 out one. 
 
 Notebooks, charts, other papers, and pencils to be kept in the long 
 pocket. 
 
 Instruments to be boiled before and after dressings. 
 
 Brush to be boiled twice a week and after all infectious cases. 
 
 3. Thermometer Disinfection. 
 
 To be washed before and after using- in running- water if possible. 
 After using- wrap in cotton soaked in alcohol and leave i;ntil the 
 work is finished. Then wash with green soap under running water. 
 
 4. Routine in the Home. 
 
 G-eneral Care: 
 
 A. Remove hat and coat, folding coat right side out and placing 
 
 on chair away from wall. Place bag on chair or on table with 
 newspaper underneath. 
 
 B. Ask nature of illness, doctor's orders, etc. 
 
 Ask family for a kettle of boiling water ; pitcher of cold water ; 
 basin, soap and soap dish; pail for the waste; tumbler; towels 
 and wash cloth; bath blanket or sheet; clean gown and neces- 
 sary bed linen ; newspapers ; comb and brush. 
 
 C. Open the bag; put on apron; roll up sleeves; take from bag 
 necessary articles, placing on clean newspaper or napkin. 
 Wash hands and thermometer. Take everything needed from 
 the bag at once to prevent unnecessary handling. Take and 
 record T.P.R. of all cases except chronics of long standing. 
 
 D. Place newspapers — one on chair, one under edge of bed for 
 soiled linen, one for utensils (kettle, pitcher, etc.) 
 
 Make cornucopia of newspaper for waste and pin to the side 
 of bed. 
 
 E. Bath. Cover patient with blanket or sheet. 
 Remove upper bed clothes, fold and place on chair. 
 
 Soiled linen should be placed on paper with the stains turned 
 
 in. 
 Avoid unnecessary exposure of the patient at all times. 
 Give thorougli bath, nsing plenty of soap and rinsing carefully. 
 Change water at least once. 
 Bathe upper half of body, give local bath, change water and 
 
 bathe lower half. 
 Put on nightdress before completing bath. 
 Clean teeth and nails. 
 Comb hair, protecting pillow with towel. 
 In making the bed be sure that there are no wrinkles under the 
 
 patient and that the bed clothes are neatly tucked in. 
 
CARE OF THE MOTHER AND BABY 441 
 
 F. Clear room of articles used. Empty basin. Wrap soiled linen 
 in paper. 
 
 Burn cornucopia before leaving the house. 
 
 Wash hands. 
 
 Complete bedside record, si^n receipt for fees, and place in an 
 
 envelope. 
 Instruct the family to give it to the doctor, 
 
 G. Instruct the Family 
 
 1. To have hot water and necessaiy articles ready for the next 
 
 visit. 
 
 2. To keep rttnni clcjin and well ventilated and emphasize the 
 
 importance of damp dusting and sweeping. 
 
 3. To have table cleared tor patient's u.se. 
 
 4. About the care to be given between visits. 
 
 Choose most suitable member of the faiuily and instruct care- 
 fully. 
 H. Observe general health of other members of family and the 
 hygienic conditions of the home. 
 
 Partial Care : 
 
 Prepare as for general care. 
 
 Bathe the patient's hands, face, neck, axilla, and breasts, and 
 
 give local bath. With maternity cases do post-partum 
 
 dressing. 
 Cleanse the mouth. 
 Make bed as in general care. 
 
 DELIVERY ROUTINE 
 
 Ektra articles to be carried in bags : gown, 2 towels, clamps, 2% 
 silver nitrate solution. 
 
 The doctor should be called at the same time as the nurse. This 
 should be ascertained when call is taken over telephone. 
 
 If the nurse arrives first, she should judge from the progress of 
 labor whether an urgent call should be sent for the doctor and how 
 much time she will have to spend in preparation for the deliveiy. Un- 
 less directed otherwise bj^ doctor, the nurse should proceed as follows : 
 
 Have a supply of boiled water and pour some in covered vessel 
 to cool. 
 
 Take necessary articles from bag, wash hands, put on gown. 
 
 Prepare patient by giving enema, sponge bath, braiding the hair, 
 putting on clean white stockings and a gown which can be rolled up 
 around waist. 
 
 Make bed with tight sheet, oilcloth and draw sheet, f)rotect with 
 pads made of many thicknesses of newspajier, covered with old muslin. 
 
 Protect floor with newspapers, and place basin for placenta. On 
 
442 OBSTETRICAL NURSING 
 
 bedside table, place alcohol, sneen soap, glass of boric acid solution, 
 silver nitrate, basin containing scissors, clamps, catheter, medicine drop- 
 per, cotton gauze, cord tape and dressing, perineal pads, hyperdermic, 
 thermometer. Basin of h'sol within reach. Prepare a place for baby 
 by covering pillow with blanket and placing hot water bottle. Have 
 olive oil (warmed). Get baby clothes, also gown and binder for mother. 
 
 Scrub hands and cleanse patient locally with green soap and water 
 and put on sterile pad. 
 
 Assist doctor in any way possible during delivery. 
 
 Ask doctor whether he wishes to instill silver nitrate into baby's 
 eyes. This should be followed by normal salt solution and boric acid. 
 
 After deliveiy, cleanse vulva with warm lysol, put on fresh p,ad 
 and binder, and make patient as comfortable as possible, giving her 
 something hot to drink. 
 
 Weigh, oil, cleanse, dress baby. Unless doctor orders otherwise, 
 instruct mother to nurse even' three hours and to cleanse nipples with 
 boric acid solution before and after nui-sing. The following additional 
 information is to be written on the medical history card of patient 
 attended at delivery- : 
 
 1. Time nurse arrived. 
 
 2. Time baby was born and sex and weight. 
 
 3. Presentation. 
 
 4. Instrumental — high or low. 
 
 5. Laceration. 
 
 6. Repair, kind and number of sutures. 
 
 7. HemoiThage. 
 
 8. Prophylactic used for the eyes. 
 
 9. Number of hours in labor. 
 
 10. Condition on discharge — fundus and lochia. 
 This technique is given as a general standard but the nurse is ex- 
 pected to use her own discretion in adapting it to the condition of 
 patient, the home surroundings and the wishes of the doctor. 
 
 ROUTINE AFTER DEX,rV'ERY 
 
 Care of the Baby: 
 
 A. Make preparations as for general care. 
 
 Have everything ready before the baby's bath. 
 
 Have separate basin for the baby whenever possible. 
 
 Test temperature of water with the elbow. 
 
 If the room is cold bathe in the kitchen. 
 
 Use table whenever possible for the baby's bath. 
 
 If not possible sponge on lap beside the mother's bed so that she 
 can observe technique. 
 
 When cord is off, tub. 
 
 Place on paper napkin on third chair, table, or corner of dresser, 
 
CARE OF THE MOTHER AND BABY 443 
 
 glass of boracic acid sol., olive oil, warmed, cord powder, and dressings, 
 safety pins, band, absorbent cotton, rectal thermometer, vaseline and 
 alcohol. Have baby's clothes within easy reach. Protect lap with 
 blanket or bath towel. 
 
 Remove clothing. 
 
 To protect cord dressing, unpin but do not remove band. 
 
 Take temperature first and last visit, and when indicated. 
 
 Weigh baby on fii"st and last visit. 
 
 Examine carefully for any abnormalities and note when found. 
 
 B. Eyes. 
 
 Unless there is a secretion, let the eyes alone. 
 
 When secretion or redness, wash eyes gently with 2% Boric acid sol. 
 using separate pledget for each eye. 
 
 C. Mouth. 
 Examine mouth. 
 
 No treatment unless required. 
 
 If necessary to cleanse use cotton wrapped around little finger and 
 dipped in boracic acid. 
 
 D. Nose. 
 
 Xo treatment imless required. 
 
 If necessary- use piece of twisted cotton and boracic acid sol. 
 
 Never use toothpicks. 
 
 E. Wash face "and ears gently with wash cloth or absorbent cotton 
 and drj-. 
 
 Soap head with hands, rinse with cloth and dry carefully. Soap 
 body with hands, rinse with cloth and pat diy with soft towel. Fold 
 binder across abdomen, protect with hand and turn baby on stomach. 
 Bathe the back. Fold diaper and place under buttocks. 
 
 F. Genitals should be carefullj' cleansed. 
 
 In the ease of boys, the foreskin should be gently pushed back once 
 in every two or three days, and the parts underaeath bathed carefully 
 with absorbent cotton and boracic acid sol., removing the white pasty 
 material which causes irritation. 
 
 In the case of girl babies, carefully bathe genitalia. If deposit is 
 difficult to remove, soften with olive oil. 
 
 G. On first visit wash umbilicus with 70'~f alcohol and apply drj' 
 sterile dressing. Do not remove this dressing except when soiled. After 
 the first time dress with cord powder. Put on clean binder, pinning 
 on side with safety pins. Oil under arms, buttocks and all creases. 
 
 Put on shirt. 
 
 Pin diaper. 
 
 Petticoat and dress should be drawn on over the feet. 
 
 Use hot water bottle filled with warm, not hot, water. 
 
 If necessary beer bottle, tightly corked, is a good substitute. 
 
444 OBSTETRICAL NURSING 
 
 Clear away articles used for the baby. 
 H. Points to be observed, recorded and reported to the physician if 
 urgent : 
 
 1. Condition of cord. 
 
 2. Eyes; discharge, swelling or redness, 
 
 3. Urination and stools. 
 
 4. When foreskin is veiy tight and in every case when it cannot 
 be easily pushed back. 
 
 I. Instruct the Mother: 
 
 1. To nurse every three hours unless otherwise ordered. 
 
 2. To cleanse nipples with boracic acid sol. before and after nurs- 
 ing, and to keep the breasts covered with clean cloth. 
 
 3. To give cooled, boiled water at least twice a day between feedings. 
 
 4. If fluid appears in the baby's breasts, caution the family not 
 to touch. 
 
 J. Do not discharge the baby until cord is off, umbilicus is in good 
 condition and no further nursing care required. Premature babies 
 should be oiled and wrapped in cotton. Premature jackets can be se- 
 cured from the V.N.S. for 35 cents. 
 
 Care of Mother: 
 
 Make preparations as for general care. 
 Extra articles needed : 
 
 1. Pitcher for solution. 
 
 2. Glass for boracic acid. 
 
 3. Absorbent cotton. 
 
 4. Dressings, 
 
 5. Binder, 
 Take T.P.R. 
 
 Give complete bath, 
 Post-partum dressing: 
 
 1. Make sol. of lysol in pitcher (or glass jar) which has been 
 washed and scalded. 
 
 Directions for lysol Sol. : Use V2 teaspoon lysol to 1 quart 
 hot Avater. 
 
 2. Place paper napkin on table or chair at side of bed and on it 
 pledgets of cotton, and clean pads. 
 
 3. Arrange sheet or bath blanket to avoid exposure. 
 
 4. Place soiled pad in cornucopia. 
 
 5. Place clean douche pan or basin under patient, 
 
 6. Scrub hands with green soaf) and brush under running water. 
 
 7. Pour sol, over vulva. Use i>ledgets for cleaning vulva, wiping 
 always towards rectum. 
 
 Dxy thoroughly with pledgets. 
 
CARE OF THE MOTHER AND BABY 445 
 
 8. Remove pan. 
 
 Turn patient on side and wipe from perineum back over rectum 
 
 ■with pledget. Dry. 
 
 Dry back and put on pad. 
 
 Wbile in this position place binder and draw sheet. 
 
 9. Wash hands. 
 
 10. Binder. 
 Locate fundus. 
 
 Draw edges of binder together and begin pinning from fundus 
 
 down. 
 
 Then pin from fundus up, taking dart in either side. 
 
 Fasten pad to binder, front and back. 
 
 Unless especially ordered the binder may usually be replaced 
 
 by a T-binder on the fourth day. 
 
 11. Complete as in general care. 
 
 Points to be observed and recorded on bedside notes if neces- 
 sary: 
 
 1. Condition of the breasts. 
 
 2. Urination. 
 
 3. Condition of bowels. 
 
 4. Lochia. 
 
 5. Position of uterus. 
 Record any abnormal conditions. 
 
 Do not massage breasts unless ordered. 
 
 Full post-partum care to be given on first visit if possible. 
 
 Give general care every other day. 
 Douche. 
 
 When douche is ordered boil nozzle before and after lusing. 
 
 Boil douche bag before using and wash aftem^ards — use boiled water. 
 
 When sutures, instruct the family how to irrigate after urination 
 and movement of the bowels. 
 
 Normal maternity cases should be visited daily until after the 8th 
 day of puerpeiium and at least once a week for supervision until the 
 5th week. The case is then transferred to Child Welfare nurse. 
 
 Additional visits should be made if the patient is still in bed and 
 there is no intelligent adult to give care, or if the baby's condition is 
 not satisfactory. 
 
 A SUGGESTION FROM MONTREAL 
 
 Ingenuity, resourcefulness, and ((iiick wit on the part of an 
 intelligent nurse can almost always apply hosjiital ideals to 
 circumstances which would at first seem hopeless. It is the 
 nurse's knowledge of obstetrical nursing and principles, rather 
 than her equipment, that counts in saving lives. The following 
 
446 OBSTETRICAL NURSING 
 
 directions given to visiting nurses, by Cecil A. K. Dawkins, R.N., 
 Supervisor of the Outdoor Department of the Montreal Ma- 
 ternity Hospital, indicate the possibility of clean, efficient care 
 in conditions far from ideal : 
 
 "maternity case conducted in a house where there is 
 
 VERY little to WORK WITH 
 
 "Appliances You Are Likely to Find in Any House: 
 
 "Bed, table, cliaii', twu boxes, basin, i)ail^ kettle, saucepan, plate, two 
 cups, spoon, several fair sized bottles, sbeet, two towels, pillow, pillow 
 case, handkerchief, newspapers, old clean rags, small package boracic 
 powder, small bottle vaseline, soap, baby clothes. 
 
 "Doctor's bag- will nsually contain towel, clamps, scissors, ergot, 
 chloroform, creolin, rnbber apron, hypodermic syringe, nail brush. 
 
 "1. I would take a look at the fire. Put on the kettle to boil, also 
 saucepan containing scissors, clamps, hypo (cord ligatures), 
 clean rags to use as sponges, if absorbent is not available. I 
 would put several pieces of clean rag- (some small for cord 
 dressings, others large for vulva pads) on a plate in the oven 
 to bake. This will only take a minute. 
 "2. Attack the bed. Strip it, place a good pad of newspapers 
 where the patient is to lie. Then the sheet. Cover this all over 
 with newspapers, jiarticularly where the patient lies. Here I 
 would form a Kelly pad, rolling: the jiaper up at the top and 
 bottom and left side, the right side falling' over the edge of the 
 bed into the pail. Cover with clean rag. Paper under the pail. 
 "3. Place basin, towel, soap and nail brush on table. Wash up and 
 prepare patient. Braid her hair. Put on a clean nightdress. 
 "4. Clip away the pubic hair with scissors, if razor not available 
 to shave. Give S.S. enema, provided you have the time to do 
 it in, and the syringe to do it with. Wash the vulva well with 
 soap and water. Put on pad, rag wet with disinfectant. 
 "5. The instruments, swabs, etc., should be boiled by this time. 
 Place scissors and clamps on jjlate, and swabs in basin. Get 
 hypo ready. Water for ergot. Boracic for baby's eyes. Baby's 
 clothes together, — also warm cloth to wrap baby in. Fold 
 handkerchief crosswise, and make funnel for chloroform mask. 
 "6. When baby comes, wrap him up warmly, and place on the right 
 side in a safe place. If no other place available, pull bureau 
 drawer half open and put him in, but be careful not to close 
 it again. 
 
 The plate that has held the scissors and clamps may be used 
 for the placenta. 
 
CARE OF THE MOTHER AND BABY 447 
 
 "7. To clean up the bed and make the patient comfortable, roll her 
 on her right side, rolling the paper up to her back. Wash her 
 and turn her on her left side, removing paper. Put on a clean 
 pad and "T" binder. 
 
 ''8. A jug- of boiled water left to C(jol would be useful in emergency, 
 — as also several glass bottles filled with hot water for ease of 
 shock. The boxes may be used for raising the foot of the bed." 
 
Yet it is but a little human babe, 
 Given at last into his reaching arras 
 And carried to the hollow of her breast! 
 
 Marguerite Wilkinson. 
 
PART VII 
 THE CARE OF THE BABY 
 
 CHAPTER XXI. CHARACTERISTICS AND DEVELOPMENT OF THE 
 AVERAGE NEW-BORN BABY. New Functions. Description. 
 Growth and Development. Weight. Height. Head and Chest. 
 Fontanelles. Teeth. Stools and Urine. Skin. Tears. General 
 Behavior. 
 
 CHAPTER XXII. NURSING CARE OF THE NEW-BORN BABY. 
 Mortality of First Months and Year of Life. Preventable Causes. 
 Dangers of Babyhood. Essential Features of Early Care. Daily 
 Schedule. Bath. Clothes. Fresh Air. Exercise. Training the Baby. 
 Bowels. Thumb-sucking. Ear-pulling. Crying. Ruminating. Feed- 
 ing: Breast Feeding. Artificial Feeding. Necessary Characteristics 
 of Artificial Food. Requirements for Milk Used. Articles Needed 
 in Preparing Food. Preparation of Milk. Pasteurization. Boiling. 
 Giving the Bottle. Ingredients of Food. Percentage Feeding. 
 Average Formulae. Mixed Feeding. Commercial Baby Foods. Pro- 
 prietary Foods, Canned Milks, Milk Powders. Other Articles of 
 Food Sometimes Included in Baby Diet. Travelling. The Prema- 
 ture Baby. Summer Care of the Baby. 
 
 CHAPTER XXIII. COMMON DISORDERS AND ABNORMALITIES 
 OF EARLY INFANCY. Malnutrition, Marasmus and Inanition. 
 Diarrheal Diseases: Acute Gastro-enteritis. Symptoms. Treatment 
 and Nursing Care. Acidosis. Colic, Constipation, Convulsions, and 
 Vomiting. Infections: Ophthalmia Neonatorum. Symptoms, Treat- 
 ment, and Nursing Care. Syphilis. Thrush, or Sprue. Impetigo. 
 Pemphigus. Vaginitis. Abnormalities: Icterus or Jaundice. Cephal- 
 ematoma. Club Foot. Engorgement of Breasts. Hare Lip. Cleft 
 Palate. Hernia. 
 
CHAPTER XXI 
 
 CHARACTERISTICS AND DEVELOPMENT OF THE 
 AVERAGE NEW-BORN BABY 
 
 Before undertaking the care of the new-born baby the nurse 
 should stop and consider him for a moment and review in her 
 mind just what he represents; what he has been through; what 
 struggles and dangers are ahead of him ; what are the weaknesses 
 of his equipment to meet these perils and what must be the 
 the character of her service to him if she is to do all in her power 
 to help him safely over that most hazardous period in the entire 
 span of his existence : the first month of his life. 
 
 That little new-born baby is quite as helpless and appealing 
 as he looks, for his chances for present and future health lie very 
 largely in the hands of those who care for him during these 
 early weeks, and any injury which is done at this time, either 
 through acts of omission or commission, can never be entirely 
 repaired. 
 
 At the time of birth, the baby makes the most complete and 
 abrupt change in his surroundings and condition that he will 
 make during his entire lifetime. 
 
 He has existed and evolved as a parasite for nine months, 
 during which time he has been protected from injury ; kept 
 at the temperature which was best for him, and above all has 
 been furnished with exactly the proper aijiount and character of 
 nourishment necessary for his growth and development. 
 
 Suddenly he emerges from this completely protecting envi- 
 ronment into a more or less hostile world, where he must begin 
 life as a separate entity with a frail little body that in many 
 respects is only imperfectly developed. And yet the baby must 
 not only continue the bodily functions and activities that were 
 begun during his uterine life, but must also elaborate and es- 
 tablish others which were imperfect or were performed for him. 
 Otherwise he will not live. 
 
 451 
 
452 OBSTETRICAL NURSING 
 
 The nurse will recall that the fetus received its nourishment 
 and oxygen, and gave up waste material, through the placental 
 circulation ; that the lungs were not inflated and that most of the 
 blood flowed through the foramen ovale instead of through the 
 pulmonary vessels, as it does after birth. The digestive tract, 
 excretory organs and nervous system were not needed during 
 fetal life and therefore are imperfectly developed at birth and 
 are capable of functioning only Avithin very narrow limits. 
 
 The pulmonary circulation usually is established immediately 
 after birth, and when the baby cries vigorously the lungs are 
 expanded and filled with air and the respiratory function is 
 inaugurated. The ductus arteriosus, ductus venosus and two 
 hypogastric arteries are gradually obliterated, as the normal 
 circulation of the blood becomes established and the foramen 
 ovale is closed. See Figs. 28 and 29. 
 
 The other functions are established more slowly and the care 
 of the baby must be such that the immature, unused organs will 
 not be overtaxed, and yet that their development will be pro- 
 moted through activity. 
 
 The new-born baby weighs 3250 grams, or 7^/4 pounds, and 
 is about 50 centimetres, or 20 inches long. The body is well 
 rounded and the flesh firm. The skin is a deep pink, or even red, 
 and is covered with a white, cheesy substance, the vernix caseosa, 
 which is likely to be thickly deposited in the folds of the skin, 
 in the creases of the thighs and axilla and over the back. Some 
 babies still have the fine, downy lanugo hair over parts or all 
 of the body. 
 
 The head and abdomen are relatively large, the chest narrow 
 and the limbs short. The legs are so markedly bowed that the 
 soles of the feet may nearly or quite face each other, but they 
 finally assume a normal position. The bones are largely cartilage 
 and the entire body is therefore very flexible. Some of the bones, 
 which are separate at birth unite later in life and the adult 
 skeleton finally becomes firm and rigid. 
 
 Most babies have faded blue eyes at birth, the permanent 
 color appearing gradually, while the amount and color of the 
 hair varies greatly, some babies being bald and others having 
 abundant hair from the beginning. 
 
DEVELOPMENT OP AVERAGE NEW-BORN BABY 453 
 
 The shape of the baby's head is sometimes distorted at birth, 
 being so elongated from chin to occiput as to give tlie parents 
 deep concern. But they may be confidently assured that in the 
 course of a few days the head will assume the lovely rounded con- 
 tour, so characteristic of babyhood. The temporary deformity 
 is caused by a moulding and overlapping of the bones of the 
 skull as it is forced through the birth canal, and sometimes also 
 to a collection of fluid under the scalp, called the caput succe- 
 daneum, and which, too, is due to pressure during birth. Both 
 the anterior and posterior fontanelles may be felt at birth. 
 
 Growth and Development. The progress during the first 
 year, of average, normal babies who are satisfactorily nourished 
 and cared for, is fairly uniform and the accepted average is sug- 
 gested by the following schedules which are based upon observa- 
 tions made upon a large number of normal, healthy infants. 
 
 Weight. The average baby boy weighs at birth, 7I/4 to ly^ 
 pounds and girls a little less, as a rule. There is an initial loss 
 of from six to ten ounces during the first week, through body 
 waste and the passage o£ meconium and urine, before the full 
 amount of nourishment is taken and assimilated, large babies 
 losing more than small ones.. (Chart 5.) From this time the 
 gain is usually from four to eight ounces, each week, during the 
 first five months, after which it is only about half as rapid, or at 
 the rate of from two to four ounces weekly. At six months, 
 therefore, the average baby weighs from fifteen to sixteen 
 pounds, or double the normal birth weight of 7^/2 pounds, and at 
 twelve months, from twenty to twenty-two pounds, or three 
 times the average birth weight. The weight is perhaps the most 
 valuable single index to the baby's condition, that w'e have, but 
 at the same time, it must be remembered that a baby whose food 
 is rich in carbohydrates may be of normal weight, or over, but 
 be incompletely nourished and very susceptible to infection. 
 Other babies who are small and seem to gain unsatisfactorily are 
 sometimes very well and vigorous. And very commonly there 
 are periods in the lives of entirely normal babies when there is 
 little or no gain in weight. This may occur during the period 
 from the seventh to the tenth month, for example, or during very 
 warm weather. But the baby's weight should be watched care- 
 
454 
 
 OBSTETRICAL NURSING 
 
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DEVELOPMENT OF AVERAGE NEW-BORN BABY 455 
 
 fully, for a loss or prolonged failure to gain may be an evidence 
 of faulty nuti'ition or disease. 
 
 Height. The average height at birth is 20 iiK-Iies, though 
 boys may measure a little more and girls a little less; at six 
 months, 25 to 25yo inches and at one year, 28 to 29 inches. 
 
 Head and Chest. The circumference of the head and chest 
 are about the same at birth, the chest being possibly a little 
 smaller. Both measure about 131/^ inches, increasing gradually 
 to about 161/2 inches at six montlis and 18 inches at the end of 
 the first year. 
 
 Fontanelles. The posterior fontanelle usually closes in six 
 or eight weeks but the larger, anterior fontanelle is not entirely 
 obliterated until the baby is eighteen or twenty months old. 
 Closure of the fontanelles is usually late in rickets, cretinism 
 and hydrocephalus and early in cases of malnutrition and micro- 
 cephalus. 
 
 Teeth. Although it occasionally happens that a baby has 
 one or two teeth at birth, the average infant has none until the 
 sixth or seventh month, Avhen the two lower, central incisors 
 appear. After a pause of a few weeks the two, upper, central in- 
 cisors appear, followed by the two lateral incisors in the upper 
 jaw. At the end of the first year, therefore, the average baby 
 has six teeth, or eight, if the lower, lateral incisors have come 
 through by the first birthday, as they sometimes do. (Fig. 148.) 
 This is the usual course of dentition during the first year, but 
 there are wide variations among entirely well and normal babies, 
 the first tooth sometimes not appearing before the tenth, eleventh 
 or even twelfth month. But as a rule if no teeth are cut by the 
 time the baby is a year old, it is regarded as an evidence of 
 faulty nutrition, perhaps bordering on rickets. 
 
 The baby who is properly fed and cared for cuts his teeth 
 with little or no trouble, in spite of the widely current belief 
 that a teething baby is a sick baby. We have no way of estimat- 
 ing the numl)er of babies who die needlessly from infections and 
 digestive disturbances because of this fallacious conviction. For 
 if the baby is sick while teething, the disturbance is all too fre- 
 quently accepted as a normal occurrence and nothing is done 
 until too late. 
 
456 
 
 OBSTETRICAL NURSING 
 
 Frail, delicate babies may have convulsions each time that 
 a tooth is cut and if a baby is having digestive trouble it is likely 
 to grow worse while he is teething. But dentition is a normal 
 physiological process and the healthy, properly fed baby suffers 
 little or no inconvenience at this time. 
 
 The care of the baby 's teeth should begin when the first tooth 
 appears. It should be wiped, front and back, with a piece of 
 
 gauze or cotton dipped in a solu- 
 tion of boraeie acid, or sodium 
 bicarbonate or some other weak 
 alkaline wash, to neutralize the 
 acid secretions of the mouth 
 which start decay. After the 
 baby has five or six teeth, the use 
 of a very soft brush, with tooth 
 paste, is often advised, the teeth 
 being brushed with a circular 
 motion or from the gums toward 
 their edges. The teeth should be 
 wiped, or brushed, morning and 
 evening and after feedings. The 
 reason for such close care of the 
 temporary teeth is that they 
 serve as a mould or brace to 
 hold the jaws in proper shape 
 for the permanent teeth which appear later. If the **milk" or 
 deciduous teeth decay or crumble away before the jaws are 
 developed to the point when the permanent teeth appear, these 
 second teeth are likely to be crooked and uneven. 
 
 Stools and Urine. During the first two or three days, the 
 stools are of dark green, tarry material called meconium. Me- 
 conium consists of cast-off cells from the skin and intestines, fat, 
 mucus, hairs and bile pigment. In the course of two or three 
 days, the stools begin to grow lighter and shortly the normal, 
 milk-feces appear, being bright yellow, of a smooth pasty con- 
 sistency and having a characteristic odor. During the first 
 month or six weeks the baby's bowels may move three or four 
 times daily, but after this they usually mo\e but once or twice in 
 
 ^ § 
 
 r^ a i i 
 
 CO ^« cvj ii! "^ 
 
 
 
 
 o 
 
 Fig. 148. — Diagram of first or 
 deciduous teeth and ages at which 
 they usually appear. 
 
DEVELOPMENT OF AVERAGE NEW-BORN BABY 457 
 
 the course of twenty-four hours. As the diet is increased, the 
 stools grow somewhat darker and firmer and finally become 
 formed. 
 
 Fig. 149. — Appearance of umbilical cord immediately after birth. 
 
 The new-born baby's bladder usually contains urine which 
 may be voided immediately after birth or not until several hours 
 later. After the first voiding the bladder may be emptied five 
 
 Fig. 150.— Appearance of umbilical cord, four days after birth. 
 
 or six times a day, or oftener. The nurse should watch for the 
 first evacuation of the bowels and bladder, and if they do not 
 occur during the first few hours, the fact should be reported to 
 
458 
 
 OBSTETRICAL NURSING 
 
 the doctor, as the omission may be due to an imperforate anus 
 or meatus. 
 
 Cord. Within a few days after birth the stump of the um- 
 
 FiG. 151. — Appearance of umbilicus immediately after separation of cord. 
 
 bilical cord begins to shrivel and turn black, and a red line of 
 demarcation appears at the junction of the cord Avith the abdo- 
 men. By the eighth or tenth day, as a rule, the cord has atro- 
 phied to a dry black string, when it drops off and leaves an ul- 
 
 FiG. 152. — Appearance of a well healed umbilicus. 
 
 cer, or small granulating area which heals entirely in a few days. 
 (Figs. 149, 150, 151, 152.) Before the days of sepsis, infections 
 of the cord were not uncommon and babies frequently died of 
 t;etanus, streptococcus and other infections. But at the present 
 
DEVELOPMENT OP AVERAGE NEW-BORN BABY 459 
 
 time an infected cord is a rare, and, it may be added, an almost 
 inexcusable occurrence. 
 
 Skin. By the end of the tirst week any lanugo remaining 
 usually disappears and there is frequently a scaling of the super- 
 ficial layers of the skin which lasts for two or three weeks, while 
 a delicate pink tint replaces the deeper color of the skin in the 
 course of ten days or two weeks. The baby does not perspire until 
 after the first month, as a rule, when insensible perspiration 
 begins, gradually increasing until perspiration is free by the 
 time the baby is a few months old. 
 
 Tears. There are no tears at birth and opinions differ as to 
 whether they appear in the course of two or three weeks, or three 
 or four months. The absence of the lachrymal secretion is one 
 explanation for the necessity of bathing the baby's eyes during 
 the early days and weeks, for if dust or other foreign material 
 gains entrance it is not washed out by the tears as it is later. 
 
 General Behavior. During the first few weeks the average 
 baby sleeps most of the time : that is from nineteen to twenty-one 
 hours daily. He gradually sleeps less, as the special senses de- 
 velop and will sometimes lie quietly for an hour or more with his 
 eyes open, sleeping only sixteen or eighteen hours daily at six 
 months and fourteen to sixteen hours at the end of a year. 
 
 The baby begins to make noises and "coo" at about two 
 months and to utter various vowel sounds when about six months 
 old. By the end of a year these indefinite noises and sounds be- 
 come distinct words. At about the fourth month, he grasps at 
 objects and smiles and very soon even laughs. He holds up his 
 head at about the third or fourth month ; sits up and also begins 
 to creep at six or seven months; while sometime between the 
 ninth and twelfth months he will stand by holding to some one 's 
 hand or the furniture, and will begin to walk with assistance. 
 
 These degrees of development at different ages are not to be 
 taken as the only measure of normal progress, for many well 
 babies mature more rapidly and others more slowly than at the 
 rate which is found to be the average. 
 
 In addition to these fairly specific evidences of the baby's 
 condition and progress, such as weight, height and muscular de- 
 velopment, there are other and less definite indications of his 
 
460 OBSTETRICAL NURSING 
 
 well-being which the nurse must watch for and accord a very 
 high value. 
 
 The baby who is well and is being properly fed in all re- 
 spects, will have good color ; his flesh will be firm ; he will take 
 his nourishment with a certain amount of eagerness and seem 
 satisfied afterward. He will sleep for two or three hours after 
 each feeding; will sleep quietly at night, and while awake, un- 
 less he is wet or uncomfortable for some other good reason, he 
 will seem contented, good-natured and happy. 
 
CHAPTER XXII 
 NURSING CARE OF THE AVERAGE NEW-BORN BABY 
 
 It is estimated that out of every thousand babies born alive, 
 in this country, forty die during the first month of life, and that 
 more than as many again, or about eighty-five all told, perish 
 before reaching the first birthday. 
 
 So hazardous is this period of early infancy, in the United 
 States, that our annual loss of baby life is between seven and 
 eight times as great as was the yearly toll of our young men dur- 
 ing the war, for upwards of 200,000 babies less than a year old 
 die each year. That the first month of life is fraught with 
 greater danger than any which follow is shown by the fact that 
 about 100,000 of these deaths occur during the first four weeks. 
 
 The tragedy of these figures is made darker by the knowledge 
 that at least half of the l)al)ies who are lost die from preventable 
 causes. In other words, they die from lack of proper care. 
 
 That is the significant fact for the obstetrical nurse, since 
 more and more frequently she has the young baby in her care 
 during the crucial first month and inevitably plays an important 
 part in increasing his chances to live. She does this by helping 
 to keep the w^ell baby well, rather than by nursing a sick baby. 
 
 The dangers which make babyhood such a precarious period 
 may be grouped very largely under the general headings of 
 unfavorable ante-natal conditions, nutritional disturbances and 
 infections. The care and supervision of the expectant mother 
 will remove many of the unfavorable ante-natal causes. Nutri- 
 tional disturbances and infections must be dealt with after birth. 
 
 Faulty nutrition may result in rickets, scurvy, malnutrition, 
 marasmus, acute inanition or the less serious colic, constipation 
 or diarrhea. The most frequent results of infection among 
 young babies are the respiratory diseases in winter, such as 
 bronchitis and pneumonia, and the intestinal disorders in sum- 
 mer, commonly referred to as "summer complaint." Since 
 
 461 
 
462 OBSTETRICAL NURSING 
 
 undernourished babies are very susceptible to infection, the two 
 conditions are frequently coincident. 
 
 "With the baby's frailty and imperfect development in mind, 
 as well as the needs of his growing body and the evils that beset 
 his way, we can understand the reasons for the painstaking, pro- 
 tecting care which he is given during the early weeks of his life. 
 
 The essential features of this care are as follows : 
 
 1. Proper feeding. 
 
 2. Fresh air. 
 
 3. Regularity in his daily routine. 
 
 4. Cleanliness of food, clothing and surroundings. 
 
 5. Maintenance of an equable body temperature. 
 
 6. Conservation of his forces. 
 
 These requirements seem so rational that one might expect 
 them to be met as a matter of course; but the annual sickness 
 and death rate among babies are a constant reminder that they 
 are not. 
 
 The nurse should begin by arranging a daily schedule for 
 the baby's feedings, fresh air, bath, sleep and exercise, and follow 
 it with unfailing regularity. The hours for the nursings, which 
 vary with different doctors, will constitute the greater part of the 
 daily schedule, and for a baby on four hour feedings, for ex- 
 ample, some such program as the following may be arranged : 
 
 Feeding. 
 
 Orange juice (when ordered). 
 
 Bath. 
 
 Feeding. 
 
 Out of doors. 
 
 Feeding, 
 
 Out of doors. 
 
 Orange juice (when ordered). 
 
 In-door airing and exercise (when ordered). 
 
 Preparation for the night. 
 
 Feeding. 
 
 Feeding. 
 
 Feeding (when ordered). 
 
 The importance of punctuality in the daily routine cannot be 
 stressed too often and it is one aspect of the baby 's care for which 
 the nurse is absolutely responsible. No matter how well the baby 
 
 
 6 
 
 a.m. 
 
 
 8 
 
 a.m. 
 
 
 9 
 
 a.m. 
 
 
 10 
 
 a.m. 
 
 10.30 to 
 
 2 
 
 p.m. 
 
 
 2 
 
 p.m. 
 
 2.30 to 
 
 4 
 
 p.m. 
 
 
 4 
 
 p.m. 
 
 4 to 
 
 5.3C 
 
 ) p.m. 
 
 
 5.30 
 
 1 p.m. 
 
 
 6 
 
 p.m. 
 
 
 10 
 
 p.m. 
 
 
 2 
 
 a.m. 
 
NURSING CARE OP AVERAGE NEW-BORN BABY 463 
 
 is nursed, in other respects, nor how skillfully the doctor directs 
 his care, the baby cannot be expected to progress satisfactorily 
 if his life is irregular. 
 
 The Bath. The first office which the nurse usually per- 
 forms for the new-born baby, and which she repeats daily, is to 
 bathe and dress him. The bath may be given in a tub, under a 
 spray or in the nurse's lap, according to the wishes of different 
 doctors, while sponge baths are sometimes given with soap and 
 water and sometimes with oil. 
 
 The first bath, particularly, is likely to be an olive oil sponge, 
 given immediately after birth, before the baby is taken from the 
 mother's bedside, and many doctors have the sterile cord dress- 
 ing and abdominal binder applied at this time. This oil bath is 
 given, not alone for the purpose of removing the vernix caseosa, 
 but also, to lessen the radiation of body heat, which the baby can 
 ill afford to lose. When such a practice is followed it only re- 
 mains for the nurse to dress the baby and place him in his crib 
 to sleep undisturbed for several hours. 
 
 Some doctors have the baby sponged every morning with 
 albolene or olive oil, instead of with soap and water, until the 
 cord separates, when tub bathing is adopted. AVhen the daily 
 bath is given with oil, the baby 's thighs and buttocks are wiped 
 clean with an oil sponge each time that the diaper is changed. 
 Other doctors have the babj^ 's first bath given in a tub, with soap 
 and water, while still others who fear that the cord may be in- 
 fected by immersing the baby, have him sponged with soap and 
 water, after the vernix caseosa has been softened with oil. 
 
 Sponge bathing is commonly employed for all babies until 
 the cord separates and for frail delicate babies or those suffering 
 from skin trouble. The sponge bath may be given in the nurse's 
 lap or on a table covered with a pad, either method being satis- 
 factory if the baby is kept warm and comfortable. But one in- 
 clines to the idea of having the baby bathed in the nurse's lap 
 for he seems happier there ; more comfortable and less frightened 
 and we cannot be sure that these factors are unimportant. 
 
 The best time for the dailj' bath, during the first three or 
 four months, is about an hour before the second feeding in the 
 morning. After this age the full bath is sometimes given before 
 
464 OBSTETRICAL NURSING 
 
 the six o'clock feeding, in the evening, for a bath at this hour is 
 soothing and restful and often helps toward giving the baby a 
 good night. 
 
 Preparation for the bath should made with its possible effects, 
 both good and bad, in mind, for the baby may be helped or 
 harmed according to the skill with which he is bathed. He must 
 not be chilled during his bath, and fatigue and irritation must 
 be avoided by giving it quickly and Math the least possible han- 
 dling and turning. These ends may be served by conveniently 
 arranging all of the articles which will be needed, on a low table 
 at the right hand side of the nurse's chair, before the baby is 
 undressed. 
 
 There should be a pitcher of hot and one of cold water; a 
 bath thermometer ; two soft wash-cloths ; soft towels ; bath 
 blankets ; Castile, or some other mild soap ; boracic acid solution ; 
 sterile cotton pledgets; large and small safety pins, or large 
 ones and a needle and thread if the band is to be sewed on ; un- 
 scented talcum powder; sterile albolene or olive oil; soft hair 
 brush and a complete outfit of clothing. The little garments 
 should be arranged in the order in which they will be put on, the 
 petticoat slipped inside the dress, and all hung before the fire 
 or heater, to warm. 
 
 The temperature of the room should be about 72° F. and if 
 it is possible to bathe the baby before an open fire or a heater, 
 so much the better. In any case he must be protected from 
 drafts. A sheet hung over the backs of two straight chairs will 
 serve very well as a screen if no other is available. 
 
 The tub or basin should be about three-quarters full of water 
 at 100° F. for the new baby; about 95° after the third month 
 and gradually lowered to 85° F. or 90° F. for the baby a j^ear 
 old. The temperature of the water should not be guessed at, but 
 tested with a thermometer, though in an emergency the nurse 
 may safely use water that feels comfortably warm to her elbow. 
 
 It is a good plan to lay a folded towel in the bottom of the 
 tub, before beginning, as babies are often frightened by coming 
 in contact with the hard surface. 
 
 The nurse should wear a waterproof apron, covered with one 
 of flannel over which is laid a soft towel until the bath is fin- 
 
465 
 
466 OBSTETRICAL NURSING 
 
 ished, when it is slipped out, leaving the dry flannel apron to 
 wrap about the baby. She should wash her hands thoroughly 
 with hot water and soap ; sit squarely, with her knees together, 
 in a chair without arms; take the baby in her lap and undress 
 him under a blanket. 
 
 In order that the bath may be given deftly and quickly, it is a 
 good plan to give the different parts in the same order every day, 
 for practice makes perfect. 
 
 It is usually a routine to weigh the baby every morning, dur- 
 ing the first two or three weeks and once or twice a week after- 
 wards. Premature babies and those who are very frail are 
 weighed at longer intervals because of the inadvisability of dis- 
 turbing them so often. The baby is undressed for his bath, 
 wrapped in a blanket, and laid in the scoop or basket of a beam 
 scale (Fig. 153) and a note made of tlie entire weight, for if he 
 is placed in the scales without protection he is likely to be chilled 
 and frightened. The weight of the blanket is ascertained sep- 
 arately and deducted from the total thus giving the baby 's exact 
 weight. 
 
 The eyes should be bathed first, with pledgets of sterile cot- 
 ton dipped in warm boracic acid solution, each pledget being 
 used but once. To prevent the solution from running from one 
 eye into the other, the baby 's head is turned slightly to one side 
 and the lower eye wiped gently from the nose outward. The lids 
 may then be separated by placing one thumb below the brow and 
 lifting it slightly, and the eye flushed with a gentle stream by 
 squeezing a freshly soaked pledget just above it. The head is 
 turned to the other side and the eye on that side bathed in like 
 manner. 
 
 The mouth is swabbed out very gently with boric-soaked cot- 
 ton wrapped about the tip of the little finger, care being taken 
 not to abrade the delicate mucous lining. The nostrils are 
 cleaned with little spirals of cotton dipped in liquid petrolatum 
 or olive oil. 
 
 The face is then washed with warm water, no soap, and patted 
 dry. The scalp, neck and ears are washed with soap and water 
 and thoroughly dried by patting and wiping gently in the 
 creases. The body should then be well soaped, with the nurse's 
 
NUESING CARE OF AVERAGE NEW-BORN BABY 467 
 
 hand, only one part being exposed at a time, to avoid chilling. 
 To place the baby in the tub the nurse may slip her left hand 
 under his head in such a way that his head will rest upon her 
 wrist, her fingers support his shoulders and her thumb curve 
 over and hold the upper part of his arm. She may then grasp 
 his ankles with her riglit hand and lower the little body into the 
 water, feet first. If his nvm and siiouhler are firmly held and 
 supported by tlic left hand it is an easy matter to steady the 
 entire body and keep the baby's head out of the water while 
 giving the bath Avith the ri^dit hand. (Fig. 154.) The new baby 
 
 Fig. 154. — Method of supporting baby 's head above water while giving 
 tub bath. 
 
 is not usually kept in the tub for more than two or three minutes, 
 but when he is three or four months old he may stay in for five 
 minutes and still longer as he grows older. 
 
 Hot water should not be poured into the bath after the baby 
 has been placed in it but cold water is often added, for a three 
 or four months old baby, or the warm bath folloAved by a quick 
 sponge with cold water. The little body is quickly patted dry 
 and rubbed briskly with the palm of the nurse's hand; the legs 
 and arms stroked toward the body ; the back from the neck down- 
 ward and the chest and abdomen with a circular motion. Babies 
 who react well to cold baths are benefited bv them but such 
 
468 
 
 OBSTETRICAL NURSING 
 
 "toughening" methods have to be tempered to the resistance of 
 the individual baby and are employed only under the supervi- 
 sion of the doctor. 
 
 Fig. 155. — Prcjiaration for circumcision. (From photograph taken at 
 The Cleveland Maternity Hospital, with description, by courtesy of Miss 
 MacDonald.) 
 
 On TaMe at Left: 
 
 Basin of sterile water. 
 3 sterile towels. 
 12 small sponges. 
 6 cotton pledgets. 
 1 inch gauze bandage. 
 Tube of 00 plain catgut with 
 small needle. 
 
 Stand at Eight : 
 
 Large basin of sterile water. 
 
 For Baby: 
 
 Brandy, 1 dram. 
 Sterile water, 6 drams. 
 Sugar, % dram. 
 
 One nurse holds the baby by his knees with his hands under her arms. 
 The second nurse begins the anesthetic, three minutes before doctor begins 
 to operate, by dropping brandy and water on small piece of sterile cotton 
 in gauze in baby 's mouth. 
 
 The genitals should be bathed and dried with care ; inspected 
 daily and any abnormality reported to the doctor. It is not un- 
 common for girl babies to have a slight bloody discharge from 
 the vagina. This is unimportant and soon disappears, but a 
 
 Needle holder. 
 
 2 small hemostats. 
 
 Curved Kelly clamp. 
 
 Sharp pointed curved scissors. 
 
 Blunt dissector. 
 
 Mouth tooth forceps. 
 
 In sterile medicine glass with 
 
 dropper. 
 Used for anesthetic. 
 
NURSING CARE OF AVERAGE NEW-BORN BABY 469 
 
 purulent discharge is likely to be an evidence of gonorrheal vag- 
 initis. It is routine in many hospitals to retract the foreskin of 
 male babies every morning at the time of the bath by rubbing 
 it back with gauze or cotton, taking pains that it is again pulled 
 forward into the original position after the part underneath has 
 been bathed with boracic acid solution. If retraction is im- 
 possible after several successive daily attempts, the baby is not 
 infrequently circumcised. (Figs. 155, 156.) 
 
 When the entire body, including creases and folds, has been 
 
 Fig. 156. — Baby in Fig. 155 draped with sterile sheet. 
 
 patted quite dry, it may be dusted with an unscented talcum 
 powder, but this powdering must not be resorted to as an aid 
 in drying the skin. In order to prevent chafing, the buttocks 
 and thighs should be wiped clean with oil or bathed with warm 
 water, no soap, patted dry and powdered or oiled each time that 
 the diaper is changed. 
 
 If the first bath is a tub bath the cord is dressed after the 
 baby is dried and powdered. The form and method of cord 
 dressings vary somewhat with different doctors but in practically 
 all instances the dressings are sterile, to prevent infection, and 
 porous in order that air may gain access to the cord and promote 
 
470 
 
 OBSTETRICAL NURSING 
 
 the drying, separating process. The dressing itself may consist 
 of dry, sterile gauze or gauze wet with alcohol, applied to the 
 cord in the manner of a finger bandage (Fig. 157) ; or it may 
 consist of squares of sterile gauze or muslin with holes in the 
 centres to fit around the cord, and dusted with some such powder 
 
 Fig. 157. — Cord stump dressed with dry sterile gauze. (From photo- 
 graph taken at .lohns Hopkins Hospital.) 
 
 as boric acid, bismuth or salicylic acid and starch. These 
 squares are folded about the cord stump which is laid over on 
 the abdomen, being directed upward to prevent its being wet 
 with urine. A gauze sponge is placed over the dressing and the 
 binder applied with firm, even pressure, but not tightly, and 
 sewed on or held in place with safety pins. (Fig. 158.) The 
 
NURSING CARE OF AVERAGE NEW-BORN BABY 471 
 
 cord dressing is not removed until the cord separates, unless it 
 is wet or soiled, but as a rule the band is removed every morning 
 at the time of the bath, or whenever it is soiled. 
 
 After the band has been applied the warmed shirt, diaper, 
 petticoat and dress are put on, with the fewest possible motions, 
 
 Fig. 158. — Flannel band applied over cord dressing. 
 
 and the baby's hair brushed upward from the neck and back 
 from his forehead. He should be wrapped in a small blanket, 
 fed and laid quietly in his crib to sleep. If his hands and feet 
 are cold a hot-water bottle at 125° F. with a flannel cover, may 
 be placed beside him. 
 
472 OBSTETRICAL NURSING 
 
 When the baby is made ready for the night he may have 
 either a sponge l)ath or simply have his face and hands sponged 
 with warm water, according to the wishes of the doctor. The 
 clothing which the bab}' has worn during the day should be re- 
 placed by an entirely fresh outfit. The day and night clothing 
 may be worn more than once, if clean and if aired between times, 
 but it is better jiot to have the baby wear the same clothes day 
 and night. 
 
 Clothes. The baby's clothes may play an important part 
 in promoting liis well-being, and to accomplish this they must 
 be warm, light-weight, soft and porous. They should be simple ; 
 fit smoothly and be loose enough and short enough to permit the 
 baby to move unhampered. In order that his body may be kept 
 at an even temperature their weight must always be adjusted 
 to the needs of the moment. The general tendency is to dress 
 the baby too warmly, as a result of which he perspires ; is listless, 
 pale, fretful ; sleeps badly ; is susceptible to colds and other infec- 
 tions and has poor recuperative powers. His digestion is likelj' 
 to be deranged and he may have prickly heat. On the other 
 hand, if the baby is not dressed warmly enough his hands and 
 feet will be cold and his lips blue ; he will cry from discomfort 
 and the general result may be lowered vitality and disturbed 
 digestion. If the baby's clothes are not comfortable, if they pull 
 and drag or have tight bands, he will be fretful and restless, 
 with disturbed sleep and digestion in consequence. 
 
 The little wardrobe will be entirely adequate, under ordinary 
 conditions, if it consists of shirts, bands, diapers, flannel petti- 
 coats, dresses, flannel wrappers and sacques with a cap and cloak 
 for extra warmth during in- or out-door airing. (Fig. 159.) 
 
 The shirts should have long sleeves and high necks; they 
 should open all the way dowai the front and come well down over 
 the hips. During the cold months they should be of silk, silk 
 and wool or cotton and wool, as all wool shirts are usually too 
 warm, and during the summer months they should be of all 
 cotton and very thin. Size No, 2 is the best size to start with as 
 the smaller size is soon outgrown. 
 
 The first bands usually consist of strips of all wool or cotton 
 and wool flannel about six inches wide and eighteen or twenty 
 

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 OBSTETRICAL NURSING 
 
 inches long, torn across the width of the material and not 
 hemmed. This straight binder is worn until the cord dressing 
 is discontinued, when it is replaced by a knitted band with 
 shoulder straps. If the cord dressing is held in place by a gauze 
 
 Fig. 160. — Appearance of properly adjusted diaper which has been 
 folded diagonally. 
 
 binder, the knitted band with straps is used from the beginning. 
 Whether the binder be flannel or gauze, it must be applied firmly 
 and with even pressure, but not tight. It is a mistake to think 
 that a tight band strengthens the baby's abdominal muscles for 
 
 ,r*MSi>^- 
 
 Fig. 161. — Appearance of properly adjusted diaper which has been 
 folded longitudinally. 
 
 it has the opposite tendency. A tight band may give pain or 
 discomfort and even cause colic or vomiting. 
 
 The knitted band is usually worn for three or four months, 
 particularly in cold weather, to provide a little extra warmth 
 
NURSING CARE OP AVERAGE NEW-BORN BABY 475 
 
 over the abdomen. Thin, delicate babies sometimes need this 
 band for a year or more. 
 
 The diapers should be of soft, absorbent material, of a loose 
 weave, such as cheese cloth, bird's-eye, stockinette, thin Turk- 
 ish towelling or outing flannel ; should be 18 or 20 inches square 
 and hemmed. There are two methods of putting on the diaper. 
 One is to fold the square diagonally and bring the diagonal fold 
 around the baby's waist. One of the lower corners is drawn up 
 between the thighs, the two corners from the sides brought over 
 this and the fourth corner brought up over tiiese and all pinned 
 securely with a safety pin. (Fig. 160.) Small safety pins hold 
 the margins together above the knees. The other method is to 
 fold the diaper straight through the centre, forming a rectangle, 
 twuce as long as it is wide; lay the baby on it lengthwise, draw 
 it up betw^een his thighs and pin it on each side at the waist line 
 and above the knees. (Fig. 161.) 
 
 In either case the diaper must be put on smoothly and care 
 taken to avoid forming a thick pad between the thighs as this 
 will tend to curve the bones of the legs. Squares of soft, ab- 
 sorbent material, which may be burned, placed inside the diapers, 
 will greatly facilitate the laundry work. In some hospitals a 
 very soft absorbent paper is used for this purpose, sometimes 
 being covered with gauze. 
 
 The baby's diaper should be changed whenever it is wet or 
 soiled, for in addition to making him restless and fretful for the 
 time being, the skin about the thighs and buttocks will grow red 
 and chafed if he is allowed to wear wet diapers. Wet diapers 
 should not be dried and used again but washed with a mild soap, 
 boiled and whenever possible, dried in the open-air and sun- 
 shine. 
 
 All of this makes it apparent that the regular use of water- 
 proof protectors cannot l)e justified since tiie chief reason for 
 putting them on a baby is to avoid tiie necessity of changing 
 his diaper as soon as it is wet. Under special circumstances such 
 as a drive, a short journey or visit the diaper may be protected 
 by water-proof drawers. Their habitual use saves work for the 
 nurse but makes the baby uncomfortable and unhappy. 
 
 The petticoat should be of light-weight, cotton and wool flan- 
 
476 OBSTETRICAL NURSING 
 
 nel, cut after the familiar Gertrude pattern and hang straight 
 from the shoulders. It may fasten in the back or on the shoul- 
 ders, with small buttons or with tapes. Tapes are often objected 
 to on the ground that the baby tangles them up with his fingers, 
 which annoys him, and often puts them in his mouth. This 
 petticoat is worn practically all the time, except during very 
 warm weather. 
 
 The slips or dresses are most satisfactory if cut after the 
 same pattern as the petticoat, with the addition of sleeves which 
 may be set in, or of the kimono style. The dresses serve chiefly 
 to keep the petticoats clean and make the baby look dainty, and 
 are accordingly made of soft cotton material such as nainsook, 
 cambric or lawn. In summer, it is true, the petticoat is often dis- 
 carded and the thin slip put on over the shirt and diaper. 
 
 The night gowns are made like the dresses but are of soft 
 flannel or stockinette, in cold weather, and tape is often run 
 through the hems in order that they may be drawn up, bag- 
 fashion, to keep the baby's feet warm. During very warm 
 weather the baby sleeps in a thin cotton slip. 
 
 In addition to these garments there are many times when a 
 soft little sacque or wrapper is used to keep the baby warm, and 
 one or two flannel squares (one yard), to wrap around him when 
 he is carried about the house are practically indispensable. 
 
 The petticoats, dresses and night gowns are cut about twenty- 
 seven inches long and many doctors feel that thej^ offer sufficient 
 protection for the feet of the average baby to make stockings un- 
 necessary until he is from four to six months old. The skirts 
 may then be shortened to ankle length and stockings added to 
 the little wardrobe. Some doctors think it wiser to put knitted 
 socks or part wool stockings on the new baby particularly if he 
 is born during cold weather. 
 
 When the baby begins to creep, he should wear soft soled 
 shoes, part wool stockings in cold weather and thin cotton or silk 
 ones during the summer, and firm but flexible soled shoes as soon 
 as he tries to stand alone or to walk. 
 
 During the first month or two, the baby scarcely needs spe- 
 cial clothing for out-door wear, as he may be warmly wrapped in 
 one of the flannel squares by being placed on it diagonally, the 
 
NURSING CARE OF AVERAGE NEW-BORN BABY 477 
 
 upper corner folded about his head to form a hood and held under 
 his chin with a safety pin. The corners on the siih's are folded 
 about his shouhh'rs, tlie h)wer one br()Uf>iit up over his feet and 
 limbs and tlic achlilional hhtiikcts tucked in over all. \\\\\ as he 
 grows older and moves about in his carriage, lie will need a cap 
 and cloak or wrap with hood attached. In cold weather the cap 
 should be knitted or wool lined and tiie cloak of soft woolen 
 material or wool lined. In moderate weather the cap may be 
 of one thickness of cotton or silk, or very light flannel, wliile on 
 very warm days he will need no head covering. 
 
 To sum up: The baby's clothes should be simple in design, 
 hang from the shoulders, fit smoothly but loosely and have no 
 constricting bands; they should be soft, light and porous, their 
 warmth always adjusted to the immediate temperature so that 
 the baby will be protected from being either chilled or over- 
 heated. And his clothing must always be clean and drj'. 
 
 Fresh Air. An abundance of fresh air is one of the baby's 
 greatest needs as it increases his resistance and recuperative 
 powers, improves his appetite and aids digestion. In general, 
 the more the baby is in the open air and the more fresh air he 
 has while in the house, the better. 
 
 The two factors which must be considered in supplying the 
 baby with fresh air are the condition and vigor of the baby him- 
 self and the immediate temperature and state of the weather. 
 His age and the season of the year can be only partial guides be- 
 cause of the difference betw'een individual babies of the same age 
 and the variations in temperature, winds and moisture during 
 any one season. 
 
 The air of the room which the baby occupies should be 
 changing constantly in order that it may always be fresh, but the 
 temperature should be equable and the baby protected from 
 drafts. As the tendency here, as with the baby's clothes, is 
 toward overheating, the nurse will do well to remember that the 
 new baby who lies covered up in his crib, may usually be kept 
 in a colder room than is advisable for an older one who is creep- 
 ing or walking about. 
 
 During cold weather the baby's bed should not be directly 
 in front of an open window and he should be protected from 
 
478 OBSTETRICAL NURSING 
 
 direct currents of cold air by a sheet hung over the head and 
 side of his crib. (See Fig. 153.) 
 
 Two or three times daily, while the baby is out of the room, 
 the windows should be opened wide to air the room thoroughlj^, 
 one of these airings being just before the baby is put to bed for 
 the night. 
 
 The usual instructions concerning the temperature of the 
 nursery are to keep it from 68° F. to 70° F. during the day and 
 about 65° F. at night, during the first three months and lower 
 it gradually to 64° F. during the day and about 55° F. at night 
 as the baby grows older. It is customary to begin to open the 
 nursery window at night when the baby is three or four months 
 old, if he is well and the temperature is above freezing. 
 
 In planning to take the baby out-of-doors it is wiser, as a rule, 
 to begin with the indoor airing when he is about a month old, 
 except, of course, during the moderate or mild months of the 
 year, when he is taken out at once. If the weather is cold, the 
 baby may be protected with extra wraps and carried in the 
 nurse's arms, into a room in which the windows are open and 
 kept there for fifteen or twenty minutes. This indoor airing is 
 increased by being gradually lengthened to two or three hours 
 and by having the windows opened wider and wider. By the 
 time he is two or three months old he is taken out of doors on 
 clear, bright days, the best time being between ten and three 
 o'clock, when the sun is high. If he is carried in the nurse's 
 arms at first the warmth of her body serves as a protection and 
 helps to accustom him to the out-of-door life, .when he spends 
 a good deal of his time out of doors in his carriage. 
 
 On windy, stormy days or when there is melting snow on 
 the ground the baby may be given his airing on a protected 
 porch or in a room with the windows open. He is not usually 
 taken out if the temperature is below freezing until the third or 
 fourth month. After this time the average baby is taken out 
 when the temperature is not lower than 20° F. 
 
 When the baby is dressed in his extra wraps he must be taken 
 out of doors or the windows opened immediately, for otherwise 
 he will become overheated and be in danger of chilling when 
 taken into the colder air. 
 
NURSING CARE OF AVERAGE NEW-BORN BABY 479 
 
 Warm hands and feet, a good color and the baby's tendency 
 to sleep most of the time while out-of-doors are evidences of his 
 being adequately clothed for his airing, while the reverse is true 
 if he is not warm enough. 
 
 A robust baby who has been gradually accustomed to l)eing 
 out-of-doors during the day will usually be much benefited by 
 sleeping out at night. But he must be protected from winds and 
 his clothing so arranged that he cannot be chilled. Kiutted or 
 flannel sleeping garments or sleeping bags (See Fig. 159) are 
 
 I 
 
 ^ 
 
 Fig. 162. — Sutton poncho which keeps the baby warm by covering all 
 but his head. The insert shows slit for his head. The regular bedding is 
 temporarily turned back in this picture. (From photograph taken at 
 Bellevue Hospital.) 
 
 valuable and in addition, the blankets which cover the baby 
 should be securely pinned to the mattress with safety pins and 
 tucked well under it at the sides and foot. The baby should 
 wear a warm cap and the bed should be warmed before he is put 
 into it. Or better still, he may be dressed for the night, put 'to 
 bed in a warm room and the crib then moved out on the sleeping- 
 porch. 
 
 An excellent device for protecting the baby's arms and chest 
 
480 OBSTETRICAL NURSING 
 
 and keeping him generally well covered is the poncho (Fig. 162) 
 devised by Dr. Lncy Porter Sntton of Bellevue Hospital. The 
 poncho is a rectangle made of flannel, outing flannel or an old 
 blanket and cut large enough to tuck well under the liead and 
 sides of the mattress and extend below the babj^'s feet. The 
 baby's head slips through an opening, which is almost a right- 
 angled slit, near the centre of the poncho and about 20 inches 
 from the top. The slit is firmly bound and provided with tapes 
 to tie it together after the baby is put in. The poncho should be 
 put on loosely enough to permit the baby to move about at will 
 beneath it. After it is adjusted the bed is made up as usual 
 with additional blankets. 
 
 Under all conditions the baby's airings must be increased 
 gradually, both as to lowering the temperature and lengthening 
 the time, and always adjusted to the vigor and reaction of the 
 individual baby. He must be warm, but not too warm ; he must 
 be protected from wind and dust, and his eyes shielded from 
 glare and from flickering light such as may be caused by a tree 
 in a light breeze. 
 
 Exercise. Although the baby should not be handled unnec- 
 essarily nor tossed about and played with by friends and rela- 
 tives, it is important that his muscular development be promoted 
 by regular and carefully planned exercise. It is usually consid- 
 ered best for the baby to lie quiet and undisturbed in his crib 
 most of the time during the first three or four weeks. Dr. Grif- 
 fith begins the baby's exercise about that time by having the 
 nurse take him in her arms on a pillow and carry him about for 
 a few moments, several times daily. After a week or two of this 
 form of exercise, the nurse carries the baby without a pillow 
 but supports his head and back. 
 
 The position of the baby's body is changed by being carried 
 about in this way, while the movement of the nurse as she walks 
 about causes a certain amount of motion of the baby's muscles, 
 constituting a gentle exercise. 
 
 This exercise, in the form of picking up and carrying about 
 is regarded by many pediatricians as of great importance. There 
 is a possibility that lack of this form of "mothering" is one rea- 
 son why babies in hospital practice sometimes fail to progress 
 
NURSING CARE OF AVERAGE NEW-BORN BABY 481 
 
 as they should. Certainly lying too long in one position is 
 harmful. The nurse should carry the baby first on one arm and 
 then on the other in order that both sides of his body may be 
 equally exercised. By the third or fourth month he sits up in 
 her arms as she carries him about, and he may be placed on the 
 outside of his crib coverings for a little while every day, to kick 
 and struggle at will. His skirts should be rolled up under his 
 shoulders, or removed entirely, to leave his legs quite free, care 
 being taken that the room is warm and that he has on stockings. 
 
 Fig. 163. — A comfortable position for the baby being trained to use 
 chamber. 
 
 By about the sixth month he will usually begin to make an 
 effort to creep, if turned over on his stomach and helped a little, 
 and he may be propped up in the sitting position, in his crib, 
 for a few moments every day. As he gives evidence of having 
 enough energy to creep farther than the size of his crib permits, 
 he may be put into a creeping-pen, or upon the floor under cer- 
 tain conditions. It must be remembered that the floor is likely 
 to be cold, drafty and dusty. The nurse must assure herself, 
 therefore, that the floor is warm; must cut off all drafts and 
 spread a clean sheet or quilt on the floor before the baby is put 
 down to creep. When the sheet is taken up, it is folded with the 
 upper surface inside in order that when it is again put down the 
 
482 OBSTETRICAL NURSING 
 
 baby will play on the clean side and not on the side that has been 
 next the floor. 
 
 A ereeping-pen or cariole or some such provision is often more 
 satisfactory than the floor, consisting as it does of a railed-in 
 platform raised about six or eight inches from the floor. 
 
 The suggestions for exercise, like those for the baby's airing, 
 must be very general since it must always be adjusted to the 
 powers of the individual baby and under the doctor 's supervision. 
 
 TRAINING THE BABY 
 
 Bowels. It is possible to train even a very young baby to 
 have regular daily bowel movements; this training should be 
 started when the baby is about a month old. At the same hour 
 each day he may be laid on a padded table, or taken in the 
 nurse 's lap, a small basin being placed against or under the but- 
 tocks, and a soap stick introduced an inch or two into the rec- 
 tum and moved gently in and out. This slight irritation will 
 usually result in the baby's emptying his bowels almost immedi- 
 ately. Or he may be held on a small chamber on the nurse's 
 lap, in a comfortable reclining position (Fig. 163) or with his 
 back supported against her chest, and the desire to empty the 
 bowels stimulated by using the soap stick. 
 
 It is of greatest importance that the position and method 
 which are adopted, be employed at exactly the same time each 
 day. If this is done, and the baby is being properly fed, it will 
 usually be found that, before he is many months old, his bowels 
 will move freely and regularly without the stimulation of the 
 soap stick and only when he is resting on the small basin or 
 chamber. This establishment of a regular bowel movement not 
 only simplifies the laundry work but is of great moment to the 
 baby's health. 
 
 Thumb-Sucking. It is scarcely necessary to remind a nurse 
 that the baby must not be allowed to suck on an empty bottle or 
 a pacifier nor be permitted to suck his thumb. The habits are 
 very dirty and help to spread infections. The baby may swallow 
 air while practicing them, with colic as a result, and he may so 
 deform the shape of his upper jaw that, later in life, the upper 
 and lower teeth will not meet as they should when he masticates ; 
 
NURSING CARE OF AVERAGE NEW-BORN BABY 483 
 
 his front teeth may protrude in a disfiguring manner; and by 
 narrowing and elongating the roof of his mouth the structure 
 of the air passages is altered, with respiratory troubles and ade- 
 noids as a frequent consequence. Thumb-sucking may be pre- 
 vented by the simple procedure of putting stiff cuffs on the 
 baby's elbows (Fig. 164) which make it impossible for him to 
 reach his mouth with his thumb. These cuffs may be made by 
 covering pieces of cardboard with muslin and attaching tapes 
 with which to tie them on the baby's arms. His hands may be 
 
 Fig. 164. — Stiff cuffs to prevent thumb sucking. 
 taken at Johns Hopkins Hospital.) 
 
 (From photograph 
 
 put into celluloid or aluminum mitts, or little bags made of stiff, 
 heavy material, which in turn are tied to his wrists, or his sleeves 
 may be drawn down over his hands and sewed or pinned with 
 safety pins. It should be borne in mind that a baby sometimes 
 sucks his thumb because he is hungry or thirsty and gives up the 
 practice when his food is increased or when he is regularly given 
 water to drink. 
 
 Eax Pulling is not uncommon among young babies and if 
 allowed to continue a long, mis-shapen ear may result. This may 
 be prevented by using a thin, close fitting cap which ties under 
 
484 
 
 OBSTETRICAL NURSING 
 
 the chin, or by using the same kind of elbow splints as for thumb- 
 sucking. 
 
 Crying. It is very easy to allow the baby to develop the 
 crying habit, but very difficult to break it up. A baby who is 
 properly fed, kept dry and warm but not too warm, and whose 
 clothes are comfortable will usually cry very little if wisely 
 
 handled. But a baby may cry be- 
 cause he is hungry, thirsty, wet, cold, 
 over-heated, sick or in pain or simply 
 because he wants to be taken up and 
 entertained and has learned that the 
 w^ay to realize his wish is to cry. By 
 closely observing the baby's habits 
 and his condition the nurse will usu- 
 ally be able to ascertain the cause of 
 the crying. Very often a drink of 
 fairly warm, sterile water will quiet 
 him, particularly at night. But both 
 the nurse and the mother should re- 
 frain from taking the crying baby up 
 and carrying him or holding him 
 when it is discovered that this atten- 
 tion stops his crying. Persistent cry- 
 ing should always be reported to the 
 doctor, as it may have serious significance. 
 
 Ruminating. Some babies have the habit, called "ruminat- 
 ing," of bringing up food; chewing it; moving it about and 
 finally rolling it out of their mouths. AltTiough this habit has 
 not been recognized until comparatively recently, it is now be- 
 lieved to be of fairly common occurrence and often mistaken for 
 vomiting. It is seen as a rule in precocious babies who take 
 more interest in their surroundings than the average, more 
 placid infant, beginning very early to fix their attention upon 
 light, sounds and moving objects. The ruminator begins by 
 bringing up a small amount of his last nourishment, then a little 
 more and a little more until finally he has brought up nearly or 
 quite all of it, apparently deriving a certain amount of pleasure 
 and satisfaction from the procedure. Quite obviously, a contin- 
 
 FiG. 165. — Cap, to prevent 
 ruminating. (Devised by 
 Miss Hammer.) 
 
NURSING CARE OF AVERAGE NEW-BORN BABY 485 
 
 uation of this practice results in undernourishment, sometimes 
 even starvation, since the baby actually retains very little if any 
 of his food. As liquids come up more easily than solids, the 
 first step t()wai-(l breaking up this habit is usually to give the baby 
 more solid and concentrated food than he has been taking and 
 to carry him about, talk to him and entertain him for about an 
 hour after feedings, for if his attention is otherwise engaged, he 
 
 Fig. 166. — Runiinatiug cap applied. (From photograph taken at Johns 
 Hopkins Hospital.) 
 
 is not likely to ruminate. Another efficacious measure is the use 
 of a cap (See Pig. 165) so constructed and tied under his chin 
 that the baby's jaws are held tightly together and he is unable to 
 make the movements which are necessary to rumination. (Fig. 
 166.) 
 
 FEEDING THE BABY 
 Proper feeding is probably the most decisive single factor in 
 the routine care of the baby. 
 
486 OBSTETillCAL NURSING 
 
 In order that the food be satisfactory it must be not only 
 suitable in composition for the individual baby, but it must be 
 clean, fresh and at the right temperature; given in suitable 
 amounts and at suitable and regular intervals; it must be given 
 properly — not too fast nor too slowly and it must be given under 
 favorable conditions. 
 
 Moreover, the baby himself must be kept in a general condi- 
 tion which will favor the digestion and assimilation of the food 
 that is given to him. Fresh air, suitable clothing, an even body 
 temperature, gentle handling, proper bathing, regular sleep, 
 freedom from excitement, fatigue and irritation, all promote the 
 baby's ability to use his food to advantage. Reverse influences 
 all work against it. 
 
 The character, amount and intervals of the baby 's feeding are 
 definitely ordered by the doctor, but the many factors which in- 
 fluence the baby's nutrition are so largely a matter of nursing 
 that the nurse has grave responsibilities in connection with his 
 nourishment. 
 
 After other conditions have been made favorable, the factors 
 which determine the character of the baby's food are the kind 
 and amount of food materials which are needed by his growing 
 body and the powers of his digestive organs. If he is given less 
 food than he needs at each stage of his progress he will not be 
 properly nourished ; but if he is given food materials in quan- 
 tities, proportions or character which are beyond the power of 
 his immature alimentaiy tract to digest, he not only will not be 
 properly nourished but probably will be made ill. 
 
 There are three methods of nourishing the baby : breast feed- 
 ing, artificial feeding and a combination of the two, termed 
 mixed or supplementary feeding. 
 
 Breast Feeding. From all standpoints, maternal nursing 
 under normal conditions is the most satisfactory method of inf ani 
 feeding. If the breast milk is suitable it meets all of the babj^'s 
 requirements and the proportion and character of its constitu- 
 ents are exactly suited to his digestive powers. 
 
 In order that the nursing be entirely satisfactory, the con- 
 dition of both mother and baby must be favorable to its success. 
 The preparation and care of the mother have been described : her 
 
NURSING CARE OF AVERAGE NEW-BORN BABY 487 
 
 general condition and state of nutrition ; the care and condition 
 of her nipples, flat or retracted nipples being brought out if 
 possible, and if not, the nursing facilitated by the use of a shield. 
 If the baby's diaper is wet or soiled, it should be changed before 
 he is put to the breast, partly to make him comfortable and partly 
 to avoid disturbing him after his feeding. His mouth is gently 
 
 Fig. 167. — Proper method of carrying baby to support head and back. 
 (From photograph taken at Johns Hopkins Hospital.) 
 
 swabbed with boric soaked cotton, if this is ordered, he is wrapped 
 in a little blanket and carried to his mother dry and warm and 
 comfortable. (Fig. 167.) Although nursing is an instinct, the 
 baby sometimes has to learn or to acquire the habit which is 
 one reason for putting him to the breast during those first two 
 or three days when he obtains little or no actual food. (See 
 Chapter XVI.) As he expresses the milk by a squeezing and sue- 
 
488 OBSTETRICAL NURSING 
 
 tion made possible only when the nipple is well back in his 
 mouth, he must take into his mouth practically the entire pig- 
 mented area which surrounds the nipple. To do this he lies in 
 the curve of his mother's arm as she turns slightly to one side, 
 and holds her breast away from his nostrils in order that he may 
 breathe freely. 
 
 Sometimes even when other conditions are favorable, the 
 baby is unable to nurse because of some physical disability. He 
 may be too feeble; have a cleft palate or find suckling painful 
 because of an abrasion of the mucous membrane which occurred 
 when his mouth was bathed just after birth. The manner in 
 which the baby nurses, therefore, may be significant and should 
 be carefully noted and described to the doctor. 
 
 There is a difference of opinion among doctors concerning 
 the interval between feedings which is most satisfactory. Some 
 have the baby nurse every four hours and others every three 
 hours during the early months of life. It is believed by some 
 doctors that although a baby who is fed on a four-hour schedule 
 may regain his birth weight more slowly than the baby who is 
 fed every three hours, he suffers less from digestive disturbances 
 and ultimately makes an entirely satisfactory gain in weight. 
 Another point in favor of the four-hour interval is the longer 
 period of freedom which this gives to the mother and this may 
 influence her willingness to nurse her baby. But other doctors, 
 both pediatricians and obstetricians, feel that the four-hour in- 
 terval is too long for most babies. 
 
 Whether the baby shall nurse from one or both breasts at each 
 feeding is another moot question. Some doctors believe that the 
 results are better if both breasts are partially emptied at each 
 nursing, while others feel that the function of the breasts is more 
 satisfactorily promoted by completely emptying one breast at a 
 time, at alternate nursings. Although the baby should pause 
 every four or five minutes to prevent his nursing too rapidly, 
 which is a common cause of colic, neither he nor his mother 
 shoul(f be allowed to sleep during the nursing periods. When he 
 has finished, he should be taken up very gently and placed in 
 his crib and left to sleep. If he is nursing satisfactorily, he will 
 be sleepy and contented after nursing and will sleep for two or 
 
NURSING CARE OF AVERAGE NEW-BORN BABY 489 
 
 three hours afterwards; he will seem generally good humored 
 and comfortable while awake; he will have good color; gain 
 weight steadily and have two or three normal bowel movements 
 daily. The normal stool in breast fed babies is bright yellow, 
 smooth and with no evidences of undigested food. 
 
 If he is not being adequately nourished, he will present ex- 
 actly the opposite picture, in some or all of these respects. He 
 will be unwilling to stop nursing after the normal length of time 
 and will give evidence of not being satisfied when taken from 
 his mother. He may be listless and fretful and sleep badly. He 
 will not gain weight as he should, and he may vomit or have 
 colic after nursing. 
 
 To ascertain whether or not such a baby is getting enough 
 milk it is customary to w^igh him, without undressing him, 
 before and after each nursing. Each fluid ounce of food will in- 
 crease his weight one ounce. If the baby is not getting a normal 
 amount of milk at each nursing he is often given enough modi- 
 fied milk after each meal to supply the deficit, but at the same 
 time an effort is made to increase the supply of breast milk by 
 improving the mother's personal hygiene. 
 
 The amount which the baby needs at each feeding varies, not 
 only according to his weight and age, but also according to his 
 vigor and activity, and must always be figured for the individual 
 baby. A very general estimate of the amount taken by the aver- 
 age well baby at each feeding, is about as follows : 
 
 First week li/^ to 2I/2 ounces 
 
 Second and third week 2 to 4 ounces 
 
 Fourth to ninth week 3 to 4i/^ ounces 
 
 Tenth week to fifth month 3I/2 to 5 ounces 
 
 Fifth to seventh month 41/2 to 6i/^ ounces 
 
 Seventh to twelfth month 6^/2 to 9 ounces 
 
 Artificial Feeding. There is no entirely adequate substitute 
 for satisfactory maternal nursing, and any other food that is 
 given to the young baby is at best a makeshift. Considering the 
 baby's delicacy, therefore, and his urgent needs, no pains should 
 be spared to make any artificial food which is given to him as sat- 
 isfactory as possible. In preparing and giving artificial food 
 it must be borne in mind that normal breast milk : 
 
490 OBSTETRICAL NURSING 
 
 1. Is exactly right in quantity, quality and proportion. 
 
 2. Is fresh, clean and sweet. 
 
 3. Is free from bacteria. 
 
 4. Tends to protect the baby from infection. 
 
 5. Definitely protects him from certain nutritional diseases. 
 
 Cows' milk, suitably modified, is apparently the best available 
 substitute for mother's milk, but it must first meet certain re- 
 quirements and then be handled with scrupulous cleanliness and 
 care, if it is to be at all satisfactory. 
 
 The requirements are that the milk shall be : 
 
 1. Whole milk. It must not be altered by the removal of cream 
 nor the addition of such preservatives as salicylic acid, formalde- 
 hyde or boracic acid. 
 
 2. Its composition must not vary greatly from day to day. 
 
 3. It must be clean and free from disease germs; other organisms 
 should not be present in excessive numbers. 
 
 4. It must be fresh : less than 24 hours old when it is delivered. 
 
 All of this means that the milk must come from a herd of 
 healthy, tuberculin-tested cows. The milk from a single cow 
 may vary markedly from day to day but that from several cows 
 is nearly constant. The stables and the cows must be kept clean, 
 the udders carefully washed before each milking; the milkers 
 themselves must wear freshly washed clothing, scrub their hands 
 thoroughly and milk into sterile receptacles; the milk must be 
 immediately covered and cooled to a temperature of 45° F. or 
 50° F. and kept there. 
 
 Milk produced under such conditions is usually described as 
 "certified milk" and is often prescribed as infant food without 
 being pasteurized or sterilized. But if there is any doubt about 
 the source of the milk and the method of its handling, it should 
 be strained into a clean receptacle through filter paper or a thick 
 layer of absorbent cotton and subsequently boiled or pasteurized. 
 
 When the nurse is in a position to offer advice about the 
 baby 's milk she must explain the importance of always obtaining 
 the freshest, cleanest and purest milk possible, no matter what 
 it costs. 
 
 Whether certified or not the milk must always be placed in the 
 refrigerator or some other place at a temperature of 50° F, as 
 
NURSING CARE OF AVERAGE NEW-BORN BABY 491 
 
 soon as it is received and it mnst he kept cool and clean. 
 Mother's milk, which is being imitated, is clean and sweet and 
 free from disease germs. 
 
 Keeping the milk cool means keeping it at a temperature of 
 50° F. Keeping it clean implies cleanliness of the milk itself, the 
 utensils, the nurse's hands and the destruction, by sterilization 
 or pasteurization, of disease germs. Those which are likely to be 
 present in infected milk are streptococci, tubercle bacilli, colon 
 bacilli, germs of typhoid, diphtheria and scarlet fever. 
 
 The amounts and proportions of the constituents of the sub- 
 stitute feeding will be specified by the doctor, as well as the in- 
 tervals between feedings and the amount to be given each time. 
 But the doctor's careful adjustment of the milk formula to the 
 baby's immediate needs and digestive powers will be set at 
 naught unless the nurse is absolutely accurate in preparing and 
 giving the milk. 
 
 The nurse 's invariable responsibility, therefore, is to keep the 
 milk cool and clean and prepare and give it accurately. 
 
 The nurse will appreciate the necessity and principles of 
 modifying cows' milk for the human infant if she will consider 
 for a moment, the differences between mother's milk and cows' 
 milk, as indicated by the following table, and the reasons for 
 these differences: 
 
 Mother's Milk. Cows' Milk. 
 
 Fats 3.5 to 4. % 3.5 to 4. % 
 
 Sugar 6.5 to 7.5% 4.5 to 4.75% 
 
 Proteins 1. to 1.5% 3.5 to 4. % 
 
 Salts .2% .7 to .75% 
 
 Water 87 to 88. % 87. % 
 
 It will be remembered that the tissues and bony skeleton are 
 built by the proteins and salts (lime and phosphorus). Ac- 
 cordingly Nature supplies these in greater abundance to the 
 calf, who grows so fast as to double his birth weight in about 
 47 days, than to the baby who scarcely doubles his within 180 
 days. The calf begins life with a physical need for the abun- 
 dance of proteins and salts which are present in cows' milk, and 
 with digestive organs that can cope with them, but the baby 
 needs less, can digest less and therefore must be given less. 
 
492 OBSTETRICAL NURSING 
 
 There are, of course, other and finer differences between the two 
 milks and an attempt is sometimes made to meet these. For 
 example, mother's milk is slightlj^ alkaline and cows' milk 
 slightly acid and the curd of cows' milk is larger, tougher and 
 harder to digest than that formed by mother's milk. Accordingly 
 some doctors add lime water to cows' milk to make it alkaline, 
 and render the curd softer, finer and more digestible by boiling it. 
 
 It is often not possible to give a bottle-fed baby the full 4% 
 of fat which mother's milk contains, and some doctors make 
 the protein of the artificial mixture very much larger in amount 
 than is found in human milk. The nurse will see that this is a 
 matter which can be decided only by the physician. 
 
 Articles Needed in Preparing the Baby's Food. A complete 
 equipment for preparing and giving the baby's milk should be 
 assembled, kept in a clean place, separate from utensils in gen- 
 eral use, and never put to any other service. A satisfactory 
 outfit for this purpose comprises the following articles: 
 
 One dozen graduated niu'sing bottles. 
 
 One dozen nipples. 
 
 Clean, new corks or a package of sterile, non-absorbent cotton for 
 stoppers. 
 
 Bottle brush. 
 
 Covered kettle, capacity one gallon, for boiling bottles and possibly 
 pasteurizing milk. 
 
 Pasteurizer or wire bottle rack. 
 
 Small kettle, about one quart size. 
 
 Graduated pint or quart measuring glass. 
 
 Pitcher, two quart size. 
 
 Long-handled spoon for mixing. 
 
 Funnel. 
 
 Measuring spoons — table and tea sizes. 
 
 Double boiler. 
 
 Thermometer which will register at least 212° F, 
 
 Cream dipper (if ordered). 
 
 Two small covered jars for sterile and used nipples. 
 
 Sugar (lactose, maltose or cane sugar according to orders). 
 
 Lime water, if ordered. 
 
 Utensils of enamel or aluminum ware are probably the most 
 satisfactory ones to use as they are easily kept clean, while bot- 
 tles with wide mouths and curved bottoms and inner surfaces 
 
NURSING CARE OF AVERAGE NEW-BORN BABY 493 
 
 can be thoroughly washed more easily than those with small 
 necks and sharp corners. Nipples that can be turned inside out 
 to be washed should be selected as it is almost impossible to clean 
 thoroughly those with tubes or narrow necks. New bottles will 
 be rendered less breakable if placed in cold water, which is 
 gradually heated, allowed to boil for half an hour and cooled 
 before the bottles are removed. 
 
 The bottles should be rinsed with cold water after each feed- 
 
 FiG. 168. — Preparing the baby's milk. (From photograph taken at 
 Johns Hopkins Hospital.) 
 
 ing and then carefully washed and scrubbed with the bottle 
 brush in hot soapsuds or borax water, containing tAvo table- 
 spoonsful to the pint. They may be kept full of water while 
 not in use or rinsed with hot water and stood upside down until 
 they are all boiled on the following morning, preparatory to 
 being filled with the freshly prepared milk. The baby 's bottles 
 should never be washed in dishwater nor dried on a towel. The 
 nipples should be rinsed in cold water, turned inside out and 
 
494 OBSTETRICAL NURSING 
 
 scrubbed with a brush, in hot soapsuds or borax water; rinsed 
 and placed in a jar ready to be boiled with the bottles. 
 
 Preparation of Milk. The full quantity of milk which the 
 baby will take in the course of twenty-four hours is prepared 
 at one time and the prescribed amount for each feeding poured 
 into as many separate bottles as there will be feedings. (Fig. 
 168.) 
 
 The nurse should first boil for five minutes all of the articles 
 that will come in contact with the milk, including the full num- 
 ber of bottles and nipples and the jars in which the nipples are 
 kept; remove them with the long-handled spoon without touch- 
 ing the edges or inner surfaces and place them on a clean table, 
 dropping the nipples into one of the sterile jars. 
 
 She should wash the mouth of the milk bottle before remov- 
 ing the cap and pour the amount which the formvda calls for 
 into the sterile pitcher. To this is added the sterile water in 
 which the sugar has been dissolved in the glass graduate, and 
 the potato or barley water, the lime water or soda solution as 
 ordered. This mixture is thoroughly stirred and the amount 
 for one feeding at a time measured in the graduate and poured 
 into the specified number of bottles which are then stoppered. 
 
 If certified milk is used for the milk mixture it is often given 
 to the baby without being pasteurized, in which case the bottles 
 are placed in the refrigerator as soon as they Lre filled and stop- 
 pered. Very frequently, however, the milk is sterilized or 
 pasteurized. The nurse will feel surer of keeping the mouths 
 of the bottles clean if she covers them with squares of gauze or 
 muslin before they are sterilized, holding the caps in place with 
 tapes or rubber bands. Pasteurization as applied to infant feed- 
 ing consists of heating the milk to 140-165° F. and keeping it at 
 that temperature 20 to 30 minutes. 
 
 There are many excellent pasteurizers for home use on the 
 market, or entirely satisfactory results may be obtained by using 
 a wire bottle rack (See Fig. 168) and the large kettle already 
 provided. One method is to place the rack containing the bottles 
 in the kettle which is filled with cold water to a level a little 
 above the top of the milk in the bottles, and allow the water to 
 come to the boiling point. The kettle is removed from the fire, 
 
NURSING CARE OF AVERAGE NEW-BORN BABY 495 
 
 covered tightly and the bottles allowed to stand in the hot water 
 for twenty miiiutos. Cold water is then run into the kettle to 
 cool the milk gradually and avoid breakinj^ the bottles, after 
 which they are placed in the refrigerator, well or spring-house 
 and kei)t at a temperature of 50° F. until they are taken out one 
 at a time for feedings. If a wire rack is not available the bottles 
 may be stood on a saucer or a thick pad of folded newspapers 
 in the bottom of the kettle. 
 
 Pasteurization does not destroy all germs that may be in 
 the milk, but it kills the more important ones and apparently 
 impairs the nutritive and protective properties of the milk less 
 than boiling. However, pasteurized milk must be kept cold and 
 must be used within twenty-four hours, for the nurse will recall 
 that aging of milk is quite as undesirable as souring. 
 
 Scalding is another method of destroying germs in milk. 
 The milk is placed in an open vessel and the temperature raised 
 to about 180° F., or until bubbles appear around the edge and 
 the milk steams in the centre, after which it is cooled and kept 
 at a temperature of 50*^ F. 
 
 Many doctors prefer to have the baby's milk boiled, since 
 boiling insures absolute sterilization and also renders the curd 
 more digestible. Other changes are produced by boiling, how- 
 ever, which make it important to add an anti-scorbutic and cod- 
 liver oil to the baby's diet at an early date. 
 
 Milk may be boiled directly over the flame for a time varying 
 from three to forty-five minutes, or it may be placed in a double 
 boiler, the water in the lower receptacle being cold, and allowed 
 to remain until the water has boiled from six to forty-five min- 
 utes. All of these points are definitely specified by the doctor. 
 
 When milk is boiled or scalded the other ingredients are 
 added beforehand, as a rule, after which it is measured and 
 poured into the bottles. Or the milk mixture may be poured 
 into the bottles as for pasteurization and the bottles kept in the 
 actively boiling water for any desired length of time. 
 
 Giving the Baby His Bottle. At feeding time, th» bottle 
 should be taken from the refrigerator, the stopper removed and 
 a nipple taken up by the margin and put on the bottle without 
 touching the mouthpiece. The milk is brought to a temperature 
 
496 
 
 OBSTETRICAL NURSING 
 
 of about 100° F. by standing the bottle in a deep cup or kettle 
 of warm water and placing it on the fire. The temperature of 
 the milk may be tested by dropping a few drops on the inner side 
 of the wrist or forearm where it should feel warm but not hot. 
 
 Fig. 169. — Proper position in which to hold baby and bottle during feeding. 
 
 This dropping will also indicate if the hole in the nipple is of 
 the proper size to allow the milk to drop rapidly in clean drops 
 but not to pour. If the hole is too small, the drops will be small 
 and infrequent and the baby will be obliged to work too hard 
 to obtain it ; while if the hole is too large the baby will feed to 
 rapidly and may have colic as a result. 
 
NURSING CARE OF AVERAGE NEW-BORN BABY 497 
 
 The baby's diaper should be changed if it is soiled or wet be- 
 fore he is given the bottle and he should be held comfortably 
 in a reclining position on the nurse's arm while she holds the 
 bottle with her free hand. (Fig. 169.) The bottle should be 
 
 Fig. 170. — Holding the baby iipriylit ami gently patting his back to 
 bring up air immediately after feeding. 
 
 inclined sufficiently to keep the neck full of milk ; otherwise 
 the baby may draw in air as he nurses. He should be kept awake 
 while feeding but he should be allowed to pause every three or 
 four minutes in order not to take his milk too rapidly. Not 
 less than ten nor more than twenty minutes is devoted to a feed- 
 ing, as a rule, and if the baby refuses a part of his milk, it should 
 be thrown away ; never warmed over for another time. 
 
 After being fed, the baby should be held upright against 
 the nurse's shoulder for a moment or two (Fig. 170), and ever 
 
498 OBSTETRICAL NURSING 
 
 so gently patted on the back to help bring up any air which he 
 may have swallowed. He should on no account be rocked or 
 played with after taking the bottle, but should be placed gently 
 in his crib, warm and dry and left alone to sleep. Turning him 
 or moving him about even to the extent of changing his diaper 
 at this time may cause vomiting. 
 
 The evidences of satisfactory and unsatisfactory feeding in 
 the bottle-fed baby are about the same as in the baby who is 
 fed at the breast, except that the gain in weight on artificial 
 food may be a little slower and less steady than on maternal 
 nursing; the stools have a characteristic sour odor; are a little 
 lighter in color and may contain white lumps of undigested 
 fat ; are usually dryer than in breast-feeding and may be formed 
 in even a very young baby. 
 
 It is fairly generally agreed that all babies, whether breast- 
 fed or on the bottle, require a certain amount of cool boiled 
 water to drink between feedings. A small amount is given at 
 first and gradually increased according to the doctor's instruc- 
 tions, and it may be given from a bottle, a medicine dropper or 
 poured slowly from the tip of a teaspoon. 
 
 Ingredients of the Baby's Food. In referring to the ingre- 
 dients of the baby's food we cannot use the terms "sugar" or 
 "milk" as though they indicated definite and unvarying mate- 
 rials. 
 
 There are three kinds of sugar which are commonly used 
 in modified milk: cane or granulated sugar; lactose or milk 
 sugar and maltose. Cane sugar, the one most widely used, is 
 the least expensive of the three and it apparently is satisfactory 
 for most babies. Lactose is fairly expensive and while it causes 
 diarrhea in some babies, others digest it more easily than cane 
 sugar. Lactose is lighter than cane sugar, three spoonfuls being 
 equal in weight to two of cane sugar. The maltose-dextrme 
 preparations are easily digested and somewhat laxative. Some 
 babies gain more rapidly when maltose constitutes part of the 
 sugar in their food than when only lactose is used. 
 
 The question of milk is somewhat complicated and though 
 the doctor will specify what percentage of fat shall be in the 
 milk which is used in each case, the nurse must know how to 
 
NURSING CARE OF AVERAGE NEW-BORN BABY 499 
 
 obtain it from the milk at ner disposal. If the formula is made 
 up with "whole milk," which contains 4 per cent, fat, the bottle 
 in W'hich it was delivered should be turned upside down and 
 shaken vigorously in order that the cream which has risen to 
 the top may be redistributed evenly throughout the fluid. 
 
 If the doctor employs what is termed "percentage feeding," 
 he may use whole milk, skimmed milk, or top milk. What he 
 is endeavoring to do is to prepare a food which contains definite 
 known percentages of the different ingredients, fat, carbohy- 
 drates and protein. Where a mixture is desired which contains 
 more fat than it docs protein, the milk to be employed is ob- 
 tained by discarding a certain amount from the bottom of the 
 jar of milk, the remainder being then called "top milk." When 
 he wishes the fat to be lower than the protein percentage, he 
 discards some of the top milk in the jar, using the rest, which 
 is then a partially skimmed milk. The upper 2 ounces in a 
 quart bottle of milk contains 24 per cent, fat ; the upper 8 ounces 
 is 12 per cent, fat; the upper 16 ounces is 8 per cent, fat and 
 the upper 24 ounces is 5 per cent. fat. If the formula calls for 
 6 ounces of the upper 8 ounces of milk, therefore, the nurse will 
 see that it is very important that she remove the full 8 ounces 
 and use 6 ounces of the milk which she has removed and not 
 simply take the upper 6 ounces, as this would contain a higher 
 percentage of fat than is ordered. (Figs. 171, 172, Dr. Griffith's 
 tables of fat percentages.) 
 
 Top milk may be removed by tipping the bottle gradually 
 and slowly pouring the designated amount into a measuring 
 glass, or it may be removed by pushing a cream dipper, especially 
 made for this purpose and holding one ounce, down into the 
 bottle until the cream flows in. Another method is to syphon 
 off the lower milk through a bent glass tube, leaving in the bottle 
 the desired amount of top milk. 
 
 Many doctors feed the baby according to his caloric needs 
 and prepare the formula from whole milk, sugar and water, 
 determining the amounts of each according to the age and weight 
 of the baby. 
 
 Under any condition it is so necessary that the amount and 
 composition of each baby's food be adjusted to his needs, that 
 
500 
 
 OBSTETRICAL NURSING 
 
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NURSING CARE OF AVERAGE NEW-BORN BABY 501 
 
 it is not considered possible to make out any formulae or feeding 
 schedules Avhich would be safe or satisfactory for general use. 
 Moreover, it does not ordinarily devolve upon the nurse to 
 do more than prepare and give the baby's food as ordered by 
 the doctor, but situations sometimes do arise when the doctor 
 
 Table Giving Approximate Percrntage- 
 Stuengtiis or Different Layers of Milk 
 
 
 
 ci 
 
 <U CIS 
 
 0; t- c 
 
 .2 
 
 
 
 . .24 
 
 4 
 
 4 
 
 6 tol 
 
 4 •' . 
 
 
 . .20 
 
 .5 tol 
 
 6 " . 
 
 
 ..16 
 
 4 
 
 4 tol 
 
 8 " . 
 
 
 ..12 
 
 4 
 
 3 tol 
 
 " 10". 
 
 
 .10 
 
 4 
 
 2..') tol 
 
 " 16 " . 
 
 
 .. 8 
 
 4 
 
 2 tol 
 
 " 20 " . 
 
 
 . 6 
 
 4 
 
 1.5 to 1 
 
 " 24 " . 
 
 
 
 4 
 4 
 
 1.25 to 1 
 
 1 "» 32 " 
 
 whole 
 milk 
 
 \ * 
 
 1 to 1 
 
 ■jower 30 " . 
 
 
 . 3 
 
 4 
 
 .75 to 1 
 
 " 28 " . 
 
 
 9 
 
 4 
 4 
 
 .50 to 1 
 
 " 16". 
 
 
 . 1 
 
 .25 to 1 
 
 " 8". 
 
 
 . o.s 
 
 4 
 
 .Otol 
 
 To Find the Amount of Any Layer op Milk 
 TO liE Used to Give Percentages Desired 
 
 Kiiuation : 
 
 Total amount of food X Per- 
 centaRe of fat desired 
 
 Amount of 
 r= tills milk in 
 Fat-strength of layer of milk u.sed (j,g mixture. 
 
 (1) Select from the "Layers of Milk" Table the 
 milk which possesses the desired ratio of 
 fat to protein. 
 
 (2) Substitute in the equation. 
 
 (3) As the sugar-percentage has been reduced 
 equally with that of the protein, add suffi- 
 cient sugar to raise to the desired per- 
 centage. 
 
 Example: 20-oz. mixture desired. Percentages 
 desired = Fat 3, Sugar 6. Protein 1. Use 
 upper 8 oz. (fat 12%, protein 4%, viz.: 
 
 20 X 3 
 3:1). Then " ^ .., — = 5 oz. of upper 8 oz., 
 
 with 15 oz. of water in the 20-oz. mixture. 
 The protein necessarily becomes 1%, and 
 the sugar likewise. The mixture already 
 containing 1% of sugar, add 5% of 20 oz., 
 i. e., 1 oz. of sugar to increase this to the 
 C% desired. 
 
 To Determine the Percentages Present in Any Milk-Mixture Already in Use 
 
 Quantity of substsance used (milk, cream, or skimmed milk) 
 
 X Its percentage-strength _ Percentage of element (F., 
 
 T^t^Quantity of Food «• or P.) in the mixture. 
 
 Example: The mother has mixed: Upper 8 oz. ; 6 oz. — Lower 8 oz. ; 3 oz. — -Milk-sugar 3 
 
 level tablespoonfuls. — Water 27 oz. Total quantity = 36 oz. The upper 8 oz. contains 
 
 12% fat (see Table). Both top and bottom milk contain 4% protein and sugar. 
 
 Three tablespoonfuls sugar ^ approximately 1 oz. The fat of the lower 8 oz. may be 
 
 ignored. Then — ;^ — "=■ 2 =Fat percentage from the top-milk. 
 
 36 
 
 percentage from the bottom milk. 
 
 36 
 
 ■ = = Fat- 
 
 9X4 
 36 
 
 1 =Protein and sugar percentages from 
 
 combined top and bottom milk. The 1 oz. additional sugar divided by 30 = approx- 
 imately 3% sugar added. There being already 1% sugar derived from the milk, the 
 total sugar = 4%. 
 
 Fio. 172. Reverse side of card in Fi<r. 171. 
 
 is not within reach which the nurse must meet as best she can. 
 In such an emergency she might be guided by the following 
 suggestions contained in a pamphlet entitled, ' * Save the Babies, ' ' 
 prepared by Dr. L. Emmet Holt and Dr. II. K. L. Shaw and 
 published by the American Medical Association, remembering 
 that they are intended for the average, normal baby and are 
 not necessarily suitable for all babies: 
 
502 OBSTETRICAL NURSING 
 
 ''The simplest plan is to use whole milk (from a shaken bottle) 
 which is to be diluted according to the child's age and digestion. 
 
 "Beginning on the third day, the average baby should be given 3 
 ounces of milk dail}', diluted with seven ounces of water. To this 
 should be added one tables^Doonful of lime water and 2 level teaspoon- 
 fuls of sugar. This should be given in seven feedings. 
 
 "At one week, the average child requires 5 ounces of milk daily, 
 which should be diluted with 10 ounces of water. To this should be 
 added 1^2 even tablespoonfuls of sugar and one ounce of lime water. 
 This should be given in seven feedings. 
 
 "The milk should be increased by 1/2 ounce about every 4 days. 
 
 "The water should be increased by I/2 ounce about every 8 days. 
 
 "At three months the average child requires 16 ounces of milk daily, 
 which should be diluted with 16 ounces of water. To this should be 
 added 3 tablespoonfuls of sugar and 2 ounces of lime water. This 
 should be given in 6 feedings. 
 
 "The milk should be increased by ^ ounce about every 6 days, 
 
 "The water should be reduced by % ounce about every 2 weeks. 
 
 "At 6 months the average child requires 24 ounces of milk daily, 
 which should be diluted with 12 ounces of water. To this should be 
 added 2 ounces of lime water and 3 even tablespoonfuls of sugar. This 
 should be given in 5 feedings. 
 
 "The amount of milk should be increased by Yz ounce every week. 
 
 "The milk should be increased only if the child is hungry and di- 
 gesting his food well. It should not be increased unless he is hungry, 
 nor if he is suffering from indigestion even though he seems hungrj'. 
 
 "At 9 months, the average child requires 30 ounces of milk daily, 
 which shoiild be diluted with 10 ounces of water. To this should be 
 added 2 even tablespoonfuls of sugar and 2 ounces of lime water. 
 This should be given in 5 feedings. 
 
 "The sugar added may be milk sugar or, if this cannot be obtained, 
 cane (granulated) sugar or maltose (malt sugar). 
 
 "At first plain water should be used to dilute the milk. 
 
 "At three months, sometimes earlier, weak barley water may be 
 used in the place of plain water; it is made with 1/2 level tablespoonful 
 of barley flour to 16 ounces of water and cooked 20 minutes. 
 
 "At six months the barley flour may be increased to IV2 even table- 
 spoonfuls, cooked in the 12 ounces of water. 
 
 "At nine months, the barley flour may be increased to 3 level table- 
 spoonfuls, cooked in the 8 ounces of water. 
 
 "A very large baby may require a little more milk than that allowed 
 in these formulas. A small delicate baby will require less than the 
 milk allowed in the formulas." 
 
 These formulas may be tabulated as follows : 
 
NURSING CARE OF AVERAGE NEW-BORN BABY 503 
 
 Age 
 
 Water 
 
 Harley- 
 Water 
 
 Lime- 
 Water 
 
 Sugar 
 
 No. o) 
 feed- 
 ings 
 
 Hours 
 
 Day 
 
 Night 
 
 3d 
 
 1 ir 
 
 2 
 
 3 
 
 4 
 
 5 
 
 6 
 
 7 
 
 8 
 
 9 
 
 days 
 
 3 ozs. 
 
 7 ozs. 
 
 
 Vi ozs. 1 
 
 veek 
 
 5 " 
 
 10 " 
 
 
 
 
 " 
 
 6 
 
 10^6 " 
 
 
 
 
 onth 
 
 7 " 
 
 11 
 
 
 
 
 
 11 
 
 13 
 
 
 IVz ' 
 
 
 
 10 
 
 
 16 ozs. 
 
 
 
 
 19 
 
 
 15 " 
 
 
 
 
 21 Vz " 
 
 
 14 " 
 
 
 
 
 24 
 
 
 12 " 
 
 
 
 
 20 
 
 
 12 " 
 
 
 
 
 2 s " 
 
 
 n " 
 
 
 
 
 ■Aii 
 
 
 10 " 
 
 
 
 2 teaspoons 
 
 1 Vi tablespoons 
 11^ 
 
 2 " 
 2V^ 
 
 3 
 3 
 3 
 3 
 3 
 
 7 
 
 0-9-12-3-6 
 
 7 
 
 0-9-12-3-6 
 
 7 
 
 0-9-12-3-6 
 
 7 
 
 6-9-12-3-6 
 
 7 
 
 6-9-12-3-0 
 
 7 
 
 6-9-12-3-6 
 
 
 
 6-9-12-3-6 
 
 6 
 
 6-9-12-3-6 
 
 5 
 
 0-10-2-6 
 
 5 
 
 0-10-2-6 
 
 5 
 
 6-10-2-6 
 
 5 
 
 0- 10-2-6 
 
 10-2 
 10-2 
 10-2 
 10-2 
 10-2 
 10-2 
 
 Mixed Feeding. Under some conditions the breast-fed baby 
 is given also a certain amount of modified milk, and this com- 
 bination of natural and artificial feeding is termed mixed or 
 supplementary feeding. 
 
 A deficiency in the breast milk, ascertained by weighing the 
 baby before and after each nursing, may be supplied by follow- 
 ing each nursing with a bottle feeding; or one or two breast- 
 feedings, in the course of the day may be replaced by entire 
 bottle feedings. In any case the milk mixture to be used as sup- 
 plementary feeding is prepared with exactly the same pains- 
 taking care as is the milk for entire artificial feeding. 
 
 If supplementary food is given because of an inadequate 
 supply of breast milk, it is of great importance that the baby 
 be put to the breast regularly, no matter how little food he ob- 
 tains, for his suckling is the best possible means of stimulating 
 the breasts to secrete more milk and of equal importance is the 
 fact that they will tend to dry up if the baby nurses less than 
 about five times in twenty-four hours. Moreover, even a little 
 breast milk is valuable to him and he should have the benefit of 
 all there is to be had. 
 
 An entire bottle feeding is sometimes given to a baby who is 
 nursing satisfactorily at the breast, in order to give his mother 
 an opportunity to take longer outings than are possible between 
 the regular nursings. And sometimes it is to the mother's ad- 
 vantage, and therefore to the baby 's, to give him a bottle during 
 the night and thus allow her to sleep undisturbed. 
 
 COMMERCIAL BABY FOODS 
 
 Since the baby's food is prescribed by the doctor, the nurse 
 has little concern with the various proprietary baby foods and 
 
504 OBSTETRICAL NURSING 
 
 the canned and powdered milks which are so persuasively adver- 
 tised to young- mothers. It is hoped, however, that the discus- 
 sions on nutrition in general and on baby feeding in particular, 
 have made it clear to the nurse that these foods cannot be ex- 
 pected to be satisfactory if used as a sole article of diet through- 
 out the bottle-feeding period. 
 
 There are many times and circumstances, however, when the 
 temporary use of a prepared infant food or canned or powdered 
 milk is advantageous. In some cases of intestinal disturbance, 
 for instance, or while the mother is traveling and is unable 
 to have freshly prepared milk formulas supplied to her along the 
 way; during the summer, while staying at a hotel or boarding 
 house where the freshness, cleanliness or purity of the milk are 
 uncertain; or during a sudden shortage of fresh milk, as may 
 occur during a strike or severe storm when transportation is 
 interfered with, a proprietary food may be a great boon. 
 
 If the nurse is confronted with the necessity of choosing 
 and making temporary use of a prepared food she may be guided 
 by considering the general principles of baby feeding and the 
 character of the materials at her disposal. 
 
 The Proprietary Foods may be divided into two general 
 groups: one kind contains milk powder and is usually added 
 to water while the other consists largely of sugar and starch 
 and is added to fresh milk before being given to the baby. 
 
 Canned Milk is of two kinds ; evaporated, which is unsweet- 
 ened, and condensed, which is sweetened. Evaporated milk 
 is whole milk from which part of the water has been removed, 
 the milk then being canned and sterilized. The addition of 
 water to evaporated milk restores it to the composition of whole 
 milk in many respects, but it is still milk that has been heated. 
 Condensed milk is evaporated milk to which cane sugar has 
 been added to aid in its preservation. Since bacteria do not 
 grow well in highly sweetened foods, it is not necessary to bring 
 sweetened condensed milk to as high a temperature as the un- 
 sweetened product, to prevent subsequent bacterial decomposi- 
 tion. The high percentage of sugar in condensed milk quite 
 obviously renders it unsuitable for continuous use as the sole 
 article in a baby's dietary. 
 
NURSING CARE OF AVERAGE NEW-BORN BABY 505 
 
 Milk Powders or Dried Milks are prepared by rapidly 
 evaporating the water from whole milk, skimmed milk or partly 
 skimmed milk, leaving the solid constituents in the form of a 
 light, white powder. Milk powder readily dissolves in water, 
 forming a "reconstructed milk" which closely resembles the 
 fresh milk from which it was prepared. But it must not be 
 forgotten that reconstructed milk has been heated. Many doc- 
 tors consider whole milk powder the most satisfactory form of 
 preserved milk which is available for baby food. Should it be 
 used, however, the importance of Keeping it tightly covered and 
 in a cold place must be recognized, for the presence of fat renders 
 it likely to become rancid if not kept cold. 
 
 ARTICLES OF FOOD WHICH ARE SOMETIMES 
 INCLUDED IN THE BABY'S DIETARY 
 
 Barley Water, sometimes used to dilute whole milk, is made 
 by mixing the barley flour to a smooth paste in cold water, add- 
 ing boiling water and boiling for twenty minutes or cooking 
 in a double boiler for an hour, straining and adding enough 
 water to replace the amount lost in cooking. The proportions 
 for different ages are as follows: 
 
 Three months, V2 level tablespoonful barley flour to 16 oz. water 
 Six months, iy2 level tablespoonful barley flour to 12 oz. water. 
 Nine months, 3 level tablespoonfuls barley flour to 10 oz. water. 
 
 Potato Water. One tablespoonful of thoroughly boiled 
 potato is mashed into one pint of the water in which the potato 
 was boiled and carefully strained. 
 
 Spinach. Spinach is carefully washed, steamed for half an 
 hour and mashed through a fine sieve. It is sometimes started 
 at the sixth month; one teaspoonful daily, gradually increased 
 to one or two tablespoonfuls daily. 
 
 Orange Juice. The orange should be dipped in boiling water 
 and wiped on a clean towel before being cut and squeezed, to 
 avoid possible infection of juice. It is usually given to babies 
 getting heated milk, sometimes as young as one month old. It 
 is carefully strained and started gradually by giving one tea- 
 spoonful in water once or twice daily between feedings and 
 
506 OBSTETRICAL NURSING 
 
 increasing to y^ or 1 ounce by the sixth month and IV2 to 2 
 ounces by the end of the first year. 
 
 Infusion of Orange Peel. This is sometimes used instead of 
 orange juice, and is made by boiling one ounce of finely grated 
 orange peel in two ounces of water, adding a little sugar to 
 counteract the bitter taste and adding enough sterile water to 
 bring it up to two ounces. 
 
 Tomato Juice. Canned tomato strained through a fine sieve, 
 is sometimes given to a baby a few weeks old, starting with one 
 dram and gradually increasing to four to six ounces daily. 
 
 Whey. One quart of whole milk heated to 98° F. or 
 100° F. and one-half ounce of liquid rennet or one junket tablet 
 stirred into it and allowed to stand half an hour or until firm 
 and solid, is poured into a cheese-cloth bag and allowed to drain 
 for about an hour without being squeezed. 
 
 Protein Milk. The curd from one quart of milk, which re- 
 mains after the whey is drained, as directed above, is mashed 
 through cheese-cloth in a fine wire sieve, with a potato-masher 
 or bowl of a spoon and the curd washed through with one pint 
 of water. A pint of buttermilk is added and the mixture boiled 
 while being stirred constantly. This is sometimes given in 
 diarrhea. 
 
 Beef Juice. One pound of thick round steak, slightly broiled, 
 is cut into small pieces and the juice expressed with a meat 
 press or a lemon squeezer, the amount varying from 2 to 3 ounces. 
 It may be diluted with an equal amount of warm water, or 
 slightly warmed by being placed in a cup standing in hot water, 
 and salted to taste. 
 
 Broths. One pound of lean meat, all fat and gristle re- 
 moved, is allowed to one pint of water. The meat is cut finely 
 and put on in cold water, heated slowly and allowed to simmer 
 for three or four hours, when water is added to replace what 
 was lost in cooking. It is strained, the fat removed and slightly 
 salted/ 
 
 Oatmeal Water. Two level tablespoonfuls of oatmeal in a 
 pint of boiling water is cooked in a double-boiler for two hours, 
 strained and enough boiling water added to replace the amount 
 lost in cooking. 
 
NURSING CARE OF AVERAGE NEW-BORN BABY 507 
 
 TRAVELING 
 
 The difficulties of traveling with a young baby may be 
 greatly lessened by making certain preparations. If the baby 
 is bottle-fed, the preparations will depend upon the length 
 of the journey and whether or 
 not it will be possible to have 
 freshly prepared feedings, for 
 each twenty-four hours, put 
 on the train from laboratories 
 along the way. If this is not 
 possible and the journey is 
 not to take more than twenty- 
 four hours, the entire quan- 
 tity of food, ice cold, may be 
 carried in a thermos bottle. 
 The requisite number of ster- 
 ile nursing bottles may be 
 taken or one bottle which is 
 boiled before each feeding. Or 
 the milk may be prepared as 
 usual and the bottles packed 
 in a portable refrigerator. 
 Such a refrigerator may be bought or one may be improvised. 
 The bottles are placed in a covered pail and packed solidly in 
 (yushed ice ; this is placed in a second pail or a box with a diam- 
 eter which is at least two inches larger than the inner pail and 
 the space between the two packed firmly with sawdust. Several 
 thicknesses of newspapers should be pressed down over the top 
 and a tight cover fitted to the outer receptacle. 
 
 The sterile nipples may be taken in a sterile jar and a deep 
 cup or kettle w'ill be needed in which to warm the bottle before 
 each feeding. It is usually possible to obtain water on the train 
 which is hot enough for this, or cans of solid alcohol, a stand 
 and a metal tray may be added to the traveling outfit. If fresh 
 formulae cannot be delivered to the train, dail}', and the journey 
 is to last more than twenty-four hours, one of the proprietary 
 foods or a powdered milk will often prove to be a satisfactory 
 solution to the problem of feeding. 
 
 Fig. 173. — The baby will travel 
 comfortably in a basket converted 
 into a bed. (Courtesy of the Ma- 
 ternity Centre Association.) 
 
508 OBSTETRICAL NURSING 
 
 The baby will usually travel more comfortably and sleep 
 better if he is carried in a basket. A large market basket with 
 a handle or a small clothes basket will serve. It may be lined 
 with a sheet or a blanket; have a small hair pillow or folded 
 blanket in the bottom and be made up like a crib. (Fig. 173.) 
 If this basket stands on the ear seat during the day, and on the 
 foot of the nurse's berth at night, the baby will be cleaner, 
 quieter and less exposed to drafts than if carried in the arms. 
 
 THE PREMATURE BABY 
 
 All of the precautions and gentleness which are necessary iu 
 the care of the normal baby, born at term, must be greatly in- 
 creased in caring for the baby who is born prematurely. 
 
 As was explained in Chapter III the premature baby's pros- 
 pects of living increase with the length of his uterine life, and 
 it is often j)ossible to estimate this by measuring and weighing 
 him. During the last five months the child's length in centi- 
 metres divided by five gives the month of pregnancy, according 
 to the following table by Dr. Williams : ^ 
 
 At the fifth month of pregiiancy 5x5, fetus is 25 cm. long 
 
 At the sixth mouth of preiiuauey 6x5, fetus is 30 cm. long' 
 
 At the seventh month of pregnancy 7x5, fetus is 35 cm. long 
 
 At the eighth month of pregnancy 8x5, fetus is 40 cm. long 
 
 At the ninth month of pregiiancy 9x5, fetus is 45 cm. long 
 
 At the tenth month of pregnancy 10x5, fetus is 50 cm. long 
 
 But consideration of the baby's weight is also of importance 
 when attempting to forecast his chances of living. A baby 
 weighing less than 2500 grams or about 5i/2 pounds should be 
 regarded, and treated, as premature, unless it is more than 45 
 centimetres, or about 18 inches long. This length would indicate 
 greater maturity, and therefore greater viability than would be 
 expected from the weiglit. A baby weighing less than 1500 
 grams (3 pounds and 5 ounces) can scarcely be expected to live. 
 
 The premature baby is not only small, but in general is im- 
 perfectly developed, having slenderer powers than the full-term 
 
 ^"Obstetrics," by J. Whitridge Williams. 
 
NURSING CARE OF AVERAGE NEW-BORN BABY 509 
 
 baby and at tbe same time much greater needs. His respiratory 
 and digestive organs are less ready to function than in the full- 
 term baby ; his muscles and nerves are feeble ; his heat-producing 
 mechanism is unstable and yet there is an excessive radiation of 
 body heat through the relatively large area of skin. 
 
 Accordingly, the baby who has been deprived of those valu- 
 able last weeks of growth and development is small and limp; 
 lies quietly most of the time and moves very feebly if at all. 
 He is often too weak to nurse at the breast and may swallow 
 
 TiQ. 174. — Quilted robe, with hood, for the premature baby. 
 
 with difficulty. His temperature is low, his respirations irregu- 
 lar and he is frequently cyanotic. 
 
 The care of this frail little body practically resolves itself 
 into : 
 
 1. Maintaining a normal body temperature. 
 
 2. Proniotinjj and niaintaininsr nonnal respirations. 
 
 3. Supplying- adeqiiate and suitable nourishment. 
 
 4. Conserving his strength. 
 6. Preventing infection. 
 
510 
 
 OBSTETRICAL NURSING 
 
 aik^tSg&m 
 
 Fig. 175. — Premature baby in basket lined with quilted pad; wearing 
 quilted robe and being fed from a Boston feeder. The blanket is turned 
 back showing hot-water bag. (From photograph taken at Johns Hopkins 
 Hospital.) 
 
NURSING CARE OF AVERAGE NEW-BORN BABY 511 
 
 To maintain a normal body temperature it is necessary to give 
 special thought to the lialty's chithiii'i,-, bed and room. lie sliould 
 be oiled with Avarm olive oil and entirely wrapped in cotton 
 batting or flannel or enveloped in a quilted garment, with hood 
 
 Fig. 176. — Model of improvised bed for premature baby: closely woven 
 clothes basket with padded bottom ami four, flannel-covered bottles of hot 
 water attached to the sides. Thermometer and feeder are shown in basket. 
 (By courtesy of Dr. Alan Brown, Hospital for Sick Children, Toronto.) 
 
 attached, made of cheese-cloth or flannel and cotton batting. 
 (Fig. 174.) Diapers are often omitted in caring for very feeble 
 babies, a pad of cotton being slipped under the buttocks instead 
 as this may be changed with less disturbance to the baby than 
 a diaper. 
 
512 OBSTETRICAL NURSING 
 
 His bed consists of a box or basket, with the bottom well 
 padded with several inches of cotton, a small pillow or a soft 
 blanket folded to the proper size, covered with rubber or oiled 
 muslin and a cotton sheet. The sides of the basket should be 
 lined with heavy quilted material (Fig. 175), to shut out drafts 
 and help to preserve an even temperature of the air immediately 
 around the baby. A flannel covered hot-water bag at 110° F. 
 may be placed beside the baby, or two, three or four glass bot- 
 tles, each holding about a pint, containing water at 100° F. and 
 securely stoppered, may be hung in the corners of the basket. 
 (Fig. 176.) A thermometer should hang in the basket also, and 
 the temperature kept between 80° F. and 90° F. It is easier to 
 keep the temperature even if the bottles are filled in rotation 
 instead of all at the same time. 
 
 The amount of heat needed around the baby is decided by 
 taking his temperature (by rectum) at regular intervals; sup- 
 plying more heat if the temperature is low and less if it is at 
 or above normal. Some doctors have the temperature taken 
 every four hours; others twice daily. As the baby grows able 
 to maintain a temperature of 98° F. to 100° F., unassisted, the 
 surrounding heat is gradually reduced and finally removed, and 
 flannel clothing replaces the quilted robe. 
 
 In many hospitals there are special rooms for premature 
 babies, which are divided by glass partitions into cubicles so 
 that each baby is in a three-sided enclosure. The rooms are 
 usually darkened to save the baby from the needless irritation 
 of light, and are supplied with constantly changing fresh, moist, 
 filtered air, the temperature being kept at from 80° F. to 90° F. 
 
 In a patient 's home or in a hospital where there is no special 
 room for premature babies, a cubicle may be improvised by plac- 
 ing the basket in which the baby lies, in the corner of a room 
 and placing a screen parallel with one of the walls. Such a 
 room should be darkened, well ventilated and have in it a large 
 open vessel of water. 
 
 Since the premature baby's lungs are not fully expanded, 
 respirations are likely to be shallow and irregular, thus failing 
 to supply the amount of oxygen which he sorely needs. As cry- 
 ing inevitably involves deep breathing, it is a common practice 
 
NURSING CARE OF AVERAGE NEW-BORN BABY 513 
 
 to make the premature baby cry at regular intervals during the 
 day in order to promote the respiratory function. Dr. Griffith 
 further recommends plunging the baby into a mustard bath at 
 100° F. or 105° F. if necessary to make him cry vigorously. It 
 is also important to turn the premature baby from side to side, 
 several times a day to prevent fluid from collecting in the lower- 
 most part of the lung, a condition favorable to the development 
 of pneumonia. 
 
 In feeding premature babies, breast milk is ordinarily the 
 most desirable food. If the baby is too feeble to nurse, as fre- 
 quently occurs, the milk may be expressed from the breast of 
 his mother or a wet nurse, by stripping or pumping, into a sterile 
 receptacle, and if not used immediately it should be covered and 
 placed in the refrigerator. Breast milk is sometimes used whole 
 and sometimes diluted with water, and is given by gavage if 
 the baby is very feeble ; from a medicine dropper or a special 
 feeder. Such a feeder consists of a glass tube with a small nipple 
 on one end and a rubber bulb on the other, by means of which 
 the milk may be gently expressed into the baby's mouth, thus 
 minimizing his etfort to obtain it. (See Fig. 175.) 
 
 The amount and intervals for feeding the premature baby 
 have to be adjusted to the individual with even greater care 
 than for a normal baby, for he needs more fuel and building 
 material, because of his imperfect development and yet because 
 of that same imperfect development his digestive powers are 
 feebler than those of the full-term baby. During the first day 
 or two, he is sometimes given nothing but water or sugar solu- 
 tion, the milk being started gradually when the baby is from 
 thirty-six to forty-eight hours old. He may be given a very 
 small quantity every two hours, or he may be fed at three- or 
 four-hour intervals, depending entirely upon his condition and 
 progress. It is usually considered very important for the pre- 
 mature baby to have sterile water or sugar solution to drink 
 between feedings, and this is given in the same manner as his 
 milk. 
 
 Unlike the normal baby he is not taken from his bed to be 
 fed, unless he nurses at the breast. 
 
 The premature baby is weighed as often as is safe for hira, 
 
514 OBSTETRICAL NURSING 
 
 since the suitability of his food is largely indicated by changes 
 in his weight. But sometimes very young and feeble babies are 
 weighed only once or twice a week because of the inadvisability 
 of disturbing them more frequently. 
 
 Avoidance of fatigue and the conservation of the premature 
 baby's limited strength and energy are accomplished through 
 reducing his muscular activity to the minimum, by very little 
 and very gentle handling ; and by minimizing his loss of energy 
 in the form of heat by keeping the little body warm and quiet. 
 
 In this connection the daily bath is of considerable impor- 
 tance. It almost always consists of sponging the baby with warm 
 olive oil as he lies in his bed, and with the least possible ex- 
 posure and turning. It is given every day or every second or 
 third day according to his condition. The eyes are wiped with 
 boric pledgets and the nostrils with spirals of cotton dipped 
 in oil. The buttocks are wiped with an oil sponge each time the 
 diaper is changed. 
 
 The premature baby is very susceptible to infection and 
 strongly predisposed to pneumonia. Infection in general is 
 guarded against by having everything that comes in contact 
 with the baby scrupulously clean; protecting him from drafts, 
 chilling and dust; allowing no one with a suspicion of a cold 
 to come near him and by the nurse's wearing a clean gown and 
 protecting her nose and mouth with a gauze mask while attend- 
 ing him. 
 
 CARE OF THE BABY DURING THE SUMMER 
 
 The dangers of infancy are greatly increased in summer, 
 more babies dying during the hot months than any other time 
 during the year. The cause of these deaths is variously termed 
 summer complaint, summer diarrhea, acute gastro-enteritis and 
 cholera infantum, and is due to infected or decomposing food 
 or both. 
 
 Clearly this malady is practically preventable through care. 
 
 Although such care as has been described in the preceding 
 pages largely constitutes the prevention of the much-to-be- 
 dreaded summer diarrhea, there are a few extra precautions 
 
NURSING CARE OP^ AVERAGE NEW-BORN BABY 515 
 
 and safeguards with which the nurse must surround her little 
 patient during the warm weather. 
 
 She must bear in mind the character of the illness to be 
 avoided : indigestion associated with infection. 
 
 It becomes almost a matter of life or death, then, to give the 
 baby clean, suitable food and avoid deranging his digestion. 
 
 Babies suffer from the heat more than adults do and are 
 often excessively irritated and exhausted on warm days. And 
 this overheating, exhaustion and restlessness are of themselves 
 enough to affect his digestion. 
 
 Accordingly the scourge of summer diarrhea is prevented 
 by giving the baby proper food and keeping him clean, cool and 
 quiet. 
 
 The baby should have maternal nursing if possible, for breast- 
 fed babies fall victim to summer diarrhea much less frequently 
 than bottle-fed babies. He should be fed with absolute regu- 
 larity, and as a rule, no matter what the nature of his food, it is 
 reduced one-quarter to one-third in amount during very warm 
 weather and he is given an increased amount of cool boiled water 
 to drink. His weight may increase very slightly, or even stand 
 still for a short time, as a result of his decreased food, but this 
 is not usually deplored, if he keeps well, for the important thing 
 is to avoid digestive disturbances while the weather is warm. 
 
 Cleanliness, as at other times, applies to the baby's food, 
 clothing and surroundings. Many doctors think it safer to have 
 all milk boiled during the summer, and of course require flaw- 
 less technique in its preparation and administration. The baby 's 
 soiled napkins should be placed immediately in a covered re- 
 ceptacle containing water, and not left for even a moment where 
 they can be reached by flies. They should be washed, boiled and 
 dried in the open air and sunshine as promptly as possible. 
 
 The baby should be protected from flies and mosquitoes by 
 screens in the windows and netting over his crib and carriage, 
 both because they make him restless and irritable and because 
 flies particularly are carriers of filth and disease — the kind of 
 disease that kills so many babies during the summer. Accord- 
 ingly the nurse must always regard flies with a deadly fear. 
 
 The baby should be kept away from dusty places and from 
 
516 OBSTETRICAL NURSING 
 
 cats and dogs. And since babies will put their fingers in their 
 mouths it is a wise precaution to wash their hands several times 
 a day. 
 
 The baby should be in the country, in the mountains or at 
 the seashore if possible during the warmest part of the summer 
 at least, but if he is in town there is much that the nurse can 
 do to keep him cool and comfortable. His clothing at this time 
 must be adjusted to his condition and the temperature of the 
 moment just as it is in cold weather. A thin shirt, band, diaper 
 and cotton slip will usually be enough for out-of-door wear, 
 while in the house he may often dispense with the slip and 
 sometimes with everything but his diaper. 
 
 During excessively hot days, the baby should have two or 
 three cool sponge baths, in addition to the soap and water bath, 
 one of the sponges being given before he is put to bed for the 
 night. He should sleep on a firm mattress, preferably curled 
 hair but never feathers, and in the coolest, best ventilated room 
 available. During the day it is usually best to take him out-of- 
 doors early in the morning and late in the afternoon, but to 
 keep him indoors during the warmest part of the day, when it 
 is likely to be cooler indoors than out, particularly if the blinds 
 are closed. Quite naturally the nurse will have to take into 
 consideration the size, arrangement and location of the baby's 
 home in her effort to keep him in cool, quiet, shady places and 
 out-of-doors as much as possible. 
 
 He must not be played with, held on hot laps nor subjected 
 to the entertainment and attention which misguided but well- 
 meaning mothers and friends are so eager to lavish on a hot, 
 fretful baby. 
 
 Very often during warm weather a fine rash known as 
 "prickly heat" appears on the back of the baby's neck and 
 spreads over his head, neck, chest and shoulders. This rash is 
 due to too warm clothing or to the hot weather or to both. Less 
 clothing and frequent baths will often give relief, but if the baby 
 is very uncomfortable, he may be greatly soothed by being im- 
 mersed in cool baths containing soda, bran or starch in the fol- 
 lowing proportions: 
 
NURSING CARE OP AVERAGE NEW-BORN BABY 517 
 
 Soda bath. Two tablespoonfuls of baking soda to one gallon of 
 water. 
 
 Bran bath. A cheese-cloth bag- about six inches square, partly 
 filled with bran, is soaked and squeezed in the bath water until it is 
 milky. 
 
 Starch bath. About eight ounces of cooked laundry starch to 
 one gallon of water. 
 
 No soap should be used while the baby has prickly heat and 
 after the bath he should be patted thoroughly dry and powdered 
 with some such soothing powder as the following: 
 
 Powdered starch one ounce 
 
 Oxide of zinc one ounce 
 
 Boracic acid powder 60 grains 
 
 As we look back over these pages of somewhat detailed de- 
 sciiption of the case of the baby, it is borne in upon us that the 
 nursing of this unfailingly delightful and interesting little 
 patient has special adjustments and adaptations for different 
 seasons and circumstances ; but that on the whole the care of all 
 babies the year around resolves itself into the observation of 
 a few general principles, namely : proper feeding ; fresh air ; 
 regularity in his daily routine ; cleanliness of food, clothing and 
 surroundings ; maintenance of an equable body temperature and 
 conservation of his forces. 
 
 If the nurse fixes these principles firmly in her mind and 
 acts upon them, she will do a great deal to give her baby patient 
 a fair start on his life's journey. 
 
CHAPTER XXIII 
 
 COMMON DISORDERS AND ABNORMALITIES OF 
 EARLY INFANCY 
 
 The common ills of early infancy are due largely either to 
 errors in feeding or to infection or both. Of the nutritional 
 disturbances, rickets and scurvy were discussed in the chapter 
 on nutrition, but the obstetrical nurse will sometimes see also, 
 malnutrition, marasmus, inanition, diarrheal diseases, acidosis^ 
 colic, constipation and vomiting. 
 
 All of these disorders are practically preventable through 
 suitable feeding, good care and hygienic surroundings. The 
 nurse's part in this prevention consists in giving the painstak- 
 ing care which was described iii the preceding chapter. 
 
 The terms malnutrition, marasmus, and inanition designate 
 different forms and degrees of starvation, and are characterized 
 by loss of weight, prostration, feeble powers of assimilation, 
 general weakness and arrested growth. The temperature is 
 likely to be low, but in acute inanition, a rapid loss in weight 
 may be accompanied by a sudden rise in temperature. (Charts 
 6, 7, and 8.) 
 
 These so-called "wasting diseases" are frequently seen in 
 children who have congenital nervous instability and those born 
 of tuberculous, syphilitic or otherwise delicate parents. The 
 treatment is suitable food ; fresh air and sunshine ; an abundance 
 of fluid by mouth, rectum, subcutaneously or intraperitoneally ; 
 clean surroundings and good nursing care. 
 
 THE DIARRHEAL DISEASES 
 
 These are among the most frequent and most serious illnesses 
 of early infancy. They may result from mechanical causes, such 
 as a mass of undigested food, which produces increased intestinal 
 secretion and peristalsis; from the action of bacteria, or their 
 toxins, together witli the inability of an enfeebled digestive tract 
 
 518 
 
DISORDERS OF EARLY INFANCY 519 
 
 to meet the needs of a rapidly growing body ; or from such reflex 
 causes as sudden chilling of the body, excitement, fatigue or 
 the prostration resulting from excessively hot weather. 
 
 Acute gastro-enteritis, the dian-heal disease which is so com- 
 mon and so fatal during the hot months of July and August, is 
 often referred to as "summer complaint" or "summer diar- 
 rhea." It is so largely avoidable through good nursing that the 
 methods of its prevention were described in connection with the 
 care of the baby during the Summer, resolving itself, as it does, 
 into feeding the baby properly and keeping him clean and cool 
 and quiet. 
 
 Symptoms. While there are different forms of summer 
 diarrhea, the general symptoms are much the same and may 
 develop gradually after some evidence of indigestion, or sud- 
 denly with a rise of temperature to 101° F. or 102° F., or even 
 as high as 106° F., accompanied by pain and vomiting. The 
 baby is usually restless, fretful and thirsty and his skin is hot 
 and dry. He gives evidence of pain by shrill crying, drawing 
 up his legs and flexing them on his abdomen. Diarrhea is the 
 conspicuous symptom and there may be anywhere from four 
 to twenty movements in the course of 24 hours. The stools are 
 largely fecal matter at first but they finally become fluid and 
 contain mucus. They may be expelled with a good deal of 
 force and a quantity of gas come with them. The baby grows 
 very weak, thin and hollow-eyed, if the diarrhea persists and 
 unless promptly treated the end may be fatal. 
 
 Treatment and Nursing Care. The first step is to stop all 
 food and to give water freely. When water is not retained by 
 mouth it is frequently given by rectum, into the tissues or intra- 
 peritoneally. The pain may be relieved by applying hot stupes. 
 
 Feeding is resumed very gi'adually and cautiously for one 
 attack of summer complaint predisposes to another and every 
 precaution is taken to prevent a recurrence. Thin barley water 
 or broth is usually given first, followed by whey, protein milk, 
 buttermilk or diluted skim-milk in small amounts and at com- 
 paratively long intervals. 
 
 The baby should be lightly clad; should be kept quiet and 
 in a cool, shady place out-of-doors as much as possible. During 
 

 
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DISORDERS OF EARLY INFANCY 
 
 521 
 
 the warmest part of the day, however, he will often be much 
 better off and more comfortable in the house, in a room with 
 the shutters closed. But while keeping the baby cool, the nurse 
 must bear in mind the harm that will be done by chilling him 
 or exposing him to a cold draft or Avind. Several tub baths, 
 daily, are often given, at a temperature of 100° F., rather than 
 cool sponge baths because of the baby's feebleness and inability 
 to react to cool bathing. Packs are also employed, both for 
 high temperature and restlessness and may be cool (80° F.), 
 
 Fig. 177. — Putting the baby in a wet pack. 
 
 tepid (100° F.) or hot (105° F. to 108° F.) according to the 
 doctor 's orders ; intestinal irrigations ; lavage and gavage. 
 
 To give a pack, the nurse will cover the bed with a rubber 
 and sheet and bring to the bedside a basin containing a sheet 
 wrung from water of the specified temperature ; a basin contain- 
 ing ice and compresses for the baby's head, and a flannel covered 
 hot-water bottle at 120° F., for his feet. The baby is laid on 
 the upper half of the folded wet sheet, and an upper corner 
 wrapped about each arm (Fig. 177), and the sides folded around 
 his legs. The lower half is brought up between his feet to cover 
 his entire body and tuck around his shoulders. The hot-water 
 
522 
 
 OBSTETRICAL NURSING 
 
 bottle is placed at his feet and an ice compress on his head. (Fig. 
 178.) If the sheets are wrung from warm or hot water, the 
 baby is covered with a blanket after he is put into the pack. 
 
 Fig. 178. — Baby in pack with hot -water bag at feet and cold compress 
 on head. (Figs. 177 and 178 from photographs taken at Johns Hopkins 
 Hospital. ) 
 
 Intestinal irrigations, of normal salt solution are often given 
 to babies suffering from intestinal disorders, sometimes once or 
 twice daily to wash out the lower bowel, or a cool irrigation may 
 be given to reduce temperature, the amounts varying from i/^ to 
 
 Corner's o^ sheet. 
 uJrQpped .around arms 
 
 Loojer holf o| sVieel 
 taken up betuueen 
 legs (feet not 
 covered) to cover 
 body completely 
 and is tucWed under 
 shoulders 
 
 Sides of sheet 
 wrapped around IsflS 
 
 Fig. 179. — Diagrams showing successive steps in putting baby in pack 
 shown in Figs. 177 and 178. 
 
DISORDERS OF EARLY INFANCY 523 
 
 2 gallons of solution. The baby should be placed on a pillow 
 and rest on a bed-pan, being protected from chilling as for, an 
 enema (See Fig. 186), and provision made for a two-way flow of 
 the fluid. A small catheter attached by means of a connecting 
 glass nozzle to the tubing on the irrigation bag may be passed 
 into a slightly larger catheter, which is inserted into the rectum 
 
 Fig. ISO. — Baby wrapped in blanket, before being given gavage or eye 
 irrigation, to keep him warm and hold his arms and legs to his sides. 
 (From photograph taken at Johns Hopkins Hospital.) 
 
 about six inches, the fluid flowing in through the small inner 
 tube and out through the larger one which encases it. Or a small 
 catheter for the outflow may be inserted in the rectum along- 
 side the one through which the solution is introduced. Normal 
 salt solution, glucose or bicarbonate of sodium solution are some- 
 times given by the drip method at the rate of 20 to 40 drops 
 per minute. In this case a glass tube is introduced at some point 
 in the rubber tubing in order that the rate of flow may be 
 
524 
 
 OBSTETRICAL NURSING 
 
 watched and regulated by means of a clamp or a stop-cock. The 
 catheter is inserted in the rectum about six inches and held in 
 place by strips of adhesive plaster. 
 
 LavBige and Gavage. Sometimes when the baby vomits per- 
 sistently the stomach is washed out and a small amount of water 
 
 Fig. 181. — Gavage. (From photograph taken at Johns Hopkins Hospital.) 
 
 or nourishment given before the tube is withdrawn. A tray con- 
 taining the following articles should be carried to the bedside: 
 
 A glass funnel attached to a rubber tubing which connects with a 
 small rubber catheter by means of a glass nozzle. 
 Basin to receive stomach contents. 
 
 Small rubber, towel and curved basin to x^laee under baby's chin. 
 Glass graduate containing warm water for washing out stomach. 
 
DISORDERS OF EARLY INFANCY 525 
 
 Food or solution which is to remain in stomach, standing: in cup 
 of warm water. 
 
 Glj'cerin to hibricate tube. 
 
 Mouth gag, if necessary, or roll of bandaf::e to hold jaws apart. 
 
 The baby should be wrapped tightly (Fig. 180) to prevent 
 interference' bj^ his struggling and turned slightly to the left side. 
 (Fig. 181.) The catheter is lubricated Avith glycerin or water 
 and passed back over the tongue and quickly downward until 
 an air bubble is heard as it enters the stomach. The length of 
 tubing which is to be inserted may be anticipated by marking 
 a point on the tube which is the same distance from the end as 
 the baby's mouth is from its umbilicus. The possibility and 
 the serious consequences of introducing the tube into the trachea 
 instead of into the esophagus must be borne in mind. Although 
 the baby Avill often choke and struggle when the tube is properly 
 introduced, he will not cough violently and stop breathing as 
 he will if it enters the air passage. Further information is ob- 
 tained by inverting the funnel in a basin of water after the tube 
 is inserted ; if it is in the stomach there will be no result, but if 
 it is in the trachea air will be expelled and bubbles will rise 
 through the water. To wash out the stomach, the funnel is filled 
 with warm water and slighth^ raised so that the water will run 
 in slowly, after which the funnel is turned upside down into 
 a basin which is lower than the baby's body, and the stomach 
 contents allowed to run out. This is repeated four or five times, 
 or until the solution returns clear, and the food which is to re- 
 main in the stomach is poured in slowly. Before the tube is 
 quite empty it is pinched off with the fingers and quickly with- 
 drawn. 
 
 Acidosis. The diarrheal diseases are sometimes complicated 
 by acidosis, a condition in which the relative amounts of acid 
 in the blood are so increased that the normal alkalinity is 
 markedly diminished. This condition may result from an ex- 
 cessive intake of acids ; an overproduction of acids in the course 
 of normal metabolism ; a decrease in the reserve of normal alkali 
 in the body or a failure in the mechanism by means of which 
 excessive acids are usually neutralized or eliminated. Acidosis 
 is a serious complication and often fatal. 
 
526 
 
 OBSTETRICAL NURSING 
 
 The treatment is directed toward preventing the production 
 of more acids within the body ; restoring the alkali reserve and 
 promoting elimination of the excessive acids and their salts. 
 Solutions of glucose, bicarbonate of sodium and salt are used 
 and are given by mouth, rectum, intravenously and intraperi- 
 toneally. Subcutaneous injections are not wholly satisfactory, 
 because of the small amounts which may be given in this way. 
 
 Fig. 182. — Method of obtaining a fresh specimen of urine in a test tube. 
 
 From 150 to 400 cubic centimetres are given into the peritoneal 
 cavity and as the solution absorbs readily these injections are 
 sometimes repeated every eight or twelve hours, an infusion bot- 
 tle and short infusion needle being used. From 75 to 300 cubic 
 centimetres of glucose solution (5 per cent, or 10 per cent.) is 
 given intravenously, while as much as 1000 cubic centimetres is 
 sometimes given per rectum in the course of 24 hours by the drip 
 method. Soda solution (4 per cent.) is often given by mouth, 
 if the baby is able to retain it, or intravenously, as frequently 
 as the condition of the urine indicates is necessary. From 75 
 
DISORDERS OF EARLY INFANCY 
 
 527 
 
 to 100 cubic centimetres is ^iven at one time to young babies. 
 
 In preparing the soda solution it must be remembered that 
 
 boiling drives off carbonic acid and forms sodium carbonate and 
 
 I iG. 183. — Obtaining a 24-hour specimen of urine through curved glass 
 tube attached to rubber tubing which empties into bottle tied to side of 
 bed. (From photographs taken at Johns Hopkins Hospital.) 
 
 that its reconversion into sodium bicarbonate is a complicated 
 procedure. Howland and Marriott ^ say in this connection : 
 
 Fig. 184. — Muslin band with cuffs and tape used to keep the baby from 
 kicking while a specimen of urine is being obtained. The tapes are tied 
 tightly to the sides of the crib and the cuffs fastened around the baby's 
 ankles with safety pins. See Figs. 182 and 183. 
 
 "Oscar Schloss has found that sodium bicarbonate in bulk is 
 
 always sterile. It is probably therefore sufficient to add the 
 
 bicarbonate with proper precautions to sterile water." 
 
 '"Acidosis," by John Howland, M.D., and W. McKim Marriott, M.D., 
 Pennsylvania Medical Journal, April, 1918. 
 
528 
 
 OBSTETRICAL NURSING 
 
 Since the results of urine tests frequently indicate the treat- 
 ment in acidosis, it is of very great importance that the nurse 
 be able to obtain specimens from young babies. (Figs. 182, 183, 
 184 and 185 for methods of obtaining fresh and 24-hour speci- 
 mens from babies.) 
 
 Colic, Constipation, Convulsions and Vomiting so frequently 
 seen in young babies are symptoms rather than diseases. 
 
 Colic usually consists of paroxysms of pain in the stomach 
 or intestines, due to distension or to spasmodic, muscular con- 
 tractions. The indirect cause may be unsuitable food or food 
 given too rapidly; chilling of the surface of the body, excite- 
 ment or fatigue. The distension may be due to air swallowed 
 by the baby while nursing or gas formed by carbohydrate fermen- 
 
 Fig. 185. — Belt used to hold tube in place while obtaining specimen of 
 urine as indicated in Figs. 182 and 183. The tube is passed through the 
 hole in the tab and adjusted over penis or between labia; the belt fastened 
 around the waist and straps passed between the thighs and fastened to belt. 
 
 tation. Excess of protein may form an irritating mass in the 
 intestines and cause a cramp. 
 
 While colic frequently accompanies malnutrition and con- 
 stipation, it is often seen in otherwise well and happy babies, 
 and usually before the fifth month. The attacks are usually sud- 
 den and may occur several times a day after feeding, or only in 
 the late afternoon or at night. The baby cries shrilly; his face 
 is drawn and may be flushed, from crying, or cyanotic ; his fists 
 are clenched and pressed to his body and his feet and hands are 
 cold. His abdomen is hard and distended and during a pain the 
 baby flexes his thighs upon it and afterAvard extends them with a 
 jerk. This painful seizure may last only a few moments or 
 it may persist for hours, leaving the baby exhausted. 
 
 The chief preventive measures are found in the precautions 
 and attention to detail which have been described, and which 
 
DISORDERS OF EARLY INFANCY 529 
 
 should be included in the care of all babies. In a bottle-fed 
 baby it is often found that recurrence of attacks of colic may be 
 averted by a slight change in the milk formula ; by giving more 
 water to drink; by lengthening the intervals between feedings; 
 by giving the milk more slowly or by omitting the 2 a.m. feeding, 
 thus giving the baby more digestive rest. 
 
 Witli breast-fed babies, prevention is often accomplished by 
 having the mother nurse her baby more slowly, lengthening 
 the intervals and by improving her own hygiene; particularly 
 by increasing her recreation and out-of-door exercise and re- 
 lieving constipation. Women who lead sedentary lives and eat 
 rich food very often have colicky babies as do those who are 
 nervous, irritable and inclined to worry. (See chapter on the 
 nursing mother.) 
 
 When attacks of colic occur, the pain usually may be relieved 
 by giving half of a soda-mint tablet in a little warm water and 
 an enema of about eight ounces of soap-suds or salt solution 
 at 110° F., given through a small catheter inserted about six 
 inches. The baby will experience almost immediate relief 
 through the expulsion of gas and feces and he may be made still 
 more comfortable by placing a hot-water bag at his cold feet; 
 rubbing his abdomen with vaselin and applying hot stupes. 
 Sometimes the first feeding which falls due after an attack is 
 omitted and a little warm water or barley water is given in- 
 stead, in order that the digestive tract may rest. 
 
 Constipation is very common among young infants and may 
 be manifest by the stools being too small, too dry or too infre- 
 quent. The commonest causes are : 
 
 1. Faulty diet — possibly too much protein or too httle fat or 
 sugar. 
 
 2. Intestinal atony, due to undernourishment, rickets or anemia. 
 
 3. Anal fissure which makes the baby unwilling to empty his 
 bowels because of pain. 
 
 4. Absence of habit of emptying the bowels regularly. 
 
 The prevention of this very troublesome condition lies largely 
 in suitable food; constant fresh air; regularity in the daily 
 routine and training the baby to empty his bowels at the same 
 time every day. 
 
530 
 
 OBSTETRICAL NURSING 
 
 When constipation is due to insufficient fat in the food, cod- 
 liver oil is sometimes given, 15 to 30 drops three or four times 
 a day J or a teaspoonful of olive oil two or three times a day. 
 Maltose, malt soup, malted milk, milk of magnesia, liquid petro- 
 latum, oatmeal-water and orange juice are all found among the 
 remedies for constipation; while soap sticks, suppositories and 
 enemata of oil or soap-suds sometimes have to be resorted to. 
 
 Fig. 186. — Giving an enema. The baby lies comfortably on a pillow 
 which reaches to the bed pan, the latter being covered with a diaper where 
 the baby rests upon it. He is well protected to prevent chilling. 
 
 In giving an enema to relieve constipation, the baby should 
 be protected from chilling, laid on a pillow and the pan so placed 
 that he will be comfortable and not inclined to move, and from 
 100 to 300 cubic centimetres of soap-suds, at 105° F., given with 
 a small hard-rubber nozzle. (Fig. 186.) When warm olive oil 
 is given at night (1 to 2 ounces through a catheter introduced 
 about 6 inches), it is very often retained and the feces so softened 
 that the baby empties his bowels freely the next morning with 
 little or no assistance. 
 
 Abdominal massage will often help to increase the intestinal 
 
DISORDERS OF EARLY INFANCY 531 
 
 tone and make peristalsis more vigorous. The abdomen should 
 be rubbed with a circular stroke, beginning in the right groin and 
 following the course of the colon up to the margin of the ribs, 
 across to the left side and down to the groin. This is often given 
 for about ten minutes every day, preferably at night but never 
 just after a feeding. 
 
 Constipation is sometimes entirely cured by a suitable 
 dietary ; an abundance of drinking water ; an out-of-door life ; 
 massage, and above all, the unremitting effort to establish a regu- 
 lar habit. The latter is the nurse 's responsibility and she should 
 exercise the greatest patience in trying to accomplish the desired 
 end. 
 
 Convulsions are a symptom of several disorders of early in- 
 fancy, which may occur unexpectedly rnd which the nurse may 
 suddenly be called upon to relieve in the absence of the doctor. 
 Convulsions may be due to brain lesions; to spasmophilia or a 
 special tendency to convulsive disorders; gastro-intestinal disor- 
 ders; toxemia or syphilis. They may be the initial symptom 
 of an acute infectious disease or may occur on slight provocation 
 in a frail, undernourished baby or one suffering from rickets or 
 tetany. For this reason one sometimes sees convulsions in a 
 baby who is teething ur has colic or indigestion. 
 
 As convulsions are a symptom of some abnormal condition, 
 the doctor will often prescribe a sustained treatment designed 
 to remove or relieve the cause. But when an attack occurs un- 
 expectedly, and tha doctor cannot come at once, the nurse may 
 often terminate the seizure by employing measures that will 
 quiet and relax the struggling baby. The room should be quiet 
 and darkened and the baby handled with utmost gentleness be- 
 cause of the extreme irritability of his nervous system. As a 
 rule, the most satisfactory course is to immerse the baby in water 
 at 100° F., and keep him there for five or ten minutes, support- 
 ing his head and shoulders meantime. Someone else should place 
 cold compresses on his head and change them frequently. When 
 removed from the bath, the baby should be wrapped in a blanket, 
 kept very quiet and the cold applications to his head continued. 
 
 When it is known that the convulsions are due to indigestion 
 the stomach is often washed out and a high colonic irrigation 
 
532 OBSTETRICAL NURSING 
 
 ^ven before the baby is quieted by the bath. In tetanoid con- 
 vulsions the baby may take a long deep inspiration and fail to 
 expire. Respirations should be stimulated, in such a case, by 
 spanking him sharply or by dashing cold water on his face and 
 chest. When the attacks are recurrent the nurse may be in- 
 structed to terminate them by giving the baby a few whiffs of 
 chloroform, which, with an inhaler is kept in readiness for in- 
 stant use. 
 
 Mustard baths and packs are sometimes given when the need 
 for counter irritation is indicated. For a bath, one ounce, or 
 six level tablespoonfuls of dry mustard is added to one gallon 
 of water at 105° F. and the baby kept in it for about ten min- 
 utes, or until the skin is well reddened. He is then wrapped in 
 a warm blanket and surrounded by hot-water bottles, with cold 
 compresses applied to his head. The mustard pack is given in 
 the manner of other packs, with a sheet wrung from mustard 
 water which is possibly a little warmer and stronger than that for 
 the bath, caye being taken that the sheet is not cooled before it 
 is wrapped about the baby. He is usually left in the pack for 
 about ten minutes or until his skin is reddened, and then wrapped 
 in warm blankets, with cold compresses to his head. 
 
 It is often helpful to the doctor if the nurse is able to describe 
 the onset of the convulsions and tell him where the twitching 
 began, how it progressed and whether or not it was preceded 
 by a cry. 
 
 Vomiting during early infancy is a symptom of any one of 
 several conditions, the nature of which sometimes may be re- 
 vealed by the character of the attacks. The commonest causes 
 and varieties of vomiting are as follows: 
 
 1. Too rapid feeding or too large amounts of food given at one 
 time. The vomiting amounts to little more than regurgitation and is 
 often induced by moving or handling the baby immediately after feed- 
 ing him. 
 
 2. Acute gastric indigestion. Sour stomach contents may be 
 vomited immediately after feeding, or not until several hours later and 
 may be followed by mucus and bile. The baby is usually pale, par- 
 ticularly about the mouth; he may perspire about the forehead and 
 give evidence of pain, being relieved by the vomiting. 
 
 3. Stenosis of the pylorus. The vomiting from this cause is 
 
DISORDERS OF EARLY INFANCY 533 
 
 projectile in character and may occur immediately after food is taken 
 into tlie stomach, or, some time later without apparent cause, a larger 
 amount of fluid may be expelled than was given at the preceding fe_ed- 
 ing. The vomiting may begin a few days after birth or several weeks 
 afterwards in a baby who has been well previously. 
 
 4. Intestinal obstruction due to congenital obstruction, which 
 causes persistent vomiting from birth ; or due to intussusception of 
 the intestines, when vomitus consists first of stomach contents which 
 later becomes bile stained and sometimes contains fecal matter, blood 
 and mucus. It is attended by prostration, and after fecal matter is 
 passed at the beginning, there is frequent evacuation of blood and 
 mucus. 
 
 5. Chronic or habit vomiting, sometimes occurring in early in- 
 fancy, may be difficult to control because of being incited by such 
 slight causes as laughing, crying or being moved. 
 
 In addition to being caused by the above mentioned condi- 
 tions, vomiting in young babies may usher in an acute infectious 
 disease, as a chill does in an adult, or it may accompany such 
 diseases as peritonitis, meningitis, brain tumors and toxic con- 
 ditions such as uremia, 
 
 INFECTIONS 
 
 The infectious diseases which the obstetrical nurse is most 
 likely to see in her baby patient are ophthalmia neonatorum; 
 syphilis ; impetigo ; pemphigus and vaginitis. 
 
 Ophthalmia Neonatorum, intiammation of the eyes of the 
 new-born or "babies' sore eyes," is one of the common diseases 
 of infancy and certainly one of the most dreaded because of the 
 tragedy of lifelong blindness which may follow in its wake. In 
 the early days of organized work for the prevention of blind- 
 ness the term "ophthalmia neonatorum" implied a gonorrheal 
 infection, but it is now known that inflamed eyes and subse- 
 quent blindness may result from infection of innocent origin. 
 Accordingly, in those states where it is required that the disease 
 be reported, ophthalmia neonatorum is defined as inflammation 
 of the eyes of new-born babies, irrespective of the cause. The 
 disease is frequently due to the gonococcus, the baby 's eyes being 
 infected from the mother during passage through the birth 
 canal or infected later by her hands or clothing. Or the in- 
 flammation may be caused by the streptococcus, pneumococcus 
 
534 OBSTETRICAL NURSING 
 
 or the colon, diphtheria or influenza bacilli while very fre- 
 quently the infection is mixed. 
 
 It is estimated that about 20 out of every 1000 new-born 
 babies have sore eyes, and though many of the infections are 
 mild, between 5 and 8 of these 20 cases are capable of becoming 
 serious and causing blindness if not speedily and skillfully 
 treated. The number of cases which are neglected is suggested 
 by the fact that about 10 per cent, of all blindness, the world 
 over, is due to infant ophthalmia and that about 20 per cent, of 
 the inmates of schools for the blind in this country are sightless 
 from this cause. This does not take into account the unnum- 
 bered army of those who are partially blind, or blind in one 
 eye, and thus seriously handicapped, as a result of this disease. 
 
 Symptoms. The first symptoms are redness and swelling 
 of the lids, usually accompanied by a discharge of pus from the 
 beginning, and they ordinarily appear during the first few days 
 of life, but sometimes develop as late as the second or third 
 week. The disease may run a very rapid course and cause blind- 
 ness in 48 hours from the time the first symptoms appear, or it 
 may persist for weeks. Ulceration of the cornea is the dreaded 
 consequence of the inflammation as ulcers are followed by scars. 
 When the scar is small, or to one side of <he pupil, there may 
 be little or no impairment of vision, but if it is large and cen- 
 trally located it forms an opaque screen and causes blindness 
 by shutting out the light, although the interior of the eye behind 
 the scar is sound and uninjured. Sometimes the ulcer causes 
 a perforation of the cornea through which the lens and vitreous 
 humor are discharged. 
 
 Attempts have been made to remove the scar following a 
 centrally located ulcer and replace it with a clear cornea from 
 some such animal as a guinea pig, but the operation apparently 
 has not been perfected. When it is, many blind persons may 
 have their sight restored to them. 
 
 Prevention. It may be stated almost without qualification 
 that ophthalmia neonatorum is a preventable and curable dis- 
 ease, and accordingly that blindness from this cause is inexcus- 
 able. Prevention lies first, in wiping the baby 's eyes immediately 
 after birth and instilling a drop or two of a silver salt, such as 
 
DISORDERS OP EARLY INFANCY 535 
 
 nitrate of silver, argyrol or protargol, or bathing them with 
 boracic acid solution; and second, in close watching for early 
 symptoms and giving speedy treatment when they appear. This 
 is urgent because there is no way of determining in the begin- 
 ning whether the infection is mild or virulent. Nitrate of silver 
 solution, 1 per cent., is the prophylactic most commonly em- 
 ployed and its use is now routine in most hospitals and in the 
 practices of many physicians in this country. The solution is 
 sometimes dropped between the baby's lids, immediately after 
 the birth of the head, and before the birth of the entire body, 
 and sometimes immediately after delivery is completed. Many 
 doctors follow the silver drops with normal salt solution to pre- 
 vent the slight silver catarrh which so frequently occurs other- 
 wise, and which may be confused with early symptoms of 
 ophthalmia. Still others prefer simply to bathe the eyes with 
 boracic acid solution (unless they know that the mother has 
 gonorrhea) and to watch them closely for the slightest redness, 
 swelling or discharge and give prompt treatment if these appear. 
 
 The Crede method, made famous by the Viennese obstetrician 
 who introduced it in 1881, was to drop from a glass rod, a single 
 drop of nitrate of silver, 2 per cent., into each eye immediately 
 after birth. The routine use of this prophylaxis reduced the 
 occurrence of ophthalmia in Crede 's clinics from 10 per cent, 
 to .1 per cent, among the new-born babies. 
 
 Since it is now believed that close vigilance and subsequent 
 care are equally as important as the prophylactic drops, the 
 Crede treatment has been variously modified and other and 
 weaker silver solutions are frequently used, and with satisfactory 
 results. The dropping of a germicide into the baby's eyes kills 
 the organisms which may be present at the time, but it does not 
 protect against subsequent infection. For this reason the nurse 
 cannot be charged too earnestly to watch the baby's eyes closely 
 for the first evidence of infection, and report it to the doctor 
 immediately, day or night, for the late infections are as destruc- 
 tive of sight as those which occur before or during birth. 
 
 Treatment aaid Nursing Care. The treatment and nursing 
 care in ophthalmia frequently require the greatest skill. There 
 may be merely an application of silver and sponging with boracic 
 
536 
 
 OBSTETRICAL NURSING 
 
 acid solution or a gentle irrigation with a blunt nozzle (Fig. 
 187), or the preservation of the baby's sight may necessitate 
 dressings and treatment which will require elaborate preparation 
 (Fig. 188), and may also require some form of treatment every 
 quarter- or half -hour, day and night and occupy the entire time 
 of two or three special nurses. The nurse 's duties in caring for 
 
 Fig. 187. — Irrigating the eye with a blunt nozzle, the irrigation bag 
 hanging low in order that the stream may be gentle. (From a photograph 
 taken at Johns Hopkins Hospital.) 
 
 the eyes will be explicitly defined by the doctor, but in general 
 she must remember that she is nursing a baby suffering from 
 an acutely infectious disease, who should be strictly isolated, 
 and that as a rule she should wear a gown, rubber gloves and 
 protective goggles while caring for him. All of her attentions 
 to the inflamed eyes must be given with the greatest gentleness 
 in order to avoid abrasion of the conjunctiva or injury of the 
 cornea. Moreover, the baby with suppurative conjunctivitis is 
 
DISORDERS OF EARLY INFANCY 
 
 537 
 
 Fig. 188. — Method of holding baby for eye examination or treatment. 
 (Photograph and appended notes by courtesy of Dr. W. Gordon M. Beyers, 
 Eoyal Victoria Hospital, Montreal.) 
 
 "The child's bodj- is swathed in a sheet or blanket in such a way that the arms are 
 lightly, but securely, fixed against the sides. The nurse can easily support the body 
 with one hand, and with the other draw down the lower lid (as shown in the photograph), 
 or otherwise assist the physician. The doctor sits opposite the nurse, with a rubber 
 sheet across his knees, and upon this a sterile towel. He holds the baby's head gently, 
 but firmly, between his knees, thus freeing both his hands for necessary manipulations. 
 In the picture the physician is represented as about to apply a solution of nitrate of 
 silver with an applicator of sterile absorbent cotton. 
 
 "Close at hand is a table on which are a bowl of boracic acid solution and sterile 
 absorbent cotton for irrigating the eyes ; an undine (if one prefers) for the same purpose ; 
 a kidney dish for collecting the washings ; sterile applicators, and small dishes for 
 nitrate of silver solution and for saline solution (to neutralise) : besides bottles containing 
 solutions of cocaine, atropine, and fluorescein. Culture tubes, sterile swabs, cover slips, 
 forceps, and a spirit lamp are ready for bacteriological examinations ; and in a glass are 
 displayed lid retractors, which are usually indispensable to a thorough examination of 
 the cornea. On the floor is a paper bag, which, with the contaminated swabs, applicators, 
 etc., is burned on the completion of the treatment. Other articles may be added as 
 required ; but the important point is, that everything should be at hand before the 
 examination is begun. 
 
 "The physician and the nurse are clothed in surgical gowns ; and wear rubber gloves, 
 which heighten cleanliness, and safety and comfort. It is to be carefully noted that 
 they both are provided with protective glasses ; for under no circumstances should this 
 precaution be omitted in treating the purulent ophthalmias. 
 
 "The conditions here depicted will not always be possible of fulfilment, but they 
 represent the ideal for which one should strive." 
 
538 OBSTETRICAL NURSING 
 
 a sick baby often fighting for his life as well as his sight, and 
 every effort must be made to preserve his strength and increase 
 his resistance. Fresh air and careful feeding are imperative. 
 Breast-fed babies have a distinct advantage over bottle-fed babies 
 and for this reason the mother should always accompany the 
 nursing baby if he is taken from his home to a hospital to be 
 treated for ophthalmia neonatorum, unless there is a wet nurse 
 available at the hospital. 
 
 It is of interest to nurses that the effort to safeguard the 
 eyes of babies through preventive treatment and early care was 
 developed into a national movement by one who also was influ- 
 ential in starting the training of nurses in this country, Miss 
 Louisa Lee Schuyler. The lay work for the prevention of blind- 
 ness, which is now country-wide, was started by the New York 
 State Committee for Prevention of Blindness, which was or- 
 ganized by Miss Schuyler in 1908. She was its first Chairman 
 and skillfully directed the work of the Committee for ten years. 
 During the Civil War Miss Schuyler was a member of the Sani- 
 tary Commission and afterwards was one of the group which 
 was responsible for starting at Bellevue Hospital, in New York 
 City (in May, 1873), the first training school for nurses in this 
 country, planned in accordance with Miss Nightingale's stand- 
 ards for the organization and conduct of a school for nurses. 
 Later, in 1911, the Bellevue School for Midwives was estab- 
 lished as a result of the combined efforts of the Hospital Trus- 
 tees and Miss Schuyler 's Committee for Prevention of Blindness, 
 the course of training being outlined by a sub-committee com- 
 posed of Miss Lillian D. Wald, Dr. J. Clifton Edgar and myself. 
 So far as it is possible to learn this school was the first in this 
 country to be conducted along the lines of a school for nurses, 
 or after the manner of the midwife schools in England. 
 
 Syphilis, which ranks high among the scourges of mankind, 
 is seen with distressing frequency among young babies. It may 
 be contracted during uterine life, when it is said to be ''in- 
 herited," or it may be "acquired" after birth by kissing a 
 syphilitic person or coming in contact with contaminated articles, 
 such as clothing, or nursing from a diseased breast. 
 
DISORDERS OF EARLY INFANCY 53S 
 
 The most conspicuous symptoms are the familiar "snuffles;" 
 the scaling, fissures or eruption on the soles, palms, buttocks and 
 about the mouth; shrill, hoarse crying; swollen painful joints; 
 partial paralysis and a general feebleness and inanition. Some 
 or all of these symptoms may be present when the baby is born 
 or they may develop any time within the first two or three 
 months of life. 
 
 Babies of syphilitic mothers are often given mercurial in- 
 unctions immediately after birth, even though they have no 
 symptoms of the disease as it is very likely to be present in a 
 latent form. This is one reason for the routine inspection of 
 the placenta, since in it is sometimes found the only indication 
 for treating the baby. An infant who is known to have syphilis 
 is given mercurial inunctions or baths, the ointment being rubbed 
 into the groin, axilla, back and abdomen in rotation on succes- 
 sive days, to prevent irritation of the skin. The nurse should 
 protect herself with rubber gloves, wash the area with warm 
 water and soap and thoroughly rub in the ointment. Sometimes 
 the ointment is put on the inside of the back of the baby's binder, 
 by which means he rubs it in himself. The syphilitic baby should 
 be isolated and should not be put to the breast of an uninfected 
 woman, but he may nurse from a syphilitic woman without harm 
 to either her or himself. Good general care, including fresh air 
 and sunshine are important to the baby suffering from syphilis. 
 
 Thrush or Sprue is a highly communicable disease of the 
 mouth of new-born babies, due to one of the fungi. It is com- 
 mon among sickly, undernourished babies and those living in 
 unhygienic surroundings, but it is seldom seen in healthy babies 
 who are cared for with absolute cleanliness. The disease is char- 
 acterized by small raised, white spots in the baby's mouth, fre- 
 quently on the back of the tongue and inner surface of the 
 cheeks. 
 
 Prevention lies in good care and in cleanliness of the mother 's 
 nipples, or the bottles and nipples for artificially fed babies, and 
 of all other articles coming in contact wath the baby, particu- 
 larly his mouth. Some doctors have the baby's mouth bathed 
 before each feeding, as a preventive measure, while others feel 
 
540 OBSTETRICAL NURSING 
 
 that a gentle swabbing once daily is sufficient, if the nipples are 
 kept clean, since an abrasion of the mucous lining is easily 
 caused and is favorable to the development of thrush. 
 
 Treatment consists in cleanliness and in gently swabbing the 
 spots, three or four times a day, with sterile cotton wet with an 
 alkaline solution such as borax (10%), bicarbonate of sodium 
 (6%) and sometimes with formalin {!%) or a weak solution of 
 permanganate of potassium. 
 
 Impetigo and Pemphigus are highly infectious skin diseases 
 of early infancy which are seen more often in hospitals than in 
 patients' homes. The treatment of the raised blisters that ap- 
 pear on different parts of the body is entirely a medical ques- 
 tion, but in caring for the patients suffering from either of these 
 infections the nurse must take every precaution to avoid ex- 
 tending the trouble on the skin of the infected baby, himself, 
 and of communicating it to other babies in the ward. Strict 
 isolation is imperative; gentle handling and frequent changing 
 of the underclothing to prevent extending the disease to unin- 
 fected areas. 
 
 Vaginitis. This highly infectious malady is considered 
 troublesome rather than serious, as a rule, though it may be 
 complicated by ophthalmia or arthritis. Gonorrheal vaginitis is 
 the commonest form seen in early infancy and may be due to 
 infection which the baby acquired during its passage through 
 the birth canal or later from the mother's hands or clothing. 
 The symptoms are a vaginal discharge, which may be thin and 
 serous or thick and yellow and purulent and it may be scanty 
 in amount or abundant; a reddened, swollen condition of the 
 vagina and vulva and sometimes redness and excoriation of 
 the inner surface of the thighs. The nurse's chief responsibili- 
 ties are to be constantly on the alert to detect evidences of the 
 disease and report them promptly to the doctor, and to observe 
 strict isolation in caring for the baby while carrying out the 
 doctor's orders for douches or suppositories. 
 
 COMMON ABNORMALITIES OF THE NEW-BORN 
 
 Icterus or Jaundice, which is so frequently seen in new-born 
 babies, is occasionally a symptom of some septic condition; of 
 
DISORDERS OF EARLY INFANCY 541 
 
 syphilis or congenital cirrhosis of the liver or obstruction of 
 the bile ducts, but as a rule it is without any serious significance. 
 The jaundiced appearance usually begins on the second or third 
 day and may continue for two or three weeks or it may subside 
 in three or four days. The depth of the color varies, being very 
 pale in some cases and almost green in others. When this dis- 
 coloration of the skin is unaccompanied by other symptoms, no 
 treatment is given. 
 
 A Cephalhematoma is a tumor of blood between the peri- 
 osteum and the bones of the skull of the new-born baby. It is 
 often due to some injury sustained during birth and is most 
 frequently seen after prolonged labors. Cephalhematoma is 
 sometimes confused with a caput succedaneum, but whereas the 
 caput disappears in a few days the cephalhematoma may not be 
 entirely absorbed for two or three months. Although certain 
 conditions sometimes indicate the advisability of surgical treat- 
 ment, the nurse's care consists solely of protecting the. tumor 
 from injury. 
 
 Club foot is one of the commonest deformities of the extremi- 
 ties of young babies, occurring once in about every 1000 births. 
 It may be congenital or caused by injury or it may be due to 
 such diseases as cerebral paralysis or poliomyelitis. The nurse 
 should watch for any abnormality in the structure or position of 
 the feet, for the earlier treatment is started, the better is the 
 prospect of a cure. 
 
 Engorgement of the Breasts. Not infrequently the breasts 
 of new-born babies are engorged, in which state they are easily 
 infected by being rubbed or squeezed. Since the greatest care 
 must be taken to avoid bruising swollen breasts, they are some- 
 times protected by the application of a pad of sterile cotton. 
 Hot compresses are sometimes applied when there is redness 
 with the swelling, or a tiny ice-bag, made by tying off the fingers 
 and thumb of a rubber glove, and partly filling it with finely 
 crushed ice, after which the wrist is tightly tied. 
 
 Hare Lip. The fissured lip, which is not infrequently seen 
 in new babies, may consist merely of a small notch or it may 
 amount to a deep cleft reaching up into the nostril. It is due 
 to a non-union of the fronto-nasal plate with the lateral processes 
 
542 OBSTETRICAL NURSING 
 
 and may occur on one or both sides, thus forming a single or 
 double hare lip. An extensive fissure will usually interfere 
 with suckling and the nurse may need both ingenuity and pa- 
 tience in feeding such a baby, for the prospect of successful 
 treatment, which is surgical, increases with the baby's age and 
 improved nutrition. The longer she can feed the baby success- 
 fully, therefore, the better his chance of recovery. 
 
 Cleft palate, a common congenital abnormality, consists of 
 a fissure of the soft, and sometimes of the bony, palate ; it may 
 be on one or both sides and may be continuous with a hare lip. 
 The problem of feeding the baby with a cleft palate is very grave 
 since the fissure may make it impossible for him to form the 
 vacuum in the back of his mouth which is necessary for suck- 
 ling. He is sometimes fed with a medicine dropper or by gavage 
 or by means of a special nipple provided with a flap which fits 
 into the roof of the mouth and closes the opening into the nasal 
 passages. Even more than in the care of the baby with a hare 
 lip is it important to nourish the baby with a cleft palate, and 
 build him up for as long as possible before he is subjected to the 
 strain and shock of the inevitable operation. 
 
 Hernia. Umbilical and inguinal hernias are both seen in 
 young babies. 
 
 Umbilical hernia is the commoner type and is not uncommon 
 in thin babies and those with indigestion and distension and 
 in babies who cry violently. Such hernias are not regarded as 
 serious if prompt measures are taken to reduce them as they 
 usually respond very readily to treatment. But since neglect 
 may have serious consequences, the nurse should watch for pro- 
 trusions and report them promptly. She will often be instructed 
 to reduce the hernia and apply adhesive strapping, in which 
 case the following observations by Dr. Griffith will be helpful: 
 
 * ' Usually it is quite sufficient to draw the skin into two folds, 
 one on each side of the hernia and meeting over it ; holding these 
 in place by straps of adhesive plaster crossing over the navel, or 
 by a broad horizontal band of adhesive plaster reaching to the 
 lumbar regions. Another method is the following: A silver 
 quarter of a dollar is laid upon the adhesive surface of a piece 
 of rubber plaster about two inches square; over this is placed 
 
DISORDERS OF EARLY INFANCY 543 
 
 the broad strap referred to, with its adhesive surface next to 
 that of the smaller piece. After reducing the hernia and press- 
 ing the sides of the abdominal walls slightly together the band 
 is applied with the quarter dollar directly over the position of 
 the navel. My own preference is for a simple adhesive band 
 without the use of the coin. The dressing should be worn con- 
 stantly, changing it from time to time as the old one loosens. 
 The dressing must, of course, not be removed during the bath. 
 Several months are required before the opening is permanently 
 closed. Occasionally the plaster produces a great deal of 
 cutaneous irritation, especially in the first few months of life. 
 The employment of zinc oxid plaster tends to avoid this diffi- 
 culty."^ 
 
 Inguinal hernia is less common in very young babies but it 
 should be watched for since it usually may be easily reduced 
 by the use of a truss, if discovered and treated early, but may 
 be serious if neglected. 
 
 In general, the new baby who is ill, needs the same thought- 
 ful, gentle, painstaking care that the nurse gives to the well 
 baby, but these must be shaped to his immediate requirements 
 and the doctor's special instructions. 
 
 *"The Diseases of Infants and Children," by J. P. Crozer Griffith, M.D. 
 
CHAPTER XXIV 
 A FINAL WORD 
 
 It will be well for us now to take a retrospective view of 
 the various functions of the nurse which are associated with 
 the phenomena of pregnancy, labor, the puerperium and the 
 beginning of a new life. As we see these in perspective, our 
 attention is fixed by a few important principles which stand out 
 from the picture as a whole in clear and shining relief. 
 
 "We see, for example, that no matter what else may become 
 vague and unimportant, be changed or discarded, there remains 
 the conspicuous, unalterable requirement that the nurse shall 
 do clean work throughout this entire series of experiences. All 
 maternity patients and all babies need scrupulously clean care 
 no matter what else they may have or may lack. 
 
 But also must they all be watched throughout these transi- 
 tional stages, in order that impending disaster may be appre- 
 hended and warded off. And that this watchfulness be 
 intelligent, the nurse must of necessity know something of 
 the normal physiological changes which occur during these 
 momentous periods in the lives of her patients, lest she fail to 
 detect evidence of abnormality, should it appear. 
 
 Since this invariable cleanliness and close watchfulness are 
 needed by all patients, whether of high or low degree, and 
 by those in the care of doctors with widely varied methods, 
 the nurse must be able to make adaptations to each patient's 
 environment and temperament and to the doctor as well, if all 
 of her patients are to be well and happily nursed. She must be 
 clean, then, and watchful in her work, and adapt it to every con- 
 ceivable condition. These features stand out clear and bold in 
 the perspective. But to make these offices effective to their 
 utmost, the nurse's attitude and her care of her patient must be 
 mellowed by an always deepening sympathy and understanding. 
 She must endeavor, in each instance, to imagine the mental ex- 
 
 544 
 
A FINAL WORD 545 
 
 perience of the bewildered and timid expectant mother; of the 
 terrified woman in labor and the discouraged young mother — 
 these she must appreciate if she is to give of her best. And so, in 
 the end, the character of the nurse's work will be influenced, in 
 fact almost determined, by her awareness of her patient's 
 needs, mental and physical, and the earnestness with which she 
 tries to relieve them. More than this, the nurse whose skill is 
 warmed by a sincere desire to give of her best will, by virtue of 
 this very desire, learn something from each patient, and will be 
 steadily enriched and broadened by her experiences. She will 
 have more to give, and accordingly will derive increasing satis- 
 faction from her service to each succeeding mother and baby that 
 she takes into her care. 
 
 One word more. The maternity nurse almost inevitably be- 
 comes deeply attached to her baby patient, whether he is sick or 
 well, and she is eager to protect him and safeguard him as long 
 as possible. She may continue to serve him, even after he has 
 passed from her trained hands, if she will teach his mother how 
 to take care of him, should she be inexperienced, particularly if 
 the young mother is to have full charge of her baby after the 
 nurse leaves, or is to have only the assistance of a partly trained 
 nursery maid. In such a case the nurse may often perform her 
 most valuable and enduring service to the baby by gradually 
 teaching his mother how to prepare the milk with cleanliness and 
 accuracy, if he must be bottle-fed ; how to give his bath deftly and 
 comfortably, and impressing upon her the importance of fresh 
 air and of regularity in the baby's daily routine. All of these 
 things, and also how to do the thousand and one other things 
 that seem so trivial and yet mean so much to the baby's im- 
 mediate health and future well being. 
 
 The first day after the nurse leaves, and the first few after 
 that are often very dark ones for the inexperienced young 
 mother, and if she is alone they are likely to be filled with 
 fear and misgivings. The nurse may rob these days of much 
 of their discouragement by anticipating them ; trying to imagine 
 the young mother's possible perplexities and then teaching her 
 how to meet them. This teaching is perhaps not a part of the 
 nurse's professional obligation but it is one of the privileges. 
 
546 OBSTETRICAL NURSING 
 
 one of the gratifying by-paths of nursing that she may take 
 for the sheer joy of it. 
 
 Not infrequently the young mother is so tilled with awe 
 over possessing anything so wonderful as her own baby that 
 she is afraid to handle the exquisite little body; is fearful of 
 harming it; and because of her timidity and inexperience she 
 fails to give him the care that he needs, and that she wants 
 to give. On the other hand, all too many young mothers have a 
 blind confidence that the mere act of having a baby vests one, in 
 some instinctive way, with the requisite knowledge and skill 
 to care for it, and in this belief they are supported by a legion 
 of women friends and relatives. 
 
 It would be difficult to imagine a single factor that works 
 more destruction among babies than this one of ignorant 
 motherhood. And the damage is equally great whether the 
 ignorance arises from timidity or from overweening confidence. 
 
 "Is it not preposterous," says Herbert Spencer, ''that the 
 fate of a new generation should be left to the chance of un- 
 reasoning custom, impulse, fancy, joined with the suggestions 
 of ignorant nurses and the prejudiced counsel of grandmothers? 
 To tens of thousands that are killed, add hundreds of thousands 
 that survive with feeble constitutions, and millions that grow 
 up with constitutions not so strong as they should be, and you 
 have some idea of the curse inflicted on their offspring by 
 parents ignorant of the laws of life. ' ' 
 
 The nurse is in the most effective position possible, to help 
 in dispelling maternal ignorance, during the long days of 
 pleasant intimacy which she and the young mother spend to- 
 gether in devotion to the baby. And by helping the inex- 
 perienced young mother to give skilful care to her baby, with 
 all of the gentleness and tenderness that a mother can lavish, 
 the nurse will not only serve the baby; she also will awaken 
 for many a young woman, an interest that will be ever fresh 
 and absorbing, and point the way to unexpected joys and de- 
 lights in her motherhood. 
 
 "Can there be any higher work than this? 
 Can any woman wish for a more womanly work?" 
 
INDEX 
 
 Abdomen, changes in, during preg- 
 nancy, 102 
 
 enlargement of, during pregnancy, 
 98 
 Abdominal binders, in pregnancy, 
 122 
 
 in puerperium, 349 
 Abdominal palpation, 226 
 Abdominal pedicle, 76 
 Abdominal supporters, in pregnancy, 
 
 122 
 Abdominal wall, in puerperium, 321 
 Abnormalities of newborn, 540 
 Abortion, 165, 166 
 
 attempted, 151 
 
 causes of, 166 
 
 complete, 170 
 
 early signs of, 142 
 
 incomplete, 170 
 
 induced, 309, and see Induced ab- 
 ortions 
 
 missed, 170 
 
 prevention of, 168 
 
 symptoms of, 167 
 
 therapeutics, 171 
 
 threatened, 170 
 
 treatment of, 170 
 complete, 170 
 incomplete, 170 
 threatened, 170 
 Abscesses, in breast, 344 
 Accidental hemorrhage, 178 
 Accidents of pregnancy, 164 
 Accouchement forc6, 309, 313 
 Acidosis, 525 
 
 Acute yellow atrophy of liver, dur- 
 ing pregnancy, 207 
 Advice for mothers, 427 
 After -birth, see Placenta 
 After-care, immediate, of patient, 
 
 281 
 After-pains, 318 
 
 Air, fresh, during pregnancy, 129 
 Albumen in urine, tests for, 118 
 Alcohol, during pregnancy, 127 
 Amenorrhea, 56 
 Amnion, 70 
 
 development of, 70 
 Amniotic fluid, 71 
 Analgesia, nitrous oxid gas, 291 
 Anatomy of pelvis and genitalia, 19 
 
 Anesthesia, h la reine, 288 
 
 chloroform, 287, 288 
 
 complete, 292, 293 
 
 ether, 289, 290 
 
 light, 288 
 
 nitrous oxid gas, 291 
 
 obstetrical, 286, 288 
 
 scopolamin and morphin, 292 
 
 unfavorable signs in, 294 
 Animal foods, allowed during preg- 
 nancy, 128 
 Ante-partum hemorrhage, 174 
 Areolae, 43 
 
 Artificial feeding of baby, 489 
 Attitude of fetus, in utero, 217 
 Auscultation of fetal heart, 231 
 Axis-traction forceps, 301 
 
 Baby, and see Infant, and New-born 
 basket for, while travelling, 507 
 care of, by visiting nurse, 437 
 during summer, 514 
 immediate, 265 
 while travelling, 507 
 feeding, 486, and see Baby's food 
 artificial, 489 
 breast, 486 
 giving bottle to, 495 
 method of holding, for eye exam- 
 ination, 537 
 nutrition of, 368 
 preparations for, 162 
 supplies for, 428 
 sore eyes of, 533 
 toilet tray for, 417 
 Baby 's food, articles used in prepar- 
 ing, 492 
 commercial, 503 
 ingredients of, 498 
 proprietary, 504 
 Baby basket, for travelling, 507 
 Ballottement, 100 
 Barley water, preparation of, 505 
 Bartholin's glands, 40 
 Bath, bran, preparation of, 517 
 in puerperium, 329 
 soda, preparation of, 517 
 starch, preparation of, 517 
 Bathing, during pregnancy, 119 
 Baudelocque's diameter, 25, 27 
 Bed exercise, in puerperium, 349 
 
 547 
 
548 
 
 INDEX 
 
 Bed, position in during puerperium, 
 326 
 preparation of for labor, 248 
 Beef juice, preparation of, 506 
 Beri-beri, 376 
 
 Binders, abdominal, during preg- 
 nancy, 122 
 in puerperium, 349 
 for breast, 123, 345, 347 
 Birth, changes in fetal circulation 
 
 at, 84, 87 
 Bladder, 37 
 
 care of in puerperium, 332 
 Blastodermic vesicle, 65, 66 
 Bleeding, see Hemorrhage 
 Bones, changes in, during pregnancy, 
 
 104 
 Bottle, giving of to baby, 495 
 Bowels, care of in pregnancy, 120 
 care of, in puerperium, 331 
 of fetus, 88 
 Bradycardia, puerperal, 322 
 Bran bath, preparation of, 517 
 Bread, allowed during pregnancy, 
 
 128 
 Breast, and see Lactation, and Nur- 
 sing 
 abscess in, 344 
 anatomy of, 41, 42 
 binders, in pregnancy, 123 
 in puerperium, 345, 347 
 caked, 344 
 care of, during pregnancy, 131 
 
 in puerperium, 339 
 changes in, in pregnancy, 96, 
 
 103 
 drying up of, 366 
 feeding, 486, and see Nursing, 
 Lactation 
 contraindications, 357 
 infusion under, 202 
 stripping, 348 
 
 supporting, in puerperium, 343 
 supports for, in puerperium, 343, 
 345 
 Breast tray, 417 
 
 Breath, shortness of, during preg- 
 nancy, 140 
 Breech extraction, 298 
 Bregma, 89 
 Broad ligament, 33, 38 
 Broths, preparation of, 506 
 
 Caesarean section, 305 
 
 conservative, 307 
 
 extra-peritonealj 307 
 
 indications for, 306 
 
 radical, 307 
 Caked breasts, 344 
 Cane sugar, 498 
 Canned milk, 504 
 
 Caput succedaneum, differentiated 
 
 from cephalhematoma, 541 
 Cardiovascular system, changes in 
 
 in pregnancy, 103 
 Care of baby, by visiting nurses, 437 
 in traveling, 507 
 during summer, 514 
 immediate, 265 
 of mother, by visiting nurses, 437 
 Carriage, in pregnancy, 105 
 Catheterization, 333 
 Cephalhematoma, 541 
 Cereals allowed during pregnancy, 
 
 128 
 Certified milk, 490 
 Cervix, changes in in pregnancy, 99, 
 102 
 during labor, 234 
 Champetier de Eibes' bag, 311 
 Childbirth, deaths in, 112, 405 
 Chloasma, 97, 105 
 Chloroform anesthesia, 287, 288 
 Chorion, 68 
 
 development of, 68 
 frondosum, 70 
 laeve, 70 
 primitive, 67 
 villi, 68, 70 
 Circulation, fetal, 84, 85 
 
 changes in at birth, 84, 87 
 Cleft palate, in new-born, 542 
 Climacteric, 56 
 
 Clinic assistant, duties of, 431 
 Clinic equipment, 432 
 Clitoris, 40 
 
 Clothes, during pregnancy, 121 
 Club foot, in new-born, 541 
 Coccyx, 20 
 Colic in infants, 528 
 Colonic irrigations in eclampsia, 195 
 Colostrum, 103 
 Commercial baby foods, 503 
 Complete abortion, 170 
 Complicated labors, 295 
 Complications of pregnancy, 164 
 early signs of, 141, 143 
 of puerperium, 391 
 Concealed hemorrhage, 178 
 Conception, 62 
 Condensed milk, 504 
 Confinement, to calculate date of, 
 
 93, 94 
 Constipation, during pregnancy, 120 
 
 in infants, 529 
 Contracted pelvis, measurements in, 
 
 29 
 Convulsions, in infants, 531 
 Cord, umbilical, 76 
 development of, 61 
 ligation of, 272 
 prolapsed, 285 
 
INDEX 
 
 549 
 
 Corpus luteum, 49 
 
 false, 49 
 
 of menstruation, 49 
 
 of pregnancy, 49 
 
 verum, 49 
 Corsets, during pregnancy, 121 
 
 front-lace, 122 
 
 maternity, 122 
 Cow 's milk compared with mother 's 
 
 milk, 491 
 Cramps in legs, during pregnancy, 
 
 140 
 Cravings, during pregnancy, 127 
 Cul-de-sac of Douglas, 36, 39 
 
 Dammerschlaf, 292 
 
 Date of confinement, to calculate, 
 
 93, 94 
 Deaths in childbirth, 112, 405 
 Decidua basalis, 66 
 
 graviditatis, 65 
 
 reflexa, 66 
 
 serotina, Q6 
 
 vera, 66 
 Deficiency diseases, 372, 378 
 Delivery, dressings required for, 
 159 
 
 patient draped for, 262 
 
 preparation of dressings for, 155, 
 158 
 of equipment for, 155 
 of room for, 155 
 
 requirements of mother for, 158 
 of physician for, 161 
 
 room ready for, 258, 259 
 Detachment of placenta, 241 
 Desserts allowed in pregnancy, 128 
 Development of cord, 61 
 
 of embryo, 61, 76, 78, 80 
 
 of fetus, 61, 76, 78, 80 
 
 of membranes, 61 
 
 of ovum, 61 
 
 of placenta, 61, 72 
 Diameters of fetal head, 90, 91 
 
 of pelvis, 25, 26, 27, 28 
 Diarrhea, during pregnancy, 136 
 Diarrheal diseases of infants, 518 
 Diastasis of rectus muscles, 102 
 Diet during pregnancy, 125, 128 
 
 during puerperium, 329 
 
 of nursing mother, 363 
 Digestive tract, changes in during 
 pregnancy, 104 
 
 during puerperium, 321 
 Discoloration of skin during preg- 
 nancy, 97 
 Discomforts during pregnancy, 134 
 Discus proligerus, 48 
 Distress during pregnancy, 136 
 Douches, vaginal, in puerperium, 338 
 Douglas, cul-de-sac of, 36, 39 
 
 Dressings, post-partum, 336 
 
 required for delivery, 155, 158, 
 
 159 
 Dried milk, 505 
 Drugs excreted in milk, 331 
 Dry labor, 235 
 
 Dry pack, hot, in eclampsia, 197 
 Ductless glands, changes in during 
 
 pregnancy, 105 
 Duncan 's mechanism of placental 
 
 separation, 239, 242 
 Dysmenorrhea, 56 
 
 Eclampsia, 190 
 
 colonic irrigations in, 195 
 
 frequency of, 190 
 
 mortality of, 191 
 
 nursing care in, 193 
 
 symptoms of, 191 
 
 treatment of, 193 
 Ectoderm, structures derived from, 
 
 67 
 Elevated Sims' position, 139 
 Embryo, 67, 68 
 
 development of, 61, 76, 78, 80 
 Embryonic area, 66 
 
 development, 67 
 Emotional changes during preg- 
 nancy, 105 
 Endometrium, 32 
 
 premenstrual swelling of, 49 
 Enema, to give to infant, 530 
 Engagement of presenting part, 224 
 Engorgement of breasts, in new- 
 born, 541 
 Entoderm, structures derived from, 
 
 67 
 Episiotomy, 298 
 
 Equipment, preparation of for de- 
 livery, 158 
 Esbach's test for albumen in urine, 
 
 118 
 Ether anesthesia, 289, 290 
 Evaporated milk, 504 
 Examination of eye, method of hold- 
 ing baby for, 537 
 
 of urine, in pregnancy, 117 
 
 rectal, during pregnancy, 231 
 
 vaginal, in labor, 248, 252 
 in pregnancy, 230 
 Excretions during pregnancy, 117 
 Exercise, bed, during puerperium, 
 349 
 
 for nursing mother, 364 
 
 in pregnancy, 129 
 Expectant mother, 110 
 
 mental hygiene of, 145 
 Extra-uterine pregnancy, 82 
 
 Face presentation, positions in, 223 
 Fallopian tubes, anatomy of, 33 
 
550 
 
 INDEX 
 
 Fallopian tubes, changes in during 
 pregnancy, 102 
 
 fimbriae of, 34 
 Fat soluble A. vitamines, 371, 377 
 Feeder, for premature babies, 513 
 Feeding, 486 
 
 artificial, 489 
 
 breast, 486 
 
 mixed, 503 
 
 percentage, 499, 500, 501 
 Feet, swelling of during pregnancy, 
 137 
 
 varicose veins of during preg- 
 nancy, 138 
 Fertilization, 62 
 Fetal circulation, 84, 85 
 
 changes in at birth, 84, 87 
 Fetal head, 88, 90 
 
 circumference of, 91 
 
 diameters of, 90, 91 
 
 fontanelles of, 89, 90 
 
 rotation of during birth, 236 
 
 sutures of, 89 
 Fetal heart, auscultation of, 231 
 Fetal heart beat, sign of pregnancy, 
 
 99 
 Fetal mortality, 112 
 Fetus, 68 
 
 at term, 80, 218 
 
 attitude of in uterus, 217 
 
 bowels of, 88 
 
 development of, 61, 76, 78, 80 
 
 growth of, 84 
 
 head of, 88, 90, and see Fetal head 
 
 kidneys of, 88 
 
 maturation of, time required for, 
 68 
 
 movements of, as sign of preg- 
 nancy, 99 
 
 palpation of, 224 
 
 as sign of pregnancy, 99 
 
 physiology of, 84 
 
 position of, 217 
 
 presentation of, 217, 220 
 
 presenting part of, 220 
 Fimbria ovarica, 34 
 Flatulence during pregnancy, 136 
 Follicle, primordial, 47 
 Fontanelles of fetal head, 89, 90 
 Foods for baby, commercial, 503 
 
 proprietary, 504 
 Forceps, 300 
 
 axis-traction, 301 
 
 high, 303 
 
 indications for, 301, 302 
 
 low, 303 
 
 Simson's, 301 
 
 Tarnier 's, 301 
 Fornix of vagina, 35 
 Fossa navicularis, 40 
 Fourchette, 40 
 
 Frank hemorrhage, 178 
 
 Fresh air during pregnancy, 129 
 
 Front-lace corset, 122 
 
 Fruits allowed during pregnancy, 
 
 128 
 Funis, 76 
 
 Gastro-enteritis, acute, 519 
 
 nursing care in, 519 
 
 symptoms of, 519 
 
 treatment of, 519 
 Gavage, 524 
 Genitalia, anatomy of, 19 
 
 external, 39 
 
 internal, 30 
 Germinal spot, 48 
 
 vesicle, 47 
 Gonorrhea complicating pregnancy, 
 
 212 
 Gonorrheal vaginitis in infants, 540 
 Graafian follicle, 34, 48 
 Gymnastics during pregnancy, 130 
 
 Harelip in newborn, 541 
 Head, fetal, 88, 90 
 
 circumference of, 91 
 
 diameters of, 90, 91 
 
 fontanelles of, 89, 90 
 
 rotation of during birth, 236 
 
 sutures of, 89 
 Health, general, during pregnancy, 
 
 106 
 Heart, fetal, auscultation of, 231 
 
 lesions of complicating pregnancy, 
 209 
 Heart beat, fetal, sign of pregnancy, 
 
 99 
 Heart burn, during pregnancy, 135 
 Heat and acetic acid test for albu- 
 men in urine, 118 
 Hebotomy, 303 
 Hemorrhage, accidental, 178 
 
 antepartum, 174 
 
 concealed, 178 
 
 during pregnancy, 143 
 
 during puerperiuni, 391 
 
 frank, 178 
 
 postpartum, 286, 391 
 causes of, 391 
 treatment of, 392 
 Hemorrhoids during pregnancy, 140 
 Hernia, in newborn, 542 
 
 inguinal, 543 
 
 umbilical, 542 
 Hot dry pack in eclampsia, 197 
 Hygiene, of nursing mother, 363 
 
 of pregnancy, 116 
 Hysterotomy, vaginal, 305 
 
 Icterus, in newborn, 540 
 Ignorance, dangers of, 546 
 
INDEX 
 
 551 
 
 Ilium, 19 
 Impetigo, 540 
 Impregnation, 62 
 Inanition, 518 
 Incomplete abortion, 170 
 Indian binder for breasts, 347 
 Induced abortion, 309 
 
 indications, 309 
 
 methods, 310 
 Infancy, abnormalities of, 518 
 
 disorders of, 518 
 
 infection in, 533 
 Infant, and see Newborn 
 
 colic in, 528 
 
 constipation in, 529 
 
 convulsions in, 531 
 
 diarrheal diseases of, 518 
 
 enema for, 530 
 
 gonorrheal vaginitis in, 540 
 
 syphilis in, 538 
 
 vaginitis in, 540 
 
 vomiting in, 532 
 
 wasting diseases in, 518 
 Infantile scurvy, 374 
 Infection, in infancy, 533 
 
 puerperal, 393 
 
 nursing care in, 399 
 prevention of, 399 
 symptoms of, 396 
 treatment of, 399 
 Infusion, of orange peel, prepara- 
 tion of, 506 
 
 aaline, in eclampsia, 200 
 
 under breast, 202 
 Inguinal hernia, in newborn, 543 
 Injection of salines, in eclampsia, 
 
 200 
 Innominate bones, 19 
 Instructions to patients, 427 
 Intestinal irrigations, 522 
 Invalidism, due to lack of obstetrical 
 
 care, 112 
 Involution of uterus, 317 
 Irrigations, colonic, in eclampsia, 
 195 
 
 intestinal, 522 
 ischium, 20 
 
 Itching of skin, during pregnancy, 
 141 
 
 Jaundice, in newborn, 540 
 
 Kidneys, during pregnancy, 117 
 of fetus, 88 
 
 Labia majora, 39 
 
 minora, 40 
 Labor, cause of, 232 
 
 cervix during, 234 
 
 complicated, 295 
 
 course of, 232 
 
 definition of. 232 
 
 Labor, dry, 235 
 duration of, 233 
 first stage of, 233 
 
 nurses duties during, 245, 256 
 mechanism of, 232 
 nurses duties in, 243 
 
 during first stage, 245, 256 
 during second stage, 256 
 during third stage, 278 
 when doctor is delayed, 283 
 onset of, 232 
 pains of, 232 
 premature, 172 
 causes of, 172 
 induced, 309, 310 
 treatment, 173 
 preparation for, 248 
 of bed, 248 
 of room, 248 
 signs of, 232 
 second stage of, 236 
 
 nurses duties during, 256 
 stages of, 232 
 symptoms of, 232 
 third stage of, 240 
 
 nurses duties during, 278 
 vaginal examination in, 252 
 when to call physician, 247 
 Lactation, 320, 342 
 Lactose, 498 
 Lacerations, perineal, 296 
 
 repair of, 297 
 Lavage, 524 
 Layette, details of, 162 
 
 recommended by Maternal Centre 
 Association, 416 
 Leg, cramps in during pregnancy, 
 
 140 
 Leg, milk, 400 
 Leg straps, to improvise, 296 
 Leggings, for delivery or operation, 
 
 304 
 Ligaments, broad, 33, 38 
 ovarian, 34, 38 
 round, 38 
 uterine, 38 
 Ligation of cord, 272 
 Linea nigra, 197 
 Linear albicantes, 102 
 Liquor amnii, 71 
 
 foliiculi, 48 
 Liver, acute yellow atrophy of dur- 
 ing pregnane)', 207 
 Lochia, 319 
 alba, 319 
 rubra, 319 
 serosa, 319 
 Longitudinal presentations, 221 
 Loss of weight during puerperium, 
 
 319 
 Lutein, 49 
 
552 
 
 INDEX 
 
 Malnutrition, 369, 387, 518 
 
 Maltose, 498 
 
 Mania, puerperal, 400 
 
 Marasmus, 518 
 
 Marital relations during pregnancy, 
 
 133 
 Masque de femmes enceintes, 105 
 Massage during pregnancy, 130 
 Mastitis, 345 
 Maternal mortality, 112 
 Maternity Centre Association, 410 
 
 baby's supplies, 428 
 
 clinical equipment, 432 
 
 clinical routine, 429 
 
 doctor's duties, 431 
 
 duties of clinical assistants, 431 
 
 forms and routines used by, 423 
 
 instructions to patients, 427 
 
 mother 's supplies, 428 
 
 nurse 's duties, 429 
 
 nursing visits, 424 
 
 orders for nurses, 484 
 
 post-natal follow up, 435 
 
 records, 427, 431 
 
 requirements, 432 
 Maternity Centre Nurse, 413 
 Maternity Centre orders for nurses, 
 434 
 
 antepartum, 484 
 
 post-natal, 435 
 
 post-partum, 435 
 Maternity corsets, 122 
 Maternity Protective Committee of 
 the Woman's City Club, 411 
 Maternity records, 427, 431 
 Maternity Service Association of 
 Physicians and Hospital Su- 
 perintendents, 411 
 Maternity service for rural communi- 
 ties, 422 
 Maternity nursing, visiting, in 
 
 Montreal, 445 
 Maternity work of Visiting Nurses 
 Society of Philadelphia, 439 
 
 delivery routine, 441 
 
 equipment for bags, 439 
 
 routine after delivery, 442 
 
 routine in home, 440 
 
 routine technique, 439 
 Maturation of fetus, time required 
 
 for, 68 
 Mauriceau's maneuver, 299 
 Measurements, in contracted pelvis, 
 
 29 
 Meatus urinarius, 37 
 Membrana granulosa, 48 
 Membrane, vitelline, 47 
 Membranes, development of, 61 
 
 examination of, 280 
 Menopause, 56 
 Menorrhagia, 56 
 
 Menstrual cycle, 50 
 Menstruation, 50 
 
 cessation of, sign of pregnancy, 
 
 96 
 corpus luteum of, 49 
 difficulties of, 54 
 during puerperium, 320 
 modifications of, 56 
 painful, 54 
 
 relation to ovulation, 55 
 vicarious, 56 
 Mesoderm, structures derived from, 
 
 67 
 Mental changes during pregnancy, 
 105 
 hygiene during pregnancy, 145 
 Micturition, frequent, as sign of 
 
 pregnancy, 97 
 Migration of ovum, 61 
 Milk, canned, 504 
 certified, 490 
 condensed, 504 
 cow 's compared with mother 's, 
 
 491 
 dried, 505 
 
 drugs excreted in, 331 
 drying up of, 366 
 evaporated, 504 
 mixtures, formulas for, 500, 501, 
 
 503 
 mother 's compared with cow 's, 491 
 pasteurized, 494 
 powders, 505 
 
 preparation of for baby, 494 
 reconstructed, 505 
 top, 499 
 Avhole, 499 
 Milk leg, 400 
 Miscarriage, 165 
 
 early signs of, 142 
 Missed abortion, 170 
 Mixed feeding, 503 
 Mons Veneris, 39 
 Montgomery, tubercles of, 48 
 Morning sickness, 97, 135, 142, 181 
 Mortality, fetal, 112 
 
 maternal, 112 
 Morula, 64, 65 
 Mother, advice for, 427 
 
 care of by visiting nurses, 437 
 expectant, 110 
 
 mental hygiene of, 145 
 milk of compared with that of 
 
 cow, 491 
 nursing, 357 
 bowels of, 364 
 diet of, 368 
 exercises for, 364 
 hygiene of, 363 
 recreation for, 365 
 rest for, 364 
 
INDEX 
 
 553 
 
 Mother, nutrition of, 368 
 
 requirements of for delivery, 158 
 
 supplies for, 428 
 Movements of fetus a sign of preg- 
 nancy, 99 
 ^Multipara, definition of term, 219 
 Multiple pregnancy, 82 
 
 Nausea, during pregnancy, 134 
 Nephritic toxemia, during preg- 
 nancy, 203 
 
 nursing care of, 205 
 
 symptoms of, 204 
 
 treatment of, 205 
 Neurotic vomiting during preg- 
 nancy, 183 
 Newborn baby and see Infant 
 
 abnormalities of, 540 
 
 bathing of, 463 
 
 behavior of, 459 
 
 bowels, training of, 482 
 
 cephalhematoma in, 541 
 
 characteristics of, 451 
 
 chest, 455 
 
 cleft palate in, 542 
 
 clothes for, 472 
 
 club foot in, 541 
 
 cord, 458 
 
 dressing of, 469 
 
 crying of, 484 
 
 development of, 452 
 
 diapers for, 475 
 
 ear pulling, prevention of, 483 
 
 engorgement of breasts in, 541 
 
 exercise for, 480 
 
 fontanelles, 455 
 
 fresh air for, 477 
 
 growth of, 453 
 
 harelip in, 541 
 
 head, 455 
 
 height of, 455 
 
 hernia in, 542, 543 
 
 icterus in, 540 
 
 inguinal hernia in, 543 
 
 jaundice in, 540 
 
 nursing care of, 461 
 
 resuscitation of, 273 
 
 ruminating, prevention of, 484 
 
 schedule for, 462 
 
 size of, 452 
 
 skin of, 459 
 
 sore eyes in, 533 
 
 stools of, 456 
 
 tears of, 459 
 
 teeth of, 455 
 
 thumb-sucking, prevention of, 482 
 
 training of, 482 
 
 umbilical hernia in, 542 
 
 urine of, 456 
 
 weight of, 452, 453 
 
 Newborn baby, weight chart, 454 
 Nipples, 41 
 
 care of, during pregnancy, 132 
 care of, in puerperium, 340, 342 
 cracked, care of, 342 
 flat, 132 
 retracted, 132 
 toughening, 132 
 Nipple shields, 340, 341, 342 
 Nitrous oxid gas anesthesia, 291 
 Nullipara, definition of term, 219 
 Nurses' bag, contents of, 434 
 Nurses' duties, in clinic, 429 
 during labor, 243 
 first stage, 245, 256 
 second stage, 256 
 third stage, 278 
 maternity centre orders for, 434 
 ante-partum, 434 
 post-natal, 435 
 post-partum, 435 
 Plunkett, 408 
 
 requirements of for delivery, 161 
 visiting, care of mother and baby 
 
 by, 437 
 work of in prenatal ease, 112 
 Nursing mother, 357 
 bowels of, 364 
 diet of, 363 
 exercise for, 364 
 hygiene of, 363 
 recreation for, 365 
 rest for, 364 
 Nursing of baby, see Lactation and 
 Nursing mother 
 frequency of, 361 
 methods of, 358 
 Nursing care in puerperium, 32^3, 
 
 326 
 Nursing visits, 424 
 Nutrition, 369 
 of baby, 368 
 of mother, 368 
 
 Oatmeal Avater, preparation of, 506 
 Obstetrical anesthesia, 286, 288 
 
 operations, 295 
 Oocyte, 47 
 
 Operating table, to make, 295 
 Operations, destructive, 309 
 
 obstetrical, 295 
 Ophthalmia neonatorum, 533 
 
 nursing care of, 535 
 
 symi)toms of, 534 
 
 prevention of, 534 
 
 treatment of, 535 
 Orange juice, ])reparation of, 505 
 Organized ])renatal work, 405 
 Organs of reproduction, female, 30 
 Ossa innoniinata, 19 
 Ova, 34, 47 
 
554 
 
 INDEX 
 
 Ovarian ligament, 34, 38 
 Ovaries, 34 
 
 changes in during pregnancy, 102 
 Ovulation, 47 
 
 relation to menstruation, 55 
 Ovum, 47, 68 
 
 development of, 61 
 
 migration of, 61 
 
 segmentation of, 64, 65 
 
 Pack, to give, 521, 522 
 Palpation of fetus, 224 
 
 sign of pregnancy, 99 
 Pasteurized milk, 494 
 Pellagra, 380 
 Pelvic cavity, 22 
 Pelvic examination in puerperium, 
 
 329 
 Pelvimetry, 19, 25, and see Diam- 
 eters of pelvis 
 Pelvis, anatomy of, 19 
 
 brim of, 22 
 
 contracted, measurements of, 29 
 
 diameters of, 25, and see Dia- 
 meters of pelvis 
 
 false, 23 
 
 female, 19, 21, 30 
 
 inferior strait, 23 
 
 inlet, 22 
 
 male, 21, 30 
 
 measurements of, 25 
 
 normal female, 19, 30 
 
 outlet of, 23 
 
 rachitic, 30 
 
 true, 23 
 Pemphigus, 540 
 
 Percentage feeding, 499, 500, 501 
 Perineal dressings, in puerperium, 
 336 
 
 lacerations, 296 
 repair of, 297 
 Perineum, anatomy of, 40 
 
 care of in puerperium, 335 
 Peritoneum, 34 
 
 Pernicious vomiting of pregnancy, 
 134, 181 
 
 classification, 182 
 Phlegmasia alba dolens, 400 
 Physician, requirements of for deliv- 
 ery, 161 
 
 when to call in labor cases, 247 
 Physiology, 45 
 Pigmentation, in pregnancy, 103, 
 
 105 
 Placenta, 68, 72 
 
 delivery of, 279 
 
 detachment of, 241 
 
 development of, 61, 72 
 
 examination of, 280 
 
 function of, 73 
 
 origin of, 72 
 
 Placenta, separation of, 239, 279 
 mechanism of, 239, 241, 242 
 premature, 178 
 size of, 75 
 weight of, 75 
 Placenta praevia, 174 
 causes of, 176 
 central, 176 
 complete, 176 
 frequency of, 174 
 incomplete, 176 
 marginal, 176 
 mortality in, 174 
 partial, 176 
 symptoms of, 176 
 treatment of, 177 
 Phmkett nurses, 408 
 Poncho, Sutton 's, 479 
 Position of fetus, 217 
 
 definition of, 221 
 Position, elevated Sims, 139 
 
 right angled, 138 
 Positions, in face presentations, 223 
 in transverse presentations, 223 
 in vertex presentations, 222 
 Post-natal follow-up, routine for, 
 
 435 
 Post-natal work of Maternity Centre 
 
 nurses, 419 
 Post-partum care by visiting nurses, 
 437 
 dressings, 336 
 hemorrhage, 286, 391 
 causes of, 391 
 treatment of, 392 
 Potato water, preparation of, 505 
 Pouting umbilicus, 103 
 Powders, milk, 505 
 Pre-.eclamptic toxemia, 187 
 prevention of, 188 
 nursing care in, 189 
 symptoms of, 187 
 treatment of, 189 
 Pregnancy, abdominal binders dur- 
 ing, 122 
 abdominal changes in, 98, 102 
 abdominal enlargement, sign of, 
 
 98 
 accidents of, 164 
 
 acute yellow atrophy of liver dur- 
 ing, 207 
 alcohol during, 127 
 bathing during, 119 
 bones, changes in during, 104 
 bowels, care of during, 120 
 breasts, care of during, 131 
 changes in a sign of, 96 
 changes in during, 96, 103 
 breast-binders during, 123 
 cardiovascular system, changes in 
 during, 103 
 
INDEX 
 
 555 
 
 Pregnancy, carriage in, 105 
 
 cervix, changes in during, !)9, 1 02 
 softening, a sign of, 99 
 
 cessation of menstruation, a sign 
 of, 96 
 
 clothes, during, 121 
 
 complications of, 164 
 early signs of, 141, 143 
 
 constipation during, 120 
 
 corpus luteum of, 49 
 
 corsets during, 121 
 
 cramps in legs during, 140 
 
 cravings during, 127 
 
 diarrhea during, 136 
 
 diet during, 125, 128 
 
 digestive tract, changes in dur- 
 ing, 104 
 
 discoloration of skin, as sign of, 
 97 
 
 discomfort during, 134 
 
 distress during, 136 
 
 ductless glands, changes in dur- 
 ing, 105 
 
 duration of, 93 
 
 emotional changes during, 105 
 
 excretions during, 129 
 
 exercise during, 129 
 
 extra-uterine, 82 
 
 fallopian tubes, changes in dur- 
 ing, 102 
 
 fetal heart beat, a sign of, 99 
 
 fetal movements a sign of, 99 
 
 flatulence during, 136 
 
 fresh air during, 129 
 
 gonorrhea complicating, 212 
 
 gymnastics during, 130 
 
 health, general, during pregnancy, 
 106 
 
 heartburn during, 135 
 
 heart lesions complicating, 209 
 
 hemorrhage during, 143 
 
 hemorrhoids during, 140 
 
 hygiene of, 116 
 
 itching of skin during, 141 
 
 kidneys in, 117 
 
 marital relations during, 133 
 
 massage during, 130 
 
 mental changes during, 105 
 
 mental hygiene during, 145 
 
 micturition, frequent as sign of, 
 97 
 
 morning sickness during, 97, 135, 
 142, 181 
 
 multiple, 82 
 
 nausea during, 134 
 
 nephritic toxemia in, 203 
 
 neurotic vomiting in, 147 
 
 nipples, care of during, 132 
 flat, 132 
 retracted, 132 
 
 ovaries, changes in during, 102 
 
 Pregnancy, palpation of fetus, sign 
 of, 99 
 pernicious vomiting of, 134, 181 
 pliysiology of, 93, 100 
 pigmentation in, 105 
 positive signs of, 99 
 premature termination of, 165 
 
 early signs of, 142 
 presumptive signs of, 96 
 pressure symptoms during, 137 
 probable signs of, 98 
 pulmonary tuberculosis compli- 
 cating, 209 
 psychoses during, 147 
 pyelitis complicating, 212 
 quadruplet, 82 
 quickening, as sign of, 98, 99 
 
 to calculate date of confinement 
 from, 94 
 quintuplet, 82 
 rectal examination in, 231 
 respitary organs, changes in dur- 
 ing, 104 
 rest during, 130 
 sextuplet, 82 
 shoes during, 124 
 shortness of breath during, 140 
 signs of, 93 
 
 positive, 99 
 
 presumptive, 96 
 
 probable, 98 
 skin, care of during, 118 
 
 changes in during, 104 
 
 itching of during, 141 
 
 stretching of during, 141 
 sleep during, 130 
 spurious, 96 
 
 stocking supporters during, 124 
 supporters, abdominal, during, 122 
 
 stocking, during, 124 
 swelling of feet during, 137 
 symptoms of, 93 
 syphilis, complicating, 207 
 teeth in, 104, 133 
 temperature of body in, 105 
 thyroidism complicating, 210 
 toxemias of, 142, 179 
 
 early signs of, 142 
 travelling during, 133 
 triplet, 82 
 twin, 82 
 
 umbilicus, changes in during, 103 
 urinary apparatus, changes in dur- 
 ing, 104 
 urine in, 117 
 
 tests for, 118 
 uterus, changes in during, 101, 83 
 
 sign of, 98, 99 
 vagina, ciiangos in during, 102 
 vaginal discharge during, 140 
 
 examination in, 230 
 
556 
 
 INDEX 
 
 Pregnancy, varicose veins during, 
 138 
 
 vomiting during, 134, 181 
 Premature baby, 508 
 
 bed for, 512 
 
 care of, 509 
 
 feeder for, 513 
 
 feeding of, 510, 513 
 
 heat required for, 511, 512 
 
 size of, 508 
 Premature labor, 172, 165 
 
 causes of, 172 
 
 early signs of, 142 
 
 induced, 309, 310 
 
 indications for, 310 . 
 methods, 311 
 
 treatment of, 173 
 Premature separation of normally 
 implanted placenta, 178 
 
 causes of, 178 
 
 symptoms of, 178 
 
 treatment of, 179 
 Premature termination of preg- 
 nancy, 165 
 early signs of, 142 
 Premenstrual swelling of endomet- 
 rium, 49 
 Prenatal care, 111 
 
 work of nurse in, 112 
 Prenatal work, organized, 405 
 Prenatal visits, routine for, 423 
 Preparations for delivery, 155, 158 
 Presentation of fetus, 217 
 
 definition of, 220 
 
 face, 223 
 
 longitudinal, 221 
 
 transverse, 221, 223 
 
 vertex, 222 
 Presenting part, definition of, 220 
 
 engagement of, 224 
 Pressure symptoms during preg- 
 nancy, 137 
 Prickly heat, 516 
 Primigravida, definition of, 219 
 Primipara, definition of, 219 
 Primordial follicle, 47 
 Prolapsed cord, 285 
 Proprietary baby foods, 504 
 Protein milk, preparation of, 506 
 Pseudocyesis, 96 
 Psychoses during pregnancy, 147 
 Puberty, 45 
 Pubiotomy, 304 
 Pubis, 20 
 
 Pudendal crease, 39 
 Puerperium, 317 
 
 abdominal binder, in, 349 
 
 abdominal wall in, 321 
 . bath in, 329 
 
 bed exercise in, 349 
 
 bladder, care of during, 332 
 
 Puerperium, boAvels, care of during, 
 331 
 bradycardia during, 322 
 breasts, binder for, 345, 347 
 care of during, 339 
 supports for during, 343, 345 
 complications in, 391 
 diet in, 329 
 
 digestive tract during, 321 
 douches, vaginal during, 338 
 hemorrhages during, 391 
 infection in, 393 
 nursing care of, 399 
 symptoms of, 396 
 treatment of, 399 
 loss of weight during, 319 
 mania during, 400 
 menstruation during, 320 
 nipples, care of during, 340 
 nursing care in, 323, 326 
 pelvic pxamination in, 329 
 perineal dressings in, 336 
 perineum, care of during, 335 
 physiology of, 317 
 pulse during, 322, 335 
 jDOsition in bed during, 326 
 respiration in, 335 
 sitting up in, 328 
 skin in, 322 
 temperature in, 321, 335 
 urine in, 322 
 
 uterus, changes in during, 317 
 height of during, 327, 328 
 Puhnonary tuberculosis complicating 
 
 pregnancy, 209 
 Pulse, in puerperium, 322, 335 
 Pyelitis complicating pregnancy, 
 212 
 
 Quadruplet pregnancy, 82 
 Quickening, as sign of pregnancy, 
 
 98, 99 
 to calculate date of confinement 
 from, 94 
 Quintuplet pregnancy, 82 
 
 Rachitic pelvis, 30 
 Reconstructed milk, 505 
 Records, maternity, 427, 431 
 Recreation, for nursing mother, 365 
 Rectal examinations, during preg- 
 nancy, 231 
 Rectum, 37 
 Reflex vomiting during pregnancy, 
 
 182 
 Reproduction, organs of, 30 
 Respiration, in puerperium, 335 
 Respiratory organs, changes in dur- 
 ing pregnancy, 104 
 Rest, during pregnancy, 130 
 for nursing mother, 364 
 
INDEX 
 
 557 
 
 Resuscitation of newborn baby, 273 
 Richardson Y binder, 345, 347 
 Rickets, 381 
 
 symptoms of, 382 
 
 treatment of, 385 
 Right angled position, 138 
 Room for delivery, preparation of, 
 
 155, 258, 259 
 Rotation of fetal head during birth, 
 
 236 
 Round ligaments, 38 
 Routine for prenatal visits, 423 
 Rubl)er gloves, sterilization of, 253 
 Kuminating cap, 485 
 Huinination, prevention of, 484 
 Ruptured uterus, 307 
 
 causes of, 308 
 
 frequency of, 308 
 
 symptoms of, 308 
 
 treatment of, 308 
 
 Saero-eoecygeal joint, 20 
 
 Sacro-iliac joints, 20 
 
 Sacro-vertebral joint, 22 
 
 Sacrum, 20 
 
 Saline infusion, in eclampsia, 200 
 
 Schenk 's theory of sex determina- 
 tion, 63 
 
 Schultze's mechanism of placental 
 separation, 239, 241 
 
 Scopolamin and morphin anesthesia, 
 292 
 
 Scorbutus, 373 
 
 Scurvy, 373 
 infantile, 374 
 
 Segmentation of ovum, 04, 65 
 
 Separation of i)lacenta, 239, 279 
 mechanism of, 239, 241, 242 
 
 Sex, determination of, theories of, 
 63 
 
 Sextuplet ])regnanoy, 82 
 
 Shoes, during j)regn:iiu'y, 124 
 
 Shortness of breath, during preg- 
 nancy, 140 
 
 ' ' Show, ' ' 235 
 
 Sims' elevated position, 139 
 
 Simson's forceps, 301 
 
 Sinciput, 89 
 
 Sitting up, during puerperium, 328 
 
 Skin, care of in pregnancy, 118 
 changes in, during pregnancy, 97, 
 
 104 
 discoloration of as a sign of preg- 
 nancy, 97 
 in puerperium, 322 
 itching of, during pregnancy, 141 
 stretching of, during pregnancy, 
 141 
 
 Sleep, during pregnancy, 130 
 
 Society for the Health of Mothers 
 'and Children, 408 
 
 Soda bath, preparation of, 517 
 
 Soups, allowed during pregnancy, 
 128 
 
 Spermatozoa, 61, 62 
 
 Sphincter ani, 37 
 
 Spinach, preparation of, 505 
 
 Sprue, 539 
 
 Spurious pregnancy, 96 
 
 Starch bath, preparation of, 517 
 
 Stocking supporters during preg- 
 nancy, 124 
 
 Stretching of skin, during preg- 
 nancy, 141 
 
 Stria?, 97, "102 
 gravidarum, 102 
 
 Stripping of breast, 348 
 
 Subcutaneous injection of salines 
 in eclampsia, 200 
 
 Sucking of thumb, prevention of, 
 482 
 
 Sugar, 498 
 
 Summer, care of baby during, 514 
 complaint, 519 
 diarrhea, 519 
 
 Supplies for baby, 428 
 for mother, 428 
 
 Supporter, abdominal, during preg- 
 nancy, 122 
 
 Supi^orts for breasts, in puerperium, 
 343, 345 
 
 Sutton's poncho, 479 
 
 Sutures of fetal head, 89 
 
 Swelling of feet during pregnancy, 
 137 
 
 Symphysiotomy, 305 
 
 Syphilis, complicating pregnancy, 
 207 
 in infants, 538 
 
 Tarnier's forceps, 301 
 Teeth, care of during pregnancy, 
 133 
 
 in pregnancy, 104, 133 
 Temperature, in pregnancy, 105 
 
 in puerperium, 335 
 Tests for albumen in urine, 118 
 Theca folliculi, 48 
 Therapeutic abortion, 171 
 Threatened abortion, 170 
 Thrush, 539 
 
 Thumb sucking, to prevent, 482 
 Thyroidism complicating pregnancy, 
 
 210 
 Toilet tray, baby's, 417 
 Tomato juice, to prepare, 506 
 Top milk, 499 
 Toxemia, nephritic, 203 
 
 nursing care in, 205 
 
 symptoms of, 204 
 
 treatment of, 205 
 
558 
 
 INDEX 
 
 Toxemia, pre-eclamptie, 187 
 
 nursing care of, 189 
 
 prevention of, 188 
 
 symptoms of, 187 
 
 treatment of, 189 
 Toxemias of pregnancy, 142, 179 
 
 early signs of, 142 
 Toxemic vomiting, during preg- 
 nancy, 184 
 Transverse presentations, 221 
 
 positions in, 223 
 Travelling, baby basket for, 507 
 
 care of baby in, 507 
 
 during pregnancy, 133 
 Triplet pregnancy, 82 
 Tubercles of Montgomery, 43 
 Tuberculosis, pulmonary, complicat- 
 ing pregnancy, 209 
 Twilight sleep, 292 
 Twin pregnancy, 82 
 
 Umbilicus, changes in during preg- 
 nancy, 103 
 pouting, 103 
 Umbilical cord, 76, and see Cord 
 Umbilical hernia, in newborn, 542 
 Ureters, 37 
 Urethra, 37 
 
 Urinary apparatus, changes in dur- 
 ing pregnancy, 104 
 Urine, albumen in, to test for, 118 
 in pregnancy, 117 
 
 examination of, 117 
 in puerperium, 322 
 to obtain specimen of from baby, 
 526, 527 
 Uterus, anatomy of, 30 
 blood supply of, 32 
 body of, 32 
 cervix of, 32, 33, 
 
 changes in during pregnancy. 83, 
 98, 101 
 as sign of pregnancy, 98 
 changes in during puerperium, 317 
 contractions of as sign of preg- 
 nancy, 99 
 cornua of, 33 
 external os, 33 
 fundus, 32 
 
 height of in puerperium, 327, 328 
 internal os, 33 
 involution of, 317 
 ligaments of, 33, 38 
 muciparous, 32 
 ruptured, 307, and see Ruptured 
 
 uterus 
 virgin, 32 
 
 Vagina, changes in during preg- 
 nancy, 102 
 fornix of, 35 
 
 Vaginal discharge during pregnancy, 
 140 
 
 douches during puerperium, 338 
 
 examination in labor, 248, 252 
 in pregnancy, 230 
 
 hysterotomy, 305 
 
 opening, 40 
 Vaginitis, in infants, 540 
 Varicose veins during pregnancy, 
 
 138 
 Vegetables allowed during preg- 
 nancy, 128 
 Venesection in eclampsia, 200 
 Version, 299 
 
 cephalic, 299 
 
 combined, 300 
 
 external, 300 
 
 indications, 299 
 
 internal, 300 
 
 podalic, 300 
 Vertex presentations, positions in, 
 
 222 
 Vestibule, 40 
 
 Vicarious menstruation, 56 
 Villi, chorionic, 68, 70 
 Visiting nurses, care of mother and 
 
 baby by, 437 
 Vitamiues, 371 
 
 fat soluble A., 371, 377 
 
 water soluble B., 371, 377 
 
 water soluble C, 371, 373 
 Vitelline membrane, 47 
 Vomiting during pregnancy, 134, 
 181 
 
 pernicious, 134, 181 
 
 neurotic, 147, 183 
 
 reflex, 182 
 
 toxemic, 184 
 Vomiting in infants, 532 
 Voorhees' bag, 312 
 Vulva, 39 
 
 cleansing of, 249 
 
 varicose veins of during preg- 
 nancy, 139 
 
 Wassermann's reaction, in obstet- 
 rics, 208, 209 
 Wasting diseases of infants, 518 
 Water soluble B., 371, 377 
 Water soluble C, 371, 373 
 Weaning, 365 
 Weight, loss of, during puerperium, 
 
 319 
 Weight of newborn baby, 452, 453 
 
 chart, 454 
 Whey, preparation of, 506 
 Whole milk, 499 
 Woman's Municipal League, 409 
 
 Xerophthalmia, 377 
 
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