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^- ■ 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-■ 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.....\,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 W w ,£3 ct3 THE NURSE '8 DUTIES DURING LABOR 259 OQ >» Ut ^ *3 cd p< X> ^ m be • ^ c .3 & CS rt o r^ .■*;rQ o '3 . c r^ 3 -ti . I— 1 'o ^ c3 «> a a . rH -c ^ . ;-< u 03 CQ 7I di CO rt rt e ^^ "o 0) — ; ic c ft .9 -2 f 1 ledg bs f red sing h ^ CO 73 ^ M C3 ft 3 w of insf of bic f glove t< -« bo •S.S *= '"^ "S Nightg Sheet. Stockin Towel. « rt ft ^ 00 > PQW 32 M ^ ito T3 S « ."*> •^ tq fQ P bo 3 .0 a; .9 -« . 03 CO vater blan and baby (6 spon pad legg: sliee gow ftl C3 « anl pper for m -t-> bag of delivery pair of delivery doctor 's —1 '«-i til ft 13 3 _• .-1 « -i, X (U QQ 1 rt S 5* s 260 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 y '^ -el.^ ^ / Ht ^ '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 i Name CLww VS^ \-» ©. W \^ v 6. Z a 9. fO. \L 12L 13. (4.15. 16. 17. 18. 19. 2Q Temp. i 1 1 " 1 109 Utf^ j "in i n 1 108 ^Sm!]'^ , u . j ! m\ - .... ! ! 1 107 I i1.< 106 ^rr?5i i ! • 1 106 1 ! i 1 104 -^ t 1 1 1 f\ !^ [___!_ \ 103 ^-yj^i-L/"X ^J\ \f^ 1 "•'• 1 V r ^ Kj r V \ ■ 102 i • V \ V -' 1 T^^ 1 Vi ^ m » 101 i ! ^ ^ A ^ — i 1 ~ ^ 100 . A "■i"H"i ~ 1 1 99 «< r7i::rn_ri ^...^ _ J-U _ _ -J p c^^h —^ i I 1 — ' — — — H — H F] ^-+iH ~H 1 — 1 98 Vi 1 1 1 97 ! ■ . 1 96 ■ 1 ■! 95 - — 94 Retp. ^_ StooU 1 1 1 1 1 Urine 1 1 1 1 1 1 1 1 1 1 1 M 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 .BiLi L Z^ 3. 4. 5. 6. i: a >9^ 10. \V 12. 13. 14. 15. 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. n 1 i ill ' M 1 1 +■ I i 109 ! ! i ... 1. L ! ! i i ' i i i 1 ! 1 1 : 1 i i 1 108 i i : i T- 1. {. ..| i.._L \ \ 1 1 1 Mi 1 M i 107 I , 1 1 : :.:..:[:3f 1 .1 1 ! .._ .ii.... 106 ! ! 'L ^ 1 1 ^T 1^^ 105 i 1 \ r 1 i'l- " " 1 -i p, :jZjii:.i: n ■ 104 - 1 _^ i i ! 1 i i '■"■"t — 1 — •" .... ^ ; i.Ji . r i 103 i ..._ f — -- r-lf i i ' /ti X i 1 ■ u 1 i l s s.Ti i/,i:. i i 102 i '■ —r■■-^ ..... ■ ;i-.... j^\ \\r- \i A i triji: \ -V 1 ■"[ 101 \. \ y ^ \^\\\ ■ \ 1 ■ 1 ■■"[ II u \ i\i M 100 1 r :li..::~a ■ ! \ 1 1 rT"t"n 1 i 1 1 ^ L!^-- 99 _ a» Ai rj^i^l^r 1 1 i i i i ! \ ' « ' ^ r\ i/T 1 i A ¥ W y ^ ^■.,\..y^.A . i- H 98 ^ \* \^i ^ ^ i k ■ 97 . 96 ■ 95 . 94 Resp. Stools 1 Urine 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 ^^^^i^^^^^^^Ti^^^vj^^^^ ■ '-- ■ 1 ^x?^ ■=iF ^ 1 A »1 £ 1 ■ II ■_..^IBI ■ a 1 . H 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 u o CO o CC TS > _m h3 1 1 !z; a> PU rd .a ^ ^ r^ .9 n3 O a ^-2 3 ::;; w :2 g f^ g ^-^ « JO. be <1 ^ d •^ (^ f-l 0) r ^-1 o I' in o o c ^ o3 a <13 CO d 'o s a 02 en a ■5b a i &B > f^ .9 0) .a ^ .s 03 Q) V ^ Q ^ H W CO .^ 03 na '-4-3 Co o c8 O -=« & o g tk^ ^ pin P o O Pu cc (?3 -* -H o 3'^ scsSooj-^ga a •TS QJ ^ be ^ a ^ eS (M CM _a MI a a >5 ."^ "eS "a Oj a a m Ph a O" M cS rl T! «J 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 — 1 — "■ — ~ "■ ^ ^ ^" ^ ^ ~ ~ *"" r \ ■~" ~ ^ V 'i 0^ 3; ^ \ A V =*:: \ \ - • -^ ' '^ p t o\ ,;^ ^ \ \ '■^ ^^ V; i n1 ', 5b' ( ^\ ^ 1 >-i \ \ ^ V h 'J A 5-1 \ v ^ s, X- J\ N vs N \, ' V, N A \ 3s k s ^ .'z \ V N *-, ^ \. "?; \ ^ \ \ ^ GOaor<-i^(b(oibin^^mr<)NN^i->ooa)a>obcot«t« ^ U f^ "^ M m •' ^ PhO CI O £ o !» o ij " r= P^ it- " Js aj S oj a> C ,Ji 3 ^S M 6 ^- 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 : Up- per 8 oz. : : m m : 1 O.S o tS 0.0 LO c c '"' c N c o< ^ o P 0.50 m iH f 0,^0 LO o t3 0,0 1-H IM O-oI S o t> o,^ (M I* ^ LO in ■ lO lO L^ O (M I-H m 1-H o N &^. ° lO O' o a» 00 I-H J (N o i-H & o lO in in in OCO (M Od C\l (M c o in in lO in m in s^ Hh tH (M 1—1 iH (M i-H I-H 1-H n CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO ■* T g-s cc CLi ^ m »o in in in in in C Em o o rH I-H I-H tH iH (M (M M i !• 1 -1 1 1 I 1 ' 1 T « Ti I'l 1 1 1 M M 1 1 I 1 IN* 1 1 1 1 1 1 1 ' CVI 1 1 "C "i i "M 1 i 1 ' i -■- ! 1 r- n r "Nl M 1 1 i I 1 i — ~q 1 ' ' 1 \ if ^ ! \ 1 1 1 \ \ J^ III ■ n i -TI ^ 1 1 i 1 1 r 1 •»! i 1 i '■ — a> - -^ ! ^M i id'J M ! i ifl 1 ! 1 r rji i> ! 1 ""i 1 ! 1 00 9 1 i 1 ! ¥■ - i ' 1 i 1 1 1 1 1 il li 1 \ \ i^l I II 1 1 ' \5 1 1 1 f ' i i 1 1 r i i 1 ! i! — ""d 1 1 J 1 ! > i ! 1 !l f>3 1 1 i 1 •( M 1 i i 1 i ^r • Tf _^ j =- r * ! ! i 1 1 1 'i — ci / if 1 1 1 — i — i — T"^ 1 ! i Ap^ ^■'^lW^ •=d ! "t~j 1 : ! ^ * i^ i 1 ' ■►-J--. _^ i ! ! 1 ^1 — ^ .-,_i--l r ^! 1 ! ;i O 1 ^. ^^i ! 1 > i i •! r Tu V <[ HI 1 ! ■ rJ 1 7 . I 1 ' 1 ! J ! i ! 1 ■ 1 1 4 1 1 ' i ' - fe:i 1 1 ZL IL_ - ""111 ZE ^ M IN a> *^ -q^ be 3 a o 00 -^ cs ,- rt J5 03 q; o "^ 'T^ A a ^ -^ u ^ MM \ H^ 1 i 1 1 = 2 i i i i i 1 j i i ■ : i i it^ ■^i M i i M i i i ■ cu Mil ill! i i 1 1 i i i • i M ^N i M ! 1 j i : c i i i 1 ' ! M M MM 1 1 i ill' ! ; 1 1 >|M 1 1 i 1 o M M 1 1 : i I i i M \\\\ i i j iM> ill: 0) 1 ; i i MM ■ i i i i i 1 1 MM i i I CO i 1 1 1 i 1 1 • 1 ; ; \ \ \ 1 1 1 i j i N i i i ; N 1 j 1 i i ! 1 I i 1 ; : i ! i i n 1 I i i ; «o ; i ; i ! ' \\\\ i i I 1 i i ' i ! I-M i t 1 1 1 1 1 ; i i ! "^i \ 10 1 j 1 Mil 1 M 1 ]. i 1 1 i 1 1 M i 1 1 1 ! 1 Mr^i * 1 ! i 1 ; i 1 i i ' i ! i i i i 1 i i|t> (0 1 ; i i i 1 i 1 ; ; 1 1 i \ ^JJr PJ 1 1 i 1 Mil. 1 i ; I'M H Mm i ; : ; "^^ 1 : ! i i ^1 o a m S - n'" ■ 1 1 I 1 8-i Nt no 1 "T" T 1 'ill : I ; 1 1 i^ i i 1 : j MM i i i i i i i i ! ; i 1 t (VJ i 1 M 1 M i III! •1 = 1 ! ! 1 1 : 1 1 i ! ! j i i i i ! 1 _i.. 4.4 'ik ; ; i 1 : 1 1 1 1 i i 1 i 4- o i M i i • i ' 1 1 ^ rn Mm i M ; o ■ i • i j i M 1 i i 1 ivi.1 •i i i i • ' M 1 i i 1 1 1 1 ^ 00 i M i MM MM M i |> M ^ ^ i 1 1, J r^ i i 1 1 i i 1 I ' i K i 4.[.-4- +|4-f < u> 1 1 1 i i i ' i : ! i 1 1 i ; i ; :' i j : i MM i In fi in iM i i i i ill; 1 i I i ■i i J [\ ! ! ' i M ; ■ 1 i ; t i 1 • ! i i- Mil i 1 ^ Mil = i j- j '■ 1 i j- ! i i i 1 i Mil ^iji M ! i • i •! 1 ' i ! 1 i : i Mi; '-H*^ ■ Mi ■ i i u- ! .1, 1 i i i i M j i i ! -ftT; j M i i i i i. ^n ?i 6» S-i»i5 fi2n 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 7 1949 1954 0tG2 ^F'B 4 1955 LD 21-100m-7,'33 #^-^r.! 9%: '^^i e:^8&oi ^ UNIVERSITY OF CALIFORNIA UBRARY