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The cover image was created by the transcriber and is placed in the public domain.

OBSTETRICS
FOR NURSES

BY

CHARLES B. REED, M.D.,

Obstetrician to Wesley Memorial Hospital, Chicago.

ONE HUNDRED THIRTY ILLUSTRATIONS

ST. LOUIS

C. V. MOSBY COMPANY

1917

Copyright, 1917, by C. V. Mosby Company

Press of

C. V. Mosby Company

St. Louis

TO HIS LOYAL FRIEND

EUGENE S. GILMORE

THIS BOOK IS AFFECTIONATELY DEDICATED BY THE AUTHOR

PREFACE

It might seem that an apology was necessary for presenting a new textbook on obstetrics for nurses when so many are to be had for the asking. But when a teacher is rarely or never satisfied with his own work it is too much to expect that he will ever fully endorse the product of another. It may be therefore largely a personal matter that none of the existent books seem to exhibit the fullness of information, the conciseness of expression, and the emphasis due to certain subjects that the present writer would hope to find.

The necessities apparently demand such an arrangement of our obstetrical doctrine that the book may serve for class instruction and at the same time be complete enough for post-graduate reference.

To secure this much discrimination is necessary. The confusion attendant upon overabundance must be avoided as well as the discouragement that is not infrequently produced by a large book or a periphrastic style.

Hitherto there has been a tendency to teach the nurse too little rather than too much but conditions have changed. Vocational instruction is not only more methodical and far reaching but it is developmental. The present day nurse expects not merely to assist the physician and earn a stipulated reward, but she is constantly alert to attain her own maturity as a professional woman.

To be a capable and intelligent assistant it is not sufficient to have a clear comprehension of her particular duties, but she must have a defined and critical conception of what the doctor is aiming to accomplish.

This is especially true in obstetrics where the nurse has the additional responsibility of giving support and counsel to her patient in the various emergencies that arise. Moreover, to attain her intellectual maturity the nurse must strive unremittingly to understand the complicated processes that take place under her observation.

She must cooperate with her doctor whose associate she is and secure the confidence of her patient who relies upon her for guidance in the perils she is facing. For childbirth is a peril. It is no longer the normal process it once was. Civilization has changed the shape of the pelvic bones, altered the muscles of parturition and weakened the nerve centers that control the event.

The birth of a child is equal in severity and seriousness to many of the major operations. It is not an affair to be entered upon lightly nor managed without the utmost foresight and care.

The dangers that are recognized and prepared for in this book by what may seem to some to be an extravagant technic, are very real dangers, extremely subtle, and against them at times every precaution and every defense proves unavailing.

Nevertheless, skill, thoughtfulness, and above all, cleanliness, will avert the worst, as well as unhappily the most common of these disasters. If our nurses could be convinced of this, the difficulties and apprehensions of childbirth would be greatly diminished.

The nurse should see to it that her patient is surrounded by all the precautions and safeguards against infection that she would demand for a member of her own family. This means of course that her work will be far more exacting and onerous but also it will save many nights of anxiety and not infrequently a life.

This book represents the obstetric ideas and technic which the writer has endeavored for years to impress upon his students and nurses with such emendations and changes as experience and scientific progress have suggested. It is a selective essence distilled from the recurrent harvests that workers in this field have brought forth during centuries of consecrated effort. To all these forerunners the writer acknowledges a deep personal indebtedness.

In the preparation of the book thanks are due particularly to Charlotte Gregory, Head Nurse of the Wesley Maternity, whose rare ability as teacher, technician and executive and whose untiring vigilance has been a leading factor in securing and maintaining the high state of efficiency in this department. She has kindly contributed Chapters XXIII and XXIV, together with valuable suggestions and criticisms in other portions of the text.

The author also takes pleasure in acknowledging his obligations to Florence Olmstead, Head Nurse of the Dispensary of the Northwestern University Medical School, whose long experience in feeding babies gives to her words an unquestioned authority. Chapter XXII is almost entirely her work.

To the various publishers who have courteously allowed the reproduction of valuable illustrations from the books of other writers thanks are also extended, and to his own publishers especially for their cordial and sympathetic cooperation the author wishes to express his warmest gratitude.

C. B. R.

Chicago, 1917.

CONTENTS

ILLUSTRATIONS

OBSTETRICS FOR NURSES

CHAPTER I
ANATOMY

The study of obstetrics is an investigation of the passage, the passenger, and the driving powers of labor, as well as of the various complications and anomalies that may attend the process of reproduction.

The passage is composed of a bony canal, called the pelvis, and the soft tissues which line and almost close its outlet.

The pelvis is made up of four bones; the sacrum, the coccyx, and two other large structures of irregular shape, called the hip, or innominate bones. Joined by cartilage and held in place by ligaments, they form a cavity or basin which, in the male is deep, narrow, small and funnel-shaped, while in the female, slighter bones, expanded openings and wider arches make a broad, shallow channel, through which the child is born.

The bony pelvis is divided for description into two parts, the upper or false pelvis, and the lower or true pelvis. The upper pelvis is formed by the wings of the innominate bones and has but two functions of importance to child-bearing. It acts as a guide to direct the child into the true passage, and when measured by the pelvimeter, it gives information as to the shape and size of the inlet to the true pelvis. The true pelvis is of most concern to the obstetrician, because anomalies in its size or shape may impede the progress of labor or render it impossible. The pelvis is divided conveniently into three parts: the brim, the outlet, and the cavity.

The brim, inlet, or upper pelvic strait, is the boundary line between the false and true pelvis. It is traced from the upper border of the symphysis along the iliopectineal line on both sides to the promontory of the sacrum. The shape and size of this opening varies much in different races and individuals, both normally and through disease; and when pathologically altered, both shape and size may exercise a marked influence on the course of labor. In American women, the outline of the brim is roughly heart-shaped, like an ovoid with an indentation where the promontory of the sacrum impinges upon the opening.

Fig. 1.—The normal female pelvis. (Eden.) The lines ab and cd divide the pelvis into the right and left anterior and the right and left posterior quadrants. ab indicates the anteroposterior diameter of the brim, cd shows the transverse diameter while gh and ef represent, respectively, the right and left oblique diameters.

The brim or inlet has four important diameters to be remembered; important because the hard, round head of the child must pass through them by accommodating its diameters as favorably as possible to those of this opening. These diameters are named respectively the anteroposterior or conjugate diameter, the transverse, and the right and left oblique diameters. The two oblique diameters attain their greatest importance when the pelvis is irregularly distorted, but the others are essential in every case where labor impends. It is to secure an estimate of these latter diameters that the bony prominences are measured. This upper opening lies not horizontally, but in oblique relation to the body in standing position, and the weight of the abdominal viscera rests largely upon the bones and in consequence does not crowd into the inlet unless forced in by corsets or faulty habits.

Fig. 2.—The planes of (a) the brim, (b) the cavity and (c) the outlet. (Eden.)

Passing through the brim, a cavity is found below it, midway between the inlet and outlet, which is nearly round in shape. This is the “excavation,” or the true pelvis. Then comes the outlet, bounded in front by the pubic arch and soft parts, and behind by the coccyx pushed back as far as it can go. It is ovoid in shape, but the long axis of this ovoid lies at right angles with the axis of the ovoid inlet.

We find, therefore, a succession of three geometric figures or planes through which the head must pass by means of a spiral motion called rotation. These figures are inclined to one another so markedly in front that a line drawn through the center of each will curve forward at both ends, one end passing out near the umbilicus, the other through the vulva. This is known as the axis of the pelvis or the curve of Carus.

Fig. 3.—Visceral relations. (Redrawn from Gray.)

THE SOFT PARTS

Inside the pelvis are the organs of generation with their accessory structures and supporting tissues.

Of first importance are the ovaries, tubes and uterus, together with the vagina. These special structures are the true genital organs. They are bounded in front by the bladder, behind by the rectum, above by the abdominal viscera, and surrounded everywhere by muscular, mucous and fatty tissues, which support them and aid their function.

The Vagina.—The vagina is a hollow organ, about four inches long, attached to the cervix above and the vulva below. It is an elastic sheath bounded in front by the bladder and behind by the rectum. Under normal conditions, this tube easily admits one or two fingers, but during labor it dilates enormously to allow the head to pass. The vagina is lined with a thick mucous membrane, ridged and roughened by folds, which are called rugæ. Thus a continuous channel connects the ovary with the outside and through it pass, at appropriate times, the ovule, the menstrual blood, the uterine secretions, the child, the placenta, and the lochia.

The Uterus.—The uterus (womb) is a pear-shaped organ, flattened from before backward, and composed of unstriped or involuntary muscle cells and connective tissue. Normally the virgin uterus measures from two and one-half to three inches in length, and weighs about two ounces. It is suspended in the middle of the pelvis by strong ligaments, so that the fundus inclines gently forward against the bladder. When the bladder fills, the uterus is pushed backward. Most of the organ is internal, but a small part of the lower pole is grasped by the vagina, in which the lower end with its invaluable aperture, the os, dips and swings. The part above the vagina is called the body or fundus, and is covered with the serous membrane (peritoneum) that lines the abdominal cavity. Below the fundus is the cervix or neck, which lies partly above and partly within the vagina. The cavity of the uterus is usually closed by the apposition of the walls. The inner surface is covered with a peculiar kind of membrane called the endometrium, which is highly vascular. The uterine cavity opens into the vagina through the os, which is small and round in the nulliparous woman, and slit-shaped or gaping in the woman who has borne a child.

Fig. 4.—Uterus and appendages. On either side of the uterus will be seen the ovary, the fimbriated extremity of the tube, the tube, and the round ligament. The vagina lies open below. (Lenoir and Tarnier.)

Fallopian Tubes.—On either side of the upper end of the uterus are the orifices of the Fallopian tubes, through which the egg, escaping from the ovary, finds access to the uterine cavity. These tubes extend outward from the uterus about four inches, and terminate in a bell-shaped opening with long, ragged fingers which hang loosely down toward the ovary. The tubes are lined by epithelial cells having hair-like projections, (ciliæ) which wave automatically toward the uterus. Thus impelled by a gentle current, the egg moves definitely along the tube toward the uterus and against this current the spermatozoa force their way to meet and fertilize the egg.

The Ovaries.—On either side of the pelvis, close to the fringed end of the Fallopian tube and attached to it, lies a small, hard, almond-shaped organ, called the ovary. This is the intrinsic sexual gland of the female. It contains the small cells which are to ripen and become eggs. Each ovary is said to contain about thirty-six thousand eggs, or ovules.

The Bladder.—The bladder lies between the pubic bone and the uterus. It is a reservoir for urine, filled by means of two little tubes called ureters, that run down from the kidneys. It drains through the urethra which opens just below the pubic bone in front of, and just above, the vaginal opening. The bladder should be emptied frequently during labor.

The Anus.—The large bowel (colon) terminates in an opening near the middle of the genital crease. This opening is called the anus. It is closed by a contracting muscle, the sphincter, which acts like a puckering string. Just inside of the opening is a group of large veins which may become enlarged, inflamed, and bleed during pregnancy. They are then called hæmorrhoids.

The Rectum.—Upward from the anus and to the left of the uterus extends the rectum. This is the end of the intestinal canal and is supplied with an abundance of nerves. When the head presses upon it, it gives the sensation of a bowel movement, and warns the observer of the low position of the head. The anus pouts as the head comes down and the anterior walls become visible. In severe cases of labor, the sphincter is sometimes torn. The bowels should be emptied by an enema as early as possible in the first stage of labor.

The Peritoneum.—The peritoneum is a thin, glistening, serous membrane, which lines the abdominal cavity and drops down from above over the uprising tops of the bladder and uterus. Folding together at the sides and extending to the walls of the pelvis, it encloses the tubes and round ligaments in deep, flat masses, called the broad ligaments. This is the structure that becomes so perilously inflamed (peritonitis) when infected by germs that find entrance through the genital passage.

Fig. 5.—Normal position of pelvic organs, seen from above and in front. They are enveloped in peritoneum. (Bougery and Jacob, in American Text Book.)

THE EXTERNAL GENITALS

The external genitals form the vulva. Under this name are included the mons veneris, the labia majora, the labia minora, the clitoris, the vestibule, the hymen and the glands of Bartholin.

The entire groove from the mons veneris to a point well up on the sacrum forms a deep fold or crevice, which is known as the genital crease. That part of the genital crease lying between the anus and vulva is technically known as the perineum (q.v.)

Fig. 6.—The external genitals. (Redrawn from Gray.)

The Mons Veneris.—The mons veneris is a gently rounded pad of fat lying just above the junction of the pubic bones (the symphysis). The overlying integument is filled with sebaceous glands and covered with hair at puberty.

The Labia Majora.—The labia majora are the large lips of the vulva. They are loose, double folds of skin extending downward from the mons veneris to the anterior boundary of the perineum and covered externally with hair. Normally they lie in apposition and conceal the vaginal opening. They correspond to the male scrotum.

The Labia Minora.—The labia minora, or nymphæ, are two small folds of skin and mucous membrane, that extend from the clitoris obliquely downward and outward for an inch and a half on each side of the entrance to the vagina. On the upper side, where they meet and invest the clitoris, the fold is called the prepuce, but on the under side they constitute the frænum.

The labia minora are sometimes enormously enlarged in the black races and are then called the Hottentot apron.

The Clitoris.—The clitoris is an erectile structure analogous to the erectile tissue of the penis. The free extremity is a small, rounded, extremely sensitive tubercle, called the glans of the clitoris. About the clitoris there forms a whitish substance called smegma. This is a good culture medium for germs and must be carefully sponged away when the vulva is prepared for delivery.

The Vestibule.—The vestibule is bounded by the clitoris above, the labia minora on the sides, and the vaginal orifice below. It contains the opening of the urethra, which is called the meatus urinarius.

The Hymen.—The hymen is a thin fold of membrane which closes the vaginal opening to a greater or lesser extent in virgins. It varies much in shape and consistency. It is sometimes absent, or it may persist after copulation, hence its presence or absence can not be considered a test of virginity. When torn, the edges shrink up and form little irregularities called carunculæ myrtiformes.

Fig. 7 A.—Varieties of hymen. (American Text Book.)

Bartholin Glands.—Bartholin glands are located on each side of the commencement of the vagina. Each gland discharges by a small duct just external to the hymen. They are often the seat of a chronic gonorrhœal inflammation and must be watched carefully, lest infection extend to the mother after labor, or to the eyes of the child in passing.

Fig. 7 B.—Varieties of hymen. (American Text Book.)

The Perineum.—The perineum is a body of muscle, fascia, connective tissue, and skin, situated between the vagina and the rectum. The vagina bends forward and the rectum backward, so a triangular area is left between them which is filled by the perineal body. It is about two inches long from before backward, and becomes progressively thinner the deeper it extends.

Fig. 8 A.—The excreting ducts of the mammary gland. (Lenoir and Tarnier.)

Fig. 8 B.—Lobules and duct of the mammary gland. (Lenoir and Tarnier.)

The perineal body is flattened out and compressed by the passage of the head and in many cases torn. (Thirty per cent of primiparas and ten to fifteen per cent of multiparas.) It should be repaired immediately.

The Mammary Glands.—The mammary glands are secondary but highly important parts of the genital system. They are formed by a dipping down of skin glands and they perform the special function of secreting milk.

The breast is made up of fifteen or twenty lobes, each of which, like a bunch of grapes, clusters about and discharges into a single tube which, in turn, leads to the nipple. The area between the lobes is filled with fat and connective tissue.

Fig. 9.—Nipple, areola, and the glands of Montgomery. (Eden.)

The nipple is pink or darkly pigmented. It is composed of erectile tissue and under stimulation, it rises from the surface of the gland so that it is easily taken into the mouth.

Fig. 10.—Supernumerary milk glands in the axillæ. They may be found also below the breasts. (Witkowski.)

Fig. 11.—The three ages of the breast—virginity, maturity, and senescence. (Witkowski.)

Surrounding the nipple is a darkly pigmented area from one inch to four inches in diameter that is called the areola. It contains hard, shot-like nodules, the glands, or tubercles, of Montgomery. These often secrete milk and sometimes become infected. It occasionally happens that more than two breasts may be found on the human female, and not infrequently pieces of mammary tissue may be discovered in the axilla or on the chest or back.

The mammary gland is undeveloped at birth, but, nevertheless it may fill with milk (witches’ milk). At puberty, after marriage, and during pregnancy, the gland reaches maturity. It is only after delivery, however, that the functional climax is attained.

CHAPTER II
PHYSIOLOGY

Ovulation.—Ovulation is the process whereby the eggs are discharged from the Graafian follicle which matures and protects them in the ovary. The egg is a true cell with one, and sometimes more than one, nucleus.

The ripening of the eggs, as well as their discharge, is attended with much general disturbance and great physical changes. This phenomenon begins from the twelfth to the fifteenth year, depending on race, climate, occupation and temperament, and marks the transition of the individual from childhood into maturity.

This period is called puberty. At this time the breasts enlarge, the hips round out, the vagina, uterus and external genitals increase in size. Hair appears upon the vulva, the emotions become more evident, and modesty develops through a consciousness of sexual difference and attraction.

Simultaneously a new function appears—

Menstruation.—Menstruation may be defined as a process wherein a bloody fluid is discharged from the uterus at regularly recurring periods between puberty and the menopause, except during pregnancy and lactation. It is a hæmorrhage which in some way is closely associated with ovulation, but it is not known positively which is the precedent of the other, or whether one causes the other.

Menstruation is not essential to pregnancy, for pregnancy may occur when the flow is normally absent, as before puberty, after the menopause, or during lactation. Nevertheless, regularity of menstruation is the rule in fertile women and clinicians agree that while conception may occur at any part of the menstrual cycle, it is most likely to happen just before or just after the menstrual flow.

The best authorities at present support the theory that ovulation usually occurs soon after the close of the menstrual period. This is confirmed by the similarity of the physical changes that take place in the endometrium during menstruation and after conception.

Fig. 12.—Development of the ovary (after Wiedersheim). A, an ingrowth of the germinal epithelium, forming a cell-cord, which breaks up into primitive Graafian follicles; B, a primitive Graafian follicle, with its contained primitive ovum; C, D, E, later stages in the development of the Graafian follicle. (Crossen.)

As the period of the flow approaches, the lining membrane of the uterus becomes hyperæmic and swollen with blood, serum, and glandular secretions. The blood vessels are engorged, the glands become longer and more tortuous, little hæmorrhages appear, and the superficial epithelium is thrown off. A large amount of mucus is produced by the increased activity of the glands, and all is discharged into the vagina as a bloody, incoagulable flow with an odor of marigolds. The process continues usually from three to seven days, when the discharge ceases and the endometrium slowly resumes its uncongested state.

Fig. 13.—Graafian follicles. One contains two ovules which, if fertilized, will produce twins. If all three ovules are fertilized, triplets will result. (Bumm.)

Meanwhile, the psychic and bodily conditions have not remained unaffected. The nervous system is disturbed, the disposition is irritable and capricious and the head may ache. The woman takes cold easily. She is indisposed to exertion from a sense of languor and malaise. Pain may develop in the back, or cramps in the pelvis, so severe as to keep the woman in bed. Frequently the approach of the period is signalized by skin changes, such as a marked odor or an eruption of acne pustules.

The flow usually returns every twenty-eight days, but it may vary within normal limits from twenty-one to thirty days. The flow continues at such intervals regularly from puberty to the menopause (change of life), which occurs between the ages of forty-five and fifty.

Conception, or Fertilization.—This is the process wherein the male element (spermatozoon) meets and unites with the female egg. From what is known from investigations of lower animals, this meeting usually takes place in the Fallopian tube.

Fig. 14.—Human spermatozoa. h, head; c, intermediate portion; t, tail. (Williams.)

The egg expelled from the ovary is carried into the open end of the tube by peritoneal currents and passed on toward the uterus by the waving action of the hair-like outgrowths of the cells (ciliæ) that line the tube, aided, possibly, by the tubal muscle.

The spermatozoon makes its way upward from the vagina by means of its tail. This activity, like the tail of a fish, or snake, or as a boat is sculled, drives the cell forward through the thin layer of fluid that covers the mucous membranes.

The arrow-shaped spermatozoon travels at a rate that completes the passage to the ovary in twenty-four hours, but spermatozoa may lie in wait for the egg a considerable time, as is shown by the fact that they have been found alive in Fallopian tubes removed three and a half weeks after copulation. As soon as the male and female elements approach each other, they exercise a powerful magnetic attraction, which draws them together, and as soon as they touch, the two cells unite and the spermatozoon almost immediately disappears.

Only one spermatozoon is required for the fertilization of an egg, and hence enormous numbers must perish without achieving their destiny.

The fertilized egg has become the ovum, and originally 1/125 of an inch in diameter, it now begins to grow, and filled with a new energy, it passes down the tube and enters the uterus. Here it comes into contact with the soft mucosa and digs a hole for itself—a nest, very much as a warm bullet might sink into ice or snow—and is soon completely surrounded by a proliferating tissue called the decidua. The woman is now pregnant. The menstrual flow does not appear, and local and systematic changes are inaugurated.

The egg enlarges rapidly. Little glove-finger-like projections (the villi) appear on its surface and dip down into the maternal tissues. Through these villi the egg gets nourishment until about the twelfth week, when the placenta forms. Externally the ovum resembles a chestnut burr. As the egg grows, the villi on the surface find it more and more difficult to secure nutriment, and except at one place, all gradually shrink and disappear. At this significant point, they increase greatly in size, number, and complexity to form the thick, cake-like placenta.

The egg or ovum is simply a growing cyst, filled with a fluid, normally sterile, in which the developing embryo lives and swims. This fluid is the liquor amnii and it is retained by a cystic wall made up of two layers—the chorion, which represents the original cell membrane, and the amnion, which develops out of the fœtus. At maturity, the ovum will contain from one to two pints of liquor amnii.

Fig. 15.—The chorionic villi about the third week of pregnancy. (Edgar.)

The Liquor Amnii.—The liquor amnii is of vast importance to the child. It allows free movement for the growing limbs and body, protects the child from sudden changes of temperature, prevents injury both from without and within, saves the child from birthmarks and deformities by keeping it from contact with the surrounding walls, and in labor lubricates the passages for the advancing part. In a measure, too, it probably serves as a food. In labor it forms a pouch called the bag of waters, which aids in dilating the os.

Fig. 16.—Diagram illustrating relations of structures of the human uterus at the end of the seventh week of pregnancy. (American Text Book.)

Gradually, as nutrition becomes more abundant at the site of the growing placenta, a stalk-like structure thrusts out from the fœtal abdomen and forms an attachment with the formative placenta. This is called the ventral stalk and as soon as the communication with the placenta is established, it is combined with other parallel structures and becomes vascularized, to form the umbilical cord.

Fig. 17.—Maternal surface of the placenta and membranes. The cord protrudes from the cavity which held the fœtus. (Edgar.)

The Umbilical Cord.—The umbilical cord at maturity measures from five to fifty inches in length and from one-half to one inch in thickness. The cord is composed of a gelatinous connective tissue, called Wharton’s jelly, in the midst of which lie the twisted vessels (two arteries and a vein) that supply the embryo with air and food and carry off the waste.

The Placenta.—The placenta or “after-birth” is an oval or circular somewhat flattened disc, six to ten inches in diameter, and three-quarters to one and one-half inches thick. It weighs about a pound and a half. It is the organ of respiration and nutrition for the fœtus.

Fig. 18.—Fœtal surface of human placenta. (Eden.)

Fig. 19.—The egg at term with uterus removed and child showing through the membranes. (Edgar.)

It is formed about the third month outside the membranes covering the child and is more or less loosely attached to the uterine wall. The umbilical cord is attached to its fœtal surface, inside the ovum. Like a flat sponge it takes oxygen, blood, and the nourishing fluids from the blood vessels in the uterine wall, carries them to the child by means of the umbilical vein, and carries back the carbonized blood and waste products by the umbilical arteries to the placenta, and there returns them to the maternal blood for disposal. The blood of the veins is bright red, and of the arteries, dark and turbid.

Fig. 20.—Normal attitude of fœtus (complete flexion). (Barbour.)

There is no direct communication between the maternal tissues and the placenta, hence all the changes occur by osmosis, and by the activity of the cells which form the walls of the villi.

The liver of the child is large and active. The stomach and intestines functionate mildly. The kidneys act, and urine is discharged into the liquor amnii, which the child occasionally swallows.

During development, the movements of the child become more and more pronounced. Arms, legs, and entire body participate in turn. Periods of rest are also observed. Gradually the child assumes a definite attitude in the uterus. It becomes more and more folded and flexed to accommodate its size to the limitations of space. The head bends on the chest, the arms are folded, the thighs flex against the abdomen, the legs on the thighs, and even the back ultimately becomes convex. It attains a complete flexion, the normal attitude of the child. As maturity approaches, the head becomes more and more palpable and seeks its usual location in the lower pole of the uterus, resting on the pelvic brim.

Fig. 21.—Fœtal skulls showing sutures. Note the differences between the anterior and posterior fontanelles. (Eden.)

Fig. 22 A.—Child’s head at term (from side), showing diameter. (American Text Book.)

Fig. 22 B.—The child’s head at term (from above), showing diameters and fontanelles. (American Text Book.)

The fœtal skull at maturity (at term) is still incompletely ossified. The bones are thin and pliable and separated at their edges by intervals of unossified membrane which form the sutures and fontanelles. Thus the skull is compressible to a slight degree and capable of much change in shape. It can be measurably moulded by the uterine contractions to suit the pelvis.

In front, the two coronary sutures meet the frontal and sagittal sutures to produce a kite-shaped figure, called the large or anterior fontanelle, or the bregma. Behind, the lambdoidal suture meets the sagittal suture to form the small or posterior fontanelle.

The large fontanelle is made up of four bones and four angles; the small, of three bones and three angles, and are usually easy to differentiate. Furthermore, the difference between these fontanelles is of great importance in labor, since by it the observer is enabled to determine the position of the head. In America, the shape of the head is that of an ovoid with the long diameter anteroposterior (Dolico-cephalic). Thus it happens that when the head is completely flexed, the smallest diameters are presented for delivery.

The important diameters of the head, with their measurements and names, are as follows:

Nape of neck to center of bregma, 9.5 cm.—Suboccipito-bregmatic diameter. Occipital protuberance to root of nose, 11.25 cm.—Occipito-frontal diameter. Between the eminences of parietal bones, 9.25 cm.—Biparietal diameter. Between anterior ends of coronal sutures, 8 cm.—Bitemporal diameter.

The smallest circumference is that of the suboccipito-bregmatic plane, which comes into relation with the brim of the pelvis when the flexion of the head is complete. It measures 27.5 centimeters.

The fœtus grows at a definite rate throughout gestation and so regularly that the increase is rarely simulated by any other condition.

To find the probable length of the fœtus at any given time, square the month of the pregnancy (up to five) and the result is the fœtal length in centimeters. After the fifth month, multiply the number of the month by five. Thus:

7th month ×5=35 cm., the approximate length of the fœtus at the lunar month.—(Hasse’s rule.)

The Mature Fœtus.—Although subject to considerable variation, the fœtus at term will weigh about seven and one-fourth pounds, and measure 50 cm. in length. The weight is far more uncertain than the length, and therefore not so reliable as a sign of maturity.

To obtain an estimate of the weight of the child at any given month of the pregnancy, the number of lunar months minus 2, is squared and divided by 2, and the result is the average weight of the child at that time in hundreds of grams. Thus:

8th month −2=6. 6×6=36. 36÷2=18, or in hundreds of grams, 1800, the weight of the child.—(Tuttle’s rule.)

Differences between the mature and immature fœtus:

The Fœtal Circulation.—The placenta is an organ of nutrition as well as respiration, and through the umbilical vessels the food materials are brought to the fœtus and the waste products removed.

Surrounded by the jelly of Wharton that fills out the cord, and running in and out between the two arteries, the umbilical vein passes into the fœtal abdomen and divides into two branches, one, the larger, short-circuits directly into the inferior vena cava. This branch is called the ductus venosus. The other joins the portal vein and passes through the liver, after which it also enters the vena cava.

Thus the heart is fed with a mixed blood, part coming fresh from the placenta and part coming up from the lower half of the fœtus. This blood is poured into the right auricle, where it becomes mixed again with the blood coming down from the upper pole of the fœtus through the superior vena cava.

Fig. 23.—The fœtal circulation. (Edgar.)

Now a small part goes down into the right ventricle and is forced into the pulmonary arteries to supply the lungs. But the lungs are not functionating, hence the greater part is again short-circuited through the ductus arteriosus into the arch of the aorta, where it meets with the great volume of blood which passed over into the left auricle through the hole in the septum between the right and left auricles, called the foramen ovale, thence down into the left ventricle and out through the aorta to supply the rest of the fœtal body.

With the exception of the ductus venosus and the ductus arteriosus and the foramen ovale, the circulation is the same as in the adult.

The blood in the descending aorta again divides and part goes on to supply the lower extremities while the greater part leaves the internal iliac arteries by means of the hypogastric vessels and returns through the umbilical arteries to the placenta for oxygenation.

As soon as the child is born, the fœtal structures are altered. The child breathes, the pulmonary circulation is established and the ductus arteriosus is closed. The placental circulation is abolished, and the ductus venosus and the hypogastric arteries are converted into solid fibrous cords. Owing to the immediate change of pressure in the auricles, the foramen ovale closes and the circulation assumes the adult type.

CHAPTER III
NORMAL PREGNANCY

The entire body participates in the changes brought about by pregnancy. The hips and breasts become fuller, the back broadens, and the woman puts on fat. She becomes mature in appearance, but, of course, the phenomena connected with alterations in the breasts and genitals are most important, and late in pregnancy, most conspicuous.

The uterus exhibits the most marked alteration. From an organ that weighs two ounces, it becomes the largest in the body, and increases in size from two and one-half or three inches to fifteen inches. The typical pear-shape becomes spheroidal near the end of the third month, becomes pyriform again at the fifth month, and continues thus until term.

Up to the fourth month the walls become thicker, heavier and more muscular, but as pregnancy advances, more and more tissue is demanded, until at the end, a muscle wall of only moderate thickness protects the ovum. Meanwhile the muscular functions of contractibility and irritability are greatly increased.

At the fourth month the womb, which has occupied a position of anteversion against the bladder, rises out of the pelvis. It is now an abdominal organ and as it gets heavier and heavier, it rests a certain amount of its bulk on the brim of the pelvis. About the sixth month, the uppermost part of the uterus (fundus) is at the level of the umbilicus. At the eighth month, the fundus is found a little more than midway between the umbilicus and the ensiform cartilage. About two weeks before term, it reaches its highest point, the ensiform cartilage, and then sometimes sinks a little lower in the abdomen.

The ovum, or egg, does not completely fill the uterine cavity at first, but grows from its side like a fungus until the third month. Then the uterine cavity is entirely occupied and thereafter the egg and the uterus develop at an equal rate. As the uterus rises in the abdomen, it rotates to one side, usually the right, forward on its vertical axis.

Fig. 24.—Gravid uterus at the end of the eighth week. (Braune.)

The blood vessels and lymphatics also increase in size, number, and tortuosity. Many of the veins become sinuses as large as the little finger. This increased amount of fluid both within and without the uterus has a marked effect upon its consistency. The walls of the uterus, vagina, and cervix become softened, infiltrated and more distensible. There is also an increase in size and in number of the muscle cells.

During pregnancy the uterine muscle exhibits a definite functional activity. Intermittent contractions occur, feeble at first, but growing markedly stronger as pregnancy advances. These are the contractions of Braxton Hicks. They are irregular and painless, but can be felt by the examining hand. At term they merge into, and are lost in, the regular, painful contractions of labor.

The breasts can not be said to be fully developed until lactation has occurred, nevertheless, the glands show pronounced changes as a result of marriage and pregnancy.

The size of the gland, as well as the size and appearance of the nipple and areola, varies greatly in different women; but under the stimulation of pregnancy the whole gland enlarges, including the connective tissue stroma.

About the fourth month a pale yellow secretion can be squeezed from the nipple. This is called colostrum. The pigmentation extends over a wider area and deepens in color, while the increased vascularity is shown by the appearance of the blue veins under the thin tender skin. Light pinkish lines sometimes radiate from the nipple. These are striæ and are more evident in blondes.

The milk comes into the breasts about the third day after labor, and normally continues to flow for six, to ten or twelve months.

Why the pregnancy and labor induce such marked mammary activity is not known, but the fact is patent.

The skin reacts both mechanically and biologically to the stimulus of pregnancy.

Fig. 25.—Striæ Gravidarum. (Edgar.)

Striæ Gravidarum.—Striæ gravidarum appear on the abdomen similar to those observed on the breasts and are due to the same cause—mechanical stretching. When fresh, they are pinkish in color and variable in length and breadth, but attain the greatest size below the umbilicus. Occasionally they extend to the thighs and buttocks.

After labor, they become pale, silvery, and scar-like and are called linea albicantes. They are sometimes found in other conditions than pregnancy, such as tumors or ascites.

Increased Pigmentation.—Pigmentation is not limited to the breasts. On the abdomen, a dark line will appear between the umbilicus and the pubes. This is the linea nigra, and it becomes most conspicuous in the latter half of pregnancy. In the groins, the axillæ, and over the genitals, the deposit is common, and sometimes patches appear on the face, either discrete or in coalescence, to form a continuous discoloration, called chloasma; or when extensive, the “mask of pregnancy.” The pigmentation is absorbed, or at least greatly diminished, after labor. The sebaceous and sweat glands are more active.

The hair may fall out and the teeth decay. “With every child a tooth,” is the cry of tradition. These changes are due to imperfect nutrition, or to the presence of toxins in the circulation.

Eruptions of an erythematous, eczematous, papular or pustular type are not uncommon; and itching, either local or general, may make life miserable.

The blood undergoes certain modifications that are fairly constant. The total amount is increased, but the quality is poorer, especially by an increase in water and white cells and a diminution of red cells. The amount of calcium is slightly increased and the fibrin is diminished up to the sixth month, when it rises to normal again at term.

The heart is slightly hypertrophied on the right side and blood pressure somewhat raised. A marked increase in blood pressure is suggestive of eclampsia.

The thyroid gland enlarges frequently, both as a consequence of menstrual irritation and of pregnancy. Goiters may show an increase of development, which remains after labor.

The urine is diminished in amount, but increased in frequency of evacuation. The bladder is more irritable during the first and last months, and micturition may be painful and unsatisfactory. The kidneys must be watched carefully during gestation.

The nervous system is disordered in most women, but especially in those of neurotic tendencies.

Irritability, insomnia, neuralgia of face or teeth, or perversion of appetite in the so-called “longings” are the more common manifestations.

Cramps occur in the muscles of the legs, owing to varicose veins or pressure upon the lumbar and sacral plexus of nerves.

The lungs are crowded by the growing uterus and the respiration interfered with.

The liver is enlarged, but functionally it is less competent, and constipation is common.

It is probable that most of the changes enumerated above are due to the circulation through the body of some definite product of fœtal activity, which is more or less toxic in character. The more pronounced effects of this toxin will be studied under the abnormal conditions of pregnancy.

Generally, if the pregnancy is normal, the whole body responds to the stimulating influence. After the nausea and vomiting of the early months subside, the woman feels energetic and ambitious. She is eager to do something at all times and feels fatigue but slightly. Music, literature or housework engages her attention and is zealously and joyfully practiced. The world seems bright and the thought of her labor does not bring solicitude, but pleasant anticipations. The body fills out in all directions and the woman takes on the appearance of maturity.

DIAGNOSIS OF PREGNANCY

The presence of pregnancy is naturally determined by the recognition of those changes in the maternal system which the growing ovum produces.

During the second half of the period the fœtus can be made out distinctly by palpation, or by its movements, and the heart tones observed by auscultation.

During the first half this is impossible and the diagnosis must be made from subjective symptoms elicited from the patient and upon physical signs observed by the physician.

It is of extreme practical importance to be able to recognize a pregnancy at all periods. The subjective symptoms of the first half are—amenorrhœa, morning sickness, irritability of the bladder, discomfort and swelling of the breasts, enlargement of the abdomen and quickening; but the appearance of any or all of these phenomena is not to be regarded as conclusive, but merely as a presumption that pregnancy exists. Either through ignorance, intent to deceive, or from pathological conditions, any or all of these symptoms may be present, but not until the tenth week are the changes in the uterus sufficiently definite to confirm a diagnosis unless the circumstances are especially favorable.

Amenorrhœa.—Cessation of the menses is practically invariable in pregnancy. One or two periods may occur after conception, but care must be used to exclude other causes of hæmorrhage. Sudden cessation of the periods in a healthy woman of regular habits who is not near the menopause, is strongly suggestive of pregnancy. Why a developing ovum causes an immediate arrest of menstruation is not understood.

Amenorrhœa may occur in consequence of chlorosis, heart disease, hysteria, tuberculosis, fright, grief, and some forms of insanity; a change from a low to a high altitude, or an ocean voyage not infrequently causes the flow to remain absent for one or more months. In addition to its value as a presumptive symptom, the amenorrhœa affords a common and convenient method of estimating the date of confinement. The method is fallacious but practical, and will be discussed later.

Morning Sickness.—This symptom is not invariable. It is most frequent in primiparas, but not so likely to occur in subsequent pregnancies. It usually appears about the second month, shortly after the first period missed. It varies in intensity. Some women have a little nausea on arising and no further trouble during the day, others are nauseated and vomit either on rising or after the first meal, and yet others after each meal; but the general health is not ordinarily affected and the tongue remains clean. Some cases are of extreme severity (hyperemesis) and will be discussed elsewhere.

The morning sickness is probably toxic in origin. It must be remembered that chronic alcoholism is accompanied by morning sickness, but with it the tongue is furred.

Irritability of bladder is shown by a frequency of urination. It is caused by the congestion and stretching of the tissues that lie between the uterus and bladder and hold them in relation to one another. After the third month an accommodation is established and the symptom does not reappear until late in pregnancy, when the pressure of the heavy uterus tends to keep the bladder empty. If especially annoying, this irritability may be much relieved by putting the patient in the knee-chest position night and morning.

Enlargement of the breasts is common in primiparas, but this, with changes in the areola, may occur at menstrual periods in nervous women. Tingling, pricking and shooting sensations may also be noted.

Enlargement of the abdomen is only noticeable toward the latter part of the first half, when the uterus rises out of the abdomen.

Quickening means “coming to life,” and refers to the first movements of the fœtus that are felt by the mother. It is described as similar to the flutter of a bird in the closed hand. It is sometimes accompanied by nausea and faintness. Quickening usually occurs about the seventeenth week of pregnancy, and continues to the end. Gas in the intestines will sometimes simulate quickening.

The movements are important in the second half as indicating that the child is alive.

Physical Signs.—During the first weeks no conclusive changes occur that can be detected by examination, and unless conditions are especially favorable, the earliest time for the definite diagnosis of pregnancy is the eighth week. Previous to this it is presumptive only.

At the eighth week, the breasts may show enlargement and tenderness, with some secretion. In the multipara, this sign has no significance. Secretion is present sometimes in the breast of nonpregnant women with uterine disease (fibroids).

Examination of the abdomen at this time is of little value, but changes in the uterus can be detected by careful bimanual examination. It is needless to say that all internal examinations should be made with the utmost care and gentleness.

Softening of the lips of the os (Goodell’s sign) may be found, but it must not be confused with erosions of the os. The os of a nonpregnant woman feels like the tip of the nose, and that of the pregnant woman like the lips.

Fig. 26.—Bimanual examination. (Edgar.)

The increased size and globular shape must also be considered as confirmatory.

Hegar’s Sign.—The upper part of the uterus is soft and distended by the ovum, the lower part is soft and not filled out by the ovum. Between the two is an isthmus that is compressible between the fingers of one hand in the vagina, and of the other upon the abdomen. When found, this sign is of great value.

At the eighth week, pregnancy can be regarded as highly probable by the conjunction of the following symptoms and signs: Amenorrhœa, morning sickness, irritability of bladder, slight breast changes in primiparas, lips of os externum softened, uterine body enlarged, softened, and nearly globular in shape, and Hegar’s sign.

Abderhalden’s test is a serum reaction based on the well established principle that the introduction into the blood of an organic foreign substance leads to the formation of a ferment to destroy it. Abderhalden’s plan was to discover whether the blood of a pregnant woman contained a ferment capable of destroying placental protein. It is a very complicated test, and subject to many inaccuracies and numerous sources of error. At the same time, the main features of this reaction have been confirmed, and when it is worked out, it will be of immense value not alone in early uterine pregnancies, but in extrauterine pregnancy. This view very properly demands that pregnancy be regarded as a parasitic disease. It is practicable as early as the sixth week to make a diagnosis, and it only fails in possibly ten per cent of the cases. The negative test is equally definite as eliminating pregnancy.

Sixteenth Week.—Morning sickness and urinary symptoms have disappeared but amenorrhœa remains. Enlargement of the breasts is noticeable, as well as the increased pigmentation. The uterus begins to rise above the symphysis as an elastic, somewhat ill-defined, boggy mass. The cervix is softer. The characteristic dull lavender coloration of the vulvar mucous membrane is now evident. It is due to the congestion and is called Jacquemins’ sign.

Two New Signs.—Irregular, painless contractions of the uterus (Braxton Hicks’ sign), and ballottement.

The contractions of Braxton Hicks now become more easily palpable.

Ballottement consists in the detection in the uterus of a movable solid body surrounded by fluid. In a standing position, the fœtus rests in the lower part of the uterus, just above the cervix. The woman stands with one foot on a low stool, and two fingers of one hand are pushed into the vagina until they touch the cervix, the other hand is placed on the fundus. A smart upward blow by the internal hand is transmitted to the fœtus, and it can be felt to leave the cervix, strike lightly the tissues underneath the external hand, and return to the cervix. It is simulated by so few things, and so rarely, that in practice it must be regarded as a positive sign.

During the second half, the subjective symptoms are of minor importance since unmistakable evidence is furnished by the physical signs. The symptoms of this period are mostly discomforts. Increased intraabdominal pressure brings on edema of the feet, cramps in the legs, varicose veins of the legs and vulva, dyspnœa, and palpitations.

Twenty-sixth Week.—About the twenty-sixth week, or, at the end of the sixth calendar month, the hypertrophy of the breasts, the presence of secretion, and the marked pigmentation are unmistakable. The abdominal protrusion is now clearly visible, and the fundus will be found at the level of the upper border of the umbilicus.

Spontaneous fœtal movements appear and may be felt by the palpating hand.

Auscultation reveals the uterine souffle and the fœtal heart sounds. The heart sounds and the fœtal movements, when obtained by the observer, are positive signs.

Uterine souffle is a soft, blowing murmur, synchronous with the mother’s pulse. It is best heard at the lower parts of the lateral borders of the uterus. It is due to the passage of blood through the greatly dilated uterine arteries. It may be heard also in cases of fibroid tumors of the uterus.

Fig. 27.—Abdominal enlargement at third, sixth, ninth, and tenth months of pregnancy. (Williams.)

Fig. 28.—Height of the uterus at various months of pregnancy. (Bumm.)

The fœtal heart sounds are the most anxiously sought for of all the signs of pregnancy. They are conclusive. They not only determine the diagnosis, but afford valuable information during labor, and nurse and student should lose no opportunity of becoming familiar with them. The heart tones can be heard as early as the twenty-sixth week, but they become more and more distinct as pregnancy advances. They vary from 140 to 160 beats to the minute at the twenty-sixth week, and at term, from 120 to 140. When they rise above 160 or sink below 120, some danger threatens the child. The fœtal heart tones have no significance as an indication of sex.

Funic souffle is the sound made by the passage of blood through the umbilical cord when a loop accidentally lies under the tip of the stethoscope. It is synchronous with the fœtal heart tones, but of no great practical importance when the heart tones can be obtained.

Determination of the period to which pregnancy has advanced is sometimes important. This can be approximated by a calculation of the time that has elapsed since the last period, or from the date on which quickening has occurred. Measurement of the height of the fundus and comparison with such scales as Spiegelberg’s, may be carried out, but it is not often required.

A method of estimation in gross, that is approximately correct, in many cases depends on the observation of the steady growth of the womb.

Thus, the uterus rises out of the pelvis at the fourth month, and may be found well above the symphysis pubis. At the fifth month the fundus is midway between the symphysis and the umbilicus. At the sixth month it reaches the umbilical level. At the eighth month it is a little more than midway between the umbilicus and the ensiform cartilage, which it attains in another month, the ninth. Then it usually sinks a little, especially in primiparas during the last two or three weeks. This is called lightening.

CHAPTER IV
HYGIENE OF NORMAL PREGNANCY

The time of confinement can never be accurately determined, because the onset of labor is purely an accident, dependent on many factors. Furthermore, conception does not take place necessarily at the time of intercourse, and we have no means of knowing whether conception occurred just after the last period present or just before the first period missed. So there is always a possible error of three weeks.

Pregnancy in the human family normally lasts from 275 to 280 days, and the approximate date of confinement can be obtained by the following convenient rules:

1. Take the first day of the last menstruation, count back three months and add seven days.

2. Or, assuming that quickening occurs at the seventeenth week, count ahead twenty-two weeks from the day on which quickening was observed.

3. Or, count two weeks from the day of lightening.

4. Or, with a pelvimeter, get the length of the fœtus by Ahlfeld’s rule (measure from symphysis to breech of child, subtract two cm. for thickness of abdominal wall and multiply by two. The result is the length of the child in centimeters) and compare with fifty centimeters, which is the average length of a mature child. After the seventh month, the child in utero grows at the rate of about 1 cm. a week (0.9 cm.).

5. Or, by the tape, according to Spiegelberg’s standard of growth, as previously mentioned.

The hygienic rules to be observed during pregnancy are founded on three basic principles: (1) To watch attentively the different organs and see that they functionate normally; (2) To eliminate all those conditions that favor the premature expulsion of the egg; and (3) To provide, so far as possible, for the normal gestation and the physiological delivery of the child. These factors will be taken up in detail.

The Diet.—The appetite is usually somewhat increased, but it is unnecessary to indulge the stomach on the ground that the mother “must eat for two.” Longings, however, should be gratified so far as the demand is not for unwholesome things. Food should be simple and plainly cooked. Meat is permitted in moderation unless some organic change exists to contraindicate it. Rich pastries and gravies should be avoided, but cereals, fruits and vegetables should be used in abundance. It may be better to eat four times a day instead of three. Fluids should be taken freely, from one to two quarts daily. Milk is especially valuable, and alkaline, natural and charged waters, such as Vichy and seltzer, are useful. Wine, beer and other alcohols should not be taken, or if the patient is habituated to their use, the amount should be restricted on account of danger to the pregnancy and danger to the child.

In contracted pelves it is sometimes desired to furnish a special diet, with the idea of controlling the size of the child (see Prochownick’s Diet, p. [332]) but this is an emergency. Certain books on maternity, designed for popular reading, advocate diets that are supposed, by depriving the child of lime salts, to keep its bones soft and make the labor easy. If it succeeds, the child will be injuriously affected. If it does not succeed, the claim is false.

Exercise.—Exercise should be taken, but it should not be violent, nor attended by risk. Golf, swimming, tennis, dancing, horseback or bicycle riding and fast driving in automobiles should be forbidden, lest abortion follow. General exhaustion must be avoided and all conditions that even approximate traumatism. Walking and slow driving are best, and housework is excellent up to a mild degree of fatigue. Travel should be restricted. If exercise is not feasible, massage will furnish the required stimulation to the circulation. The menstrual epochs are peculiarly favorable to abortive influences.

The Bowels.—Most women have a tendency to constipation during pregnancy. Many times this can be corrected by increasing the “roughening” in the food; more vegetables and fruits, bran bread and muffins, whole wheat bread, spinach, beans, carrots, turnips, peas and especially potatoes, baked and eaten, skin and all. Prunes, figs, and dates are valuable aids. Agar may be eaten three or four times daily. Russian oil (liquid petrolatum), taken in tablespoon doses three times daily, is an adjuvant, and finally, some form of cascara or aperient pill may be taken, if necessary.

Violent cathartics should not be used at all, and enemas as little as possible; only when quick results are necessary.

Heartburn.—Heartburn is a frequent complication, especially in the later months. It is due to an inordinate secretion of acid in the stomach. Soda mint tablets, bicarbonate of soda, and magnesia, in cake or as milk of magnesia, will relieve. The magnesia is also a laxative.

The kidneys require particular care during pregnancy, and in every case the urine should be examined monthly, up to the fifth month, and every two weeks thereafter, until the last six weeks, when a weekly test should be made.

The amount passed in twenty-four hours should be measured. Three pints is an average quantity. Albumin, sugar, and casts must be looked for and reported. Albumin may or may not be a serious symptom. Casts are significant of nephritis and indicate danger. Sugar may be lactose and be derived from the milk secreted in the breast. Edema of feet, hands and eyelids must always be investigated, with the possibility in mind, of heart and kidney lesions. Blindness, dizzy spells, headaches and spots before the eyes are always alarming symptoms until their innocence is established.

Through constant watchfulness of the urine, many cases of eclampsia may be averted.

Bathing is more important in pregnancy than at other times. The more the skin secretes, the less the burden on the kidneys. The skin must be kept warm, clean, and active. Then again, during pregnancy the skin is often unusually sensitive and only the mildest soaps and blandest applications can be used. The water must be neither hot nor cold, but just a comfortable temperature. Cold bathing, whether shower, plunge, or sitz, must be denied. Sea bathing is also unwise. The warm tub bath of plain water or with bran answers all conditions until the expected labor is near, then the warm shower or sponge bath should be substituted, lest germs from the bath water enter the vagina.

If the kidneys need aid, a hot pack may be used; but in all cases, frequent rubbing of the skin with a coarse towel should follow the bath.

The dress must be warm, loose, simple and suspended from the shoulders. To prevent chilling, wool or silk, or a mixture of both, should be worn next to the skin,—light in summer and heavy in winter.

The patient must be sensibly clad in broad, loose, low-heeled shoes. There should be no constriction about chest or abdomen. Circular garters must not be worn. If a corset is insisted upon, it must support the abdomen from below and lift it up. No corset is admissible that pushes down on the abdomen. This is especially true if the woman has borne one or more children and has a pendulous abdomen. The breasts may get heavy and require the rest and ease supplied by a properly fitting bust supporter.

Fainting is an annoying symptom in some women. It may come when quickening is first perceived, or from the excitement of crowds, or from hysteria. It usually passes quickly. The pallor is not deep, the pulse is not affected, and consciousness is not lost. It does not affect the ovum. Heart trouble should be excluded, and the daily habits of dress, diet, and bowels investigated. Smelling salts will usually suffice for the attack.

The abdominal walls may be strengthened by appropriate exercise before and after gestation, so that the muscles will preserve their tone. After delivery nursing the child will help greatly in the preservation of the waist line and figure, by aiding involution.

About the seventh month in primiparas, the abdomen gets very tense and in places the skin is stretched until it gives way and forms striæ. This tightness can be relieved to a considerable degree by inunctions of cocoanut oil or albolene.

Pain in the abdomen at this time may be due to mechanical distention, to strain on the muscles, to stretching of operative adhesions, to gas, constipation, or appendicitis. The physician should be informed of it. In every case, constipation, swelling of feet, hands or eyelids, blurring of vision, ringing in the ears, vomiting, persistent backache, or the passage of blood, no matter how slight, should be reported to the doctor.

The Breasts.—There should be no pressure on the glands and they should be warmly covered. The nipples must be kept clean and soft by soap and water, and about a month before the labor is expected, the nipple should be anointed with albolene or cocoanut oil and rubbed and pulled for a few minutes every night. This removes the crusts and dried secretions that collect on the nipple and prepare it for the macerating action of the baby’s mouth. No alcohol or strongly astringent washes should be used. Injuries must be avoided. If the nipples become tender they may be protected from external irritation by the lead nipple shield or by a wooden shield with a hollow center, such as Williams recommends.

Leucorrhœa.—This is one of the commonest discomforts of pregnancy, and the sense of uncleanliness, if the discharge is excessive, as well as the resulting irritation, may demand attention. It must be kept in mind, however, that the normal vaginal discharge of a healthy pregnant woman is strongly germicidal and should not be douched away without definite indications.

Vaginal douches of warm boric acid solution will do for cleanliness, but the douche bag must not be higher than the waist. Stronger and more antiseptic solutions are potassium permanganate 1:5000, or chinosol 1:1000. A suppository may be used, consisting of extract belladonna, gr. ss; tannic acid, gr. v, and boroglyceride dr. ss.

Sexual intercourse is distasteful to most pregnant women, but sometimes the inclination is intensified.

Coitus often causes much pelvic discomfort and may be an influential factor in producing abortion. It should be forbidden during the early months, at all menstrual epochs, and for at least two weeks before labor. The uterus may be infected by germs beneath the foreskin and hæmorrhage may follow the act if the placenta is low. In healthy persons, at the instance of the female, intercourse in moderation is permissible.

The mental condition should be placid without either excitement or fatigue. Anxiety should be dissipated by cheerful company and surroundings. Judicious amusement is desirable and a congenial occupation, but neighbors who tell frightful tales of disaster in labor, or nurses who relate the details of their critical cases, are equally to be avoided.

Many women of neurotic temperament dread the labor desperately. They are sure that death impends and they dwell with tragic interest on the stories of complicated cases related by thoughtless or malicious neighbors. The nurse can do much to allay these apprehensions by cheerfulness, optimism, and gentleness. Her buoyant temperament will drive away the patient’s fears just as effectively as the assurances of the physician.

Great allowances must be made for attacks of irritability, for the changes going on in the woman’s pelvis keep her in a capricious and whimsical condition. A good book to read at this time is, the “Prospective Mother,” by Slemons.

The subject of maternal impressions is the cause of much anxiety during pregnancy. It is safe to assure the mother that it is nearly impossible to mark her child by emotional stress. There is no demonstrable nervous communication between mother and child, and most of the deformities that occur and are attributable to shock, etc., can be explained by our knowledge of intrauterine changes. Furthermore, the same deformities occur in lower animals, to which it is difficult to ascribe such high nervous organization.

Many of the birthmarks, supposedly due to shock, occur too late in the pregnancy to affect the child, even if it were possible, for the child is completely formed before the fourteenth week.

The Determination of Sex.—It is not possible to know in advance of delivery whether the child will be a male or a female. It is equally impossible to determine or even to influence the sex of the coming child. Many theories have been advanced, and much talent has been wasted in trying to solve this problem.

Reasoning by analogy from the facts obtained from lower animals, the sex of the child is unalterably decided the moment conception occurs. The responsibility for the decisions seems to lie with the male cell. All we really know is that the sexes appear in the ratio of 100 girls to 106 boys.

CHAPTER V
ABNORMAL PREGNANCY

After the diagnosis of pregnancy has been satisfactorily established, no further internal examinations are necessary in the absence of special indications, until about the thirtieth week.

At this time a series of complete physical examinations may be required to determine the presentation and position of the child, the presence and rate of fœtal heart tones, the diameters of the head, the length and approximate maturity of the child, as well as the condition of the bony and soft passages of the mother.

It is thus that an appreciation of the obstetrical problem is secured and a course laid out for its successful solution.

Pregnancy is not a disease, but a normal function; but the woman is exposed, nevertheless, to many grave risks that are peculiar to her condition and to many complications accidental or otherwise which are more serious on account of her pregnancy.

The Toxæmias.—The growing ovum brings about changes in the maternal metabolism that are manifested by characteristic symptoms which in other better known conditions are recognized as due to toxæmia. Therefore, while there is no positive proof as yet that these symptoms, arising during pregnancy, are toxæmic in origin, the evidence goes to show that they are; and, therefore, should be classified as toxic.

Postmortem findings in eclampsia and pernicious vomiting such as extensive thromboses, cell necrosis, and interstitial hæmorrhages are very suggestive.

Clinical findings in regard to the excretion of nitrogen (urea, ammonia, uric acid, etc.), the occurrence of acidosis, elevation of blood pressure, fever, diminished excretion, coma and convulsions, all point to toxæmia.

It is the minor disturbances, however, that the nurse will come in contact with most. They are nearly all toxæmic in origin, and a brief description of them must be given, together with suggestions for their management.

Salivation or Ptyalism.—In the majority of cases, saliva is not especially noticeable; but at times the secretion shows an enormous increase, and may even demand abortion. Patients will have saliva running constantly from the mouth. The amount may reach a pint or a quart a day, and the skin of the lower lip becomes greatly inflamed.

The only satisfactory treatment is a rigorous milk diet on the theory that the disturbance is an intoxication. In extreme cases abortion may be indicated.

Gingivitis.—The gums may become inflamed, spongy and hæmorrhagic during pregnancy, usually in patients of low vitality. If a generous diet and astringent mouth washes do not relieve the condition, the milk diet should be considered.

Toothache and Dental Decay.—The patient may be given hypophosphites, and the teeth should be put in good condition by a dentist.

Constipation has already been referred to. Strong cathartics should be avoided lest abortion follow.

Condylomata of pregnancy occur most frequently around the labia, perineum, and anus. They are wart-like growths that develop slowly or quickly and may remain discrete or cover the entire area with masses as small as beans or as large as cauliflowers, which in appearance they much resemble. The etiology is obscure, but they are generally associated with irritating vaginal discharges, such as an old gonorrhœa.

Treatment consists in stopping the discharge or neutralizing it, and in keeping the growths dry with a salicylic acid dusting powder. (See Therapeutic Index.)

Pruritus is often distressing. The itching may be limited to the genitals or appear on other parts of the body. It may be due to the irritation of local discharges or to a condition of the nervous system, arising from toxæmia. Astringent douches and protective ointments will relieve some cases.

Bromides and milk diet, bran or alkaline baths give good results, and local applications of sedative lotions and ointments containing menthol, carbolic acid or cocaine (cautiously) will aid. The woman in some instances becomes almost frantic, and tears at the vulva with her nails until it bleeds.

The iodine treatment of Hensler is simple and often effective. If no skin changes are visible and but little leucorrhœa, the vulva is thoroughly prepared as for a vaginal operation, dried and painted with a 10 per cent solution of tincture of iodine. Generally one application suffices, but when the leucorrhœa is bad, it may be necessary to repeat the treatment on the third and fifth day thereafter. Between treatments, the vulvar surfaces and even the vaginal walls (by insufflation) are kept dry with zinc oxide powder. If all measures fail and exhaustion is imminent, emptying the uterus may be advisable.

Herpes is an inflammatory, superficial eruption, characterized by red patches, blisters, or pustules. It is accompanied by burning, itching, and nervous depression. The origin is probably toxic and the termination may be fatal. Milk diet, soothing lotions, and, if necessary, abortion, constitute the means of treatment.

Areas of pigmentation (the chloasmata) are not amenable to treatment. They usually disappear after labor.

Albuminuria of Pregnancy.—Albuminuria is so common as to be almost physiological when the amount of albumin is small. When the amount of albumin in the urine is large, it may be due to pre-existing disease, which is first discovered when the urinalysis is made during pregnancy. (Chronic nephritis?).

If it makes its debut during gestation and continues as a mere trace without casts, it is spoken of as the albuminuria of pregnancy, but the patient must be watched with great care, since the albuminuria may be a premonitory sign of eclampsia.

Albuminuria and eclampsia must be considered together, because, while the two conditions may exist separately, they are most frequently associated, and it is believed that they have a common causation. It is true that most cases of albuminuria terminate favorably, yet the higher the albumin content, the greater the danger of eclampsia.

Albumin appears in the urine in from three to five per cent of all pregnancies. It is more common in the latter half of gestation and the attacks differ greatly in severity.

Symptoms.—In the early stages the urine shows an abundant, pale fluid of low specific gravity.

The seriousness of the case is generally indicated by the amount of albumin, although this is not a reliable guide as to the danger of eclampsia. Casts and red and white blood corpuscles are occasionally found. The output of urea usually remains normal, but diminution usually occurs in connection with eclampsia. Anæmia and anasarca are common, but it is a hopeful clinical sign that the cases of extensive edema rarely develop eclampsia.

In albuminuria of pregnancy there is a large fœtal mortality which, to a degree, is independent of eclampsia. The infant dies in utero or is born feeble, or prematurely.

Eclampsia is the sudden appearance of convulsions in the course of pregnancy. It may precede, follow, or accompany albuminuria. It occurs rarely in the absence of albuminuria in a woman who was apparently in good health. The two phenomena are best explained as a consequence of toxæmia due to poisons at present unidentified.

Treatment of the albuminuria is treatment for impending eclampsia. Regular examination of the urine is indispensable. The presence of albumin suggests toxæmia. The daily output of urine and the output of urea must be compared, for a fall in urea is a premonitory sign of eclampsia. The bowels and the skin should be stimulated, respectively, by saline cathartics, hot baths and packs. The digestive organs must be spared as much work as possible, especially the liver. Water is given in abundance, and milk is the staple diet. Koumiss, butter milk and ice cream may be allowed. As the patient improves, vegetables are allowed. The food should be salt-free; and alcohol, as well as rich, indigestible things should be forbidden. In the milder cases boiled fish and a little chicken may be permitted.

The course of the disease and the condition of the patient is determined by frequent examinations of the urine, while in all serious cases an examination of the fundus of the eye must be made to detect a possible albuminuric retinitis.

The treatment of eclampsia will be considered under the complications of labor, where the attack usually begins.

Pyelitis of pregnancy is an acute, and rarely, a chronic infection of the pelvis of the kidney, due to the Bacillus coli. It usually appears after the fourth month (fifth to eighth) and attacks by preference the right side. Extension to the kidney substance, ureters, and bladder is occasionally observed.

Symptoms.—Sudden, acute abdominal pain, at first diffuse, but after a few hours, becoming localized in the right side, and on this account is often confused with appendicitis, especially as vomiting is not infrequent. A chill may mark the onset and the temperature rise to 103° F. or 104° F. The bowels are constipated, the tongue coated, and there is tenderness over the kidney. The urine is scanty, turbid, slightly albuminous and contains pus and epithelium in the urinary canal. A culture reveals the bacillus which has obtained access to the kidney, either by extension of the ureter from the bladder, by direct invasion of the tissues from the adjacent colon, or through the circulation.

Treatment.—The diet should be fluid and mostly milk, the bowels should be moved freely and frequently. The urine is alkalinized with sodium citrate, since the Bacillus coli lives only in an acid medium. As the symptoms subside, urotropin may be administered. If the patient does not improve within two weeks, abortion must be seriously considered. Nephrotomy is not to be thought of unless abortion has failed.

Hyperemesis Gravidarum.—The nausea and vomiting of pregnancy is so usual as to be regarded as normal. It usually ceases from the fourth to the fifth month spontaneously; has no ill effect upon the ovum, and may respond readily to treatment.

Hyperemesis comes on at the same period and exhibits all stages of violence, from the mild form above described, to cases that end fatally.

Three classes of this serious disorder may be distinguished as associated (Eden), neurotic, and toxæmic vomiting.

Associated vomiting is the vomiting that comes with gastric ulcer or cancer, chronic gastritis, cirrhosis of the liver, and cerebral disease. These conditions must be excluded in diagnosis.

Neurotic vomiting—severe and persistent nausea and retching—is common in pregnant women of the nervous type. It does not lead to loss of flesh ordinarily; the urine is somewhat diminished in quantity from the lack of fluids, but the amount of nitrogen excreted remains normal. This is important.

Toxæmic vomiting includes a small but very important class of cases, for all are severe and intractable and some end in death.

Clinical Features.—The normal nausea and vomiting may seem unusually severe. It persists and gets worse. Then vomiting occurs when no food is taken and nothing is held on the stomach. The vomit is stained with bile or blood. The tongue remains clean, and the general condition is good.

Next, weight is lost and the pulse quickens. A persistent pulse of over 100 is serious. The tongue becomes coated, sordes develops, sleeplessness and muscular twitching appear, and the patient complains of epigastric pain. Abortion may now occur and the condition clear up.

In its final stage, the urine becomes scanty and albuminous, icterus may appear and the temperature rise to 100° F. or more, though sometimes it is subnormal. The pulse may go to 120. Delirium and coma supervene, and emptying the uterus is of no value. Fifty per cent of these bad cases die.

The especially prominent points to be noted are the urine, which shows acetone, albumin and blood, either one or all, as well as an increased amount of ammonia. A persistently rapid pulse, marked loss of flesh, coated tongue, jaundice and delirium are regularly present.

Treatment.—Organic disease must be excluded and a diagnosis of pregnancy strongly evident.

For the neurotic type, the patient must be segregated from her friends, and a competent, cheerful nurse put in charge. A cool, darkened room is best. If the patient can be transferred to a hospital, the results are more satisfactory. Here the isolation from external interests and irritations can be made complete. The patient does not talk, even the nurse comes with food, attends to the obvious necessities, and departs in silence. Once a day a sedative bath is given (see Baths, p. [325]) and medication in kind and frequency as the conditions demand.

In any case, the patient should be put to bed and fed carefully every two or three hours on milk, peptonized food or barley water. If this is not retained, albumin water may be given for twenty-four hours at regular intervals, or rectal alimentation may be tried after stopping all foods by mouth. Iced champagne, seltzer or Vichy, either alone or with milk, may be tried. A dry diet is sometimes effective, rusk, toast, toasted shredded wheat biscuit, crackers, etc., taken early in the morning, as one eats cheese. No exercise is permitted except such muscular and nervous excitation as may be derived from massage or the sedative bath.

Drugs are sometimes of great value—the bromides, in full doses, or 1 m. doses of tincture of iodine, well diluted, every hour; or bismuth with hydrocyanic acid; or cocaine or oxalate of cerium. Occasionally good results are reported from a capsule of pepsin, 2 gr. and ¼ gr. silver nitrate given just before meals; and adrenalin in 10 drop doses may be considered. Extract of corpus lutea has been tried by Hirst with favorable results.

Sinapisms to the epigastrium and ice bags to the spine have been found useful, and washing out the stomach is efficient at times. In washing out the stomach, be sure the stomach tube is iced before it is introduced.

When the case gets worse in spite of treatment and acidosis supervenes, bicarbonate of soda may be given in sixty grain doses every four hours, by rectum, if necessary, until the urine gives an alkaline reaction.

Glucose as a readily assimilable carbohydrate may be given in doses up to 10 oz. of a 6 per cent solution (Eden) or sugar infusions by rectum, 1000 c.c. in twenty-four hours by drop method.

The obstetric treatment is the emptying of the uterus. To be effective the abortion must be done before the condition of the patient is desperate. It is most favorable before the febrile stage. If the vomiting persists in spite of treatment and is accompanied by emaciation, a pulse of over 100, albumin in the urine, with an increase of the ammonia output, the pregnancy should be terminated at once. If the patient can not go to a hospital, the nurse should prepare the room as described for operations.

After emptying the uterus, the vomiting usually ceases but much labor is thrown upon the nurse in supplying nourishment and caring for an exhausted and whimsical patient.

The back must be inspected daily for decubitus (bed sores) and her position changed frequently. A daily rub with alcohol and water (50 per cent) followed by an oil inunction will be valuable. The teeth and gums should be cleaned with gauze, wrapped around the finger and dipped in solution of boric acid. No brush should be used.

Fig. 29.—Twins. (Lenoir and Tarnier.)

Multiple Pregnancy.—Twins occur about once in ninety labors, triplets, once in seven thousand.

Heredity and multiparity seem to be the only recognized predisposing factors. The more pregnancies a woman has, the more liable she is to have twins.

Twins may occur through a division of the primitive cell through the fertilization of two ova from the same or different ovaries, or by fertilization of a single ovum having two nuclei. (See Fig. 13). The former are called binovular twins, and may or may not be of the same sex. The latter are called uniovular twins and are always of the same sex. Twins are usually somewhat smaller than a single child, and frequently associated with hydramnios. Binovular twins have separate placentæ and uniovular twins have one placenta, with separate cords.

Twin pregnancies usually go into labor earlier than the single child, possibly on account of the over-distention of the uterus.

The diagnosis is occasionally difficult and at other times easy. Two sets of heart tones must be distinguished and differentiated by their variation in frequency, heard at the same time by different observers. The presence of twins may be strongly suspected also when the external measurements of child and uterus greatly exceed the average. In such cases a systematic and persistent search must be made for the two fœtal heart tones.

The delivery is generally uncomplicated, unless the chins become locked.

Displacements of the Uterus.—In most cases displacements of the uterus are a consequence of conception in organs that are previously retroflected or retroverted. They rarely produce symptoms until the end of the third month, when the attention is directed to the bladder. There may be absolute retention or a constant dribbling from a full bladder (ischuria paradoxa), possibly associated with pain. If recognized early, an attempt should be made to replace the uterus by posture (knee chest) and when replaced, to hold it by pessary or tampon. The prone position in bed will aid.

After retention has occurred, the patient should be put to bed and the bladder catheterized regularly every eight or ten hours for three or four days. As a rule, the organ will rise spontaneously into the abdomen. If it does not, it is probably incarcerated under the promontory, and the physician must try to replace the uterus by manipulation or by continuous pressure, but in bad cases, he will empty the uterus before the condition of the patient becomes too serious.

In multiparas with weak abdominal walls, or women with spinal curvature or contracted pelves, the uterus may fall forward and, passing between the recti muscles, continue to drop until the fundus lies lower than the symphysis pubis.

Management, until labor occurs, may be made more effective by using a strong, well-fitting abdominal bandage.

Malformation of the uterus may possess an obstetric interest at times. The double uterus (uterus didelphys) and the uterus with a rudimentary horn (uterus bicornis) are examples. These are congenital conditions, due to imperfect development, and pregnancy may take place in one or both sides. If in one side only, the other half will also exhibit the softening and other changes as in normal cases. Binovular twins may be the result of a pregnancy in each side.

Pressure Symptoms.—Edema of legs and sometimes of the vulva occurs during the last trimester. It is due to increased intraabdominal pressure and to direct interference with the return circulation by the pressure of the heavy uterus on the iliac veins at the brim of the pelvis. The urine should be examined for albumin and the patient put in the horizontal position if the edema is troublesome.

Varicose veins of legs and vulva may cause much distress. The limbs should be bound with flannel spirals or with rubber bandages in the recumbent position, or elastic stockings may be obtained. Operation during pregnancy is not to be considered. The vulva can only be relieved by a double bandage, which is sewed at the point where it crosses the vulva, and buckled or tied to a waistband above the hips, both before and behind. This brings support to the vulva. If the veins rupture, the part should be elevated and compressed with an aseptic pad.

Hæmorrhoids may either appear or grow worse late in pregnancy. If they protrude, they should be replaced. Ointments and iced applications may be used and the bowels kept loose.

Cramps may occur in the muscles of the legs, due sometimes to the varicose veins and sometimes to pressure on the lumbosacral plexus.

Moles.—Mole is the name given to an ovum which is destroyed by disease of its coverings during the early months of gestation. Two kinds are known, the blood mole (carneous mole, fleshy mole, or hæmatoma mole) and the hydatidiform mole (vesicular mole).

The blood mole results from progressive or recurrent slight hæmorrhages during the first three months of pregnancy, but hæmorrhages insufficient in quantity to produce an abortion. The blood forms a clot, which may be retained for several months and become solidified.

Hydatidiform mole is a disease of the young chorionic villi, characterized by the growth of an immense number of irregular clusters and chains of grape-like cysts from the very minute to bodies four-fifths of an inch in diameter. The causation is unknown.

Both forms occur in the first half of the pregnancy and are characterized by undue enlargement of the uterus and hæmorrhagic discharge.

Diseases of the Membranes.—Hydramnios, or polyhydramnios, is the name applied to the condition where an excess of liquor amnii is formed. The amount normally present varies, but anything in excess of four pints could be called hydramnios. Six gallons have been reported. Since the source of the liquor amnii is not positively known, the etiology of hydramnios must be equally obscure.

It is occasionally associated with morbid conditions of the mother, such as hepatic or cardiac dropsy, but more frequently with developmental anomalies of the fœtus.

Since the mother is usually healthy and the fœtus frequently deformed, the theory is advanced that the disease is fœtal in origin. It frequently occurs with twin pregnancies, and in the first months it is most plausible that the liquor amnii is in some way derived from the fœtus.

The disease is more common in multiparas. It is generally slow in onset, but it may be acute, and an immense amount of fluid may be formed in a few weeks.

The symptoms are those due to pressure from the extremely large uterus.

The treatment, if interference with heart or lungs becomes pronounced, is puncture of the membranes. The child need not be considered for it is usually dead or deformed.

Oligohydramnios is the condition where the liquor amnii is deficient in amount. It gives no maternal symptoms, but it is the cause of many birthmarks and fœtal deformities (club-foot, spinal curvature, wry-neck, ankylosis of joints).

Amniotic adhesions are usually associated with oligohydranmios and cause deformities by amputation of limbs, strangulation of cord, and production of six fingers.

The placenta may show anomalies of size and shape. Thus, there may be two lobes, or three. There may be the main placenta and a small out-lying mass connected by membrane and vessels with the larger segment. The cord may be inserted in the middle or at the edge and yellowish-white masses called infarcts may be found in its substance.

Unusual size and weight of the placenta are suggestive of syphilis.

Abnormal conditions of the fœtus may arise from primary or transmitted disease or from errors of development. The developmental errors may be monsters, hydrocephalus spina bifida, etc., which may not influence the pregnancy. The most commonly transmitted disease is syphilis, which may produce abortion, premature labor, or a child born with syphilitic skin changes on palms and soles, as well as internally.

CHAPTER VI
ABNORMAL PREGNANCY (Cont’d)

Extrauterine Pregnancy.—This is a pregnancy which occurs outside the uterus, and while the event usually happens in the tube, cases have been reported where the egg developed in the ovary or abdomen.

The ovum, owing to some delay in passage to the uterus, is fertilized either in the ovary or in the tube, and by reason of a chronic inflammation of the tube or pelvis, or of overgrowth does not succeed in reaching the uterus at all.

As the ovum develops, the tube expands, but it does not possess the power of growing into a large organ like the uterus, hence a sudden jar, a strain, or a blow may cause it to rupture and discharge the egg into the abdomen (ruptured tubal pregnancy) or force it out through the end of the tube (tubal abortion).

This phenomenon may be accompanied by a severe or even fatal hæmorrhage; or the prostration may pass off in a few days or weeks, and leave the patient well.

In the early stages the ovum is absorbed, but after the pregnancy becomes more advanced, it may remain as a tumor, or require an operation for its removal.

Infection may occur and the mass ulcerate its way into neighboring organs (rectum, vagina, or bladder) and discharge itself in a long, suppurative process.

Most cases of ectopic (extrauterine)gestation present definite and even dangerous symptoms between the second and fourth month. The symptoms are those of pregnancy, together with irregular hæmorrhages from the uterus, which may result in the expulsion of pieces of tissue or of membrane. Besides this, there is a vomiting and acute irregular pain on one side, associated with a sense of fullness. Such symptoms should be brought to the attention of the physician, who will learn the true condition of the pelvis by internal examination, conducted as gently as possible so as not to produce rupture.

If rupture occurs, it will be ushered in by a sharp lancinating pain on one side, followed by faintness, nausea, vomiting, prostration, rapid pulse, sighing respiration, and collapse. The temperature is subnormal and death may occur in a few hours, unless an operation is done.

Fig. 30.—Diagram representing the sites for the various forms of tubal pregnancy. 1, interstitial pregnancy; 2, isthmial pregnancy; 3, ampullar pregnancy; 4, infundibular pregnancy; 5, tubo-ovarian pregnancy. (Gilliam.)

In cases of tubal abortion (where the ovum escapes through the end of the tube) the symptoms are very similar, but the patient soon rallies and gradual recovery takes place.

If the diagnosis is made before rupture or abortion the treatment is laparotomy. If rupture occurs, the laparotomy must be done immediately to check the hæmorrhage, which threatens the life of the patient. In tubal abortion, if the diagnosis is certain, some delay may be permitted under extreme watchfulness of the nurse and physician. In such case, the nurse will keep the patient absolutely quiet and forbid exertion of any kind.

If operation is necessary, the utmost gentleness must be used in preparing the abdomen. The tincture of iodine application to the site of the incision is sufficient preparation, and, of course, an abundance of sterile gauze, cotton, and towels should be supplied, as in every case where laparotomy is done.

If the rupture occurs while the nurse is present, the doctor should be notified at once, and if not at home, another doctor should be summoned. Meanwhile, the nurse prepares the room, solutions and utensils for an abdominal operation. Immediate incision to check the hæmorrhage and remove the mass offers the greatest safety.

The after-care is the same as for any laparotomy, with the additional duty of making up the lost blood as soon as possible by nourishing foods, normal saline solution by rectum, and, if necessary, by hypodermoclysis.

Acute fevers are a serious complication of pregnancy on account of the danger of abortion or premature labor, which may come on either from the associated high temperature or from the transmission of the disease to the ovum.

The following diseases are known to affect the fœtus in utero: cholera, yellow fever, small pox, scarlet fever, typhoid, measles, erysipelas, meningitis and syphilis.

CHRONIC INFECTIONS

Tuberculosis does not affect fertility or the course of the pregnancy, but the progress of the disease is hastened, and the maternal death accelerated.

The question of artificial abortion in the early months must be seriously considered, and if the case goes on to term, the child must not be nursed or cared for by the mother.

Syphilis is the most frequent systemic cause of the interruption of pregnancy. It is a blood disease, due to an organism, called spirochæta pallida, and it appears in three distinct stages. The first is the primary stage, wherein a hard, nodular ulcer appears on some part of the body, as the vulva, lips, gums, tonsils, or hand. It is not always venereal in origin. The second stage begins six or eight weeks after the sore, and is marked by a general eruption of red spots, chronic sore throat, falling hair, and rheumatic pains in the joints. The third stage is the name given to the later conditions of the disease which affect the bones, blood vessels, and nervous system.

Infection of the ovum may usually be traced to the father, who may transmit syphilis at any stage of the disease. In the third stage, the child alone will be infected; the mother escapes.

The mother may or may not transmit the disease, depending on the period of pregnancy wherein her infection occurs. If she gets the disease at, before, or just about, the time of conception, she will abort three times out of four, and the ovum will show definite lesions. If infected later, abortion occurs less frequently; and if the disease is contracted late in pregnancy, the child may be born apparently free from infection.

Symptoms.—A child with congenital syphilis will show the eruption of coppery spots, blisters on palms and soles, deep cracks on the feet, snuffles, cracks and ulcers around the mouth and rectum, and the weakly, marasmic condition of the body.

The diagnosis in suspected cases can be rendered more certain by the Wassermann reaction. This is a laboratory test of the blood which should always be made before a wet nurse is allowed to nurse a child, or before a suspected child is nursed by a clean woman. In all cases of transfusion of blood, it is imperative.

Treatment.—Antisyphilitic treatment of an infected mother or child by salvarsan, mercury, and potassium iodide must be carried out vigorously in all cases.

The syphilitic patient must be prevented from spreading the infection by having dishes and utensils of her own, which are kept sterile. Discharges are collected and burned, and the nurse in charge of these cases must carefully cover her hands with rubber gloves, and see that all cracks and fissures are properly protected from contact with sources of infection.

Gonorrhœa is an acute or chronic disease of the mucous membranes due to a germ called the gonococcus.

Beginning with a sharp inflammatory disturbance of the urethra or vagina, it may pass slowly up through the genital passage and produce chronic and permanent disabilities, such as sterility, pus tubes, and pelvic peritonitis.

The symptoms are painful urination, painful inflammation of the vagina, with a purulent discharge. During pregnancy all these symptoms are intensified, and warty growths (condylomata) may appear on the vulva.

If infection occurs after pregnancy has begun, the course of the gestation is rarely affected, as the uterus is closed to germ invasion. During delivery, however, there is a serious danger of infection of mouth or eyes of the child if they come in contact with the discharge.

Prophylaxis.—The eyes at birth must be immediately instilled with a drop or two of 1 per cent solution of silver nitrate in water. This is not neutralized by normal saline. Great care must be used that the discharge does not come in contact with the eyes of the mother or attendants, lest infection follow.

Treatment.—Scrupulous cleanliness must be observed. Douches of potassium permanganate, 1:5000, or painting the vagina with iodine or solution of silver nitrate, or suppositories of argyrol or protargol furnish the best means of treatment before labor.

Neither syphilis nor gonorrhea is necessarily caused by venereal infection. They may be spread by barbers, dentists, physicians, and nurses,—by anyone who is unclean; and may be acquired innocently everywhere.

These diseases should not be discussed by the nurse or physician except with the patient. Certainly nothing from the sick room should be repeated elsewhere.

The valves of the heart are not uncommonly found to be diseased in pregnancy, the mitral being the most often affected, either as an insufficiency or as a stenosis (a narrowing of the mitral opening). Mitral stenosis is the most serious of all heart complications of pregnancy, and where this is present, a woman should be advised to avoid conception.

In other mitral lesions, many pregnancies may be successfully passed, if compensation is maintained; but every one brings further damage to the already weakened heart, and reduces its reserve of force. If the heart breaks down early in pregnancy, and does not respond to medication, abortion should be induced. In the second half of pregnancy, the mother should be given the prior chance, but the child should be saved, if possible.

Renal diseases, such as nephritis, may not only induce abortion by destroying the fœtus, but the kidney lesion may be greatly aggravated by the pregnancy. The most careful observation of the patient’s condition, the regular examination of the urine, and the scientific management of the diet is necessary to relieve the work on the kidneys and keep the patient in a moderate degree of health.

It is the duty of the nurse to protect her patient against fatigue and chill, and to see that the proper diet is followed; but other symptoms, such as headache and disturbance of vision and developing edema, must be noted and reported to the physician at once.

Diseases of Liver.—Acute yellow atrophy is a rare condition, which, for reasons unknown, is promoted by pregnancy.

The symptoms are intense headache and pain in the abdomen, possibly accompanied by vomiting and purging, which are soon followed by coma. There is generally a certain amount of jaundice. The urine is diminished in amount and contains albumin, casts, and sometimes blood. There is no known treatment, and the end is death.

Diabetes is seldom found associated with pregnancy. Its presence is unfavorable to conception and to gestation. Mother and child are both less secure. Abortion or premature labor is the rule.

The hæmorrhages of pregnancy in the first half generally mean abortion, and in the last half, either placenta prævia or premature detachment of the normally implanted placenta (see p. [228]).

Abortion is the expulsion of the ovum before the fœtus is viable, that is, before it is capable of maintaining life after birth. This means the twenty-eighth week, or the seventh month. Subsequent to the seventh month, the interruption is called premature labor. Abortion is a miniature labor, consisting of a stage of dilatation, a stage of expulsion, and a stage of involution.

The interruption of the pregnancy may occur spontaneously or be induced. In spontaneous cases the causes may be sought in diseases of the ovum, or in the mother, in injuries to the uterus or its contents, and such systemic affections as syphilis, Bright’s disease, alcoholism, lead poisoning, etc.

Abortions happen about once in every five or six pregnancies, and more frequently at the third month than at any other time.

The symptoms are hæmorrhage and pain. The dangers are hæmorrhage and infection.

Infection is most common and most serious in abortions that are brought about mechanically.

Hæmorrhage, in some degree, is an invariable symptom, which has its origin in the separation of the ovum from the uterine wall. Hæmorrhage from the uterus is serious at whatever stage of pregnancy it appears.

The duty of the nurse is to put the patient in a cool, dark room, on her back, elevate the foot of the bed, put ice bags on the lower abdomen, and summon the attending physician, with the hope that an abortion can be averted. Bromides and opium are the drugs most to be relied upon. Opium may be given in suppository, 1 grain night and morning.

If the hæmorrhage is alarmingly profuse and the nurse is skillful and clean, under exceptional circumstances she may pack the vagina with sterile cotton while waiting for the doctor. Then the room should be set for operation.

Dead Ovum.—The ovum may be discharged in pieces or in a single complete mass.

The egg may die at any period of the pregnancy, and be discharged in a few hours, or it may not be expelled for weeks, if at all. Fœtal death in the uterus may have its cause on the paternal side in a father too old or too young, or affected with such diseases as diabetes, nephritis, tuberculosis, syphilis, or chronic lead poisoning; on the maternal side, the same diseases, plus cancer, anæmia, insufficient food, and inflammation of the uterus; on the part of the embryo, syphilis or any transmitted or primary disease of the ovum.

The results of retention of the dead ovum vary with the case. Infection of the ovum is rare, except where the membranes have ruptured and an open channel exists. No harm follows the death of the fœtus, except in the presence of infections, all other changes are benign. The embryo in the first and second months may be absorbed, but at later periods, it becomes macerated petrified, or otherwise altered.

Among the signs of fœtal death are prolonged cessation of fœtal movements after being definitely observed, chilliness, languor and malaise of the mother, sense of weight in abdomen, and possibly a bad taste in the mouth. Furthermore, the uterus does not correspond to the period of pregnancy, and may have become smaller. Retrogressive changes take place in the breasts.

The diagnosis is only certain when the heart tones are persistently absent, or the macerated head of the fœtus is felt through the partly dilated os as a flabby bag of bones.

Treatment in noninfective cases is expectant. Spontaneous expulsion will occur sooner or later and there is no necessitous indication for interference. Local signs of putrefaction, however, make the immediate emptying of the uterus necessary.

CHAPTER VII
PREPARATIONS FOR LABOR AND THE NORMAL COURSE OF LABOR

The Nurse.—Scientific obstetric nursing is a specialty that enlists the interest of exceptional women only.

It demands a high sense of duty, a strong physique, broad training, unusual judgment, and rare tact. The nurse must be professionally aseptic and personally clean. She should keep herself free from odors, and bathe at least three times a week. The presence of pus anywhere on her body disqualifies her at once, and she should report off duty.

The compensation should always be somewhat higher than for other work, because there are two patients to be cared for.

An obstetric nurse should specialize in her work, and not take infectious cases. Unhappily the haphazard character of the onset of labor presents a difficulty. The patient frequently can not afford to have the nurse for a long time in advance of labor, and the nurse whose income is limited by the number of her cases can not afford to be idle. Hence, it is better for two nurses to work in alternation with one another, so that one is always available in an emergency.

Both doctor and nurse should visit the lying-in room before labor begins, and plan its rearrangement. At least a week before the expected confinement, the chamber selected should be thoroughly cleaned and the woodwork wiped off. Curtains, draperies and bric-a-brac and all useless furniture should be removed. Carpets must be taken up, or at time of confinement, well protected. Rugs can be easily managed. A chair, a bed, and the various tables for instruments and solutions are all that are required.

The nurse usually is called to the case first, and upon her falls the responsibility of the diagnosis and the burden of the preparation. As soon as she arrives and satisfies herself that the patient is really in labor, she puts the final touches to the room. In her own mind she goes over all possible emergencies and prepares to meet them.

The following supplies should be in the house for the labor:

3 hand basins, 10 inches in diameter.

3 hand brushes.

1 two-quart douche bag.

15 yards nonsterile gauze.

2 lb. each of cotton batting and absorbent cotton for making bed pads.

2 pieces of rubber sheeting 1 by 2 yards.

5–yd. jar of borated gauze.

4 oz. lysol (or ziratol).

100 c.c. of Squibb’s chloroform.

2 oz. green soap.

2 oz. solid albolene.

8 oz. alcohol.

½ oz. ergotol.

½ oz. bismuth subnitrate and ½ oz. boric acid powder mixed.

1 nail file.

Nurse’s outfit consists of the following: Nail file, surgical scissors, catheter (silver is best), hypodermic syringe with tablets of morphine, strychnine, and digitalis; two fever thermometers, one for mouth and one for rectum; a pair of tissue forceps and a razor.

Some time before the labor, the nurse should call on the patient and establish a working acquaintance. It adds greatly to her authority and to the patient’s confidence in her. Her advice will be sought on a multitude of subjects, partly real and partly to try her out.

Fig. 31.—Abdominal binder with crosspiece to hold vulvar pads.

Fig. 32.—T-binder, used in all cases after the fifth day post partum.

Sterilizing may be done in a hospital, or, if this is not feasible, the nurse should go to the house two or three weeks before the expected labor and sterilize in an Arnold or Rochester sterilizer the following articles:

½ doz. sheets.

3 doz. towels.

2 pillow slips.

3 abdominal binders of unbleached cotton, 16 in. wide and 36 in. long, folded and hemmed.

4 T bandages.

3 breast binders.

2 jacket parts of pajama suits.

3 pairs of long white stockings.

3 packages of vulvar dressings (see Preparation of Supplies, p. [326]).

2 obstetric pads 1 by 36 by 36 inches.

1 pillow slip full of cotton pledgets for sponges.

1 jar applicators (cotton twisted about toothpicks).

1 jar of gauze pledgets for perineorrhaphy and cord dressings.

Everything must be neatly wrapped and labeled.

Fig. 33.—Breast binder.

Fig. 34.—Baby’s dress with winged sleeves.

Infant’s Outfit.—

12 plain slips 27 inches long of dimity or nainsook (with winged sleeves).

3 long sleeve shirts, silk and wool (size No. 2).

6 pinning blankets, made of outing flannel, if it is a winter baby.

3 bands, 6 by 18 inches, clip or notch edges, do not hem.

3 petticoats, flannel bottoms and muslin waists, without sleeves and with small button on shoulders.

3 outing flannel wrappers.

6 plain, soft muslin dresses.

3 (Arnold) knitted night gowns, light weight.

4 doz. light weight cotton diapers, 20 x 40 inches. Bird’s-eye linen is the best. Wash and dry these in the air before using.

4 soft towels (linen preferred).

2 quilted pads.

4 soft wash cloths.

4 wool wrapping blankets.

1 pair scales that weigh ounces and fractions thereof.

4 oz. of olive oil or benzoated lard.

4 oz. of alcohol (95 per cent).

¼ lb. boric acid crystals.

½ lb. absorbent cotton.

1 cake of castile soap.

2 oz. solid albolene.

½ oz. subnitrate of bismuth powder and ½ oz. of powdered boric acid mixed.

1 bed pan.

2 basins, holding 2 quarts each.

1 papier mache, rubber, or enamel ware bathtub.

Anæsthetics.—Excessive pain is destructive and disintegrating to the vital forces. Many a woman who has passed through a particularly severe labor remembers her experience with a horror that forever precludes its repetition.

This is the day of relative painlessness in labor, and all the world is striving to make childbirth easier and less lethal. No woman, unless she herself requests it, should be permitted to go through the agony of labor without an anæsthetic, judiciously selected and carefully administered.

Pain-deadening agents are numerous and inexpensive, and it is only a matter of experience and judgment to choose a method that will reduce the suffering of childbirth to a minimum. The second and first stages of labor, in the order named, demand the most in the way of relief.

A prolonged first stage with nagging, violent and apparently useless pains may devitalize the patient more than short, but acute pains of the second stage. In the first stage, under proper selection of cases and experienced supervision, “Twilight Sleep” will be successful in seventy to eighty per cent of the cases.

By success, is meant that the patient is relatively free from pain. When the drugs do not relieve pain, the case is a failure (fifteen per cent), although in no case, when properly given, is the mother or child endangered. Morphine solution ⅙ gr. and scopolamine hydrobromid 1/200 gr. to 1/150 gr. is the customary dosage for the first injection. Another injection of 1/200 gr. is given in a half or three-quarters of an hour. The room is darkened, talking is forbidden, and the family exiled. The patient gets red in the face and very thirsty, the pulse is rapid but full. She answers questions very slowly and drowsily, awakes for her contraction but goes right off to sleep again. In this condition she is kept through bi-hourly repetitions of the scopolamine until the delivery. It is this half waking and half sleeping condition that suggested the name of “Twilight Sleep.”

Morphine and scopolamine will relieve the pains of the first stage without greatly protracting the labor. The same drugs may and probably will prolong the duration of the second stage. The first dose should be given as soon as the patient is well started in labor.

“Twilight Sleep” is at present a hospital procedure, and the technic so exacting as to weary the attendants greatly. It can not be employed until the woman has definitely gone into labor and is at least three hours away from delivery. It is not serviceable where the pains are weak and shallow; and it must be used with wise circumspection, if at all, in the presence of complications.

For the second stage, there is a choice of three drugs: gas, chloroform, and ether. Like twilight sleep each is open to some objection, but each may be of the greatest assistance if used under appropriate indications and conditions.

Gas has one advantage, in that it in no way interferes with the pain activities; and Lynch and Davis have shown that with a proper admixture of oxygen, it may be given with comparative safety for the two or three hours which may mark a normal second stage. To administer it a competent machine for mixing the gas is necessary. It should not be given to patients who have bad hearts, high blood pressure, or toxæmia. Neither is it a satisfactory anæsthetic when the head delivers, for the mother being less relaxed and more rigid, the legs and muscle action are harder to control and unnecessary perineal lacerations are liable to occur. The patient is instructed to take several deep breaths just as the uterine contraction comes on and the gas bags supply about 75 per cent nitrous oxide and 25 per cent oxygen. As the pain passes off the oxygen is increased and the nitrous oxide diminished until the mind is again clear.

To save the perineum and better to control the patient, when the head is about to pass the vulva, it is wiser to abandon the gas for chloroform or ether.

Obstetrical operations, such as forceps and version, require ether or chloroform, and not gas. The dangers vary with the anæsthetic chosen, as well as the amount and the method of administration. Ether affects the respiration, chloroform attacks the heart. Ether must not be given near an open flame. Chloroform is not explosive but is decomposed by fire into an irritating gas. Chloroform must be diluted with 90 per cent of air, hence the mask must be open, or the napkin held free from the face, so that plenty of air can enter. Ether and chloroform, when given “a la reine;” i. e., a few drops on the mask at the beginning of each pain and increased up to the acme, is relatively free from danger. They have the additional advantage that the sleep may be instantly deepened if operation is required. Chloroform, it is now believed, predisposes mildly to post partum hæmorrhage. Davis has shown that neither ether, gas, nor chloroform affects the child injuriously if the administration is intermittent and not too greatly prolonged.

To summarize: Morphine and scopolamine combined is a first stage analgesic, which has too much value to be neglected.

Gas, if an apparatus is to be had, may work well for the greater part of the second stage, while for operations, or for the period of expulsion, during which the head passes the perineum, chloroform and ether give bests results. Moreover, chloroform “a la reine” may be given safely and efficiently by a competent nurse and in many instances must be given by the nurse, if at all.

When the perineum bulges, or the head becomes visible at the vulva, the nurse should anoint the lips, cheeks and tip of the nose with cold cream or olive oil, to avoid burning the skin, and lay two or three thicknesses of handkerchief or gauze over the nose (an inhaler is best). An abundance of room must be left underneath and at the sides of the mask for air to enter.

At the beginning of the pain a few drops of chloroform are poured on the cloth and the patient instructed to breathe vigorously. The cloth is removed as soon as the pain ceases and when the next contraction comes on, the process is repeated. As the head passes the perineum, the chloroform should be pushed to complete anæsthesia, both to save suffering and to give the doctor full control of the perineum. When the nurse gives the anæsthetic, she should watch the doctor for his signal to increase the vapor or remove the mask.

Summary.—Cover the eyes with a wet towel and anoint the face with cream or oil before using chloroform. Remove false teeth, if present.

Obstetric degree—a few drops on mask at beginning of each pain.

Surgical degree—complete anæsthesia.

Watch pulse and respiration.

A nurse should never leave a patient who has had an anæsthetic until she is conscious. Vomiting is especially dangerous.

Normal Labor.—Labor is the process by which a fœtus of viable age is expelled from the uterus.

By normal labor is meant a case where the fœtus presents by the vertex and terminates naturally without artificial aid, or complications. It varies greatly in severity, duration and danger to mother and child. A first labor is more prolonged and difficult than later confinements. A woman in her first delivery is called a primipara, in subsequent cases, a multipara.

The date at which labor comes on is difficult to determine accurately. The average duration of pregnancy is from 275 to 280 days, forty weeks, or ten lunar months, but conception does not occur necessarily at the time of coitus, nor is it possible to know with any certainty when it does occur.

Labor may occur two weeks earlier than calculated, with benefit to the mother, and no harm to the child; but if the woman goes over time, the child becomes much larger and the labor harder and more dangerous to both.

Causes of Labor.—Why labor should occur at all is not known. Many theories have been advanced, none of which is entirely satisfactory. Some of the best known are the growing irritability of the uterus accompanied by an increase in the frequency and strength of the intermittent uterine contractions or increasing distention of the uterus. Thus it is believed that when the uterus is distended up to a certain point, it will try to relieve itself like the bladder, or a baby’s stomach. It may be that any one of the following factors, or all of them acting together, are influential.

Dilatation of the cervix by the presenting part.

Increasing distention of the lower half of the uterus with pressure on neighboring nerve structures.

The circulation of fœtal products of metabolism (toxins) acting on the nerve centers.

The menstrual periodicity.

Heredity and habit.

Physical and emotional causes.

The onset of labor probably is not purely accidental, and yet it is so inconstant in appearance and so indifferently early or late, that it has every appearance of being an affair of chance. The time when labor will come on is highly speculative in general, but the phenomenon is preceded by certain definite symptoms:

The lightening.

False pains.

Show.

Rupture of membranes.

The pains.

Lightening.—About two weeks before labor, especially in a primipara, the uterus and the head sometimes descend into the pelvis. The body of the child falls forward and the abdomen protrudes, the stomach is flatter, the patient breathes easier and feels, as she says, “lighter.” But walking is more difficult, the bladder is stimulated to frequent evacuations and the rectum is compressed.

This occurrence is a premonitory sign of labor, and also favorable inasmuch as it demonstrates that this particular head is not too large to pass this particular pelvis.

False pains may appear, especially in multiparas, from two to four weeks before labor. In some of these cases the pains may be due to gas or indigestion and respond to hot applications and enemas, or there may be definite uterine contractions, as shown by the hardness of that organ during a pain, but the phenomena are irregular and therefore not typical of labor pains.

Usually they pass off in a few hours, but if the patient is nervous, the doctor or nurse may be called needlessly. The patient, therefore, should be instructed to have the pains timed by the watch for half an hour or an hour. If they are regular during this period, the physician should be notified. Upon his arrival, an internal examination will reveal the true character of the disturbance by the condition of the cervix and os.

The show is a discharge of thick, white mucus, slightly stained with blood. This is the mucus plug which occludes the cervix during pregnancy and when the os begins to dilate, the mass is released and passes out. Labor usually comes on vigorously within twelve hours.

The membranes may rupture before labor begins and much fluid escape. The advantage of the dilating bag of water and lubricating qualities of the liquor amnii are thus lost. Such a labor is called a “dry birth” and is frequently slow, exhausting, and extremely painful.

The pains are the subjective manifestations of the powers of labor. The forces concerned are uterine and abdominal muscles, principally assisted by those of the back, legs, and arms. Their constricting action on the nerve fibers in the walls of the uterus is the cause of the pains in the first stage. The onset may be violent and go on to a quick delivery, but generally the inception is more insidious.

The irregular, painless contractions, (of Braxton Hicks) that were mentioned on an earlier page, gradually at term change their character and become regular and painful.

At first they may be slight and vague, lasting only half a minute and separated by intervals of ten or fifteen minutes and scarcely attract the patient’s attention. They are felt chiefly in the abdomen.

More or less rapidly they increase in frequency, severity and duration. They last from a minute to a minute and a half and come every three minutes. The whole uterus hardens and its outline is clearly defined during the contraction; it relaxes and becomes soft in the interval. The woman is now in labor. The pains become grinding and the patient feels that she is not accomplishing anything, yet under the influence of these contractions the cervix is effaced and the os is dilated.

The Course of Labor.—Labor is divided for convenience into three stages as follows:

The first stage, from the beginning of pains until the complete dilatation of the os.

The second stage, from the complete dilatation of the os to the delivery of the child.

The third stage, from the delivery of the child to the expulsion of the placenta.

The first stage is the stage of dilatation.

Usually at term, the cervix is columnar and unshortened, the canal intact, and closed at both ends, as shown in Fig. 36.

In multiparas the outer opening will usually admit the tip of the finger.

As labor proceeds, the cervix is effaced, the os slowly dilates, and the bag of waters forms.

The Bag of Waters.—When the cervix is effaced and only the os remains, the lower end of the egg with its fluid restrained by the membranes, bulges forward into the canal. The fœtal head, or breech presses into the pelvis, and the fluid in the membranes, compressed between the presenting part above and the cervix below, is called the bag of waters.

When the contraction comes on the longitudinal muscular fibers of the uterus are drawn upward and the bag of waters becomes tense and pushes farther and farther down into the opening; and by its even and universal pressure, mechanically and slowly increases the size of the opening which the muscular traction is pulling apart. At the same time, the fluid around the child prevents, for a time, direct and injurious compression on the body. When no definite cervical projection can be felt, and when the teat-like protrusion of the cervix has disappeared, the cervix is said to be effaced.

Fig. 35.—The bag of waters begins to act on the cervix. (Eden.)

The os now begins to stretch and widen, the bag of waters becomes more and more evident, vomiting occurs, and at last, when the os has expanded to a diameter of four inches (ten centimeters), the membrane can withstand the pressure no longer. It ruptures, a certain amount of fluid escapes, the presenting part comes down against the opening, and like a valve, prevents the outflow of the waters from above.

Fig. 36.—The effect of the pains. The cervix before labor begins. (Bumm.)

Fig. 37.—The effect of the pains. The cervix begins to be “effaced.” (Bumm.)

Fig. 38.—The effect of the pains. The cervix is effaced, and the dilatation of the os begins. (Bumm.)

Fig. 39.—The effect of the pains. The cervix is effaced, and the os continues to dilate. (Bumm.)

Sometimes the labor may be preceded by some hours (two or three), or days (two or three), even weeks (two or three), by the rupture of the membrane, and sometimes when the structure is thick and tough, the rupture may be delayed until well into the second stage, or even until the child is born. In the latter case, the head comes out, covered with membrane. In the old days, this was called being “born with a caul.” It was supposed to be a lucky omen, but it was lucky only that the babe escaped suffocation. The membrane should be torn open quickly.

The duration of this stage is variable. It is much longer in primiparas than multiparas. It averages sixteen hours in the former, and eight hours in the latter. Vomiting during this stage is quite common, but the pulse and temperature remain normal. The first stage of labor is usually under the entire control of the nurse. It is her responsibility.

With complete dilatation of the os, the second stage, or stage of expulsion, begins, whether the membranes rupture or not. The presenting part, usually the head, passes from the cervix into the vagina. The vagina in turn gradually dilates from above downward until uterus, cervix and vagina form a single, wide channel of the same diameter. The child is driven forward by the uterine contractions, strongly reinforced by the abdominal muscles, which the patient uses vigorously. The onset of each pain is accompanied by a deep inspiration, followed by straining or bearing down with the abdominal muscles as in a highly exaggerated bowel movement. The patient holds her breath, braces her feet, fastens her hands on bed or attendant, and uses all the trunk muscles in the effort. The face becomes congested, the pulse quickened, she perspires some, and groans deeply during the contraction. The pain is extreme and is due partly to the stretching of the vagina and vulva and partly to the distention of deeper sensitive structures.

When the head reaches the pelvic floor, the first change observed in the external genitals is the stretching (bulging) of the perineal body. Next, the anus becomes turgid, dilates slightly, the anterior wall becomes visible, and the hairy scalp of the child appears at the vulva. The actual expulsion of the head in a primipara is accomplished by a series of prolonged and severe contractions, accompanied by violent straining.

Fig. 40.—The cervix is effaced, and the os dilated. The second stage begins. (Eden.)

Fig. 41.—Child in second stage of labor with bag of waters unruptured and presenting at the vulva. (Braune, from Barbour.)

A short pause ensues, followed in two or three minutes by a return of the pains, which expel first the shoulders and then the trunk. As the body escapes it is followed by a rush of blood-stained liquor amnii. This is the fluid that has been pent up in the uterus by the obstructing body of the child. The second stage lasts about two hours in a primipara and from fifteen minutes to one hour in a multipara.

The third stage is the delivery of the after-birth. The after-birth sometimes called the secundines, consists of placenta, umbilical cord, and membranes.

Fig. 42.—The head passing over the perineum. (Bumm.)

After the expulsion of the fœtus, the uterus undergoes a sudden diminution in size. It is about as large as the child’s head, and the fundus lies near the level of the umbilicus. The contractions still persist feebly, but they are practically painless, and the patient is greatly relieved, possibly sleeping.

In from ten to thirty minutes, the uterus becomes smaller, harder, more globular in shape and more movable. The patient brings the voluntary muscles of the abdomen strongly into action again. The nurse presents a sterile basin and the physician sustains and slowly twists the membranes free from their final attachment and out of the uterus. When the placenta passes the vulva, a moderate sized blood clot follows it.

Fig. 43.—Normal expulsion of the placenta like an inverted umbrella according to Schultze. (Williams.)

The uterus is now much smaller, and hard and firm in consistency, but for some hours the contractions are intermittent, and while this continues, there is risk of hæmorrhage.

General Effects.—The mother’s pulse is quickened during the contraction. The fœtal heart beats more slowly and feebly during a contraction, but quickly recovers in the interval.

The amount of blood lost during labor averages from ten to sixteen ounces. The temperature may be elevated one or two degrees in a woman of moderate physique, while one with a fragile body may present the signs and symptoms of surgical shock. The chill, pallor, cold limbs and body, rapid and feeble pulse with subnormal temperature, suggest to the nurse at once the proper treatment. Heat, to all parts of the body, warm covers and hot milk or coffee. If hæmorrhage is present and the uterus relaxed, the nurse should immediately inject pituitrin (15 ♏︎) into the deltoid muscle and notify her attending physician.

CHAPTER VIII
THE MECHANISM OF NORMAL LABOR

The powers of labor are primarily the uterine contractions strongly aided by the muscles of the abdomen and diaphragm. Some assistance is given by the fixation of the legs and arms and sometimes by gravity, when a sitting or standing position is maintained.

The resistances are the bony pelvis and its relatively soft coverings of muscle and fascia.

The problem is to get the awkwardly shaped passenger through the curiously shaped passage.

In the first, and a part of the second stage, the uterine contractions do not act directly upon the body of the child, for the latter is surrounded by a wall of liquor amnii.

Pressure is transmitted by a fluid medium in all directions, hence, the weak part of the wall, which is the cervix, must give way. While the membranes remain intact, or when sufficient fluid is retained, no amount of pressure can injure the fœtus. When the membranes rupture, the force of the pains is exerted directly upon the child to drive it forward, and prolonged pressure may produce injurious effects through compression of fœtus, placenta, or cord.

The progress of labor is registered usually by watching the advance of the fœtal head.

The relation of the head to the pelvic brim is of great importance, as it travels much faster and easier in certain positions than in others. The term “presentation” is used to designate that part of the child which enters or tends to enter the pelvic inlet.

The presentation is named from the part of the child which comes into apposition with the brim. Thus, one speaks of a vertex presentation, or a breech presentation, or a shoulder presentation. The presentation is determined externally by palpation.

The vertex presents in 96 per cent of all labors. With the vertex presenting, the head may occupy any one of four positions. The term “position” is used to explain the relation which the most distinctive feature of the presenting part bears to the quadrants of the pelvic inlet. Thus, the most distinctive feature or landmark of the vertex is the occiput, which is the point of direction, and so again, the position is the relation of the point of direction to the brim of the pelvis. The point of direction is the part that takes precedence in the process of delivery. Thus, in all cases where the occiput is in advance, the occiput is the point of direction and the position is called occipital. Where the chin is in advance, it is mental (mentum is Latin for chin.) In breech cases, the sacrum is the point of direction.

The pelvis is divided by the transverse and anteroposterior diameters into four quadrants named respectively the left anterior, the right anterior, and the right and left posterior. (See Fig. 1.) Thus, in a vertex presentation the back of the child may be (and in 53 per cent is) to the front and to the left.

The occiput is the point of direction, and lies in relation to the left anterior quadrant of the pelvis, and is spoken of as a left-occipito-anterior position. Similarly a right-occipito-anterior position is named, and right- and left-occipito-posterior positions. These occur respectively in about 21 per cent, 14 per cent and 11 per cent of the cases. (Eden.)

In passing the pelvis, the fœtus not only follows the curved line of the pelvic axis, but it describes a certain series of movements which alter its relations to the pelvis.

Fig. 44.—The child in left-occipito-anterior position. (Lenoir and Tarnier.)

There are five of these movements: flexion, descent, internal anterior rotation, extension, and external restitution.

Flexion.—Flexion is usually present before labor begins. That is, the head is bent down until the chin touches the breast. This may be modified by various conditions, but so far as it becomes extended, the mechanism is disturbed and the labor complicated, since large and less favorable diameters are brought to delivery.

Fig. 45.—The child in right-occipito-anterior position. Shows the flexion of the head intensified at the beginning of labor. (Eden.)

Flexion is increased by pressure against the pelvic brim as labor begins.

Descent.—As the driving force of the contractions becomes effective, the head passes the inlet and descends to the pelvic floor. When the large diameters of the head (biparietal) have passed the inlet, the head is said to be engaged.

Fig. 46 A.—The descent of the head in right-occipito-anterior position. Seen from below. (Edgar.) Fig. 46 B.—Side view.

Fig. 47.—Internal anterior rotation and extension of the head in a left-occipito-anterior position. (American Text Book.)

Internal Rotation.—The head most frequently enters the brim with the occiput to the left and anterior (obliquely) because it finds more room and an easier passage; but upon passing this strait and entering the roomy, true pelvis, the head must rotate so that the long diameter of the head will conform to the long diameter of the pelvic outlet, which lies in a direction just opposite to the long diameter of the inlet or brim; hence, the occiput turns forward under the pubic arch. This movement is due largely to the sloping pelvic floor and the necessity of accommodation between the head and pelvis as the child is driven forward.

Fig. 48.—Extension. A, the chin leaves the chest; B, extension in progress. (Eden.)

Fig. 49.—A, extension completed; B, expulsion. (Eden.)

Rotation is much retarded or entirely stopped when the head is extended instead of flexed or when it enters the inlet with the occiput posterior instead of anterior.

Extension.—After internal, anterior rotation, the head emerges at the vulva, the occiput coming out first, then in succession the vertex, forehead and face and chin. As the chin rolls out over the perineum, it moves away from the chest wall—it becomes extended.

External Restitution.—While the head is passing through the outlet, the shoulders are entering the pelvic inlet, and so soon as the head is released from the restraint of the vagina, it naturally falls into its normal relation to the fœtal back; hence in the position now discussed, it turns toward the left.

Therefore, we may summarize the mechanism in a normal left-occipito-anterior position of the head by saying: The head is flexed and forced into the pelvis. It descends to the pelvic floor. The occiput rotates to the front of the pelvis and impinges against the symphysis. Extension ensues in consequence of the necessity for an accommodation between the pelvis and the advancing head, and during this extension, the head delivers over the perineum. External restitution follows.

The Effect of Labor on the Fœtal Head.—As the head passes through the canal, it is moulded by contact with the resistances. The degree of moulding is proportionate to the pressure required to drive it through. Thus, in a large head, or a relatively small pelvis, the moulding may be extreme, and changes in the scalp are common.

Caput Succedaneum.—Since all parts of the scalp are in contact with a resistant wall, except in the center of the birth canal, an effusion of serum takes place here, which is due to the obstruction of the venous circulation.

Fig. 50.—A cephalhæmatomata. Do not confuse with caput succedaneum. (Bumm.)

Swelling occurs in the subcutaneous cellular tissue, and a tumor forms—the caput succedaneum—which spontaneously disappears in twenty-four or forty-eight hours. It is useful in confirming the diagnosis of the position.

Cephalhæmatoma.—Following labor a tumor is sometimes found upon the head, which is often confused with a caput succedaneum.

This tumor is caused by an effusion of blood beneath the periosteum or the covering of the bone—usually a parietal bone. It is sometimes single and sometimes double, and it varies in size from a filbert to a peach. The swelling never extends across a suture. The effusion takes place gradually, and may not appear for a day or so after birth. The cause is unknown, for it occurs after normal and easy, as well as after difficult, deliveries, and after breech, as well as vertex, cases.

At first it fluctuates, then becomes hard, and in a few weeks or months is gradually absorbed. If symptoms of cerebral pressure develop, it must be remembered that hæmatoma may occur inside as well as outside the cranium.

No treatment is necessary. Puncture is inadvisable. In extremely rare instances the tumor may suppurate and require incision.

CHAPTER IX
THE CARE OF THE PATIENT DURING NORMAL LABOR

Every case of labor must be conducted with the most scrupulous attention to surgical cleanliness on the part of the patient, doctor and nurse. Puerperal infection in most cases is due to the introduction of disease-producing microbes into the wounded genital canal. To be sure, the successful enforcement of surgical cleanliness is attained only in good hospitals, but it can be approximated in a private house if the patient insists upon delivery at home.

A nurse or doctor who is clean of person, is most apt to have an “aseptic conscience.” The possession of such a conscience may entail financial sacrifices, but it has many compensations. Neither the nurse nor the doctor is doing justice to the patient, nor to the profession, who indiscriminately takes pus cases, contagious diseases, and confinements. The public will soon learn that such a nurse and such a doctor are unsafe attendants.

How may the nurse know that the patient is in labor? This is the final assumption that must be confirmed or refuted when the nurse is called to her case. It is ascertained partly by the history and partly by the conditions found.

Thus, the patient may report the passage of a piece of blood-stained mucus, and the nurse will observe that the contractions of the uterus are regular, rhythmical and painful. She will observe that when the patient complains of pain, the uterus gets hard. She will also observe the definite regularity of the contractions by timing them.

Under such conditions, the doctor should be called at once if the symptoms develop between 7 A. M. and 11 P. M. If the pains begin in the night, say from 11 P. M. to 7 A. M., the doctor need not be called unless he has requested it, or, unless in the judgment of the nurse or the anxiety of the patient, it is desirable for him to see her.

Fig. 51.—Points of greatest intensity of fœtal heart tones. V, vertex presentations; B, breech presentations. (Eden.)

When the doctor is notified he will want to know, and the well trained nurse will be able to inform him, when the pains began, their strength, duration and frequency. He will want to know whether or not the membranes have ruptured. Many doctors also require, and a well trained nurse who specializes in obstetrics should be able to say by external examination, whether the head seems high or low, as well as the position and frequency of the fœtal heart tones.

In the hospital the following rules for summoning the resident physician may be found useful:

1. For multipara, when pains are regular and five minutes apart.

2. For primipara, when pains are regular and two minutes apart, or when head is visible if pains are less frequent.

3. If a precipitate is imminent, delivery must be delayed until arrival of attending man by—

(a) Turning patient on side with legs straight;

(b) Instructing patient to breathe deeply or to cry out with mouth wide open; then

(c) Place sterile towel over vulva, and at time of pain prevent expulsion by compressing the head by means of locking the hands over a towel on the vulva.

It is possible thus to delay delivery two hours, or until the doctor arrives. Do not permit a precipitate.

After the nurse has completed her preliminary observation, she starts her history, notes the character of the pains, the pulse, temperature and respiration. All unusual phenomena should be recorded; and after the visit of her attending man, his examination, if any, and the conditions found, are put down. Then she prepares the patient and sets up the room for the delivery.

Preparation.—As soon as the patient is known to be in labor, the bowels are thoroughly cleansed with a soapsuds enema. A toilet jar should be used and not the water closet. The bladder must be emptied at the time of preparation and at frequent intervals throughout the labor. As soon as the bowels and bladder are emptied, the patient is given a bath and thoroughly soaped. The shower is preferred lest the water, contaminated by bacteria from the skin and external genitals, should enter and pollute the vagina.

Fig. 52.—Handling forceps, kept sterile in a jar of alcohol.

The hair should be braided in two braids. The vulva and perineum are shaved. No patient will object to this when its importance as a feature of protection against blood poisoning is explained to her.

Scrub thighs, hips, and abdomen as far as the navel with soap and warm water, then sterile water, followed by a 2 per cent solution of lysol. Care must be taken to remove the smegma and dried secretions from the folds of the vulva. Put on a fresh pad, a clean gown, and long stockings. A loose wrapper over all permits the patient to move about. (See Chapter XXIII.)

Guests are forbidden, and the immediate family is kept at a distance—if possible.

An air of buoyancy, composure, and competence should prevail in the sick room, and the patient should be cheered and encouraged in every possible way.

During the first stage, the patient may be up and about, as this diverts the mind. She may assist in the arrangement of the room which should always be the best room in the house. It should be well warmed and close to the bathroom. All unnecessary furniture and hangings should be removed, as previously described. After the room has been put in order, the bed is made.

Making the Bed.—Put mattress pad over mattress and cover with rubber sheet or oil cloth, and spread a sheet over all. Then a smaller rubber sheet is put on, extending from under the pillows to a couple of feet from the foot. A plain muslin sheet goes over the rubber, then the delivery pad.

When the bed is ready, a small table or stand should be placed near the head, on which is put the anæsthetic, the mask and the oil or cold cream. The patient may be lightly covered with a sheet or a sheet and blanket.

During the first stage, light and easily digested food and drinks may be served, either cold or hot, as the patient prefers.

When the doctor arrives he may want to examine the patient either externally or internally, or both. So a sheet is thrown across the lower part of the body and the night-dress pulled up as far as the breasts.

For the external examination the doctor washes his hands in warm water and green soap and scrubs with the nail brush for five minutes. This period should be prolonged to fifteen minutes, if, by any mischance, the hands have been in contact with pus or infectious material. It is extremely difficult to get them even approximately clean after such an experience.

Fig. 53.—Palpation. What is in the pelvis? (Eden.)

He now palpates the abdomen, notes the location of the head and back, finds and counts the heart tones, measures the pelvis and child, estimates the descent of the head and the character of the pains.

Fig. 54.—Palpation. What is in the fundus? (Eden.)

If he thinks an internal examination is necessary, he will now return to the bathroom, pare and clean his nails, scrub hands and arms to elbows for ten minutes in running water with green soap and a sterile brush, soak the hands in lysol solution 0.5 per cent for five minutes. Bichloride of mercury solutions have no place in obstetrics. They ruin instruments and hands, and are valueless for asepsis since the mercury unites with the albumin of the mucoid discharges and forms an albuminate of mercury, which is inert. The bichloride solutions also are nonlubricating, harsh and astringent, as well as poisonous, as soon as the mucoid protection has been removed. When the doctor takes his hands from the lysol solution, they should be wiped on a sterile towel. A sterile gown is put on, if possible. If it is not available, he should be careful not to touch anything that may destroy or contaminate his preparation. The hands are powdered and sterile rubber gloves pulled on (one will do.).

Fig. 55.—Palpation. Where is the back? Where are the small parts? (Eden.)

The nurse, meanwhile, has wrapped the legs of the patient in the ends of a sterile sheet, the bulk of which covers the abdomen. The knees are spread apart. The vulva cleansed with pledgets of cotton soaked in lysol solution. One or two pledgets are used on either side of the vulva and the same number for cleansing the introitus.

The fingers are now introduced.

The internal examination may be conveniently postponed until the waters break, or it may be omitted altogether if the heart tones of the child remain good, the labor progressive, and the head continually advances into the pelvis, as determined by the external examination. The great advantage of an internal examination at this time is the diagnosis of the degree of dilatation and the assurance that the cord has not been washed down into the vagina by the rush of fluid.

If the first stage is prolonged, the nurse should try to get the patient to rest, and she should herself snatch a few moments of repose if possible.

Fig. 56.—Patient draped for internal examination. (Williams.)

The condition of the os and the character of the pains may make the doctor feel safe in leaving the house, but his whereabouts and telephone number should be ascertained and the exact time of his return.

Second Stage.—During this stage, the patient should go to bed and the doctor should remain nearby. The nurse may observe the vulva at intervals and note bulging, if present, or she may press a finger against the soft parts outside the labia and see if the hard resistant head has come into the outlet.

The pains are severe and all accessory muscles are called into action. Partial anæsthesia should be maintained in most cases, which should merge into complete narcosis as the head passes the vulva. The nurse may have to administer this.

When this stage begins, or is well under way, the patient should be prepared. A sterile pad should be placed under her, then a sterile bed pan. The nurse having prepared her hands and arms as previously directed for the doctor, scrubs abdomen, legs, and vulva with green soap and warm water, followed by lysol solution 0.5 per cent and a rinsing with sterile water. The cleansing of the patient should take about ten minutes. Cover with a sterile towel and put on the sterile linen.

If in the hospital, the drums have been packed for sterilization so that when they are opened each article will appear in the order of its need:

No. 1. (Beginning at the bottom.) A receiving blanket, which has a ticket, marked with the weight of the blanket, attached to it.

1 abdominal binder with pad holder attached.

1 pillow slip folded half way back.

1 gown for patient.

2 surgeon’s gowns.

3 sheets.

1 pair surgical stockings folded half way.

1 surgeon’s gown for nurse.

No. 2 contains cotton pledgets.

No. 3 contains strips of gauze and combination pads.

Application of Sterile Linen—Normal Case.—Sterile linen is to be applied as follows, by a clean nurse;

1. Lay sheet across foot of bed and half way up. 2. Put surgical stocking on one foot and draw sheet up for foot to rest upon. 3. Second foot as above. 4. Lay sterile sheet across bed under patient, letting ends hang. 5. Lay sterile sheet over abdomen of patient.

In many hospitals the sterile stockings and protective sheet are all made in one piece, which greatly simplifies the application of the linen.

As soon as the second stage begins, the packet containing the perineorrhaphy and cord set, carefully sterilized, is brought out and placed in convenient reach of the doctor.

This set contains—

8 in. forceps.

2 scissors curved on the flat.

1 dissecting forceps.

1 duck bill speculum.

1 needle holder.

1 metal catheter.

8 gauze sponges.

1 medicine dropper.

1 cord clamp, or

2 cord tapes.

2 case numbers, attached.

12 needles, 4 round, 4 half-curved cervix needles, and 4 skin needles.

This is the stage of expulsion and the patient may want to pull or push on something to aid the straining effort. Unless the nurse needs time to set up the room or to get the doctor, this tendency may be encouraged.

A sterile sheet may be attached to the foot of the bed and the ends (corners) given into the patient’s hands as a knot or loop to pull on, or she may push upward against the head of the bed. Under no circumstances must she be permitted to touch or contaminate the clean linen in her movements, either consciously or unconsciously. The hands should be restrained, if necessary, to avoid this.

The face may be sponged and a cold towel laid across the eyes. Rubbing of the back and legs will bring great comfort, and cramps of the limbs may be removed by straightening the legs and rubbing the muscles underneath. Everything is now ready for the delivery. If the husband insists upon being in the room, he should take off his coat and vest and wear a gown, or if the labor is in the home, drop a clean night robe over his clothes.

The prepared room will show at close hand-reach, the basins of solutions, the pledgets of cotton, tape or clamp for cord, scissors, nitrate of silver solution (1 per cent) for the eyes, with dropper, the sterile douche can in readiness for hæmorrhage and a large reserve of supplies. Whatever anæsthetic has been chosen for the second stage, is now administered. Throughout this stage, the heart tones of the child must be watched, as well as those of the mother, for intra-partum death may occur at any moment.

A second examination may be desirable now to confirm the diagnosis and to secure an estimate of the advance. As a rule, the examinations should be as few as possible on account of the danger of infection.

This is the period of greatest responsibility for the doctor whose duty it is to watch and, if necessary, to restrain the advance of the head in order to protect the perineum from rupture.

This may be done at times most successfully, or in the case of too few assistants, most desirably, by delivery on the side. To secure this, as the head becomes more and more visible, the woman is turned upon her left side; a pillow rolled tightly and pinned in a sterile covering is placed between the knees, and a sheet flung across the body.

Fig. 57.—Delivery in side position. The hands should be gloved and the upper leg raised on a hard cushion or pillow. (American Text Book.)

The hips must be brought to the edge of the bed while the chest and head are pulled over to the other edge of the bed, leaving the legs just enough space to double up along the side of the bed parallel with its long axis.

The doctor may now sit on the edge of the bed, or on a high stool at the back of the patient and facing the buttocks. This is a most convenient and easily managed position.

As the head is born, the fæcal matter, blood and discharges must be sponged away, and the field kept clean, with the whole perineum visible. Always sponge from vagina toward rectum and throw away the sponge. Should the hand touch nonsterile things or septic material, like fæces, the glove must be changed. The hands must be kept surgically clean.

It is a part of the nurse’s duty tactfully to warn the doctor when such a thing occurs, as it may happen accidentally while his attention is concentrated elsewhere, and a conscientious man will be grateful for the information. As the head passes the perineum the anæsthesia should be deepened.

As soon as the head is born and the first respiration established (see Asphyxia, p. [278]), the cord is cut and clamped. There is rarely any necessity for haste in this maneuver. The eyes are treated, and if in a hospital, a numbered tape is tied about the wrist and a tape with a corresponding number about the mother’s wrist.

The baby is now placed in the receiving blanket on its right side, with artificial warmth at its back and feet. The head must be lower than the body so any retained mucus can drain out of nose and mouth. Meanwhile, the doctor (or nurse) keeps a hand on the fundus of the uterus to watch its contraction, see that it does not balloon up, and massage it occasionally if necessary while he awaits the onset of the third stage.

Third Stage.—The patient is turned upon her back as soon as the child is delivered. The pulse and face must be watched for signs of hæmorrhage. While waiting for the placenta, the perineum is examined to note the degree of laceration, if any. To do this, the vulva must be spread apart with clean fingers so as to bring the posterior wall into view, and the discharge is sponged away with cotton pledgets taken from the lysol solution and squeezed dry.

The patient may now have the saturated dressings removed and clean, dry ones substituted. The new pads catch the oozing blood and give an estimate of its amount.

At this time, if desirable, the perineum can be repaired. The woman is partly unconscious, the tissues numbed, and the needle hurts much less than it will later. Nevertheless, anæsthesia may be required.

In a period varying from a few minutes to an hour, the hand on the uterus will note a hardening, the mass will become smaller, more globular, and rise slightly in the abdomen. A gush of blood appears at the vulva and usually the placenta follows. If it does not, or if hæmorrhage or the condition of the mother requires it earlier, the uterus may be compressed (see Credé expression) and the placenta constrained to deliver.

The nurse holds a sterile basin for its reception. As the mass drops into the pan, the membranes drag after and it should be gently twisted, or the loose portions drawn upon until the end slips out. The placenta is set aside for examination, and ergot or pituitrin may be given to enforce the uterine contraction. The process of expulsion is generally assisted by a strong voluntary contraction of the abdominal muscles.

After a short rest, the blood is washed off the genitals, clean linen and clean pads applied, and the abdominal binder or girdle is put on to hold the pads. Warm blankets are thrown over the patient and within an hour, a glass of hot milk is administered.

The legs should be kept together, and in case of hæmorrhage, the feet crossed.

The placenta is now inspected and not only its completeness or incompleteness noted, but anomalies of every kind should be looked for.

IMMEDIATELY AFTER LABOR

Perineorrhaphy must be done if required.

A lacerated cervix is not to be repaired at this time, except in case of hæmorrhage, for the tissues are greatly swollen, and if sutures are put in tight enough to allow for sufficient shrinkage, they will cut through; while if not tight, they will be useless in twenty-four hours.

Care of Mother.—

1. Cleanse genitals with lysol solution 0.5 per cent from above downward. 2. Put on sterile pad, with pad holder and binder. 3. Wash face and hands. 4. Take temperature, pulse, and respiration. 5. Glass of hot milk. 6. Keep on back four hours. Watch uterus for hæmorrhage and keep firm by occasional massage. 7. Put tape with case number on arm.

Care of Child.—

1. Clamp for the cord. 2. Place on right side with head lower than breech. 3. Keep warm and watch for cord hæmorrhage. 4. Treat eyes with silver nitrate solution 1 per cent, or argyrol solution, 15 per cent. Do not neutralize the 1 per cent silver nitrate solution. 5. Put tape with case number corresponding to mother’s on arm.

To preserve the perineum from rupture is an important duty, and in a definite percentage of cases, unsuccessful. Nevertheless, it is a duty, which, in the absence of the doctor, may fall upon the nurse. How shall she meet it?

The greatest danger to the perineum comes from a too rapid advance of the head; hence, the nurse retards the delivery by putting the woman on her side where she can not bear down so successfully, and instructs her to cry out with her pains. She may also delay the labor by holding the head back with a clean pad until the vulva stretches to its fullest capacity.

The rules which the doctor follows in protecting the perineum as the head advances, may be thus summarized.

1. Deliver the patient on her side. 2. Maintain flexion of head. 3. Delay extension of the head. 4. Give chloroform to retard delivery and to prevent precipitate delivery. 5. Deliver between pains, if possible, by Ritgen’s maneuver (modified). 6. Do episiotomy, if necessary.

Perineorrhaphy.—Lacerations of the perineum occur in about 30 per cent of all primiparas and in from 10 to 15 per cent of multiparas. They occur when the child is large or too rapidly delivered, and when the orifice is small or the tissues inelastic.

For convenience, the lacerations of the perineum are divided for description into three degrees.

The first degree involves only the fourchette and a small portion of the mucosa. It is rarely more than one-half an inch in depth and requires no attention except cleanliness by the nurse.

The second degree may tear a variable distance into the perineal body, sometimes so deeply as to expose the sphincter ani. It is usually on one side, but may appear on both sides, and be accompanied by prolongations into the vagina.

The third degree passes through the sphincter and sometimes well up the rectal wall. This is also called a complete tear.

The lacerations of the perineum which require sutures should be attended to at once unless the patient’s condition is critical. In such cases the repair may wait from twelve to twenty-four hours.

For this operation the nurse will assemble and boil for fifteen minutes:

2 pairs of scissors.

2 tissue forceps, one with teeth and one without.

1 bull-dog forceps.

3 artery forceps.

6 needles, 3 full and 3 half-curved.

1 dressing forceps.

1 needle holder.

Suture material of catgut and silkworm gut should be ready in sterile containers. The catgut should be the twenty-day chromicized, No. 3 and 4. Even then the strands are quickly absorbed when the lochial secretions flow over them.

Silkworm gut is better, but hard to remove from the vagina; hence it is customary to use catgut inside the vagina and silkworm gut for the sutures outside.

The nurse renews the supplies of gauze and cotton sponges. Hot solutions are prepared, and the patient brought into a position on table or across the bed so that the best light may be had. The legs may be held by the husband or nurse, or both. If help is inadequate, a sheet sling can be utilized. This is made by twisting the sheet from corner to corner and passing it rope-like over the shoulders, and back of the neck. Then each end is tied above the patient’s knee on either side as the legs are flexed in an exaggerated lithotomy position.

The sutures are now introduced and tied loosely from below upward and from within outward. If tied too tightly, they will cut through. The success of the operation depends on two things: the care with which the levator ani, if torn, is found and restored; and the scrupulous cleanliness obtained by the nurse in her after-care. If the stitches become sore, a few drops of sterile glycerine should be applied with an applicator.

Fig. 58.—Sheet twisted into a sling. The patient lies on the unrolled portion. The rolled cords bearing against the shoulders are tied to the legs below the knees. See Fig. 102. (American Text Book.)

If catgut is used inside the vagina, the counting of the stitches is gratuitous, since they absorb without removal. If silkworm gut is used, the number of sutures must be recorded, lest one be overlooked in removal.

Binding the legs together after repair is not required, but the sutures must be given aseptic care after each bowel movement, each urination, and when the pads are changed, if they have become contaminated. The sutures are removed on the tenth day.

Fig. 59.—Repair of perineum. Sutures in place. (Hammerschlag.)

After complete tears, the bowels are kept constipated for two or three days, and then moved with a high enema of sweet oil, followed by castor oil by mouth. After the bowel movement, the nurse should wash out the rectum with normal saline solution. The nurse must look carefully at the stitches every time the pad is changed and note if the swelling is increasing or diminishing, if there is irritation or tenderness, or if they are cutting out through the tissues.

The external sutures are usually left long and tied together in a knot, to prevent the ends from sticking into the patient. If she complains of this, the ends may be wrapped in sterile gauze. During the progress of the case the nurse must watch for and report any sign of fluid passing from bowel through the vagina.

The perineorrhaphy being completed, the woman is permitted to rest though the nurse will make frequent examinations of pulse and respiration. She will note the look of the face and the hardness of the uterus. The pad should be watched and the amount of blood discharged, duly estimated. If the flow does not diminish or if the uterus should balloon up, the doctor should be notified and the nurse meanwhile should give a dram of ergot (fluid extract) by mouth or an ampoule of aseptic ergot hypodermically.

The doctor should remain within call of the patient for at least an hour after delivery.

In the hospital the following rules may be used as a concise guide for the conduct of the third stage:

Conduct of Third Stage.

Keep patient on back and keep a hand on fundus. Note amount of blood lost, its character, its flow, and whether steady or in gushes. The placenta should detach itself normally in thirty minutes. After thirty minutes, expulsion may be assisted by—

(1) Early expression.

(a) Massage, rub and knead the uterus, until it hardens under the hand.

(b) Seize contracted uterus by fundus with full hand, fingers behind and thumb in front.

(c) Push slowly but firmly toward the pelvic outlet.

(2) Credé expression.

Same maneuver as above, except that the fundus is compressed between thumb and fingers while the downward movement is progressing.

Conditions for Credé expression:

(a) Uterus must be contracted.

(b) Uterus must be in median line.

(c) Bladder must be empty.

If not successful, wait ten minutes and then repeat maneuver. Never make traction on the cord. Never use ergot until uterus is empty.

If placenta does not come away within an hour, manual removal must be considered. In case of hæmorrhage, it must be removed at once.

Carefully inspect placenta and be sure it is complete. (See Post Partum Hæmorrhage, p. [232].)

When the patient is put to bed, the bloody sheets and towels are put to soak in cold water, and after several rinsings, may be sent to the laundry. Drapings stained with fæcal matter must be cleansed separately.

CHAPTER X
THE NORMAL PUERPERIUM

The puerperium is the name given to the period succeeding the birth of the child as far as the time of the complete restoration of the genitals. It may last from six to ten weeks, or even longer if complicated.

When the labor is completed, the most urgent desire of the patient is for rest. She is thoroughly exhausted in nerves and body. A post partum chill may appear,—a slight shiver that may last a quarter of an hour. Since the pulse and temperature remain unaffected, this phenomenon may be regarded merely as a sign of prostration or nervous revulsion.

In the course of the first three days, the temperature may rise to 100° F. in a case entirely normal. It has no pathological significance unless persistent or increasing. The temperature should be taken night and morning, and in complicated cases every four hours. All temperatures over 100° F., after the initial rise and descent just described, must be regarded as septic.

The pulse does not rise with the temperature of the first three days, but remains firm or even falls a little. When the pulse rises and the temperature sinks, it means hæmorrhage.

The urine is usually increased for the first few days and then returns to the normal for that patient. The labor affects the patient like a surgical operation.

The digestion is disturbed. The appetite is gone, and the stomach must be treated gently until its tone is restored. The body in repose is less urgent in its demands for food. Liquids in abundance form the staple diet for the first two days. For the next three days, semisolids may be added, and after the milk is well established, a general diet is desirable; but so long as the mother nurses her child, the liquids must preponderate in most cases.

Fig. 60.—The progress of involution on the various days of the puerperium. (von Winchkel, from Knapp.)

Meanwhile, certain changes are taking place in the pelvis that are highly important.

Involution is the process undergone by the uterus in returning to its normal nonpregnant state. This shrinkage can be followed abdominally and is registered by the nurse in the number of finger-breadths or centimeters above the symphysis pubis.

Edgar gives the rate of shrinkage as follows:

The rate of involution not only varies greatly with different women, but varies much after the different labors of the same woman.

Ordinarily at the end of the first week the fundus should lie midway between the navel and the pubes, and should shrink rapidly thereafter.

The necessity for watching the rate of involution is imperative for a number of reasons. If involution is slow, or stops, it may indicate fatigue of the muscle from multiparity or over-distention (twins, hydramnios, etc.) or it may follow a post partum hæmorrhage. Subinvolution may also indicate infection, the retention of clots, or pieces of placenta. It happens also when the woman gets up too soon or does not nurse her child and thereby delays the restoration of her waistline, as well as diminishes her resistance to disease.

The binder is objectionable to some doctors on the ground that it favors retroversion of the uterus during involution.

This would be a plausible theory when the uterus is high, if it were not that the vertebræ of the patient and the pelvic brim keeps the uterus from being pushed out of its place and after the uterus descends into the pelvis the gentle pressure of the binder evenly distributed over the abdomen can not affect it appreciably. Furthermore, the uterus in involution shows a persistent tendency toward anteflexion and anteversion.

The binder is merely a girdle put on just tight enough to hold in place the bandage that supports the perineal pads and to allow the patient more easily to grow accustomed to the sudden change in intraabdominal pressure which the delivery of the child creates. However, if the doctor objects to a binder, it may be left off with safety.

The Lochia.—When the placenta is delivered, the uterus normally closes down and all gross hæmorrhages cease; but for the next two weeks or possibly longer, a vaginal discharge continues. For the first few days it is hæmorrhagic in character and it is called lochia rubra, and consists mostly of fluid blood with occasional small clots. By the fourth day, usually it has become brown and thinner. It is now called lochia serosa. By the tenth day, it is yellowish-white, and is called lochia alba.

The lochia is the wastage from the shrinking uterus, and is made up of red blood corpuscles, epithelial cells, leucocytes, and pieces of broken-down deciduæ. The entire lining of the uterus is loosened, discharged and a new one formed during the puerperium. The lochia is regularly infected by bacteria in the vagina. If involution is slow, the lochial discharge may be prolonged.

The After-Pains.—The puerperium is not infrequently accompanied by painful contractions of the uterus called after-pains. These are more common in multiparas and serve a useful purpose in maintaining a definite contraction of the uterus.

If the pains are at all severe, they are a suggestive symptom of the retention of blood clots, a fragment of placenta, or of membrane. This, of course, will occur either in a primipara or multipara. In all cases the after-pains must be differentiated from gas and from the pains of pelvic inflammation.

Gas pains can be relieved by hot spiced drinks, asafœtida and the high rectal tube.

Subinvolution is treated by the administration of fluid extract of ergot, in twenty to twenty-five drop doses, three or four times daily. This will bring about the discharge of the irritating fragment or clot, and the nurse can aid the process by gently massaging the uterus several times daily or by giving a hot vaginal douche. Codeine may be used for after-pains if absolutely necessary.

Diet in Normal Cases.—There is no restriction on the kind of food the patient may take, so long as she can digest it cleanly and without gas. Acids or alkalies, cold or hot, rich or otherwise, fruits, meats or vegetables, all go to the formation of good milk if properly digested. The old idea that acids should not be eaten is fallacious. There is more acid in the stomach normally, than could be added in a meal made up entirely of citrus fruits. At the same time, the heavy foods should be avoided on account of the serious demand on the liver and kidneys in the absence of exercise.

On the other hand, if the breasts are engorged, the fluids must be reduced to a minimum, and a relatively dry diet enforced.

The patient loses about one-ninth of her previous body weight in the course of labor and the puerperium.

The breasts are made ready for lactation twelve hours after delivery by cleansing with sterile green soap and warm water and bathing in 50 per cent alcohol. Next, the nipple is attended to, and the infant is put to the breast.

The nipple is prepared by cleansing it with an applicator soaked in fresh boric acid solution, and after nursing, the same process is repeated. This is routine, whether the mother is in bed or walking about. In the latter case, the mother must be taught to care for her own breasts.

The child is put to the breast every three hours and given six feedings a day. This leaves a six hour interval at night, which is very necessary for the mother’s rest and for the child. If the babe is feeble, seven or eight feedings in the twenty-four hours may be required for the first two weeks.

At first the breast only secretes a thick, yellowish secretion called colostrum, of which the child gets from a drachm to an ounce. It is a mild laxative.

The irritation of the nipple by the child’s mouth is begun as early as possible in order to stimulate the breasts to secrete milk and the uterus to contract, and thus aid involution and the preservation of the maternal figure.

The milk usually “comes in” on the third day and is accompanied by a sense of distention and moderate pains in the breasts. The glands may be hot, hard and swollen, but normally there is no rise of temperature with the inflow of the milk, except with nervous women who stand pain badly. There is no such thing as milk fever. If fever appears at this time, an infection must be suspected.

The engorgement of the glands may become so great that the nipples are drawn in and nothing is left for the child to grasp. If the engorgement becomes too painful, fluids are removed from the diet list, and saline cathartics administered, while ice packs are applied to both breasts. Heat should never be used except for the purpose of hastening suppuration.

This engorgement, or so-called “caking” of the breasts is not due to the milk, but to the infiltration of the connective tissue around the glands with serum and blood which stimulate the glands to secrete. The distention usually disappears in twenty-four or forty-eight hours, especially if the child is sturdy. Massage of the breasts only increases their activity and tends to make the trouble worse.

The weight of the glands may be considerable and require the application of a light supporting breast binder. Pillows under them will also give relief at times.

In putting the child to breast, the mother should lie on the side with the arm raised and the child is dropped into the hollow thus created, facing the mother (see Fig. 113). In this position the nipple will most easily and conveniently slip into the child’s mouth. The child should nurse fifteen or twenty minutes and then be removed. The toilet of the nipple is made by cleansing with boric solution as previously described, and then placing not gauze but a piece of aseptic cotton cloth over it, after which the binder is readjusted. (See Breast Covers, p. [326].)

The menstrual flow ceases during lactation as a rule, but not invariably. The flow returns in from four to six weeks after delivery, if the child is not nursing, and about the same time after lactation ceases. There is a popular idea that conception can not occur during lactation, and many women injuriously prolong lactation in the hope of avoiding another child. The theory is fallacious and conception during lactation is not uncommon.

The Bowels.—A lying-in woman is regularly constipated. Lack of exercise, a nutritious diet, but one with a minimum of wastage, together with relaxed abdominal walls, contribute to a condition that is primarily due to changes in intraabdominal pressure, which follow the delivery. For weeks the intestines have been under pressure and irritation by the growing uterus, and when this is suddenly removed the intestines become sluggish.

On the morning of the second day the patient should receive an ounce of castor oil. This dose, suspended in black coffee, beer, orange juice, or sherry wine can be taken by nearly everyone. In from four to six hours a normal saline, or soapsuds enema is given. The enema may be repeated daily, or if this is objectionable to the patient, the castor oil or Russian oil, may be given as a routine. Saline cathartics should not be used unless there is an oversupply of milk.

There is sometimes a good deal of gas following labor, which can be removed by the 1–2–3 enema (see Enema, p. [335]). In giving enemas, the nurse must use great care to avoid touching or infecting an injured perineum.

Many women secrete less gas and are agreeably influenced mentally by a five grain pill of asafœtida taken thrice daily.

Urination.—One of the commonest difficulties after labor concerns micturition.

Owing to the swollen and bruised condition of the urethra and the nerves supplying the neck of the bladder, the usual stimuli do not act and the woman, conscious of a painful distention, is unable to pass water. The helplessness is increased by her position in bed.

The nurse must make every effort to have the bladder emptied naturally. The process is aided by letting the water run from the faucet into the toilet basin, by using hot applications to bladder or vulva, by allowing warm, sterile water to run down over the vulva and perineum, by an enema, by putting smelling salts to the nose, by using slight pressure over the bladder, or by having the patient sit up on the bedpan.

If these measures fail and moral suasion is fruitless, the bladder must be catheterized at the end of twelve hours. The two dangers of catheterization are injury to mucous membrane, and infection. Many cases of cystitis have resulted from an unclean catheter or the improper use of a sterile instrument.

To catheterize a patient, she is first given aseptic care during which particular attention is paid to the meatus. This should be cleansed with an applicator dipped in a solution of boric acid. Next, the nurse prepares her hands by scrubbing ten minutes in hot running water with sterile nail brush and green soap. The catheter either of soft rubber or glass, is boiled for fifteen minutes and passed, not by touch, but by sight, and the flow is received in a clean basin and the amount recorded. As soon as the urine ceases to flow freely, the tip of the index finger is placed tightly over the end of the catheter and the instrument is gently withdrawn. The finger is placed over the end of the catheter not only to avoid the dripping of urine as it is removed, but especially to prevent the disagreeable sensations produced by the inrush of air.

Usually one catheterization is sufficient, and every time the bladder fills, the nurse must take the time and trouble to make the patient urinate spontaneously, if possible, for some women form a catheter habit, from which it is difficult to break them. After natural urination and after catheterization, the aseptic care should be repeated.

The Genitals.—The vulvar pads should be changed as often as they are soiled. Four a day is an average number, and six or eight in the first three days is not unusual. Every time the pad is changed, the nurse should give aseptic care, and extra attention whenever the bowels and bladder are emptied.

The dried secretions should be washed off with sterile sponges, wiping always toward the rectum and throwing away the sponge. Smegma collects in the folds of the labia and about the clitoris. This should be carefully sponged away. If it becomes dry and hard, oil or albolene will soften it and facilitate its removal. Plenty of soap and warm water should be used, then with a pitcher or douche point, the whole area is irrigated with a solution of lysol 1 per cent. Especial care is given to the stitches if any are present. No traction must be made on the ends of the sutures, and if unusual soreness is complained of, the doctor should inspect them at his next visit.

The nurse should be careful not to get lochia on her hands as the discharge contains germs which she may carry to herself, to the baby, or to the patient’s breasts or eyes.

Painful swelling of the vulva, or edema of the rectal protrusion may be relieved by hot boric dressings or by ice bags to the anus.

The vaginal douche is rarely employed at present except under specific indications.

If the involution is slow, it is safer to use ergot by mouth, rather than the hot vaginal douche, as sometimes recommended. The douche is a frequent source of infection, as well as a useless procedure. Nevertheless, a dainty woman gets much comfort mentally, as well as physically, if she is kept clean and free from odors; hence if the lochial discharge becomes offensive on the fifth day or sixth day, as sometimes happens, a single hot vaginal douche may be permitted. A 1:5000 solution of potassium permanganate, or a teaspoonful of formaldehyde to a quart of water, or a chinosol solution 1:1000 may be used.

Rest.—Since the patient will be in bed from eight days to two weeks in normal cases, she must be made as happy and comfortable as possible, and nothing contributes so much to her satisfaction as a cheerful, competent nurse. Her mind is at ease about herself and her child, and the companionship of the nurse can be made one of the pleasantest recollections of her illness.

Any patient who is at all reasonable can be managed by a tactful nurse without the consciousness of being opposed or directed. Gossip, hospital stories, criticism of other cases, other nurses, or of doctors should be avoided. The patient is deeply interested in her own case, and the private troubles of the nurse do not concern her nor enlist her attention for more than a few polite but unpleasant moments.

The nerves of the patient are highly sensitized, and therefore she should sleep as much as possible at night, and take an additional nap in the afternoon. Only the members of the family should be allowed to see the patient the first week, and they but for a short time. It takes the strength of the patient unnecessarily to see guests even though they be close friends. Importunate visitors may be pacified frequently by a view of the baby. The patient must be spared all household responsibilities, and if necessary, the nurse must take charge. Tact must be used to avoid being dictatorial, either to family or servants. If anything unusual arises, the nurse must show no surprise, annoyance, or bewilderment. Everything is attended to quietly, firmly, and without friction.

Getting Up.—It is a tradition that the woman is lazy who does not get out of bed by the ninth day.

There are three factors to be considered, the progressive involution of the uterus, the strength of the patient, and the presence of stitches. Involution may be complete on the fifth day, but the prostration from the labor may make the woman indifferent to arising. She may be strong enough to rise on the third day, but the uterus is large and heavy, and the erect position will put an unnecessary strain on the supports which may retard involution and cause displacement or disease later. Also, it is not desirable for a woman to sit up until her perineum is well on the road to restoration.

In general, the woman should not get up until the uterus has gone down into the pelvis and is nonpalpable. If this is the case on the fifth day and she feels strong, she may get up. If she is not strong, time will be saved by staying in bed until her vigor returns, whether it is ten days or twenty.

Getting up may be followed by a return of the bloody discharge. This may come from subinvolution, from a relaxed and flabby uterus, from a cervical tear, or from change in posture.

If there has been a retroversion before pregnancy, lying prone with an occasional knee chest position for a few moments will aid. Massage and passive exercises while in bed will aid the patient to recover and to maintain her strength. Even after she is up and about, she should lie down frequently during the day and always when nursing the babe, until she feels quite normal again.

For the hospital the following standing orders may be followed:

Standing Orders—Puerperium

Breasts:

1. Prepare for lactation 12 hours after delivery.

(a) Clean breasts and nipples with soapy water and green soap.

(b) Sponge with sterile water.

(c) Sponge with boric solution.

(d) Sterile compresses over nipples and adjust binder.

2. Babe to breast immediately after breast preparation.

3. Every morning apply fresh compresses over nipples and oftener, if necessary.

4. Cleanse nipples with boric solution (use applicator) before and after each nursing.

To dry up milk:

Restrict fluids; give saline cathartics; apply ice bags to breasts, as needed; for pain give codeine solution ¼ to ½ gr. hypodermically, if necessary.

Do not massage, do not bind, do not pump. Let breasts alone.

When breast is inflamed:

Apply ice bags constantly until pain subsides and temperature goes down. Watch for signs of suppuration.

Genitals:

1. S.S. enema each morning, followed by aseptic care.

Cleanse from above downward—1 per cent solution of lysol and cotton pledgets.

1 pledget for each side.

1 pledget for center.

1 pledget for rectum (last).

External douche of sterile water.

Dry sterile pad.

2. Aseptic care following all bowel movements and urination.

Routine:

1. Record pulse and temperature twice a day, unless otherwise ordered.

2. Bladder must be emptied in twelve hours. If all persuasive means fail (may sit up in bed), catheterize.

3. Make daily records of conditions of uterus (firmness and height), breasts and nipples.

4. No vaginal douche unless ordered.

5. Diet: liquid two days; semisolid two days; then general.

6. Watch for hæmorrhage.

7. Keep uterus firm by occasional massage.

8. All cases to have castor oil, 1 ounce within thirty-six hours after delivery (before noon).

9. Woman may get up as soon as uterus can not be felt above pubes, if there is no contraindication.

The history sheet should be kept accurately and should show every incident in the course of the lying-in period.

The condition of the bowels, bladder, and lochia, the temperature, pulse and respiration and the height of the fundus above the symphysis from day to day must be set down in finger-breadths or centimeters.

For the hospital, the following system will be found useful in establishing a routine.

Nurse’s Record

First Stage.

1. When pains began.

2. Frequency and duration of pains.

3. Character vaginal discharge.

4. Time membranes ruptured.

(a) Artificial.

(b) Spontaneous.

Second Stage.

1. Time second stage began and ended.

2. Anæsthetic.

3. Mode of delivery.

4. Who delivered.

5. Sex of child.

(a) Living.

(b) Dead.

6. Perineum.

(a) Condition.

(b) Repair.

Third Stage.

1. Method.

(a) Spontaneous.

(b) Early expression.

(c) Credé expression.

(d) Manual removal.

2. Placenta delivery.

(a) Time.

(b) Size.

(c) Complete or incomplete.

(d) Length of cord.

3. Note.

(a) Hæmorrhage.

(b) Quantity.

(c) Color.

(d) Clots.

General condition—was case number put on mother and child?

Other treatments.

Medications.

Condition of uterus.

Temperature, pulse and respiration before leaving delivery room.

Signed ..........................

(Nurse’s Name.)

CHAPTER XI
UNUSUAL PRESENTATIONS AND POSITIONS

Breech Presentation.—The pelvic pole enters the inlet first, once in thirty cases and more commonly in primiparas than otherwise.

Etiology.—Anything that interferes with or deranges the laws of normal gestation will predispose to, or produce this anomaly.

Thus, if the head is too large, as in hydrocephalous, or if the fœtus is too movable, as in hydramnios, or if an obstacle, like placenta previa, contracted pelvis or tumors prevent the proper approach of the head to the inlet, the mechanism will be disturbed and a breech or possibly a shoulder presentation will result.

Abnormal flaccidity of the uterine or abdominal walls, prematurity or twins also contribute definitely to its occurrence.

The attitude of the child generally retains its normal aspect of complete flexion. This pose, however, is not maintained invariably for on occasion the buttocks and genitals may rest upon the inlet while one or both feet may be extended on the thighs and lie beside the neck, or the thighs may be extended while the knees remain flexed, and what is known as a knee presentation, or if the foot comes down, a footling presentation results.

Positions.—The sacrum is the most prominent bony landmark of the breech, hence the positions are named from the relation this bone bears to the four quadrants of the inlet.

Fig. 61.—The breech. Left-sacro-anterior position. (Lenoir and Tarnier.)

We have therefore in their order of frequency the following designations: Left-sacro-anterior, where the sacrum lies to the left of the median line of the mother’s body and in front; right-sacro-anterior, where the sacrum lies to the right and in front; right-sacro-posterior, where the bone lies near the mother’s vertebral column, and on the right side; and the left-sacro-posterior position, where the bone occupies a corresponding place on the left side.

Diagnosis.—The recognition of this presentation is most easily secured by external abdominal palpation in pregnancy, which may be reinforced during labor by the internal examination.

Fig. 62.—The breech. Left-sacro-posterior position. (Lenoir and Tarnier.)

Externally the palpating fingers at the pelvic brim will note the absence of the hard, round head, and feel a mass, softer, quite irregular in shape, and less defined than customary. Movements also may be appreciated that would be too far down in the uterus if the head was presenting.

Next the hard, spherical tumor of the head can be outlined somewhere in the fundus, and the heart tones, instead of being below the umbilicus will be on the same level or even higher.

Vaginally the cervix is not filled out, the presenting part does not come down, but after labor has begun the distinctive features of the breech gradually become more evident, as they are driven into the pelvis.

One or both feet, or the buttocks, may be recognized. The examining finger may possibly enter the anus and be stained with meconium or pinched by the sphincter, which differentiates this orifice from the mouth.

One after another the characteristic landmarks appear until the diagnosis can not be doubtful. As soon as the sacrum is found or the legs definitely placed, the position can be named.

Mechanism.—The hips always enter the inlet in one of the oblique diameters and the back is turned to the same part of the uterine wall as in the corresponding vertex positions.

The acts described in the mechanism for vertex deliveries show a somewhat different order. Descent is first, then comes internal anterior rotation, which brings the anterior hip under the symphysis and its delivery is quickly followed by the posterior hip, which rolls out over the perineum.

The body advances, as a rule, with the back toward the front of the mother. The shoulders with arms folded move under the pubic arch and then the head delivers in a state of flexion. The head, of course, has no caput and it is not moulded.

This mechanism may be greatly impeded or complicated at any stage of the movement. The advance may be retarded to a pathological degree, the belly may be large and as it passes along the canal one or both arms may be stripped up alongside the head or even into the back of the neck. The head may be arrested at the inlet by the arms, by its degree of deflexion, or by pelvic contraction.

The rotation may not take place, or it may be abnormal, and the belly of the child look forward toward the mother’s. Any of these variations adds further to the difficulty of the labor and to the danger of the partners in the event.

Artificial aid may be required which brings with it the possibility of sepsis.

The fœtal mortality which averages five per cent is due mostly to asphyxiation. Interference with the supply of oxygen begins as soon as the cord passes the vulva and the child must be delivered in eight minutes from that time, or perish. Partial detachment of the placenta may also cut off the oxygen to a fatal degree, and the child may be unable to breathe when born on account of mucus sucked into the trachea by premature efforts at respiration.

Minor accidents also occur, such as fractures, dislocations, and paralysis from injury to the nerve trunks.

Management.—In the interest of the child, this presentation is occasionally converted into a vertex by external version during the last weeks of pregnancy or in labor before the membranes have ruptured. It is difficult, however, to maintain the vertex over the inlet. The woman must be kept quiet in a horizontal posture and long roller splints applied to the side of the child in utero and bound on.

In primiparas, this is nearly impossible, and it is wiser, in the absence of some great necessity to warn the parents of the conditions and dangers and let them share in the responsibility.

Fig. 63.—Extraction of the breech. Traction on one leg. (Hammerschlag.)

When the labor begins, the bag of waters must be kept from rupture as long as possible and when it finally breaks, an internal examination should be made to see if the cord has come down. If this happens it may be necessary to expedite the delivery by external assistance.

Fig. 64.—Breech delivery. Extraction of the trunk by pulling on the hips. (Hammerschlag.)

The doctor brings down a foot, if it is not already down, or pulls on the breech until the feet drop out. Compression of the cord must be always in mind. It is always compressed after the umbilicus has passed the navel. The shoulders are delivered by seizing the feet with the operating hand and swinging the body out of the way. This brings the posterior shoulder, which should be first, into the hollow of the pelvis. Extraction is then completed by what is called the Smellie-Veit maneuver. The child is put astride one arm, the first finger of which is hooked into the child’s mouth to maintain flexion. The fingers of the other hand then grasp the shoulders of the child astride the back of the neck and traction is made downward in the axis of the inlet until the head slips into the excavation.

Fig. 65.—Breech delivery. Delivering the shoulder. The body is swung strongly upward and outward to bring posterior shoulder into the pelvis. (Hammerschlag.)

Fig. 66.—The delivery of the after-coming head by the Smellie-Veit maneuver. (Hammerschlag.)

If the head is delayed at the inlet, it may be necessary to put the woman in the Walcher position (q. v.) and for the nurse to use the Wiegand compression (q. v.). The feet must not be fastened in stirrups for breech cases.

Fig. 67.—Shoulder presentation. Left-scapulo-anterior position. (Lenoir and Tarnier.)

Forceps are not recommended for application to the breech as they do not fit and are liable to slip off and injure both child and mother. The fingers are best.

Forceps are not recommended for the after-coming head unless the child is dead. If the child lives, the Smellie-Veit is more-successful; and if the child dies, the cranioclast, if possible, will save the mother much suffering and avoid some injury to the tissues.

Transverse or Shoulder Presentations.—These are cases in which the long axis of the child lies directly across or obliquely across the long axis of the uterus.

The shoulder (scapula) is the bony landmark, and the part which most frequently impends over the inlet. This presentation probably occurs once in two hundred labors.

It is due to the same conditions that were given for breech cases; namely, weak abdominal or uterine muscles, pelvic contraction, placenta previa, hydramnios, and twins.

It is easily recognized in pregnancy, and must not be neglected, for it is impossible of delivery without first changing it into a longitudinal presentation. If this correction is not done, rupture of the uterus is liable to occur, with the consequent death of both mother and child.

The treatment is invariably version.

Face and Brow Presentations.—The face presents once in about three hundred labors. In this case, the head is completely extended so that the occiput rests against the back of the neck. The trunk and spine are straightened out while the legs and arms remain in the normal attitude of flexion.

The causes of these anomalies must be sought in those conditions which bring about the deflexion of the chin. The most common are pelvic contraction, large child, placenta previa, hydramnios, goiter, anencephalus and multiparity.

Fig. 68.—Face presentation. (Bumm.)

Face positions take their names from the location of the chin (mentum—Latin). Thus the most frequent face position is the right-mento-posterior.

The diagnosis is not easy and may not be conclusive until the bony prominences of the face, such as the nose and orbital ridges can be distinguished by vaginal examination.

Fig. 69.—Descent of the chin in face presentation. (Bumm.)

The delivery is protracted from three to five hours beyond the average by this complication, and the mortality is higher both for mother and child. The face is badly swollen and disfigured, but the normal condition of the tissues will be restored by the end of a week. Most face cases terminate spontaneously, but operative interference is not infrequent on account of danger to mother or child.

Version or manual correction of the presentation may be done before engagement.

Forceps is the operation of choice after the head is fixed in the pelvis, but it may be necessary to precede the delivery by a preparatory pubiotomy, or in case of failure, to do a craniotomy on the dead child.

If the chin does not rotate forward under the symphysis, the labor is impossible without pubiotomy or the destruction of the child. In general, the case should be left to nature unless some definite indication to interfere develops.