Class Book Mssj TO fopyrightN q*$ COPYRIGHT DEPOSIT; A NURSE'S HANDBOOK OF OBSTETRICS A NURSE'S HANDBOOK OF OBSTETRICS BY JOSEPH BROWN COOKE, M.D. FELLOW OF THE NEW YORK OBSTETRICAL SOCIETY, ETC Seventh Edition, Revised and Reset BY CAROLYN E. GRAY, R.N. SUPERINTENDENT OF CITY HOSPITAL SCHOOL OF NURSING, BLACKWELL'S ISLAND, NEW YORK CITY AND MARY ALBERTA BAKER, R.N. LATE SUPERINTENDENT OF ST. LUKES' HOSPITAL, JACKSONVILLE, FLA. PHILADELPHIA AND LONDON J. B. LIPPINCOTT COMPANY ^t <\ ^ Copyright, 1903, "by J. B. Lippincott Company Copyright, 1905, by J. B. Lippincott Company Copyright, 1907, by J. B. Lippincott Company Copyright, 1 909, by J. B. Lippincott Company Copyright, 191 1, by J. B. Lippincott Company Copyright, 1913, by J. B. Lippincott Company Copyright, 191 5, by J. B. Lippincott Company PRINTED BY J. B. LIPPINCOTT COMPANY, PHILADELPHIA, U. S. A. (ami -9 1915 ©CI.A416274 I To the Pupils of the City Hospital School of Nursing for whose use this book was especially written, it is most cordially dedicated by The Author PREFACE TO THE SEVENTH EDITION ¥¥ In revising this book for the seventh edition, it was thought best to present the subject matter in a somewhat different grouping. The text has been considerably changed and much new material added upon current nursing subjects, as well as fifty new illustrations and a number of colored plates. It is hoped this book will still prove to be a guide and stim- ulus to all who follow the traditions and highest ideals of the nursing profession. Since 1903 its text has been a model which has found much favor. The revision was made possible through the courtesy of Honorable John A. Kingsbury, Com- missioner of Charities, and the co-operation of the officials, doctors and nurses of City Hospital, and various maternity hospitals in New York City. September, 191 5. C. E. Gray, R.N. M. A. Baker, R.N. CONTENTS CHAPTER PAGE I. — Introduction 19 II. — Anatomy 28 III. — Anatomy (continued) 34 IV. — Physiology 43 V. — Physiology (continued) 48 VI. — The Physiology of Pregnancy 67 VII. — The Phenomena of Labor 75 VIII. — The Physiology of the Puerperium 80 IX. — The Signs and Symptoms of Pregnancy 84 X. — The Mechanism of Labor 91 XL — The Management of Pregnancy 102 XII. — Preparations for Labor 118 XIII. — Preparations for Labor (continued) 125 XIV. — The Conduct of Labor 135 XV. — The Management of the Puerperium 162 XVI. — Pathology of Pregnancy 183 XVII. — Operative Delivery 214 XVIII. — Abortion and Miscarriage 244 XIX. — Accidents and Emergencies 253 XX. — Pathology of the Puerperium 274 XXI. — The Care of the Normal Infant 290 XXII. — The Ideal Nursery and Layette 299 XXIII. — The Accidents, Injuries, and Diseases of the New-Born 317 XXIV. — The Premature and Feeble Infant 348 XXV. — Infant Feeding 360 XXVI. — Obstetrical Nursing 393 XXVII.— Diets 397 Appendix 401 Key to Pronunciation 413 Glossary 415 Index 453 LIST OF ILLUSTRATIONS FIGURE PAGE i . The normal female pelvis '. 28 2. The pelvic inlet 30 3. Male and female pelvis 31 4. Female pelvis deformed by osteomalacia 32 5. Harris's pelvimeter 32 6. Measuring the distance between the crests of the ilia 32 7. Internal pelvimetry . 33 8. External organs of generation 34 9. Internal organs of generation 36 10. The internal organs of generation, seen from above 37 1 1 . The uterus and its appendages 37 12. The cavity of the uterus 38 13. Ovary and tube of a girl twenty-four years old 40 14. Mammary gland of a woman during lactation 41 15. Longitudinal section through ovary of a woman twenty-two days after the last menstruation 43 16. Longitudinal section of ovary of a woman on the first day of men- struation 44 17. Human spermatozoa 48 18. First stages of segmentation of the ovum of a rabbit 49 19. Uterus with decidua in beginning pregnancy . 51 20. Normal position of foetus in utero 52 2 1 . Fetal surface of the placenta 54 22. Maternal surface of the placenta 54 23. Human ovum at the end of the first month 55 24. Outline of human embryo of about four weeks 56 25. Human foetus at the end of the third month 56 26. Skeleton of infant at term 57 27. Fetal skull, side view 59 28. Diagram of circulation after birth. Adult type 62 29. Diagram of circulation before birth. Fetal type 63 30. Striae gravidarum, or Linear albicantes 68 31. The breasts in pregnancy 71 32. Abdominal pigmentation 72 33. Preserving the perineum 78 34. Preserving the perineum 78 35. Using the full hand in retarding the progress of the head 78 36. Emergence of the forehead and face 78 37. Delivery of the anterior shoulder 78 13 i 4 LIST OF ILLUSTRATIONS FIGURE PAGE 38. Expressing the placenta by the method of Cred6 78 39. Twisting the membrane into the form of a rope to prevent tearing . . 78 40. Inspecting the placenta 78 41. Marked pigmentation of breast 87 42. Size of the uterus at each month of pregnancy 89 43. Vertex presentation 92 44. Flexion of head during second stage 94 45. Extension of the head in anterior presentations of the vertex 95 46. External rotation 96 47. Internal rotation and extension 97 48. Shape of head of child born in face presentation 98 49. Shape of head of child born in brow presentation 98 50. Face presentation 98 5 1 . Breech presentation 99 52. Prolapse of arm in transverse presentation 99 53. Usual method of palpating the abdomen 100 54. Abdominal binder 103 55. Showing manner of elevating bed 129 56. Arrangement of sheets for vaginal examination 138 57. Esmarch outfit for the administration of chloroform 142 58. Administration of chloroform 143 59. Administration of ether 147 60. Square knot 153 61. Granny knot 154 62. Delivery of placenta and membranes 155 63. Delivery of the head in breech cases 156 64. Arms extended in breech delivery 158 65. Locked twins 159 66. Holding the fundus after delivery 162 67. Abdominal binder 169 68. Glass catheter - 173 69. Proper method of inserting catheter 175 70. Method of withdrawing catheter 175 71. Proper method of introducing douche-tube 178 72. Varicosities of the lower extremities 189 73. Ectopic gestation 207 74. Placental attachment 209 75. Internal version 214 76. Combined or bipolar version 215 77. "External version" 216 78. Forceps applied to head of brim 218 79. Walcher posture 218 80. Ready for vaginal operation 219 81 . Sterile pillow cases for covering the limbs 220 LIST OF ILLUSTRATIONS 15 FIGURE PAGE 82. Kitchen table utilized for operating table 221 83. Elliott's forceps 222 84. Simpson's forceps 223 85. Tucker-McLane forceps 223 86. Tarnier axis- traction forceps 223 87. Barnes's bags 224 88. Champetier de Ribes bag 225 89. Bulb and valve, or " Davidson " syringe 225 90. Method of inserting bag 226 91 . Method of inflating bag 227 92. Pelvic tumor preventing delivery 228 93. Kelly pad in position under patient 229 94. Sterile salt solution in flasks 230 95. Sponge made of cotton and gauze 230 96. Sponge holder 230 97. Intestinal pad of folded gauze. 231 98. Gauze packing 231 99. Saline infusion 232 100. Galbiati knife 234 101. Nurse's proper operating gown 235 102. Doctor's proper operating gown 235 103. Naegele's perforator 239 104. Braun's cranioclast 239 105. Tarnier's basiotribe 239 106. Impacted shoulder presentation 240 107. Braun's key-hook 240 108. Braun's hook applied . 241 109. Long, blunt scissors. For decapitation and evisceration 241 1 10. Bougie for the induction of labor 242 in. Sims's position 243 1 12. Author's leg-holder 247 113. Robb's leg-holder 247 114. Sims's speculum 248 115. Schroeder's vaginal retractor 248 1 16. Bullet-forceps 248 117. Modified Goodell-Ellinger dilator 248 118. Uterine sound 249 119. Placenta-forceps with heart-shaped jaws 249 120. Curettes 249 121. Sponge-holder 249 122. Two-way catheter 250 123. Concealed hemorrhage 254 124. Rupture of the uterus 257 ^ LIST OF ILLUSTRATIONS Fli;i'Rh PAGE 1 25. Complete inversion of the uterus 258 126a. Prolapse of the umbilical cord 260 1 26b. Knee-chest position 260 127. Manual extraction of the placenta 263 128. Murphy saline drip apparatus 269 129. Aspirating needle 270 130. Hypodermoclysis 271 131. Figure-of-eight ligature. For controlling secondary hemorrhage from the umbilicus 273 132. Tray with everything needed for the care of the breasts 279 133. Massage of the breast 280 134. Nursing bottles and rubber nipples 282 135. Author's breast-binder 284 136. Pattern of author's breast-binder 286 137. Oiling and dressing the new-born infant 291 138. Method of dressing the umbilical cord 294 139. Infant's crib with adjustable sides 300 140. Practical infant's crib 301 141. Double wash-basin 302 142. Paper bags pinned together 302 143. A. Infant's dressing screen. B. Infant's dressing table 303 144. Method to secure air for infant in a city apartment 305 145. Another view of Fig. 144 306 146. Diaper shaped according to pattern 307 147. Ideal infant clothing 313 148. Patterns of infant's clothing 314 149. Band and shirt fastened with tapes 315 150. Slapping upon back to induce respiration 318 151. Snapping the finger upon the soles of the feet to stimulate respi- ration 319 152. Byrd's method of resuscitation. Expiration 321 153. Byrd's method of resuscitation. Inspiration 322 154. Artificial respiration. Expiration 324 155. Artificial respiration. Inspiration 325 156. Sylvester's method combined with tongue traction 327 157. Schultze's swinging method. Expiration 328 158. Schultze's swinging method. Inspiration 330 159. Removal of mucus with aspirating catheter -. . . 331 160. Warm bath combined with tongue traction 332 161. Facial paralysis 333 162. Caput succedaneum 333 163. Double cephalhematoma 334 164. Technic of applying ice compresses to the eye 336 165. Technic of irrigating eye 338 LIST OF ILLUSTRATIONS 17 FIGURE PAGE 166. Thumb-forceps 339 167. Spina bifida of dorsal lumbar region 340 168. Spina bifida. Spontaneous cure 341 169. Opisthotonos 344 170. Electrically heated infant incubator 350 171. Gas heated infant incubator 352 172. Tarnier's incubator, interior 353 173. English breast-pump 356 174. Feeder for premature infant 357 175. Infant premature at thirty weeks 358 176. Soft, flabby breasts 361 177. Two-ounce vial with nipple 363 178. Articles required for the preparation of artificial food 383 179. Nursing bottles 385 180. Testing size of opening in nipple 386 181. Steam sterilizer 390 182. Freeman pasteurizer 390 183. Operating gown and case 393 184. Scales and hammock for weighing infant 394 185. Sponge attached to safety-pin with snaps 405 186. Delivery bag 408 187. Nurse's bag 410 188. Contents of bag 411 A NURSE'S Handbook of Obstetrics i Introduction The art of nursing the obstetrical patient is practised by various classes of people. We are very prone to consider only the doctor and the trained nurse. Statistics, however, demand consideration of other factors. Taking any city or town in the United States, we find that a woman about to present her most valuable gift to the world, a healthy child, if not provided with hospital care away from the family, may be cared for: i. By the doctor, in his out-patient and country practice. 2. The nurse midwife. 3. The graduate nurse in private, hospital, visiting nurse and rural Red Cross work. 4. Various orders of nursing sisterhoods. 5. A trained midwife from schools of midwifery abroad. 6. The midwife trained in American schools of midwifery, such as Bellevue. 7. The correspondence school graduate. 8. The untrained nurse. 9. The licensed midwife. 10. The unlicensed midwife occasionally. 11. Relatives of the patient. 12. Neighbors. The dominant issue of the present-day teaching is preven- tion of waste. All civilization is striving, by every means pos- sible, to conserve and add to the vital resources of the nation. A few daring bacteriologists have done research work which 19 20 A NURSE'S HANDBOOK OF OBSTETRICS. has given us perhaps our greatest influence and inspiration to this end, in preventive and curative medicine. This knowledge is in a large measure rendered ineffective by the dense amount of deep ignorance concerning the facts of life. Tradition, prejudice, and social customs all tend to sur- round the practice of obstetrics with conditions which are largely responsible for the following figures which are inserted as an example of some of the results of the care given at childbirth. The figures are by Doctor Haven Emerson, Deputy Commissioner of the Department of Health of the City of Xew York. IN NEW YORK CITY FOR THE YEAR I9I4 Number of births reported by physicians 87,650 Number of births reported by midwives 52,997 Number of infant deaths under ten days reported by physicians. . 3,683 Number of infant deaths under one year 13,312 Number of cases of ophthalmia neonatorum reported by physicians 14 Number of cases of ophthalmia reported by midwives 12 Number of deaths in 19 14 from puerperal sepsis 1 407 Number of midwives practising in New York City 1,448 These figures and facts are not dull, but force the logical conclusion that the most essential fact of obstetrics is a knowl- edge and a following of a high standard of asepsis. This fact cannot be brought before the public too emphatically, too clearly, or too often. It is the definite duty of every nurse to follow the medical profession closely, and by utilizing every opportunity that sym- pathy and tact may devise, to teach unceasingly the doctrine of prenatal care and the need of the best obstetrical assistance. Nature makes lavish efforts to protect the expectant mother from infection. This is interfered with by contact infection thirty-five per cent, of these deaths were in women who had fceetr- att ended by midwives prior to the development of the sepsis, which ended in their deaths. It is approximately estimated that between six and seven thousand deaths from puerperal sepsis occurred in the United States in the same year. INTRODUCTION. 21 from the family, from visitors, from the patient herself, and from the nurse or doctor. Aside from the natural immunity possessed by healthy tis- sues against infection, there is the vaginal secretion, which is usually spoken of as being a natural antiseptic. What is meant is, that while swarming with bacteria, these bacteria manufac- ture lactic acid, and no pus organism can survive in an acid medium. Normally the changes in the soft parts of the reproductive organs during pregnancy and labor are accompanied by an increased amount of vaginal secretion. Beyond this there is the closed door to infection of the uterus itself, by means of a mucous mass or plug, called the operculum. At the end of the first stage of labor the membranes rupture, the liquor amnii carries with it the vaginal contents and a large percentage of the bacteria. The vaginal walls enlarge during the actual passage of the child; this is followed by the remaining liquor amnii, and, finally, by the delivery of the placenta ; so that there is left but little chance for bacteria to survive. The whole object of asepsis is to prevent infection of the uterus from the outside. Obviously this resolves itself into a principle of prevention of infection during labor, and the practice of rigid asepsis and faultless technic on the part of the doctor and nurse. Every case of puerperal sepsis, with rare exception, proves that infection has been introduced from the outside by septic hands, septic instruments, or septic matter from the vulva or va- gina carried by douches or instruments into the uterus. The septic infection comes from anything not sterile. This is occa- sionally unavoidable, owing to complicated instrumental or oper- ative delivery, but a pyogenic infection has no more place in ob- stetrics than in surgery, and it can be almost as certainly pre- vented. Septic infection from the hands may be prevented by proper cleansing, wearing of gloves, and then by using the hands only when imperatively demanded. A NURSE'S HANDBOOK OF OBSTETRICS. Septic infection from instruments may be prevented by proper cleansing and boiling; then proper technic in the treat- ments or douching will prevent the carrying of infection from the vulva or vagina. Whether the infection is mild and results in invalidism, or whether it is virulent and causes death, the nurse who is in- telligent and conscientious will feel strongly her responsibility. POINTS FOR THE OBSTETRICAL NURSE Pasteur said : " It is within the power of man to cause all parasitic diseases to disappear from the world." Fatal cases of puerperal sepsis in a hospital are almost unknown. They should be equally rare in the home; and if proper care is exercised this will be the case. The purpose of this elementary review is to lessen the total of 6000 deaths per year in the United States. It is hoped that all who read it will consider it seriously, whether they are graduates, undergraduates, midwives or lay helpers. Bacteria are vegetable organisms. Pathogenic bacteria are those organisms which cause morbid or diseased changes in human tissues. Infection is the communication of disease from one person to another. The term is also used to denote the agent by which disease is conveyed. Septic infection is infection caused by septic organisms. Sepsis is infection by bacteria. Asepsis means without sepsis ; that is surgical cleanliness or freedom from infection. Aseptic means in a surgically clean manner. Pyogenic relating to pus-forming organisms. Sterile means entire absence of living organisms of any kind. Sterilization is the process of rendering an object free from germs. Antiseptic means preventing sepsis or pus formation or putrefaction. (1) No one should undertake obstetrical nursing who has INTRODUCTION. 23 any pus infection whatever, or who has been recently exposed to a communicable disease. In such a case, report the exact condition to the obstetrician and act under his orders. Carry out thoroughly a system of disinfection. (2) Articles for emergency use, packings, dressings, treat- ments, etc., should be sterile and in readiness; neglect to provide these is criminal. Wisdom lies in the prevention of infection and in preparation for emergencies. (3) Prepare all essentials for doctor (see list). Prepare all essentials for nurse (see list). Prepare all essentials for mother (see list). Prepare all essentials for infant (see list). (4) Hands must be thoroughly scrubbed under running water for five minutes with any good soap and a clean nail brush ; use particular care between the fingers and around the nails. Cut the nails close and manicure often. Soak in biniodide of mercury 1 : 1000, or sponge with alcohol 95 per cent. Wear rubber gloves, previously sterilized by washing and boiling for five minutes. (5) Fingers must never be used where an applicator or forceps can be made to serve. These are to be kept in a jar filled with 2 per cent, solution of lysol or 95 per cent, alcohol. (6) Use sterilized soap. (7) Never use grease as a lubricant. It is always dirty, and it destroys rubber. Use lysol, 2 per cent., or a sterile emul- sion made from soap. , (8) Never catheterize a patient unless all possible means to avoid it have been tried ; and then only by express order of the doctor, and with exact technic. (9) A nurse should not renew a vulva pad after removing a bed-pan from her patient until she has made her hands sur- gically clean. ( 10) Especial care is essential to prevent infection of vulva, bladder, and breasts. (11) A cord dressing will not be reinforced or renewed until the nurse has surgically clean hands. (12) She will never leave a patient's breast exposed, but will protect it by a sterile dressing, and use sterile cotton swabs 24 A NURSE'S HANDBOOK OF OBSTETRICS. when cleansing the nipple, at all times treating both breast and nipple as open wounds. (13) So long as she is with her patient she will keep a complete daily record of patient and infant, charting all physi- cian's visits and treatments. (14) She may use a fountain syringe for enemata, but an agate irrigator with cover and separate tubing carefully boiled is essential for infusions and for sterile uses. (15) She will tactfully instruct her patient not to infect herself or infant, and will strive to prevent the baby from developing bad habits. Failure to do this is inexcusable. (16) She will handle conditions so that the equipment the home affords may be utilized to the advantage of the patient, and by her resourcefulness and adaptability render the eco- nomic drain upon the family income as small as possible, without sacrificing a single principle of asepsis. (17) The nurse should prove a continuous exponent of personal hygiene, in person, uniform, and habits. (18) She must never relax in vigilance, duty, judgment, or loyalty. The feminist movement is strongly pushing forward a de- mand from women themselves for better obstetrics, for better training and judgment on the part of both doctors and nurses. They are less willing to accept inferior service, and demand that the best help available be given them. Operations are often attempted at home that should in justice to the mother and child be performed in hospitals. Lack of adequate assistance or equipment and improper sur- roundings not infrequently render recovery problematical. The patients and families must be taught that this is highly im- proper and that the obstetrician must have adequate assistance and remuneration. Good judgment, swift decisions, and quick action are in demand from the obstetrician. He should have assistants and a nurse worthy this need. Only with a large intelligence and sympathy, trained in technic, plus experience, can a nurse fulfil her opportunity. Private nursing lays greater responsibility upon her than does her hospital work. She must INTRODUCTION. 25 have a sufficient knowledge of psychology to follow the mental processes of her patient. Thus, the nurse should secure her patient's confidence, and persuade her to place herself in the care of a physician as soon as possible ; she should help her to live a normal life, induce her to eat proper food, take suffi- cient exercise, secure enough rest, and happily to await her baby's coming. She should ward off dread of suffering by being able to promise that a good obstetrician will not let her suffer too much actual anguish. She should make real to her that the care of her infant begins nine months before it is born ; that the baby requires only a few articles of a very special kind and that these should be in readiness ; that her own re- turn to normal health and comfort, as well as her child's best chance for life, lies in her preparing to nurse it, and that all the earth does her honor. When on the case, dignity, efficiency, cleanliness and quiet are most essential. Too many objectionable traits, such as gossiping, relating personal details, reciting history of cases, disturbing domestic regime, discourtesy, etc., when placed in the balance beside skill, are found to outweigh efficiency, and the nurse becomes a menace to the well-being of her patient. The strength and force of character possessed by a nurse will enable her to become a tower of strength to the expectant mother, and by proper suggestion and direction of her mind the actual realization of her sufferings may be much lessened. If the nurse is unintelligent or unobservant of her patient's attitude of mind, she may undo all the efforts of the physician to encourage and assist. It should be a part of her training, and it is her duty, to help her patient mentally as well as physically. In a paper read recently before one of the great medical societies of New York the gynaecologist was styled " that obstet- rical camp-follower," and this characterization may well serve as a text for a dissertation on obstetric nursing. Practically all women who consult the gynaecologist are mar- ried, have borne children, and date their troubles from the birth of one or another child, and it is safe to say that the compara- tively few unmarried women who seek advice for the relief of 26 A NURSE'S HANDBOOK OF OBSTETRICS. pelvic disorders would be in infinitely worse condition than they are if they had passed through the ordeal of pregnancy and labor. The amount of good for womankind that nurses can accom- plish by the dissemination of judicious advice concerning the requirements of the pregnant state and by intelligent care of parturient and puerperal cases, probably exceeds in many ways the best efforts of the physician. Especially among primi- gravidae does this hold true, for women who have never borne children are often remarkably diffident in regard to their condi- tion, and unless the early symptoms of pregnancy are exception- ally severe, they will neglect to place themselves under medical care until much mischief may have been done. When nurses, as a class, will impress upon women who may come under their notice the importance, not only to themselves but to their infants, of consulting and implicitly following the directions of a skilful obstetrician as soon as they have reason to suspect that they are pregnant, they will save a large number of these patients many visits to the gynaecologist in after years. A nurse can, with propriety, volunteer advice -of this kind when a physician, taking the same stand, would often be unjustly suspected of ulterior motives, and her opportunities for doing so are greater than his in the exact proportion in which a woman will discuss a delicate subject with another woman more fre- quently and more freely than with a man. Regarding nursing in the light of a noble profession, closely allied to that of medicine, no opportunity for aiding and perma- nently benefiting humanity will ever be overlooked, and scientific supervision of pregnancy, labor, and the puerperium can do more in this respect than all other branches of nursing com- bined. As the writer has expressed in another place, let the pregnant woman be taken in hand at the very beginning of her pregnancy and put in condition to withstand the ordeal through which she has to pass, much as the athlete is " trained" for months before the encounter in which he is to figure. It may be stated, as a general rule, that no woman should die INTRODUCTION. 27 or even be seriously invalided as a result of pregnancy if she is under proper care from the beginning of gestation, and it rests with the nurses of modern times more than with the physicians to see that every woman is afforded such care and attention as will insure the successful outcome of her case. The key-note of success in obstetric practice lies in a thor- ough knowledge of the patient's exact condition long before labor occurs and in ample preparation for delivery and after care, so that the labor may be conducted with every attention to aseptic detail and modern surgical method. Twentieth century civilization has done much to retard the physical development of women in general, and, among those who are in a position to afford the services of a graduate nurse, very few have sufficiently robust constitutions and normally de- veloped pelves and generative organs to make labor and its after effects anything but a matter of considerable moment. Unless the physician has been afforded an opportunity to build up their general health and keep a watchful eye on the behavior of their bodily functions, and unless the nurse has made careful and judicious preparations for conducting their labors in a thoroughly aseptic manner, complications may arise at the last moment which may result in permanent invalidism, if not in the death, of the mother or child. Obstetric nursing presents many unattractive features, for after labor there are two patients instead of one to be cared for, but it offers so many and so great opportunities for the advance- ment of " preventive medicine" that the writer cannot but look with considerable disfavor upon that large and constantly in- creasing class of hospital nurses who regard maternity cases as entirely beneath their dignity and who leave these unfortunate patients in the care of unskilled attendants, only to nurse them afterwards when they reach the operating-table of the gynae- cologist. II Anatomy THE PELVIS The pelvis (Fig. i) is that portion of the skeleton which lies between the spinal column and the lower extremities. It is Fig. i. — The normal female pelvis. (Garrigues.) A, sacrum; i?, coccyx; C, crest of the ilium; D, acetabulum; £, spine of the ischium; F, symphysis pubis ; G, spine of the pubis ; H, obturator foramen ; /, tuberosity of the ischium ; J, J, J, linea terminalis. composed of four bones, — the sacrum and coccyx behind, and the innominate bones (ossa innominata) at the sides and in front. Each innominate bone (os innominatum) is divided by anato- mists into three parts, — the ilium, the ischium, and the pubis. The ilium, which is the largest portion of the bone, is broad, thin, concave on its inner aspect, and lies above the narrow con- stricted portion of the pelvis. Like its fellow of the opposite side, it is joined to the sacrum behind, and its upper flaring 28 ANATOMY. 29 border forms the prominence of the hip, or crest of the ilium, commonly spoken of as the " hip bone." The pubis joins directly in front, in the median line, with its opposite fellow, and closes, anteriorly, the cavity of the pelvis. The ischium, which is that portion of the innominate bone lying beneath the ilium, is not of importance to the obstetric nurse, although it is of interest to know that it occasionally pre- sents bony projections {exostoses) of sufficient size to obstruct the descent of the head during labor. The sacrum is a triangular, wedge-shaped bone, consisting of five rudimentary vertebrae welded together, and lies at the back part of the pelvis, between the ilia (plural of ilium), closing in the cavity behind. Its upper surface, or base, is broad and flat, and supports the spinal column ("backbone") and with it the entire weight of the body. Its apex points downward and forward, and to it is attached The coccyx, a very small triangular bone, resembling some- what in appearance a miniature sacrum and being possibly the remains of a prehistoric caudal appendage, or tail. Regarded as a whole, the pelvis may be described as a deep, bony basin resting on the upper extremities of the two femora (plural of femur), or thigh bones, and supporting the spinal column, which carries the weight of the trunk, the head, and the upper limbs. The flaring surfaces of the ilia make a sort of funnel to guide the foetus into this basin, which, having no bottom, forms a bony canal through which the child has to pass at the time of labor. The most constricted portion of the pelvis is called the brim, or inlet (Fig. 2), and is, naturally, of the greatest obstetric im- portance; for, as a chain is only as strong as its weakest link, so is a canal only as broad as its narrowest part, and, except in certain cases of deformity, any child that can pass safely through the brim can be delivered without any further difficulty. The brim of the pelvis is bounded behind by that portion of the upper anterior surface of the sacrum, which projects farthest forward and is called the "promontory of the sacrum;" on the sides by the lower borders of the ilia; and in front by the two 3o A NURSE'S HANDBOOK OF OBSTETRICS. pubic bones, which meet in the median line and form the " sym- physis pubis." Fig. 2. — The pelvic inlet. (Garrigues.) A B, anteroposterior or true conjugate diame- ter; CD, left oblique diameter; E F, right oblique diameter; G H, transverse diameter; A S, sacrocotyloid distance; IK, crest of the ilium. The contour of the inlet is more or less heart-shaped because of the jutting forward of the promontory of the sacrum, and the most important diameter of the pelvis is the distance between the promontory and the symphysis. If this is normal (ten centi- metres, or about four and one-quarter inches), it is almost cer- tain that the entire pelvis is normal, and that the child can be born without any serious difficulty. The articulations {joints) of the pelvis, which possess ob- stetric importance, are four in number. Two are behind, between the sacrum and the ilia on either side, and are termed the sacro- iliac synchondroses (plural of synchondrosis) ; one is in front, between the two pubic bones, and is called the symphysis pubis; and the last, of little consequence, is that between the sacrum and coccyx, — the sacro-coccygeal articulation. ANATOMY. 31 All of these articular surfaces are lined with fibro-cartilage, which becomes thickened and softened during pregnancy, and a certain definite, though very limited, motion in the joints is essential to a normal labor. Even an ankylosis of the sacro- coccygeal articulation, preventing the tilting backward of the coccyx at the time of delivery, may necessitate the use of for- ceps, and, in the operation of symphyseotomy, which consists in cutting through the symphysis pubis and so separating the pubic bones, no increase in the capacity of the pelvis could be secured were it not for a very distinct hinge-like motion at the sacro-iliac synchondroses. The pelvis is lined with muscular tissue, which provides a smooth slippery surface over which the foetus has to pass during labor, and its bones are bound together by ligaments, which become softened and slightly lengthened as pregnancy advances. Comparing the female with the male pelvis (Fig. 3), we find that the former is especially adapted to the uses for which Fig. 3. — Male and female pelvis. A, male pelvis — narrow, heavy, compact ; B, female pelvis — broad, light, capacious. it is designed. It is shallow, but very capacious, lighter in struc- ture and smoother than the male pelvis, which is deep, conical, rougher for muscular attachment, and more compact. The entire problem in obstetrics consists in the safe passage of the fully developed foetus through the pelvis of the mother. Slight pelvic contractions, resulting in tedious or instrumental 32 A NURSE'S HANDBOOK OF OBSTETRICS. deliveries, are comparatively common, while any such marked de- formity as depicted in Fig. 4 would render labor by the natural Fig. 4. — Female pelvis deformed by osteomalacia. (Garrigues.) passages entirely out of the question. For these reasons the pelvis of every pregnant woman should be measured carefully at a sufficiently early date to enable the physician to determine definitely the proper course to pursue. Fig. 5. — Harris's pelvimeter. The external pelvic measurements are taken with an instru- ment called a pelvimeter (Fig. 5), which acts on the principle % Fig. 6. — Measuring the distance, iliac crests. ANATOMY. 33 of a carpenter's or plumber's calipers. The patient lies on her side or back, according to the diameters to be measured, with the abdomen exposed, as shown in Fig. 6. The internal pelvic measurements, for determining the actual diameters of the brim, are usually made by inserting two ringers into the vagina and up to the promontory of the sacrum and estimating the various dimensions in this manner (Fig. 7). Fig. 7. — Internal pelvimetry. Measuring the distance between the promontory of the sacrum and the lower border of the symphysis pubis. The importance of the knowledge gained through the skilful performance of external and internal pelvimetry cannot be over- estimated, and it should never be neglected in the case of a woman pregnant for the first time nor in any case in which the patient has suffered previously from difficult or tedious labors. In cases of slight contraction the induction of labor two or three weeks before term may be all that is necessary, while the existence of marked deformity may call for the performance of Caesarean section as the only alternative. It is to be kept in mind that the higher we ascend in the social scale the more frequently do we encounter pelvic deformities of varying de- grees, due to faulty development superinduced by lives of luxury and indolence, and that the class of patients coming under the care of the graduate nurse presents a far greater proportion of such deformities than is found among women in the lower walks of life. 3 Ill Anatomy (continued) THE FEMALE ORGANS OF GENERATION The female organs of generation are divided into two groups, the external and the internal, which are connected by the vagina. The external organs, taken as a whole (Fig. 8), constitute the vulva, and consist of — Fig. 8. — External organs of generation. A, A, labia majora ; B, B, labia minora? C, meatus urinarius; D, clitoris; E, mons veneris; F, perineum ; G, anus; H, entrance to vagina. The mons veneris, a firm, cushion-like formation covered with hair and lying directly over the symphysis pubis. The labia majora, or greater lips, made up of adipose tissue (fat) and covered externally with skin and hair and internally with mucous membrane. They begin in the median line at the lower border of the mons veneris and extend downward and 34 ANATOMY. 35 backward, on either side, to meet at a point termed the four- chette, which is almost invariably torn at the first labor. The labia minora, or lesser lips, lie entirely within the vulva, except in the case of infants and of women who have borne chil- dren or are much emaciated. They are covered entirely with mucous membrane, and their upper extremities are divided into two parts, one passing above and one below (and so forming a hood for) The clitoris. This is a small reddish tubercle situated about half an inch behind the upper and anterior junction of the labia majora. The meatus urinarius, commonly spoken of as the " meatus/* is the external opening of the urethra, which is the canal (about one and one-half inches in length) leading to the bladder. The meatus lies directly back of the clitoris and about three-quarters of an inch from it. When the labia are separated it appears as a small dimple in the median line under the symphysis. The vagina is a musculo-membranous canal, five to six inches in length, leading from the vulva to the uterus and lying wholly within the true pelvis. It is lined with mucous membrane, the secretion of which possesses marked germicidal properties. In consequence of this fact the vagina is always aseptic except in the presence of disease or very soon after direct infection from without, and for this reason a vaginal douche should never be given before labor unless it is specially ordered by the physician. Under ordinary circumstances such a douche can do no good, and it is certain to do actual harm by removing the natural and aseptic lubricant of the vagina, even if it does not, through carelessness of preparation or administration, introduce infection where none had existed previously. The internal organs of generation (Figs. 9 and 10) consist of the uterus, the Fallopian tubes, and the ovaries. The uterus, or womb (Fig. 11), is a hollow, pear-shaped organ about three inches in length in the non-pregnant state. It is composed of muscular tissue, covered externally almost wholly with peritoneum and internally with mucous membrane, and is suspended in the pelvis by means of a number of ligaments 36 A NURSE'S HANDBOOK OF OBSTETRICS. arranged in pairs and stretching across from the uterus to the sides of the pelvis or to other pelvic organs. This arrangement of the ligaments is such that the uterus is allowed considerable freedom of motion, and its position varies slightly with respira- tion, with the posture of the woman, and with the condition of the bowels and bladder. In other words, the uterus has no Fig. 9. — Internal organs of generation. (Keating and Coe.) Showing the uterus in its normal position between the bladder and the rectum. The vagina lies between the lower border of the bladder and the meatus urinarius above and the rectum and anus below, separated from the latter by the perineum. intimate attachment to any fixed point, but hangs in the pelvis in a way to permit of its enormous enlargement during preg- nancy, — from about the size of an egg before conception has occurred to that of a fairly large pumpkin at the time of labor. The uterus lies in about the centre of the pelvis, below the brim, with the bladder in front and the rectum behind, so that, of ANATOMY. 37 Fig. io— The internal organs of generation, seen from above. (Keating and Cpe.; Fig. it.— The uterus and its appendages. (Keating and Coe.) The ovaries are the almond- shaped bodies lying between the uterus and the extremities of the Fallopian tubes. 38 A NURSE'S HANDBOOK OF OBSTETRICS. necessity, a full rectum will force it forward and a distended bladder will tilt it backward. Its upper,, rounded border is called the fundus, and its lower, narrowed portion the cervix, while that part between the fundus and the cervix is termed the body of the uterus. The cervix projects into the vagina for a distance of about half an inch, much as a cork projects into the neck of a bottle. Fig. 12.— The cavity of the uterus. (Garrigues.) c, vagina; e, external os ; d, internal os : /, fundus, the letter being placed over the entrance of the Fallopian tube. The spaces between the sides of that part of the cervix which extends into the vagina and the vaginal walls are termed for- nices (plural of fornix), and are divided into four parts. The anterior fornix is between the anterior wall of the cervix and the anterior vaginal wall ; the posterior fornix is between the pos- terior vaginal wall and the posterior wall of the cervix; the lateral fornices are the spaces between the cervix and the vaginal walls on either side. The cavity of the uterus (Fig. 12) is lined with mucous membrane, and is divided into two parts, — the cavity of the body and the cavity of the cervix. The cavity of the body is tri- ANATOMY. 39 angular in shape, with its apex pointing downward, while that of the cervix is spindle-shaped. There are three openings into the cavity of the uterus. The external opening, called the external os (Latin for mouth), is in the centre of the cervix as it projects into the vagina. It is very small in the non-pregnant state, barely admitting a probe, but at the time of labor it dilates to a size sufficient to permit the passage of the foetus. The other openings are at the upper angles of the triangular cavity of the body and lead into the Fallopian tubes, which will be described later. As the Fallopian tubes open directly into the peritoneal cavity, it will be seen that there is a direct avenue from the peritoneum to the outer world, through the Fallopian tubes, the uterus, and the vagina. The cavity of the cervix is slightly distended above the ex- ternal os, to become contracted again at its junction with that of the body. This second contraction is termed the internal os, and it is because of these two points of contraction that the cavity of the cervix acquires its spindle shape. The Fallopian tubes (see Fig. n) are two trumpet-shaped tubes, from four to five inches in length, extending from the upper angles of the uterus, just below the fundus, towards the sides of the pelvis. Between their outer extremities and the uterus, on either side, are found The ovaries (Fig. 13), which are the germ-producing organs of the woman and about the size and shape of an English walnut. Each ovary contains in its substance at birth a vast number of germs or ovules (from Latin, meaning "little eggs"), and, beginning at about the time of puberty and occurring at or about every menstrual period, one or possibly two of these ovules enlarges, approaches the surface of the ovary, escapes into the Fallopian tube, and so passes on into the uterus. The ovule which has " matured" in this way is the only one that can be impregnated by the male germ, and if there is no male element present in the Fallopian tube, where impregnation usually occurs, nothing results beyond the usual menstrual phe- nomena. The perineum (see Fig. 9) can hardly be considered as 4 o A NURSE'S HANDBOOK OF OBSTETRICS. belonging to the organs of generation, but it may best be de- scribed in this chapter. Briefly, and as far as the nurse is con- cerned, it is the triangular mass of tissue which separates the vagina from the rectum. Its upper surface is covered by the 9 LQ* c :: Fig. 13. — Ovary and tube of a girl twenty-four years old. (Waldeyer.) U, uterus, T, tube; LO, ovarian ligament; o, ovary; x, limit of peritoneum ; b, cicatrices of ruptured Graafian follicles. lower wall of the vagina, its posterior surface is in contact with the rectum, and its external surface is covered with skin and lies between the lower angle of the vulva and the anus. The perineum forms the floor of the genital canal, and in certain difficult labors it is torn, when the head is born, to an extent varying all the way from a slight nick in the skin to a deep lacer- ation extending through the anus into the rectum itself. The mammae {mammary glands or breasts) are two highly specialized sebaceous glands located on either side of the an- terior wall of the chest between the third and seventh ribs. They secrete the milk which serves as the sole nourishment of the infant during the early months of its life, and they are abun- dantly supplied with nerves and blood-vessels and intimately connected, by means of the sympathetic system, with the uterus and other generative organs. This sympathetic relation is espe- cially noticeable when the infant nurses immediately after birth THE BREASTS. 41 and reflex uterine contractions result from the irritation of the nipple caused by the suckling. The breasts of a woman who has never borne a child are conical or hemispherical in form, but their size and shape vary greatly in women who have nursed one or more infants. The breasts are made up of glandular tissue and fat, and each organ is divided into fifteen or twenty lobes, which are separated from each other by fibrous and fatty walls and sub- divided into numerous lobules {little lobes) (Fig. 14). The Fig. 14.— Mammary gland of a woman during lactation, with lactiferous ducts and sinuses. (Luschka.) lobules are composed of acini (plural of acinus), in which the milk is formed, and as the ducts approach the nipple they are dilated to form little reservoirs in which the milk is stored, but contract again as they pass into the nipple. The external surface of the breast is divided into three por- tions, as follows : (a) The white, smooth, and soft area of skin extending from the circumference of the gland to the areola, (b) The areola, which surrounds the nipple and is of 42 A NURSE'S HANDBOOK OF OBSTETRICS. a delicate pinkish hue in blondes and a darker rose-color in brunettes. Under the influence of gestation the areola becomes darker in shade, and this pigmentation which is more marked in brunettes than in blondes, constitutes, in many cases, a valu- able sign of pregnancy (see Figs. 31 and 36). (c) The nipple, a large conical papilla projecting from the centre cf the areola and having at its summit the openings of the milk ducts. IV Physiology OVULATION AND MENSTRUATION As stated in the previous chapter, the ovaries contain in their substance, at birth, a great number (about seventy thousand) of undeveloped ova or " eggs," and it is unnecessary to say that these ova are microscopical in size. Beginning, in this climate, at about the thirteenth year of age and occurring about" once a month, one of these ova enlarges and approaches the surface of the ovary. This enlarged ovum, lying directly under the surface of the ovary, constitutes what is known as the Graafian follicle (Fig. 15), and projects slightly, Fig. 15. — Longitudinal section through ovary of a woman twenty-two days after the last menstruation. (Leopold.) m.f., mature Graafian follicle; pr., most prominent point of follicle, where the rupture may be expected. like a small pimple. The Graafian follicle then becomes thinned at one point, where it soon bursts and allows the ovum to escape into the Fallopian tube (Fig. 16). 43 44 A NURSE'S HANDBOOK OF OBSTETRICS. Once within the Fallopian tube, the ovum makes its way into the uterus, and, if unimpregnated by the male element, it loses its vitality in a few days and is cast off with the menstrual flow. Fig. 16.— Longitudinal section of ovary of a woman on the first day of menstruation, with one burst follicle opening on the surface and other follicles in different stages of development. (Leopold.) When, however, the male germ is present it meets and pene- trates the ovum, usually while it is still in the Fallopian tube. The ovum thus impregnated passes on, as before, into the uterus, but instead of being cast out in the menstrual discharge it becomes adherent to the wall of the uterus and develops into the fcetus and its envelopes, the point of attachment to the uterine wall being the site of the placenta in later months. It is, of course, evident that of the vast number of ova con- tained in the ovaries, a comparatively small number ever mature and are prepared for fertilization by the male element, and that of these, so prepared by maturation and discharge from the ovary, very few are actually impregnated; for the impregnated ova of any woman are accurately measured by the number of her children plus the number of her miscarriages. This lavish provision of nature against any possible inter- ference with the propagation of the human race is also found in the male, for, of thousands of male elements (spermatozoa) deposited at one time within the vagina, very few make their way through the external os and the uterus to the Fallopian tube, and, of these, but one is successful in penetrating the wall of the ovum and causing pregnancy. Ovulation. — The process, by which the ovum develops and is cast out from the ovary into the Fallopian tube, to be impregnated or not, as the case may be, is termed ovulation, PUBERTY. 45 and while it is usually accompanied by menstruation, neither process is dependent upon the other. The accuracy of this last statement is shown by the follow- ing incontrovertible facts : Without ovulation there can be no pregnancy, and yet pregnancy has occurred before the es- tablishment of menstruation ; it has occurred after menstrua- tion has ceased ; and it not infrequently occurs during lactation, when menstruation is suppressed. On the other hand, menstru- ation may occur independently of ovulation, for it has been known to take place after the ovaries and tubes have been removed on both sides. Puberty. — Puberty, in females, is the time of life at which menstruation is first established, and occurs in the temperate zones about the thirteenth year. In tropical countries it is as early as the eighth or ninth year, while in the extreme north it may be delayed until the seventeenth or eighteenth year. Adolescence, which is the period between puberty and maturity, is characterized by rapid physical changes. The ex- ternal genitals enlarge and the pubic hair appears. The hips broaden and the breasts enlarge. Along with the physical are psychical developments. The girl rapidly matures in mind and, unless properly directed, the lack of established mental balance may become serious. This transition period, from girlhood to womanhood, is one of the most critical in the life of every woman. Delicately bred girls require special safeguarding to- ward the end of perfect physical development. Proper hygienic conditions with regard to food, exercise, fresh air and sleep, with an entire absence of excitement, is to be insisted upon. Excessive study is contraindicated, and the habit of spending the first day of menstruation in bed or until all pain has disappeared is the only safe rule to follow. Menstruation. — This is the periodical discharge of blood from the cavity of the uterus, and occurs throughout the child- bearing period at regular intervals of about twenty-eight days, except during pregnancy and lactation, when it is usually sup- pressed entirely. Next to twenty-eight days the most common 4 A NURSE'S HANDBOOK OF OBSTETRICS. interval is thirty clays. Occasionally it occurs every twenty- one days without any appreciable derangement of health. The duration of the flow should be from four to five days and the amount of blood lost from five to six ounces. Regularity is the chief characteristic of a normal menstruation. At the begin- ning and again at the end of the menstrual life, marked ir- regularity may persist for from one to two years. In normal, well-developed women, when no constitutional disease exists, the symptoms preceding and accompanying the flow may be a feeling of weight and congestion in the pelvis, fulness and tingling in the breasts, and slight headache or backache. Excessive pain before or during the menstrual period, if accompanied by general symptoms, points to some disturbance of the pelvic organs, which, in turn, may be due to constitutional disease. In another very large class of women, the symptoms ac- companying menstruation are far more severe. The sensation of weight and congestion in the pelvis becomes excruciating, the backache almost unbearable, and with the intense head- ache may be associated nausea, or even vomiting of a distress- ing type. Where there is no deformity or disease, these cases may be controlled in youth by hygiene, later by a normal in- terest in the great world of out-of-doors. Monotony and confinement lead to morbid introspection or violent excitement. These cases are largely found in the extremes of indolence, and luxury, on the one hand, and great poverty and privation, on the other hand ; and the women who suffer in this way are usually pale, thin, and anaemic, though occasionally stout and plethoric. All marked abnormalities of menstruation are of direct ob- stetrical importance ; for a patient presenting such abnormal symptoms is certainly suffering from the effects of a displaced or undeveloped uterus, and a deformity or slight contraction of the pelvis will be found in a fair proportion of cases. Menopause. — The menopause, climacteric, or "change of life," occurs at or about the forty-third year. Before menstru- MENSTRUATION. 47 ation ceases, the periods become irregular for a few months. The majority of women are apt to suffer nervously and often develop vague hysterical symptoms. Pregnancy may occur at this age and a patient may regard the cessation as indicating this. Nurses need only to be re- minded that discussion of a diagnosis must be conservative and the patient should be referred to her physician. Physiology (continued) FETAL DEVELOPMENT The ovum, originating in the ovary and discharged through the Graafian follicle at or about the time of menstruation, passes into the Fallopian tube, where, if pregnancy is to occur, it meets the male element or spermatozoon. The spermatozoon, shaped t~ Fig. 17.— Human spermatozoa. (Retzius.) A, front view of a spermatozoon ; B, side view ; h, head ; m, middle piece; I, tail; e y end piece. like a tadpole, with head and long tail (Fig. 17), penetrates the wall of the egg-like ovum and conception has taken place. The interior of the ovum, corresponding somewhat to the yolk of an egg and now containing the spermatozoon, divides into two parts, each part containing half of the yolk and half of the spermatozoon. Each of these parts divides in the same way, and each subdivision again divides and subdivides until the interior of the ovum is filled with a mass of minute divisions of the original yolk and spermatozoon (Fig. 18). These are called " cells," and keep on dividing and subdividing in the same man- ner to form the foetus and its envelopes. As each separate cell 48 THE OVUM. 49 contains part of the maternal element (ovum) and part of the paternal element (spermatozoon), it is not difficult to under- stand why the child partakes of the characteristics of both father and mother. Fig. 18. — First stages of segmentation of the ovum of a rabbit. (Allen Thomson, aftei Edward van Beneden's description.) During this process of subdivision of the ovum, which is called segmentation, the entire mass passes slowly on through the Fallopian tube until it emerges into the cavity of the uterus. Once within the cavity, it lodges in one of the folds of the mucous lining, usually in the region of the fundus, and the bor- ders of this fold reach up around it to hold it firmly and prevent its dislodgement (Fig. 19). The mucous membrane lining the uterus undergoes certain changes at each menstrual period, and, as it was formerly sup- posed to be cast off with the menstrual flow and a new mem- brane formed before the next period occurred, it was called decidua (Latin, deciduus, falling off). It it now understood that little or nO tissue from the lining of the uterus is lost in the monthly discharge, but the old name is still retained, al- though the elaborate distinctions between the " decidua of men- struation" and the " decidua of pregnancy" are no longer dis- 4 5° A NURSK'S HANDBOOK OF OBSTETRICS. cussed as formerly. Upon the occurrence of pregnancy there can be, of course, no " falling off "of the uterine lining, no matter what may once have been thought to have taken place at the monthly flow, or the ovum itself would be cast away at the same time and abortion or miscarriage would result. The uterine lining contains a vast number of little creases or folds and the impregnated ovum, after passing from the Fallopian tube into the uterus, lodges in one of these and be- comes securely attached to the mucous membrane, usually near the upper part of the organ, as has already been said. Once securely fixed at this point, the walls of the fold in which the ovum is lodged begin to grow up around it until they meet and enclose it as in a shell. This little shell, containing the impregnated ovum, is made up of decidua, and there is other decidua lining the rest of the uterine cavity upon which this " shell" and its contents lie, much as would a wart in the palm of tht hand when the hand was tightly closed. Thus we have, in pregnancy, three kinds of decidua, — (a) that upon which the ovum rests as soon as it lodges in the fold of the mucous membrane, called decidua serotina; (b) that which folds up around the ovum to encapsulate it, called decidua reflexa; and (c) that which lines the remainder of the uterine cavity, called decidua vera or " true" decidua. These terms, " decidua serotina" and " decidua reflexa," date back to the time when it was believed that the uterine lining was cast off at every menstruation, and before any very clear understanding had been reached as to the manner of the forma- tion of the decidua of pregnancy. At the present day the ex- pressions decidua basilis and decidua capsularis, respectively, are undoubtedly in better usage, but as they are not so gen- erally accepted they will receive no further notice here. As the ovum enlarges, the decidua reflexa also increases in size until, at about the fourth month when the embryo entirely fills the uterine cavity, it meets and blends with the decidua vera at every point. On the decidua serotina, or point of attachment between the impregnated ovum and the uterine wall, is formed what is known THE DECIDUA. 51 as the placenta, through which the foetus receives its nourish- ment and oxygen from the mother and which will be described later. The dccidua reflexa, both before and after it has blended with the decidua vera, forms the outer covering of the amniotic sac, Fig. 19.— Uterus with decidua in beginning pregnancy. (Ruge.) o.i., internal os ; o, ovum, covered by decidua reflexa; d, decidua vera. or " bag of membranes," which is lined with a transparent mem- brane called the amnion and filled with a pale, straw-colored liquid, the amniotic fluid or liquor amnii, in which the foetus floats. Considering, now, the foetus at or near the time of labor, we find it floating in a straw-colored liquid, which is contained in 52 A NURSE'S HANDBOOK OF OBSTETRICS. a sac, the "bag of membranes," or amniotic sac, and which lies within the uterus and fills it entirely (Fig. 20). The function of the amniotic sac is to protect the foetus from blows or other injuries that may be inflicted on the mother, while, at the same time, allowing it considerable freedom of motion ; to provide it with nourishment and oxygen through the placenta ; and. at the time of labor, to dilate the neck of the uterus by forcing its way down through the internal os and stretching the cervix in every direction. Fig. 20.— Normal position of foetus in utero. (Garrigues.) Extremities completely flexed ; occiput presenting, and back of child to left of mother and directed towards the front. (First, or left occipito-anterior, position, — " L. O. A.") Except at one point, which corresponds to the point of at- tachment of the impregnated ovum to the uterine wall, the amniotic sac consists of three layers. The inner, called the amnion, which secretes the liquor amnii, is thin and transparent ; the middle layer, called the chorion, is thicker and translucent ; while the outer layer is made up of decidua reflexa and decidua vera fused together. THE PLACENTA. 53 At the point of attachment of the ovum to the uterine wall, however, a different formation is found. Instead of a thin, veil- like membrane, a thick spongy mass, called the placenta, is de- veloped. It, too, is covered on its inner (fetal) surface with amnion, under which is a layer of chorion, but its outer surface is composed of decidua serotina. The placenta (Figs. 21 and 22) is a circular mass about eight inches in diameter, one to one and a half pounds in weight, and one inch in thickness at its centre, thinning out considerably towards the periphery. It forms part of the bag of membranes, and may be regarded as a large thickened area in the sac, attached firmly to the uterine wall. It is made up almost wholly of blood-vessels, which throw out loops into the uterine tissue to interlock with somewhat similar loops in the vessels of the uterus, but there is no direct connection between the uterine and placental vessels and no actual interchange of blood. The blood of the foetus is pumped by the fetal heart through the placental vessels, and gives up its waste products to, and takes on oxygen from, the maternal blood, much as the blood of an adult is oxygenated by passing through' the lungs in vessels that lie closely in contact with the air-spaces. This process, by which waste products and oxygen can pass from fetal to maternal blood, and vice versa, through the walls of the vessels without any actual mingling of the blood currents, is called osmosis. The placenta and fcetus are connected by means of the funis, or umbilical cord, usually about twenty inches in length and the size of the forefinger. It leaves the placenta at about its centre and enters the abdominal wall of the fcetus at a point called the umbilicus, or " navel," a trifle below the middle of the median line in front. The placenta is formed during the second month of gesta- tion, but is not fully developed until the third month, after which it steadily increases in size as pregnancy advances. The umbilical cord is formed about the fourth week, and, like the placenta, increases in size with the advancement of pregnancy. It is made up of two arteries and one large vein, 54 A NURSE'S HANDBOOK OF OBSTETRICS. Fig. ai.-Fetal surface of the placenta. (Garrigues.) The filmy membrane about the circumference is the ruptured amniotic sac. Fig. 22.-Maternal surface of the placenta. (Garrigues.) THE FCETUS. 55 which are twisted upon each other, and these are protected by a soft, transparent, bluish-white, gelatinous substance called " Wharton's jelly." During the early months of pregnancy the foetus, or " em- bryo," as it is usually called, bears no resemblance whatever to the human form. At the end of four weeks the ovum (Fig. 23) is merely a spongy-looking sphere containing a small, curved, gelatinous mass, with no evidence of head or extremities (Fig. 24), and if an abortion occurs at this time it is almost invariably lost in the discharge of blood. By the end of the third month it has increased considerably in size, being about four inches in length and weighing about Fig. 23. — Human ovum at the end of the first month. Actual size. (Wood's Museum, Bellevue Hospital, No. 1193.) three and one-half ounces (Fig. 25). The head is now devel- oped, and is by far the largest part of the fcetus, being nearly one-third its entire size. The neck and extremities are also formed and the fingers are separated. The skin is of a pale rose-color and very thin and delicate. The placenta is distinctly developed, and the genital organs are formed sufficiently to per- mit recognition of the sex. From this time on the embryo is called the foetus. Development progresses rapidly as the weeks go by, and at the end of the sixth month marked changes have occurred. The fcetus is now about twelve inches long and weighs about 56 A NURSE'S HANDBOOK OF OBSTETRICS. Fig. 24. — Outline of human embryo of about four weeks. Enlarged four times. (Allen Thomson.) Fig. 2.5 — Human foetus at the end of the third month. Three-fifths actual size (Garrigues.) THE FCETUS. 57 Fig. 26.— Skeleton of infant at term, showing large head, large anterior fontanelle, small thorax, cartilaginous sternum, tilted pelvis, and bow-legs. Warren Museum, Harvard University. (Rotch.) 58 A NURSE'S HANDBOOK OF OBSTETRICS. a pound. Faint evidences of the eyelashes and eyebrows have appeared, and the skin is darker and firmer. During the seventh month development is extremely rapid, and by the end of this period the fcetus is about fifteen inches long and weighs from three to four pounds. The eyelids can now be opened, and the skin is firmer, lighter in color than before, and covered with a greasy, sebaceous deposit, called "vernix caseosa," which is most abundant in the folds of the integument, and especially in the axillae and groin. This is probably the earliest time at which a child can be born with any reasonable prospect of living. During the eighth month development is slower, and by the end of the ninth, or at " full term," the infant is plump, com- pletely formed, and ready to perform the functions of respira- tion, digestion, and excretion. It is from eighteen to twenty- two inches in length and weighs from six and one-half to seven and one-half pounds. The nails are fully developed and reach the ends of the finger-tips, the hair is long and full, and the skin is firm and paler than at any other previous time. The head of the fully developed foetus (Fig. 26) is still the largest part of its body, although it has been growing propor- tionately smaller throughout the entire period of gestation. It is oval, or egg-shaped, and it is divided into two parts, the cranium and the face. The cranium (Fig. 27) is the portion possessing the greatest obstetric importance, because, if it can pass safely through the pelvic canal, there is seldom, if ever, any difficulty in delivering the rest of the body. It is made up of eight bones, joined together firmly at the base but separated at the vertex, or top of the head. The sphenoid, ethmoid, and tzvo temporal bones lie at the base of the cranium, and are of no interest to the obstetric nurse. The frontal, occipital, and two parietal bones are, however, of great importance, and form the upper part of the cranium, separated at the time of birth by membranous intervals called sutures, the intersections of which are termed fontanelles. THE FGETUS. 59 6o A NURSE'S HANDBOOK OF OBSTETRICS. By means of this formation of the fetal skull the bones can overlap each other somewhat during labor and so diminish materially the size of the head during its passage through the pelvis. This process of overlapping is called " moulding/' and, after a long labor with a large child and a snug pelvis, the head is often so well moulded that several days elapse before it returns to its normal shape. The sutures of the cranium are five in all, but those sepa- rating the parietal and temporal bones on either side are unim- portant, as they cannot be reached by the examining finger during labor. The coronal suture separates the frontal from the two parie- tal bones, the lambdoidal suture separates the occipital from the parietal bones, and the sagittal, or " greater suture " divides the frontal bone into two parts, crosses the coronal suture, separates the parietal bones from each other, and ends at the lambdoidal suture behind. The anterior fontanelle, large and diamond-shaped, is at the intersection of the sagittal and coronal sutures, while at the junction of the sagittal with the lambdoidal suture is the small, triangular, posterior fontanelle. The sutures and the posterior fontanelle ossify shortly after birth, but the anterior fontanelle remains open until the child is over a year old, constituting the familiar " soft spot" just above the forehead of an infant. By feeling one or another of the sutures or fontanelles, and considering its relative position in the pelvis, the physician is enabled to determine accurately the position of the head at the beginning of labor. The foetus lies in the uterus in a state of complete flexion. Its body is arched forward, its head is bent upon the chest, its arms lie close to its body, with the forearms flexed and crossed in front. The thighs are flexed upon the body and the legs upon the thighs, while the feet are crossed like the hands. In nearly all cases the head points downward and the breech lies at the fundus. This is probably because the head, being the heaviest part of the foetus, would naturally sink to the lowest part of the uterus. FETAL CIRCULATION. 6i The foetus receives its nourishment and oxygen from the mother's blood into its own through the medium of the placenta. The fetal heart pumps blood through the umbilical cord into the placental vessels, which, looping in and out of the uterine tissue and lying in close contact with the uterine vessels, per- mit an interchange, through their walls, of waste products from child to mother and of nourishment and oxygen from mother to child. As has been said, this interchange is effected by the process of osmosis, and there is no mingling of the two blood- currents. In other words, no maternal blood actually goes to the foetus, nor does any fetal blood reach the mother. The fetal circulation is so arranged that this passage of blood to the placenta through the umbilical arteries and back through the umbilical vein is possible up to the time of birth, but ceases entirely the moment the child breathes and so begins to take its oxygen directly from its own lungs. In order to understand, even in a general way, the course of the fetal blood-current, it must be borne in mind that, in the infant after birth, as in the adult, the venous blood passes from the two vense cavae into the right auricle of the heart, thence to the right ventricle, and through the pulmonary artery to the lungs, where it gives up its waste products and takes on a fresh supply of oxygen. After oxygenation the so-called arterial blood flows from the lungs, through the pulmonary vein to the left auricle, thence to the left ventricle, and out through the aorta, to be distributed to all parts of the body and eventually collected, as venous blood, in the two venae cavse and discharged again into the right auricle (Fig. 28). In the foetus there are certain structures necessary to the performance of fetal circulation, but of no use after respiration has commenced and the flow of blood through the umbilical and placental vessels has ceased. Consequently these structures are abandoned as soon as the child cries, and shortly after birth they either disappear entirely or are converted into fibrous cords, and remain in after life as fetal structures only. The most important of these, and the one that must close promptly and effectually at birth if the child is to live for any 62 A NURSE'S HANDBOOK OF OBSTETRICS. DESC:,. VENA J CAV/F ARTERIAL BLOOD p]a§ VENOUS BLOOD Fig. 28.-Diagram of circulation after birth. Adult type. FETAL CIRCULATION. 63 A5CE VENA CAVA RIGHT ventricle; [^Wns [jjjj ARTERIAL BLOOD |&&| VENOUS, BLOOD Fig. 29. — Diagram of circulation before birth. Fetal type. 64 A NURSE'S HANDBOOK OF OBSTETRICS. length of time, is the foramen ovale, — a valve-like opening between the right and left auricles. The others are the ductus arteriosus, connecting the aorta and the pulmonary artery; the ductus venosus, connecting the umbilical vein and the ascending vena cava; and the two hypogastric arteries, springing from the internal iliacs and passing out of the abdomen, through the navel, into the cord, where they become the umbilical arteries. Keeping in mind the course of the blood-current after birth, when these fetal structures have ceased to exist as blood-passages, we can trace the fetal circulation from the placenta, where it is oxygenated before birth, back to its starting-point (Fig. 29). The arterial (oxygenated) blood flows up the cord through the umbilical vein and passes into the ascending vena cava, partly through the liver but chiefly through the ductus venosus which connects these two vessels. It is because of the fact that the liver receives a considerable supply of freshly vitalized blood direct from the umbilical vein that it is, proportionately, so large in the newly born child. From the ascending vena cava the current flows into the right auricle and directly on to the left auricle through the foramen ovale, thence into the left ventricle, and out through the aorta. The blood which goes up to the arms and head returns through the descending vena cava to the right auricle again, but instead of passing through the foramen ovale as before, the current is deflected downward into the right ventricle and out through the pulmonary artery, partly to the lungs (for purposes of nutri- tion only), and partly again into the aorta through the ductus arteriosus. The blood in the aorta, with the exception of that which goes to the head and upper extremities, and which has already been accounted for, passes downward to supply the trunk and lower limbs. The greater part of this blood finds its way through the internal iliacs to the hypogastric arteries, and so back through the cord to the placenta, where it is again vitalized ; but a small amount passes back into the ascending vena cava, partly through the liver and partly from the lower extremities, to mingle with fresh blood from the umbilical vein and again make the circuit of the entire body. MULTIPLE GESTATION. 65 As soon as the child is born it cries and inflates its lungs. This causes the ductus arteriosus to contract, and blood no longer passes from the pulmonary artery into the aorta. At the same time the foramen ovale closes and the blood from the venae cavse, which is discharged into the right auricle, passes at once into the right ventricle, to be sent through the pulmonary artery to the lungs for oxygenation. When the cord is tied and cut the current of blood through the umbilical vessels (arteries and vein) ceases and the blood is dammed back through the hypogastric arteries to the internal iliacs and shut off completely in the umbilical vein and ductus venosus. These processes, which occur instantaneously, change the entire course of the blood-current and convert the fetal circu- lation into the ordinary adult type. The foramen ovale remains closed and eventually disappears, and the ductus arteriosus, ductus venosus, and hypogastric arteries shrivel up and are con- verted into fibrous cords in the course of ten or fifteen days. When, as occasionally happens, two or more embryos develop in the uterus at the same time the condition is known as multiple gestation. This is of very rare occurrence, twins being encountered but once in 90 pregnancies, triplets but once in 8000, and quadruplets but once in 370,000. These figures, of course, vary considerably, but they serve to show the extreme rarity of multiple concep- tions. In twin pregnancies the most common combination of sex is a boy and a girl ; the next in frequency is two boys ; and the least common of all is two girls. Heredity plays an important part in the causation of twins, often making certain families conspicuous on this account, and the hereditary trait is most frequently handed down through the father. Twins are usually due to the fertilization of two separate ova, either from the same or from different Graafian follicles, but they may result from the double impregnation of a single ovum by two spermatozoa or from the complete fusion of a single germ. 36 A NURSE'S HANDBOOK OF OBSTETRICS. Triplets come from the double impregnation or complete fusion of one ovum and the simultaneous single fertilization of another, while quadruplets may be regarded as double twins. In the case of twins it is to be borne in mind that as both umbilical cords may come from the same placenta, the maternal end of Hie cord attached to the first-born must be tied securely before it is cut, lest the unborn child bleed to death. The nurse, from whom skill in ante-partum diagnosis is not to be expected, should make it a point to tie securely both the fetal and the ma- ternal end of every cord before cutting, in view of the possi- bility of the existence of twins. The development of the foetus in multiple pregnancies does not differ from that of single impregnation, except that the in- fants are apt to be small and feeble, usually one being decidedly weaker and more frail than the other. VI The Physiology of Pregnancy By the physiology of pregnancy is meant a consideration of those changes, both local and general, which affect the maternal organism as a result of pregnancy, but which sub- side at or before the end of the puerperium and leave the woman in practically the same condition in which she was before conception occurred. In other words, these changes are to be regarded as normal, unavoidable, and purely temporary, for they are present in varying degree in every instance, and in the case of a physically perfect woman there should be no traces of them left after convalescence is complete. It must be understood that this statement does not refer to certain skin-markings, which will be described later, or to the slight and unimportant lacerations of the genital tract which in- variably accompany a first labor, but only to such conditions as would have a tendency to affect the general health or even the comfort of the woman. Local Changes. — The uterus increases in size to make room for the growing foetus. It becomes more vascular and the thickened, growing mucous membrane becomes the de- cidua of pregnancy. At the end of four months it has risen out of the pelvis. Its muscular walls become much stronger and more active, and the abdomen must enlarge to accommodate the growing uterus. The mechanical effect of this distention of the abdominal wall causes, in the later months of pregnancy, the formation of certain reddish or bluish streaks in the skin covering the sides of the belly and the anterior and outer aspects of the thighs. These streaks are known as "stria gravidarum" or "linece albicantes," and are due to the stretching, rupture, and atrophy of the deep connective tissue of the skin. They grow lighter after labor has taken place, and finally take on the 67 68 A NURSE'S ll.wnnOOK OF OBSTETRICS. silvery whiteness of cicatricial tissue. In subsequent preg- nancies new reddish or bluish lines may be found mingled with old silvery white striae. Fig. 30. — Strias gravidarum, or Lineae albicantes, showing also abdominal pigmenta- tion especially marked around navel, and protrusion of umbilicus. Multigravida at term. Twins. The number, size, and distribution of stricc gravidarum vary exceedingly in different women, and patients are occasionally seen in whom there are no such markings whatever, even after repeated pregnancies. As the striae are due solely to the stretching of the cutis, they are not peculiar to pregnancy, but may be found in other conditions which cause great abdominal distention, such as dropsy and the presence of large tumors of rapid growth. PHYSIOLOGY OF PREGNANCY. 69 Coincident with the uterine and abdominal enlargement the umbilicus is pushed upward until, at about the seventh month, its depression is completely obliterated and it forms merely a dark- ened area in the smooth and .tense abdominal wall. Later it is raised above the surrounding integument and projects to about the size of a hickory-nut. While these changes in the uterus and abdomen are going on the vagina and external genital organs are being prepared for the passage of the foetus at the. time of labor. The parts are thickened and softened and their vascularity is greatly increased. This increase in the blood-supply of the genital canal gives to the tissues a dark-violet hue, in great contrast to the ordinary pinkish color of the parts, and often described as a valuable sign of pregnancy. Towards the end of gestation the vaginal secretion is in- creased in amount to serve as a lubricant at the time of delivery. The changes in the breasts are such as will prepare these organs for the performance of nursing, and begin to show them- selves shortly after the occurrence of conception (Fig. 31). The breasts become larger, firmer, and more prominent, and the nipples increase in size, grow sensitive, and are easily stimulated to erectility. The pinkish areola about the nipple of the woman who has never borne a child grows larger and darker until it becomes brown or, in some cases, almost black. This change in the color of the tissue surrounding the nipple is most pro- nounced in decided brunettes and less marked in women of the blonde type. The sebaceous glands which surround the nipple to the number of about a dozen, and are known as the " glands of Montgomery," become enlarged into little rounded elevations under the influence of pregnancy, and are then called the " tu- bercles of Montgomery" (see Fig. 41.) The distention of the skin covering the breasts also causes the formation of " striae" similar in every respect to those already described as occurring in the abdominal integument. Like the abdominal striae, these markings vary greatly in different sub- jects and not infrequently are entirely absent. After the third month the breasts contain a thin, bluish-white, 7 A NURSE'S HANDBOOK OF OBSTETRICS. translucent fluid known as " colostrum," consisting chiefly of fat corpuscles, epithelial cells, and " colostrum corpuscles." Colostrum is the only substance secreted by the breast until about the third day after labor, when the true milk is formed. It contains practically no nourishment, but is of value to the infant during the early days of its life because of its marked laxative effect. Systemic Changes. — The blood of the pregnant woman is increased in amount and in its fluid constituents, while the red cells are proportionately diminished. These changes fre- quently cause disturbance of the circulatory apparatus and the left side of the heart is appreciably enlarged in order to per- form the extra work of pumping this increased quantity of blood through the body. In certain cases the fluid constituents of the blood are increased to such a degree that marked swell- ing (oedema) of the legs, thighs, and external genitals may occur. This oedema must not be confused with that due to kidney disorder; and any swelling of the extremities must be reported at once to the physician. The lungs are subjected, in the later months of pregnancy, to pressure from the underlying uterus, and the patient may suffer severely from cough and dyspnoea. Owing to the in- crease in the total quantity of the maternal blood, and because of the fact that the mother is called upon to oxygenate not only her own blood, but, by osmosis, that of her infant as well, the work of the lungs is markedly increased and the elimination of carbonic acid gas is much greater than in the non-pregnant state. The digestive, secretory, and excretory organs are likewise taxed to a high degree ; for the pregnant woman must, in order to nourish both her child and herself, form more blood, digest more food, and excrete more waste products. After a few weeks these increased demands on the digestive organs begin to manifest themselves by causing nausea and vomiting, and the patient is fortunate if these symptoms do not cause her great distress up to about the middle of gestation. VII The Phenomena of Labor Labor occurs at the end of pregnancy, and is also known by the various names of "delivery" "confinement," "lying-in" and "parturition." The usual time for labor to take place is two hundred and eighty days (ten lunar months, or nine calendar months) after the occurrence of conception. This period varies somewhat, and it is possible for a child to be born and live after only about two hundred and twenty days of utero-gestation. These cases are, of course, extremely rare, and it goes without saying that the more nearly the pregnancy reaches its normal duration the better will be the development of the child and the better its chances for living. The only exceptions to this rule are in cases where the mother is suffering from a disease that greatly imperils the life of the child, or where the child is very large or the pelvis very small, and the induction of premature labor exposes the infant to less risk than would a difficult operative delivery at full term. The popular belief that a seven-months baby has better chances for life than one born at eight months is the most arrant nonsense. It probably arises from the fact that a child born at seven months is positively known to be premature, and so re- ceives the most careful attention after birth, while an eight- months baby is so nearly a full-term infant that its prematurity is often overlooked and it receives no special attention, and may die from some inadvertent neglect of small but important details. After it is dead the fact that it was one month prema- ture is brought out and commented upon. In other cases the pregnancy may exceed its usual duration of two hundred and eighty days, but probably it never goes more than three weeks over term under any circumstances, and three hundred days may be regarded as the extreme limit. In France t 1 rj"s point has been made a matter of legislation, and an infant 75 ;<> A NURSE'S HANDBOOK OF OBSTETRICS. born at any time within three hundred days after the death of its mother's husband is regarded by law as legitimate and enti- tled to property rights in the father's estate, while one born even twenty-four hours after this period is deprived of the right of inheritance. The cause of labor is probably due to the fact that at the end of pregnancy the uterus is stretched to its greatest possible extent, while the foetus continues to grow larger. The muscular fibres of the uterus resent this over-distention and put an end to it by contracting and forcing the foetus out of the womb. This theory is borne out by the fact that in twin pregnancies, or in other cases where the uterine contents is unusually large, prema- ture labor is very likely to occur, showing that when a certain degree of distention is reached labor will begin. The premonitory symptoms of labor are usually well marked in the case of a first pregnancy, but in some instances, and especially with women who have borne children, they may be entirely absent. When they do occur they may begin at any time up to two, or even three, weeks before the actual onset of labor. They are due chiefly to the sinking down of the uterus into the pelvis preparatory to the engagement of the fetal head in the pelvic brim. This relieves the pressure on the diaphragm and so lessens or stops the cough, dyspnoea, and other unpleasant symptoms of the last weeks. While the sinking of the uterus relieves the pressure above the diaphragm, it increases that on the pelvic viscera, causing constipation and irritability of the bladder. On the whole, however, the woman feels more com- fortable than she did before the sinking of the uterus. In addi- tion to the symptoms due to alterations in pressure there are occasional slight uterine contractions occurring at irregular inter- vals and causing the woman no discomfort beyond sensation of faint and indefinite cramp-like pains in the abdomen. Labor is divided, for convenience of description, into three distinct stages. The first stage begins with the first true labor-pain and ends with the complete dilatation of the os uteri. The second stage begins with the end of the first and ends with the birth of the child. STAGES OF LABOR. 77 The third stage begins with the end of the second and ends with the delivery of the placenta and membranes. In normal cases the first stage is longer than the second and third together, for after the os is fully dilated the labor pro- gresses rapidly. Labor-pains are merely the rhythmical contractions of the uterine muscle, and are called " pains " because of the suffer- ing that accompanies them. The incorrectness of the term is evident when one occasionally hears a woman say, " I always have easy labors ; my pains never hurt me at all." The term is synonymous with uterine contraction. The Phenomena of the First Stage. — The pains are short, slight, and separated by long intervals, usually about half an hour. They do not cause the patient any particular discom- fort, and are not accompanied by any straining of the abdominal muscles. What little pain there is is located in the back, and the patient is usually on her feet and walking about. If the woman has never borne a child or seen a labor, she is commonly in rather a jocular frame of mind, and often expresses great contempt for the reputed suffering of child-birth. A little later, however, the entire picture changes. The pains last longer and are more severe, and recur at more frequent intervals. The patient is still walking about, but at the begin- ning of each pain she grasps a chair-back or some other piece of furniture, and, leaning heavily against it, " grunts " audibly when the pain is at its height. Even now the pains are not specially severe, and between them the patient is usually cheerful and still of the belief that labor is not such a terrible thing after all. As the hours go by the pains become more and more frequent, until they are only five or six minutes apart, while at the same time they last longer and are more severe. The patient is now tired and fretful, and begins to complain bitterly that the end will never come and that something must be done to relieve her. Her entire disposition changes and her face bears an expression of anxiety and dread. She may be nauseated, or even vomit, and her bowels and bladder are emptied every few minutes. At the acme of each pain she usually moans slightly, and in the ;S A NURSE'S HANDBOOK OF OBSTETRICS. intervals she says little, except to ask for water, or other attention, and complain of the slow progress she is making. This picture indicates that dilatation of the os uteri is nearly, if not entirely, complete, and the nausea and vomiting are favor- able symptoms for they are accompanied by relaxation of the tissues. At or about this time the amniotic sac, which, from the begin- ning of labor, has been forcing its way down through the os and dilating it in every direction, usually ruptures and the fluid escapes with an audible gush. Even without a vaginal examination it is usually easy to tell from the appearance of the patient that the first stage of labor is at an end. It may have lasted anywhere from one to twenty- four hours, and is always protracted if the membranes rupture before dilatation of the os is complete. The Phenomena of the Second Stage. — The patient is now in bed and the pains are severe, long (fifty to one hundred seconds), and occur at intervals of every two or three minutes. The abdominal muscles are now brought into play, and as a pain occurs the woman " bears down " with all her strength, so that her face becomes red and even cyanotic, and the large vessels in her swollen neck pulsate violently. At the beginning of a pain she begins to mumble fretfully, and as it reaches its height she concentrates all her voice into a peculiar frenzied cry, so charac- teristic of labor that one who has ever heard it would recognize it at once, even amid the most improbable surroundings. With it all, however, the woman does not complain as much now as during the first stage, and, instead of plying the nurse and physician with impatient demands for relief, she devotes her entire energy to delivering herself, and at times seems almost oblivious of her surroundings. Towards the end of the second stage, when the head is well down in the vagina, its pressure often causes small particles of fecal matter to be expelled from the rectum at the occurrence of every pain. This must receive most careful attention in order to avoid infection. The pains are now occurring so rapidly that there is scarcely Fig. 33. — Preserving the perineum. Fig. 34. — Another case. Preserving the perineum. -The same case. Farther advanced. It is becoming necessary to use the full hand in retarding the progress of the head. Fig. 36. — The same case again. Emergence of the forehead and face. No perineal tear visible as yet. Fig. 37- — The same case continued. Delivery of the anterior shoulder. Note the congestion of the child's face. Fig. 38. — Expressing the placenta by the method of Crede. Fig. 39. — Twisting the membrane into the form of a rope to prevent tearing. • "*■■% ■ m Fig. 40. — Inspecting the placenta. STAGES OF LABOR. 79 any interval between them, and finally, with a sharp, agonized shriek, the head is born and the mother lies gasping for breath and sighing contentedly. One or two more pains are enough to effect the birth of the body, and practically all of the labor is over. The Phenomena of the Third Stage. — Towards the end of the second stage the placenta has become detached from the uterine wall and lies loosely in the womb or partly in the vagina. After the birth of the child the uterus contracts firmly on the placenta, and there is a period of from ten to thirty minutes in which no pains occur and the exhausted muscles rest from their exertions. A little blood trickles from the vagina, and finally, with one short and not very severe pain, the placenta and mem- branes are expelled and the uterus contracts firmly and per- manently. The total duration of labor in normal cases averages about ten hours, the greater part of which time is taken up by the first stage; but the time may vary from one or two to even twenty- four hours without being in any way injurious to the patient. VIII The Physiology of the Puerperium The puerperium, also called the "puerperal state" and the " lying-in state," is practically a period of convalescence extend- ing from the end of the third stage of labor to the time when the patient has fully recovered from its effects. While, in nor- mal cases, it cannot properly be called a pathological condition, it is so nearly on the border line between health and disease that it must be most carefully watched lest serious complications develop suddenly and unexpectedly. Immediately after labor the patient experiences a sense of exhaustion, which is soon followed by a feeling of delightful comfort and repose. Her child is born, her sufferings have ceased, and she usually passes from a state of perfect content- ment into drowsiness, and finally into sound and natural sleep. Every effort should be made to encourage this state of affairs, and the necessary toilet of the patient and arrangement of the room must be made as quietly and expeditiously as possible, while all visitors, except possibly the husband or mother, are to be rigidly excluded. A chill occurring immediately after labor, and due partly to a disturbance of equilibrium between external and internal temperature, caused by the excessive perspiration in the stage of greatest muscular exertion, and partly to the sudden removal of a large mass of tissue from the abdominal cavity, is not of infrequent occurrence and has no unfavorable significance. A warm bed, hot-water bottles, and a drink of warm tea are all that is needed to control it effectually. The pulse of the puerperal woman should show a marked drop in frequency, due probably to greatly lessened arterial ten- sion. It usually goes down to about 60, and even a fall to 40 beats per minute is not uncommon. This is always a favorable symptom, while a rapid pulse after labor is to be regarded with 80 PULSE AND TEMPERATURE. 8l suspicion as an indication of shock or possibly of concealed hemorrhage. The temperature of the patient usually rises slightly, and while 1 00.5 ° F. is generally regarded as the limit in normal cases, patients occasionally show a somewhat higher tempera- ture without ill effects. In judging of the significance of the temperature the pulse is the best guide, for a puerperal pa- tient with a slow pulse is not likely to do badly even if her tem- perature is a little high. Nevertheless, the nurse should report at once to the physician a temperature of over 100.5 ° F. or a pulse of over 100, and such a patient must be watched most carefully for the possible development of further unfavorable symptoms. The uterus begins to return to its normal condition with the beginning of labor. This process is called "involution/' and consists partly in the contraction of the womb and partly in the destruction of certain of its tissues, which are carried away not only in the discharge of blood and serum that follows later, but by means of the general circulation as well. The normal process of involution requires about six weeks, and at the end of that time the uterus should be, as nearly as it ever will be, in the condition it was in before pregnancy occurred. It never re- turns to exactly the virgin state, but may approach it very closely if there have been no lacerations of the cervix. Involution is favored and hastened by everything that tends to make the puerperium perfectly normal, and is delayed by the opposite condition. It is on this account that breast-feeding of the infant is urged in the interest of the mother, for the reflex connection between the breasts and the uterus is so well estab- lished that the irritation of the nipple in nursing acts as a power- ful stimulus to uterine contractions. "Subinvolution" is the term used to describe the condition which exists when involution is not complete at the time when it should be. It is a chronic condition, characterized by a large and flabby uterus usually more or less chronically congested, and causes the patient much discomfort and disturbance of health until it is corrected. 6 82 A NURSE'S HANDBOOK OF OBSTETRICS. The vaginal walls, the vulva, and all other tissues that have become hypertrophied during pregnancy also undergo a process of involution in their return to their normal condition, and the abrasions and lacerations of the genital canal caused by the passage of the foetus heal completely during the puerperium. Lochia is the name given to the discharges that come from the uterus and vagina for about three weeks after the birth of the child. At first the discharge consists almost entirely of blood, which escapes from the placental site on the uterine wall, mixed with a small amount of mucus and particles of decidua. This should not have large clots or membrane or be in excessive amount. It is known as " lochia rubra " (red lochia), or " lochia cruenta," and lasts about three days, when it gradually changes to a pinkish color due to the admixture of a considerable amount of serum from the healing surfaces ; it is known as " lochia sanguinolenta." Towards the eighth or ninth day the lochia is thinner, less in amount, and of a greenish-yellow color with characteristic odor, and is known as " lochia purulenta "; by the end of the third week the discharge usually disappears. The lochia should never, at any time, have an offensive odor, although it possesses a peculiar animal emanation which is quite characteristic. Premature suppression of the lochial discharge may be caused by cold, fright, grief, or other emotion, and is usually dependent upon a relaxed condition of the uterus. Late return of blood in the discharge, after it has once dis- appeared, often occurs when the patient gets up too soon, and is not of any serious import if she returns to her bed for a few days longer. But anything abnormal passed must be promptly reported to the physician and also saved for his inspection. " After-pains" are painful contractions of the womb occur- ring after labor and due to its efforts to expel a blood-clot which has formed within it when it was in a state of relaxation. After- pains are more common in women whose tissues are soft and flabby, and so are seen less frequently in primiparae than in those who have borne many children. They occur at intervals, like labor-pains, and often are said by the patient to cause her more suffering than the labor-pains themselves. The proper manage- RETENTION OF URINE. 83 ment of the fundus uteri will insure firm and permanent con- traction, and is the best preventive against after-pains. When they are at all severe they interfere markedly with the patient's rest and comfort, and the physician will usually find it necessary to remove the clot from the uterus to effect a cure. Under or- dinary circumstances they will disappear spontaneously about the fourth day. Retention of urine is not uncommon during the first two or three days after labor, owing to the swollen condition of the urethra and the tissues surrounding it. Its treatment is dis- cussed in the following chapter. Constipation after labor is the rule rather than the excep- tion, because of the relaxed condition of the intestinal and abdominal muscles and the inability of many persons to empty the bowels while in the dorsal position on the bed-pan. As the rectum has been, or should have been, emptied by enema at the beginning of labor, nothing further is needed until about two days have elapsed, when the physician usually orders a simple cathartic, such as castor oil. The appetite of the patient is usually somewhat diminished during the early part of the puerperium, and this, combined with the fact that all of her excretions are markedly increased, causes her to lose flesh to the amount of from nine to twelve pounds before she begins to gain in weight. "Milk fever" is a term occasionally, and incorrectly, used to describe a slight and unimportant rise of temperature that occurs about the third day and subsides in a few hours. This was long supposed to be due to the development of milk in the breasts, which occurs at the same time, but it is now known to depend entirely on a very slight infection due to the un- avoidable introduction of a few bacteria into the genital tract. The author believes, however, that the mere discomfort, due to tension in the early days of lactation, unless steps are promptly taken to relieve it, is not infrequently responsible for this phe- nomenon, independently of any infection whatever. It is quite a regular occurrence, and should never last more than a day. Directions for nursing and care of the breasts will be found in another chapter. IX The Signs and Symptoms of Pregnancy As stated in the introductory chapter, it is highly desirable for the pregnant woman to be under medical care from as early a date as possible, and as women who suspect that they are pregnant are very apt to discuss the matter with a nurse before consulting a physician, the first duty of the nurse under such circumstances is to advise the patient of the importance of seeking medical counsel at once. More than half the women who present themselves at the physician's office late in pregnancy have nurses engaged for their confinements, and yet it seldom happens that these patients visit the physician by the direction of their nurses. In short, it would seem that nurses and physicians do not work together in such matters to the extent that they should, and it rests with the nurses to bring about a more harmonious state of affairs. Naturally, before advising a patient to consult a physician in regard to a suspected pregnancy, the nurse will wish to be reasonably sure in her own mind that conception has actually occurred. There are many signs and symptoms which point to the existence of pregnancy, some of which can readily be recog- nized by the nurse, while others can only be made out accurately by one who has had a thorough medical training. Of these signs, but three are absolutely indicative of preg- nancy, and of these, two may be absent if the foetus has died in the womb. Moreover, these " positive" signs are not present until about the middle of gestation, when the physician can usually make a diagnosis without them by the " circumstantial evidence" of a combination of earlier and less significant symp- toms. While, in the great majority of cases, the early diagnosis of pregnancy is extremely easy to one familiar with such condi- 84 MORNING SICKNESS. 85 tions, it occasionally presents many difficulties, even to the skilled observer, and in rare instances no positive statement can be made until one or another of the three positive signs has appeared. The signs of pregnancy are divided by most writers into three groups, and in the following table those which are appre- ciable to the educated nurse are printed in heavy-faced type. A. PRESUMPTIVE SIGNS. 1. Menstrual Suppression. 2. Vomiting. (" Morning Sickness.") 3. Irritability of the Bladder. 4. Mental and Emotional Phenomena. ("Morbid Longings, etc.") B. PROBABLE SIGNS. i. Mammary Changes. (Enlargement of the Breasts, Shooting Pains, Pigmentation, etc.) 2. Bimanual Signs. (Size of Uterus, Hegar's Sign, etc.) 3. Abdominal Changes. (Size, Shape, Pigmenta- tion, etc.) 4. Changes in Cervix. (Size, Shape, Consistency, etc.) 5. Violet Color of the Vaginal Mucous Membrane. 6. Uterine Murmur. 7. Intermittent Uterine Contractions. C. POSITIVE SIGNS. i. Passive Fetal Movements. (" Ballottement.") 2. Active Fetal Movements. ("Quickening.") 3. Fetal Heart Sounds. Cessation of menstruation and morning vomiting are placed first in the list of Presumptive Signs because the former is the symptom usually first noticed by the patient and the latter is the one that is most likely to bring her to the physician. Irritability of the bladder, characterized by very frequent and often more or less painful voiding of the urine, is also apt to be the first symptom of pregnancy. This may occur very 86 A NURSE'S HANDBOOK OF OBSTETRICS. shortly after conception and before the next menstrual period is due. and as it is often ascribed by the patient to " catching cold," or to some other trivial cause, it is not, as a rule, men- tioned except in response to the questioning of the physician. This irritability is due to the pressure, on the bladder, of the recently impregnated uterus, which has a tendency to tip for- ward and settle down deeply in the pelvis, and, when accom- panied or followed by stoppage of the menstrual flow it is, in a married woman, very suggestive of pregnancy. If this combination of symptoms is followed by vomiting on arising in the morning, or even by nausea at this time, the diag- nosis becomes more probable than ever. The usual character of this form of vomiting is that of a sudden, paroxysmal emptying of the stomach, occurring the moment the patient gets out of bed. Under normal conditions, it may continue until about noon, the stomach promptly reject- ing any food or drink that may be swallowed. After twelve or one o'clock the irritability of the stomach usually ceases, and the patient has no further trouble or discomfort until the next day, when the whole affair is repeated. This symptom begins, as a rule, about the end of the second month, but it may be noticed at any time after conception has occurred, even as early as the third or fourth day. It generally stops by the end of the fourth or fifth month, and vomiting occurring late in pregnancy is always to be regarded with suspicion, as indica- tive of some severe systemic disturbance of toxasmic origin. Mental and emotional phenomena are, fortunately, not very common, but they may be noticed in some cases. For example, a woman of the most amiable disposition may, under the influence of pregnancy, become exceedingly disagreeable and fretful, while, on the other hand, one of great asperity may, rarely, go to the opposite extreme and take on the qualities of a veritable saint. In the same way, articles of food and forms of amusement, ordinarily unthought of, may suddenly be demanded, and in rare instances the most unusual and even disgusting impulses may be fostered. The writer has had recently under CHANGES IN THE BREAST. 87 his care a woman who, when pregnant, developed an irresistible appetite for raw potatoes. The changes in the breast include enlargement of the entire gland on both sides ; a sense of fulness, and shooting or tingling pains in these organs ; and darkening of the tissues surrounding the nipples (Fig. 41). Temporary slight enlarge- FlG. Marked pigmentation of breast. Tubercles of Montgomery and a drop of milk on the nipple plainly shown. ment of the breasts and sensations of weight and fulness are, of themselves, of no significance, for, in many women they may be noticed at the ordinary menstrual periods, but the darkening of the areola around the nipples and the presence of a silvery white fluid (colostrum), which can be squeezed out of the breast, constitute, in a woman who has never borne children, very significant signs of pregnancy. If, however, the woman has had a child, the areolar pigmentation from the previous preg- nancy will remain, and it is not unusual for colostrum to be present for months or even years after it has once appeared. Thus, while it is apparent that these breast symptoms are not of much account in the case of a woman who has borne chil- 88 A NURSE'S HANDBOOK OF OBSTETRICS. dren, they are of great significance if the patient has never been pregnant before. The abdominal changes are supposed to begin with a flat- tening of the abdominal wall in the early weeks of gestation, due to the tipping forward and sinking of the uterus, to which reference has already been made as causing irritability of the bladder. This supposititious flattening has given rise to the old French saying, — " Ventre plat, Enfant il y a ;" which doggerel, being translated freely and with equal poetic feeling, would read, — " In a belly that is flat There's a child, be sure of that;" but, as King has said, " One can't be sure of that," by any means. In the first place, the uterus at this time is so small that no change in its position would have any tendency to appreciably flatten or otherwise affect the contour of the ab- dominal wall, and even if such a change did occur it would be so slight that it is highly improbable that it would ever be noticed by the patient or brought to the attention of the physi- cian or nurse. The pigmentation of the abdomen, extending up the median line and surrounding the umbilicus is, in a woman who has never borne children, almost diagnostic of pregnancy, but, like the pigmentation of the breast, it varies exceedingly in different subjects, being often entirely absent in decided blondes and exceptionally well marked in pronounced brunettes. In women who have borne children previously this pigmentation remains from the former pregnancies, and cannot be depended upon as a diagnostic sign. The size of the abdomen in pregnancy corresponds with the increase in the size of the uterus, which, at the end of the third month is at the level of the symphysis pubis, at the end of the sixth month at the level of the umbilicus, and towards the end of the ninth month at the ensiform cartilage. Mere ab- PASSIVE FETAL MOVEMENTS. 89 dominal enlargement may be due to a number of causes, such as an accumulation of fat in the abdominal wall, dropsy, uterine or ovarian tumors, and the like. If, however, the uterus Fig. 42. — Size of the uterus at each month of pregnancy. The fundus reaches the symphysis at the third month, the umbilicus at the sixth month, and the ensiform cartilage at the middle of the eighLh month, after which it sinks a little before labor begins. can be distinctly felt to have enlarged in the proportions stated above, pregnancy may properly be suspected. The nurse cannot be expected to make out this uterine enlargement until the fundus is well above the symphysis, so this sign is of no value to her as a means of early diagnosis. The nurse will hardly be called upon to inspect the vaginal mucous membrane for evidences of pregnancy, but it may be said that, owing to pressure and consequent congestion within the pelvis, this mucosa becomes thickened and of a dark violet or purple color instead of its customary pinkish tint in the non- pregnant state. This sign is of no special value in women who have borne children, and as it may be due to any form of con- gestion or to the presence of new growths or varicosities within the pelvis, it is very unsatisfactory at best. Passive fetal movements (" ballottement," from the French ballotter, to toss up like a ball) can only be made out by the physician skilled in obstetric examinations, but the active movements of the fcetus within the uterus are readily 9° A NURSE'S HANDBOOK OF OBSTETRICS. recognized after the fifth month by placing the hand firmly against the abdominal wall over the uterus and holding it there until the foetus is felt to kick vigorously, as it does every few minutes. This sign is unmistakable to the examiner, although the patient may sometimes imagine the movements of gases in the intestines to be the motions of a foetus within the uterus. If the child is dead these movements will not be felt, but there will usually be a history of the previous occurrence of such fetal activity. The sounds of the fetal heart are often heard with great difficulty by the physician, and it is not to be expected that a nurse will always be able to make them out. Occasionally, however, in the latter months of pregnancy and with all con- ditions favorable, the nurse will be able to hear the fetal heart- beat, like the ticking of a watch under a pillow, by placing the ear firmly against the abdominal wall. The fetal heart should make from one hundred and thirty to one hundred and fifty beats to the minute, and is absolutely distinct from the maternal pulse. Like active fetal movements, this sign will not be discovered if the child is dead. Having decided, from one or more of the above signs, that the woman is probably pregnant, or if there is any doubt as to her condition, she should be directed to consult, at once, the physician who is to attend her during her confinement. The probable date of the labor may be computed by taking the first day of the last menstruation, counting back three months, and adding seven days. This will give a date which is to be regarded as the middle of a period of two weeks during which the labor may be expected to occur. Thus, if the woman's last menstruation began on June 14, count back three months to March 14 and add seven days, making March 21. She may then be told that her labor will probably take place between March 14 and March 28. Remember that this is merely an approximate date, for the exact time of impregnation can seldom be determined, and it is not at all certain that the woman will go her complete term of two hundred and eighty days after impregnation, even if that date were positively known — so the exact date for delivery can never be definitely known. X The Mechanism of Labor In studying the mechanical phenomena that accompany de- livery it is necessary to consider three factors, — the " passenger' (foetus) ; the "passages" (uterus, vagina, and vulva) ; and the forces of labor, which impel the " passenger" through the " pas- sages" into the world. The forces of labor may be subdivided into two classes, — the expulsive forces, situated in the muscular fibres of the uterus and assisted by the powerful abdominal mus- cles ; and the resistant forces, which consist of the resistant powers of the tissues composing the cervix, the vaginal floor, and the perineum. These two classes of forces must be very nearly balanced, but with the expulsive force slightly in excess, if the labor is to be normal. If the resistant forces are in excess, labor cannot occur without operative interference, and if the expulsive force greatly exceeds the resistant force a precipitate labor will result, with probable severe laceration of the maternal soft parts and with great danger to both mother and child. The "passenger" (foetus) lies in the womb in a state of complete flexion, and we have to consider its presentation and its position, for unless these are both normal, or can be made normal, the labor cannot be normal. Presentation refers to that part of the foetus which " pre- sents" at the brim of the pelvis at the beginning of labor. For example, if the head lies in the brim ready to come down into the vagina the case is said to be one of " vertex" presentation ; while if the breech is first to appear, it is called " breech" pres- entation. Position has to do with the relation of the presenting part to the pelvis. Thus, in a vertex presentation, the back of the head (occiput) may point to the front or to the back of the 9i A NURSE'S HANDBOOK OF OBSTETRICS. p IG ^ — Vertex presentation. (Bumm.) A, left occipito-anterior (L. O. A.); B, tight occipito-anterior (R. O. A.); C, right occipito-posterior (R. O. P.); D, left occipito- posterior (L. O. P.). VERTEX PRESENTATION. 93 pelvis. The occiput never points exactly forward or backward in the median line, but is always directed to one side or the other of the middle. Consequently we may have any one of four positions in a vertex presentation, — namely : Occiput to left of front, or left occipito-anterior. (" L. O. A.") Occiput to right of front, or right occipito-anterior. (" R. O. A.") Occiput to right of back, or right occipito-posterior. (" R. O. P.") Occiput to left of back, or left occipito-posterior. (" L. O. P.") Vertex presentations (Fig. 43) occur in nearly all cases (ninety-seven per cent.), probably because the head is the heaviest part of the foetus, and so has a natural tendency to sink to the bottom of the uterus. The position of more than half (seventy per cent.) of all vertex presentations is with the occiput to the front and to the left of the median line. This is called the " left occipito-anterior" position of the vertex, and is usually abbreviated by physicians as " L. O. A.," an expression with which the nurse will become very familiar in the course of her obstetrical training. " L. O. A." is by far the most common of all positions, and as, for this reason, it may be regarded as the normal position of the foetus in utero it is also occasionally styled the " first" position. In the same way, the other positions of the vertex, " R. O. A.," " R. O. P.," and " L. O. P.," are sometimes called, respec- tively, the second, third, and fourth positions of the vertex. In order that the vertex, or top of the head, may present, the head must be "flexed;" that is, tipped forward on the chest; and this flexion increases as labor progresses until the head has passed through the brim of the pelvis and is in the vagina (Fig. 44). While the head is descending in this way the occiput is grad- ually rotated forward (in anterior cases) until it lies in the median line in front and under the symphysis pubis. This rota- tion is due to the action of the funnel-shaped walls or "inclined 94 A NURSE'S HANDBOOK OF OBSTETRICS. planes" of the pelvis, which turn the head in the right direction much as a ball may be rolled down a winding gutter or trough. Fig. 44. — Flexion of head during second stage. (Pinard and Varnier.) The shaded head shows the minor flexion at the beginning of labor, and the unshaded the stronger flexion as labor progresses, oc, oc', occiput. As soon as the completely flexed head has passed through the pelvic brim and lies with the occiput under the symphysis, the process of " extension" begins. The chin is now raised from the infant's chest and sweeps down over the posterior vaginal wall and perineum into the world ( Fig. 45 ) . The occiput, which has been practically stationary under the symphysis, where it has acted as a pivot during the extension of the head, is now born, and the most difficult part of the labor is over. Almost immediately after the birth of the head it is again rotated in a quarter-circle, so that its back points to the same side that it did at the beginning of labor. This is called " exter- nal rotation'' or "restitution" (Fig. 46), and is caused by the action of the inclined planes of the pelvis on the shoulders of the infant, which are rotated like the head as they pass down through the pelvic canal. " External rotation" is of interest to the physician, as it enables him to verify his diagnosis of posi- tion, made at the beginning of labor. If the case is " L. O. A.," FLEXION AND EXTENSION. 95 the back of the head will, after external rotation, point to the left side of the mother, as it did before labor began. Fig. 45. — Extension of the head in anterior presentations of the vertex. (Garrigues.) We have, then, to consider during labor in anterior positions of the vertex (" L. O. A." and " R. O. A."), Flexion, Rotation, Extension, and Restitution of the head, all accompanied by De- scent (Fig. 47). If, instead of being Hexed, the head, in a vertex case, is ex- tended or tipped backward on the body of the child at the begin- ning of labor, the case will become one of "face" presentation. This is one of the most serious complications that can arise in connection with labor, for if the face cannot be changed by the physician into a vertex presentation, the child cannot be born, except in rare instances, without operative interference of one kind or another (Fig. 48). 9 6 A NURSE'S HANDBOOK OF OBSTETRICS. "Brott/' presentations are those midway between face and vertex, and occur when the head is neither fully flexed nor fully Fig. 46. — External rotation. (Garrigues.) The case was originally L. O. A., and the vertex now points to the left thigh of the mother. extended (Fig. 49). Because of the ''wobbly" position of the head, brow cases usually convert themselves into either face or vertex presentations before labor is very far advanced. Hap- pily, the most common outcome of a brow case is spontaneous conversion into a vertex presentation. Either a brow or face presentation may occur in any one of four positions, named according to the direction in which the chin points (Fig. 50). Breech presentations are those in which the breech instead of the vertex presents at the pelvic brim. They are fairly com- INTERNAL ROTATION AND EXTENSION. 97 mon, and the chief difficulty in their management lies in the fact that, during the descent of the body, the arms of the fcetus are liable to become extended above the head and interfere Fig. 47- — Internal rotation and extension. (Tarnier and Chantreuil.) seriously with its passage through the pelvis (see Fig. 64). Breech presentations occur in any one of four positions, named according to the direction in which the sacrum of the infant points (Fig. 51), thus: Left sacro-anterior (" L. S. A.") Right sacro-anterior (" R. S. A.") Right sacro-posterior ("R. S. P.") Left sacro-posterior (" L. S. P.") In breech cases the infant often passes meconium from its rectum during the course of the labor, and if, after the mem- branes are ruptured and the liquor amnii has escaped, the nurse finds a black, tarry discharge coming from the patient's vagina, she may very properly suppose that the case is one of breech presentation. 7 98 A NURSE'S HANDBOOK OF OBSTETRICS. Fig. 48. — Shape of head of child born in face presentation. (Char- pentier.) Pig. 49. — Shape of head ot child born in brow presentation. (Charpentier.) Fig. 50. — Face presentation. (Bumm.) BREECH PRESENTATION. A B 99 Fig. si—Breech presentation. (Bumm.) A left sacro-anterior; B right sacro-posteno. Fig. 52.-Prolapse of arm in transverse presentation. (Tarnier and Chantreuil.] IOO A NURSE'S HANDBOOK OF OBSTETRICS. Other presentations, all of which are very rare, are those of the foot, arm (Fig 52), or shoulder. The study of the special mechanism of the different presenta- tions and positions is one of great interest, but the brief outline given of the mechanism in anterior positions of the occiput is all that directly concerns the nurse. All other cases are more or less abnormal, and, as their progress is usually slow, their manage- ment must be left entirely in the hands of the medical attendant. OBSTETRICAL DIAGNOSIS This is made in five ways : ( 1 ) Inspection ; (2) palpation 5(3) vaginal examination; (4) auscultation; (5) pelvimetry. Nurses are expected to know whether a presentation is normal Fig. 53. — Usual method of palpating the abdomen. The palms of hands are used. or otherwise, as the work in rural, sparsely settled localities may often require of her knowledge not demanded in her hospital training. Only under most unusual conditions would she be ex- pected to do this in any other way than by inspection and pal- pation, and with this she should thoroughly familiarize herself. For palpation she lays both hands, gently always, flat upon the abdomen (Fig. 53). If done in any other manner than this the stimulation of her fingers will cause the abdominal muscles OBSTETRICAL DIAGNOSIS. IOI to contract. She can (excluding all other possible findings) so palpate the uterus in a definite routine way as to decide the pres- entation and position of the foetus. 1. She should ascertain what is lying at the fundus of the uterus by feeling with both hands — generally a little to the left or in the median line will be felt one pole of the foetus. She must decide which pole it is by observing three points : (a) Its relative consistency. The head is harder than the breech. If the placenta lies between the head and the hand — this cannot be determined, however, in this way. (b) Its shape. If the head, it will be round and hard and the transverse groove of the neck may be felt. The breech has no groove ; and sometimes the feet may be felt. (c) Its mobility. The head will move from the neck. The breech only with the trunk. 2. She should feel for the back of the foetus with both hands, pressing the uterus between the hands at about the level of the umbilicus. She will either feel : — (a) The firm back or the irregular outline of the limbs. She will know, if the back lies in the long axis of the uterus, that the head or breech presents. If the back lies horizontally or obliquely across the uterus, the presentation is, of course, transverse. 3. She will feel if the pelvic brim is empty or ascertain what part presents by means of pelvic palpation, known as Pawlik's grip. It consists in placing the fingers over the centre of Pou- part's ligament on the left side and the thumb on the right cor- responding spot and by pressing together feel either the head or breech as she did when palpating the fundus. Thus she will feel : 1. The head or breech at the fundus. 2. The back or limbs at the level of the umbilicus. 3. She may find the back of the foetus horizontally or obliquely across the uterus. This position must be remedied by an operation known as version. Owing to the fact that any position in which the child's long axis does not correspond to the long axis of the mother is a serious condition and will be fatal to one or both lives, it is im- portant that it be discovered as early as possible. XI The Management of Pregnancy When the pregnant woman consults the physician in refer- ence to her condition, he will first determine the duration of the gestation and the probable date of the expected labor, and then give the patient some general hygienic rules for her guidance during her pregnancy. It is not only proper, but important, for the nurse to have a clear understanding of the nature of these directions: Clothing. — Corsets and any other garments that constrict or compress the chest, waist, or abdomen must be laid aside from the first, and the skirts supported from the shoulders by means of some form of "corset- waist." There are a number of ma- ternity corsets on the market, the best known being the Jenness- Miller and the Ferris Maternity or Berthe May corset. The reasons for this rule are many and important. In the first place, anything that compresses the chest retards greatly the development of the breasts, which should be marked during preg- nancy, and by so doing tends to flattening or even depression of the nipples. Both of these conditions will interfere with the function of lactation, even if they do not render it entirely impos- sible ; and as the proper performance of nursing has a direct and powerful effect on the involution of the uterus and its return to its normal condition after labor, any such interference exerts a most unfavorable influence on the convalescence of the mother as well as upon the health of the infant thus deprived of its natural form of nourishment. Moreover, pressure on the chest walls, especially as- it is in- creased from day to day by the gradual enlargement of the breasts without any compensating loosening of the corsets, pre- vents necessary expansion of the lungs and hinders the working of the heart, already hypertrophied as a normal result of preg- nancy. The harmful consequences of such conditions can readily be seen, for it is not difficult to understand that a woman who has to supply oxygen for herself and another being, and who 102 WEARING APPAREL. 103 must eliminate, with her own blood, the waste products of an unborn infant as well as those of her own body, must neces- sarily have her respiratory and circulatory organs unhampered if she is to perform these tasks in a thoroughly normal way. The injurious results of pressure about the zvaist and ab- domen are much the same. Respiration is affected by interfer- ence with the play of the abdominal muscles and the diaphragm; circulation is impeded by pressure on the large abdominal blood- vessels; the normal action of the kidneys, liver, and digestive or- gans is seriously hampered ; and, lastly, the full development of the infant is markedly interfered with. The use of -corsets and the practice of " lacing " during preg- nancy are usually due to a desire on the part of the mother to con- ceal her condition as long as pos- sible, coupled with ignorance of the disastrous results that may, and often do, follow the em- ployment of such means of concealment. Most women will abandon these devices at once when their dangers have been carefully explained. Loosely fitting garments do more to conceal the progressive abdominal enlargement of pregnancy than can be accomplished by lacing or other mode of constricting the figure. If for any reason a maternity corset is not desired, comfort for the pendulous breasts and abdomen may be secured by wear- ing a maternity binder. This affords relief from the weight and movements of the child. Instead of the breast supporter a well- fitting brassiere, if properly adjusted, will serve the purpose equally well. But these supports must be perfectly fitted to the constantly enlarging figure. Undergarments should be made of wool, of a weight suited to the season of the year, and should extend down to the ankles and cover the arms to the wrists. Fig. 54- Abdominal binder. To be worn during pregnancy. 104 A NURSE'S HANDBOOK OF OBSTETRICS. Wool is insisted upon, to the exclusion of cotton or linen, because it absorbs perspiration as rapidly as it is excreted, and so keeps the skin dry at all times. When the integument is damp with perspiration, as it is in hot weather or after exertion, if cotton or linen underwear is worn, any sudden chilling of the sur- face will close the capillaries and drive a considerable amount of blood to the interior of the body, causing congestion of the in- ternal organs. At the same time, this chilling of the surface and contraction of the capillaries prevent further perspiration, and so throw an additional strain on the kidneys, now congested through increased blood-supply and overworked by the addition of fetal to the maternal elimination. Outer garments are to fit loosely, and must be enlarged as occasion requires. There are on the market a wide selection in all varieties of goods and patterns, the principle upon which they are built being the avoidance of all constriction to breasts and abdomen, and the hanging of all weight upon the shoulders. Garters that encircle the leg tend to the development of vari- cose veins in the lower extremities, and are to be discarded in favor of some form of stocking supporters attached to the corset- waist or extending over the shoulders. It will be remembered that arteries have muscular tissue in their walls, while veins have little or none, and that arteries stand open when empty, while veins collapse. Hence any constriction of an extremity affects the vein far more than the arteries, and blood, which meets with no obstruction whatever in its flow down the extremity through an artery, will, on its return through the vein, find at the point of constriction sufficient closure of the vessel to dam it back and so stretch the vein wall that a varicosity is formed. As there is already a marked tendency in this direction, by reason of the enlarged and constantly enlarging uterus imped- ing return circulation from the lower extremities by compres- sion of the great abdominal vessels, corsets or garters tend to aggravate the condition. Garters that encircle the leg should never be worn, even by unmarried women, for the tendency to varicosities is always present, and when once formed they never disappear but grow worse from year to year. WEARING APPAREL. 105 Shoes. — Comfortable, well-fitting shoes are the only foot cov- ering to be considered during pregnancy. High heels interfere with a proper poise of the body and throw weight upon the lower abdomen in addition to the strain caused by the growing uterus. The shoes may have to be worn a larger size because of the tendency of the feet to swell. If walking is to be a pleasure and not a pain, proper shoes must be worn. Exercise in the open air should be taken daily throughout the entire course of pregnancy, and, of all forms of exercise, walking is, without question, the best. Smooth roads are to be selected for the daily jaunts, and they must be so regulated as to distance that the woman will arrive home exhilarated, but just within the point of fatigue. A woman of ordinarily good physique, beginning her walks early in pregnancy, should start with about one mile and in- crease the distance half a mile a day until six miles are covered. When this distance is reached it is to be regarded as the regular daily task if it can be accomplished comfortably, but if it prove to be exhausting it must be cut down to a more suitable length. While six miles a day is not too much for a strong healthy woman accustomed to out-door life, and may safely be taken as a standard for comparison, it must never be forgotten that many patients of frailer constitution can be allowed only two or three miles a day, and no woman should ever be urged to undertake more than her strength will permit. The final test lies in the condition in zvhich the patient re- turns home. If she is tired and worn out, the distance has been too great, while if she is invigorated and refreshed at the end of her walk, it has been beneficial. Moderately stormy days need not interfere with the usual outing if the woman is properly dressed for the weather, with rain coat, high storm boots, and rubbers or overshoes. The dangers of chilling the body, and consequent congestion of the internal organs, must always be kept in mind, and if, by any accident, a pregnant woman is inadvertently exposed to in- clement weather and returns home cold and exhausted, steps must be taken at once to stimulate surface circulation and restore warmth to the body. 106 A NURSE'S HANDBOOK OF OBSTETRICS. A hot drink of milk or tea should be given, and then, after all clothing has been removed, the patient is to be rubbed vigorously, wrapped in warm blankets, and surrounded with external heat. As soon as she is perfectly comfortable and entirely free from all chilly sensations, the blankets are removed and she is again rubbed briskly with warm, diluted alcohol and dressed in warm clothing, unless she prefers to remain in bed between sheets. She is to lie in the blankets only long enough to get thor- oughly warm and not until she begins to perspire. Walking is preferred during pregnancy to every other form of exercise, because it stimulates the muscular activity of the entire body, and in the later months it distinctly favors the des- cent of the fetal head into the pelvis, insures complete flexion, and shortens materially the first stage of labor. Moreover, it is available to all women, no matter what their circumstances in life may be. Aside from walking there are very few forms of out-door exercise that meet the requirements of the pregnant woman. Dancing and horseback riding are too violent and driving not sufficiently invigorating; tennis is too uneven and tiresome, and croquet too tame and uninteresting; while golf in moderation and automobiling over smooth roads are debatable questions, and may possibly be permitted, especially if the latter is una- voidable. But a continuous motion may induce the onset of premature labor. Walking is the best of all, and if any of the other permissible forms are allowed it should be only at rare intervals and on special occasions. Of in-door exercise there is only one form worthy of con- sideration. Massage combined with passive movements is some- times most helpful where the oedema interferes with the blood circulation. (Massage of the breasts and abdomen must of course be carefully avoided.) This consists in stimulating the abdominal muscles by lying on the back on the bed or floor and, with the arms folded over the chest or the hands clasped back of the head, rising to a sitting posture without drawing up the legs or raising the heels. This is to be repeated several times until a slight sense of fatigue is experienced, and should IN-DOOR EXERCISE. ioj be begun early in pregnancy and practised twice daily, in the morning before arising and at night just before retiring. If this form of exercising the abdominal muscles is found to be too difficult, as is often the case, the patient may, instead, lie on her back and raise the feet slowly in the air, first one foot at a time and then both feet together. This should only be done by order of the obstetrician and never on the patient's initiative. The sewing machine is a most potent factor in the causation of miscarriages and must be used to a very restricted degree, if at all. It is quite a simple matter to attach electric power to a sewing machine, so the objection to its use is much lessened. The lifting and carrying of heavy weights or a child, all un- necessary stair climbing, and every form of violent exertion must studiously be avoided. The patient should avoid crowds and all conditions affording her a sense of discomfort. Bathing at frequent, stated intervals is of the utmost im- portance, and baths should be taken daily when possible. Warm water and an abundance of soap are to be used, for it is essential to keep the skin in good condition and the pores free, lest per- spiration be interfered with and too great a strain be thrown upon the kidneys. The relation of perspiration to the action of the kidneys is little understood by the laity, and most persons are unaware that the skin of an adult excretes, in twenty-four hours, from one and one-half to two pints of fluid, or nearly as much as is eliminated in the form of urine, and that if perspiration were to cease entirely, the kidneys would be unable to perform the double task which would be required of them, and death would inevitably result within a few hours. Baths are best taken at night, just before retiring, and fol- lowed with a brisk rub, but a morning bath may be allowed, even with tepid or cool water (85 ° to 90 F.) if the patient has always been accustomed to one. Salt water " still " bathing is usually beneficial when practised under proper conditions, but bathing is distinctly contraindicated throughout the entire period of gesta- tion. As routine, cold baths, cold sponges, cold shower baths must all be prohibited. At the last month many physicians advise the 108 A NURSE'S HANDBOOK OF OBSTETRICS. use of a shower bath or spray, or sponge of the proper tem- perature to avoid the possible entrance into the vagina of the water in a bath tub. This is logical and recommends itself. In addition it is often most difficult for the patient to get in and out of the ordinary bath tub unless she has help. Sleep, in greater amount than usual, is required by the preg- nant woman, and, in addition to the regular sleep at night, a nap of one or two hours in the afternoon is highly desirable. // the patient is unable to sleep in the daytime, the afternoon nap should not be entirely given up, but she should lie down on the bed or couch and rest quietly for an hour or two every day. The bedroom should be of good size on the south or east side and in a quiet part of the house, and thoroughly well ventilated. Even on the coldest winter nights a window can be opened a few inches at the top and bottom to insure a free circulation of fresh air. If the bed is, necessarily, so situated that it is in the direct line of draft, a screen may be placed at its side, or, if such a piece of furniture is not available, one may be improvised. The teeth of a pregnant woman are apt to undergo certain destructive changes, which have given rise to the old saying, " For every child, a tooth." This disorder is supposed to be due to increased acidity of the saliva, which is itself increased in amount, and it may result in caries of a rapidly progressing type. In addition, the gums may grow soft and spongy, and even bleed or become ulcerated. In rare instances there is a persistent toothache, not due to any lesion of the tooth or gums, but of reflex origin. As a precautionary measure, the woman should have her teeth examined and put in order by a competent dentist early in pregnancy, for painful or protracted dental operations performed during the period of gestation have been known to bring on mis- carriage. After the teeth have been thoroughly cleaned and any exist- ing cavities temporarily filled, further trouble can usually be averted by the frequent and systematic use of an alkaline mouth- wash. Phillips' " Milk of Magnesia " meets this indication per- fectly, and, after brushing the teeth, the mouth should be rinsed THE DIET. 109 with a properly prepared solution before and after each meal, as well as after arising and before retiring. If the teeth have been properly put in order by a dentist in the early weeks of pregnancy, and if this after-care has been faithfully followed out by the patient, any pain or soreness of the teeth, mouth, or gums which does not subside promptly should be reported at once to the physician. The diet of the pregnant woman is to be carefully regulated, and only such articles of food are to be taken as will not over- tax the already hard-worked organs of elimination. This is a nice question about which there is much difference of opinion. The general popular idea is that a pregnant woman must be given a large amount of nourishing food, because " she must eat for two." It is now generally conceded that if her food is sufficient to properly nourish her body before she becomes pregnant, the same amount is all she requires while pregnant. Again, the popular idea still persists that the size of the child may be controlled by restricting the diet of the mother. This has not been incontrovertably demonstrated and the belief is seriously questioned. A fruit diet is supposed to make labor easier by a softening of the child's bones. This theory of bone salt seems to be disproved and the fruit in quantity is quite as much a bone salt diet as is the average three meals provided. In addition there is danger to the mother and a chance of rickets for the child. A special diet may be ordered by the doctor known as Prochownik's diet. It is quite simple, and can be procured by the most humble. The claim is made for it that, if systema- tically adhered to, the results will be perfectly normal, small in- fants. This theory has failed to meet with general acceptance. The proper diet for the pregnant woman is a simple, ordinary mixed diet. It must be carefully regulated to avoid throwing waste upon the kidneys, and foods which are difficult of digestion must not be taken. Among the latter are such articles as pastries, pickles, salads, pork, cabbage, and all articles fried in fat, whether meats or starches. Fruits, vegetables, cereals, buttermilk, cocoa, milk and its products with abundance of water, should be eaten in normal amounts. The one rule to follow at this time is to no A NURSE'S HANDBOOK OF OBSTETRICS. limit the use of meat and broths. Authorities seem to agree on meat but once a day. The occasional craving of pregnant wo- men for unusual articles of food must be kept in mind, and any desire of this kind may be granted with safety when the articles demanded agree perfectly with the patient and are not of too exceptional a nature. Any marked perversion of appetite should, of course, be reported promptly to the physician. Too much em- phasis cannot be laid upon the avoidance of alcoholic liquors. These are eventually depressants, though slightly stimulating at the time. Nervous muscular and secretive glands are all de- pressed. Investigation at different times indicates that the in- fluence of alcohol upon the germ plasm of male and female at time of conception and during pregnancy is to prevent the de- velopment of normal progeny. Never before has such un- mistakable warning been sounded against the danger of develop- ing a dependence upon alcohol as at the present time. Its ill effects are always definite, but during pregnancy the dangerous results are imminent and, unless specially ordered by a physician, alcohol is to be entirely omitted from the patient's diet. Some women seem to require more food than three meals a day. This may be supplied by eating fruit (such as oranges, apples, prunes or figs) upon rising and before retiring; a glass of milk with a cracker may be taken between meals. Eclamptic Toxaemia. — The exact cause of toxaemia during pregnancy is still a question ; and while many theories have been advanced in explanation of this phenomenon, none has been ac- cepted definitely by the entire medical- profession. One general statement may be made, however, and it a suffi- ciently safe working theory for the nurse to keep in mind and regard at all times as a correct explanation of the cause of eclamptic toxaemia. This is, that eclamptic convulsions are due to a storing up in the system of matter which should have been eliminated either by the kidneys, the liver, or the digestive tract. It will be remembered that the mother has to eliminate not only her own waste products, but those of her infant as well ; and that, at the same time, her organs of elimination are handicapped by pressure from the growing uterus and by the other disturbances THE BOWELS. Ill in the general working of the bodily functions that always accom- pany pregnancy. This pressure and the accompanying disorders of nutrition increase as pregnancy advances, and the danger of digestive disturbances grows greater from week to week. Even in the early months, when the pressure is slight and the functions of the emunctories have not been seriously affected, the diet must be carefully regulated to avoid a break-down when the strain is greatest. While many patients will conscientiously follow directions expressed in a general way only, certain women will pay no at- tention to anything but the most explicit rules, and with such unruly cases the diet-sheet given in the chapter on diets may be used to advantage. This list is, of course, only a general outline of the proper diet during gestation, for, as already stated, no absolute laws can be made to fit every case, and the likes and dislikes of the patient are never to be disregarded entirely. Food must be of such a character that the patient enjoys her meals thoroughly and gains regularly in weight and strength from day to day. Bowels. — The bowels of the pregnant woman are to be watched carefully, and at least one satisfactory evacuation should be secured daily. The functions of the bowels, kidneys, and skin are intimately connected, and neglect of any of these organs is a serious matter. Constipation will probably be encountered, as nearly all women are more or less constipated, owing largely to a lack of hygienic habits. This condition is aggravated during pregnancy and the serious consequences are proportionately in- creased. The attending physician will usually order just such measures for its relief as would apply to the condition if the woman were not pregnant. Personal habits of intelligent daily hygiene are the best vital resource a pregnant woman has, and, fortunately, the present- day tendency is very strongly to emphasize the preventive value of all these matters of exercise, sleep, diet, care of the skin, bowels and kidneys, beginning with the training of the infant and carrying the principle through life. The result, however, of 112 A NURSE'S HANDBOOK OF OBSTETRICS. lack of proper habits must be combated as intelligently as pos- sible. Pregnant women are advised to live systematically, to eat proper foods, such as farinaceous foods, vegetables, and fruits. The patient should take two quarts of water daily; she should obey the faintest inclination to evacuate the bowels and adhere to a schedule, going to the closet at exactly the same hour each day. While there, she should be warm and undisturbed ; and she may find that much assistance may be derived from drink- ing a glass of hot water before breakfast. The doctor may order a soap suds enema, or injections of olive oil into the rectum at night to make a movement possible in the morning, or he may prefer drugs to the enemata, depend- ing upon the cause of the constipation. Usually cascara sagrada (Rhannus Purshiana) will be ordered at bed-time, in doses of from one-half to one teaspoonful, gradually increasing the amount. Glycyrrhiza Pulv. is sometimes effective. If the con- stipation is obstinate, it is well to administer a gentle saline laxative, such as the effervescent solution of citrate of magnesia or Seidlitz powder every third or fourth morning before break- fast. Castor oil or aloes must of course not be used. The mere mechanical effect of an overloaded bowel is to in- crease the pressure on the vital organs in a pelvis which is al- ready filled to its utmost capacity. The danger of absorption in the intestines from an accumulation of excrementitious matter in the system is very great. » Never employ massage for constipation if pregnancy exists. Diarrhoea is also a condition that cannot be safely neglected, for even if it is of simple origin and not due to any serious in- testinal disturbance, it may, if allowed to continue, be enough to undermine the patient's strength to a dangerous degree. Pro- longed or severe diarrhoea is often a direct cause of miscarriage as well, and any such condition of the intestinal tract which is not controlled promptly should be reported to the physician with- out delay. Kidneys. — Of all organs of the body perhaps none requires a larger degree of care during pregnancy than the kidneys. If THE BREASTS. 1 13 at any time the amount of urine falls below normal, 50 ounces, an immediate report should be made. A specimen of urine is to be sent for examination every three weeks during pregnancy and once a week during the last two months. Where the patient has a previous history of symptoms suggesting toxaemia the doc- tor may order it sent more often. This specimen must be a sterile twenty-four-hour specimen of eight ounces, with complete sta- tistics as to amount passed in twenty-four hours, name, address and date. This is to be pasted upon the bottle to avoid possible mistake. The significance of many examinations is lost because of carelessness in this matter. The examination should be care- fully done and measures at once adopted to combat the findings of casts or albumin. This should be sent to reach the doctor in the forenoon, so that it may be examined the same day. Any cedema of the face, particularly the eyelids, the hands and feet, any headache or dizziness, must be instantly regarded and re- ported to the physician. Breasts. — These organs must always be protected from con- striction or pressure of any kind. The relief from weight has been suggested in the paragraph on clothing. They must be pre- pared for nursing by careful attention to the condition and de- velopment of the nipples, for, if the infant is unable to nurse, both it and its mother will suffer more or less. The effect of stimulation of the breasts, by suckling, on the involution of the uterus has already been mentioned, and it will readily be understood that the infant will thrive better on breast milk than on any other kind of food. The breast should be bathed night and morning with soap and warm water, to keep the skin in the best possible condition, and after the bathing they are to be sponged briskly with water as cold as the patient can bear, to stimulate the activity of the glandular tissue. The nipples, no matter how well developed and healthy they may be, are to be anointed every night with white vaseline or albolene, which is to be carefully removed in the morning with castile soap and warm water. This is to soften and remove the colostrum which the breasts secrete during the latter part of 6 H4 A NURSE'S HANDBOOK OF OBSTETRICS. pregnancy, and which, if undisturbed, will form hard crusts on the nipples and excoriate the delicate tissues beneath. Nipples which are not treated in this way and upon which crusts of colostrum are allowed to remain are often extremely sensitive or even exquisitely painful when nursing is begun, and are especially liable to the formation of erosions or fissures which may prevent nursing entirely, either because of the suffering caused by the suckling or by the development of inflammation in the breast itself. If the nipples are small, flattened, or depressed, they should be drawn out with the forefinger and thumb and held for five minutes night and morning throughout the entire two months preceding the labor. This will often develop them to a surpris- ing degree, and nipples that at first seem absolutely unfitted for nursing can frequently be made sufficiently prominent by this treatment to meet the needs of the child perfectly. The patient can, of course, do this herself after the nurse has instructed her in the proper method ; but, as has been stated in a previous chap- ter, she must be cautioned as to the possibility of irritating the uterine muscle to contraction by too vigorous manipulation of the nipples, and warned to stop this treatment at once should any uncomfortable symptoms develop in the uterus or lower abdomen. If there are erosions, fissures, or other diseased condition of the nipples, the physician should be consulted, and he will pre- scribe appropriate treatment. Nervous Condition. — To the woman of the present day, freed as she is from much of the ignorance, superstition, and traditions of a generation ago, the period of pregnancy should be, if it proceeds normally, a period of much mental and physical quiet, comfort, and happiness. She should be spared every phase of physical and mental irritation possible. When ap- proached in the proper way, even children can be brought to co- operate and materially help in securing for the waiting mother a degree of calm, daily routine which will do much to prevent the development of abnormal nervous symptoms. The long waiting, with the hopes and fears accompanying her MATERNAL IMPRESSIONS. 1 15 condition, may depress the patient, and the physical discomfort may irritate her; but these troubles can always be met by rest, good reading matter, and an interest in a larger world than her own condition. The care of a physician is her best anchor. She should not indulge in too much reading or in thinking of the physiological process of her condition. Here again her self-control will be the result of a life time of habit, and patholo- gical mental disturbances are exceedingly rare. The patient's fears occasionally gain control, and this calls for a tactful restraint over her more exaggerated moods. A welcome baby is apt to enjoy the blessing of a happy mother. Any deviation from a normal condition seeming to indicate excessive nervousness or melancholia must be promptly reported to the physician. As A GENERAL RULE FOR THE GUIDANCE OF THE NURSE in the management of pregnancy it is safest and wisest to report to the physician any condition that causes the patient special discomfort or that seems to be at all unusual. MATERNAL IMPRESSIONS AND THE CONTROL OF SEX By a maternal impression is understood an effect on the physical development of an unborn infant due to some shock, fright, accident, or other profound nervous strain sustained by the mother during the course of her pregnancy. The possibility of phenomena of this kind is believed by a great number of individuals, among whom may be counted many of the highest intelligence, and children are frequently seen with birth-marks, harelips, supernumerary fingers or toes, and other deformities and disfigurements of various types, all of which are attributed to some form of nervous impression from which the mother suffered during the period of gestation. It is safe to say, however, that the supposed connection be- tween these unfortunate occurrences and any mental state of the mother may be traced to coincidences, or to the imagination in every case, and the nurse should be informed on this subject in order that she may be able to reassure such expectant mothers, as may be apprehensive that their children will be " marked." Il6 A NURSE'S HANDBOOK OF OBSTETRICS. The effects of heredity must not be confused with the subject under discussion, and it must be borne in mind that certain traits and characteristics and certain diseases may be transmitted from the mother to her unborn child. Also, a mother who is in a markedly debilitated condition, or one who is given to excesses of any kind, such as the habitual use of alcohol, morphine, or other drugs, cannot be expected to give birth to a healthy, robust infant; and, for this reason, such a parent may be the mother of a deformed, disfigured, or partially developed child. Maternal impressions, however, are to be considered as sup- posedly affecting the physical development of the child as a result of a sudden profound shock transmitted entirely from without. While, perhaps, it cannot be said that this is an absolute im- possibility, it may be stated with the utmost positiveness that such an effect can occur no more easily before the birth of the infant than after it is in its mother's arms. It will be remembered that the ovum in which the fcetus de- velops is nothing more than an tgg of a peculiar kind, and that the child within it is, from the very first, an absolutely indepen- dent organism developing by itself, and not connected in any very intimate way with the mother. There is no mingling of the fetal and maternal blood-currents, and the blood of the fcetus merely gives up its waste products and takes in oxygen in the placenta as does that of the mother in her lungs. The placenta is merely a thickened area in the sac formed by the amnion and chorion, and the whole may be regarded as the shell (soft, to be sure) of the tgg in which the child is being formed. It is true that the placental structure penetrates to a certain depth into the tissues of the uterine walls, but it can no more be regarded as part of the maternal organism than can the roots of a tree be considered as part of the earth into which they extend. Moreover, the umbilical cord, which is the only direct at- tachment of the foetus to the placenta, is absolutely devoid of nerves, and no matter how much the placenta may be regarded as part of the mother, it is clear that there is no actual nerve connection between the two. MATERNAL IMPRESSION. 1 17 In a word, the ovum, with its contained foetus, merely finds in the uterus a suitable nest for its development, and it is a fact that, except for the practical difficulties in the way, no mother is absolutely necessary to the development of her child after conception has occurred. If we could solve the practical prob- lem of transferring the fertilized ovum from the oviduct or uterus of one woman -to that of another, the process of development would go on just the same, much as a hen's tgg may be hatched by any hen or even in a purely mechanical incubator. That this statement is not idle speculation is proved by the fact that, in Edinburgh, two impregnated ova from a rabbit were transplanted to the oviduct of another rabbit of entirely dif- ferent breed, and this second rabbit eventually gave birth to two rabbits of the first variety, together with several others of her own kind. It should be said in explanation that both rabbits were impregnated at the same time by males of their own breeds, respectively, in order that the oviduct and uterus of the rabbit to whom the ova were to be transferred should be in exactly the necessary stage of gestational development. Thus it will be seen that the connection between a foetus and its mother is practically no more intimate before birth, while it lies in, and absorbs its nourishment from, her uterus, than after delivery, when it rests upon, and takes its nourishment from, her breast ; and that the opportunity for nerve impulses to pass from one to the other is equally impossible in either case. The question of the possibility of controlling the sex of unborn infants so that parents may beget male or female children at will has received much attention of late, and the nurse will often be interrogated in this connection. The most recent teaching goes to show that, for the present at least, this is a matter entirely beyond the power of the human mind. None of the many theories and methods that have been advanced from time to time has proved in any way reliable, and where results may seem to have been secured, the probability of coincidence must always be enough to overthrow any positive conclusions. XII Preparations for Labor THE PATIENT'S PREPARATION The average mother will need little argument to convince her that the early placing of herself under the observation and care of an obstetrician is her first duty to herself and child. She will desire to possess such accurate knowledge regarding the hygiene of pregnancy as will conserve the best interests of herself and children. Ignorance and disregard of scientific truths regarding the facts of life are often followed by tragedy. If she is wise she will concentrate her intelligence upon doing the obvious reasonable, and wholesome thing, in order to be as far as possible a poised, normal, healthy woman. Her doctor's advice, care, and watchfulness may be depended upon to avert and combat complications should they arise, and she should be strongly en- couraged to control her instinct for introspection and investiga- tion of the details of the entire physiological process of child- bearing. Instead, let her report often to her doctor, and send unfailingly for his examination every three weeks during preg- nancy a sterile, eight-ounce, twenty-four-hour urine specimen properly marked. Carrying out the best physical and mental hygiene during the whole period of pregnancy possible to her condition and circumstances, will most certainly bear good fruit for herself and child. As previously stated, obstetrical nursing demands a woman of superior intelligence, judgment, and special training. A lack of proper background of character and personality is almost as great a bar to success as is a lack of proper technic. The Nurse. — In the engaging of the nurse, the actual date of confinement cannot, of course, be given. Nurses should be selected only because of their special fitness, and on no other ground should they be considered. If patients can possibly be brought to appreciate the value of expert nursing at this time 118 THE NURSE. 119 and allow the doctor to employ the nurse, the responsibility for her work is thus squarely placed upon his shoulders and there is no division of responsibility. When other factors enter into the selection complications may inevitably be expected. Obstetrical nurses properly qualified usually receive a higher rate of pay than do those engaged in other forms of nursing. The majority of Nurses' Directories have stringent rules concerning general nursing when done by the obstetrical nurse. If she specializes she will, of course, take no contagious cases. If she does general nursing, she will refuse all contagious work for a period of at least one month before her engagement. Much argument about the necessity for this procedure exists at present, owing to the latest teaching concerning communicable diseases. But the carelessness of a few nurses and the susceptibility of an obstetrical case for some infectious diseases make it im- perative that a nurse use every safeguard that will render the danger less. All her personal effects that may have been ex- posed, without exception, must be thoroughly fumigated in ac- cordance with Board of Health rules. Then all articles that can be washed and boiled must be carefully handled. She, herself, must by a thorough bath and 95 per cent, alcohol rub, a shampoo, completed with a generous application of 95 per cent, alcohol and a persistent use of a nose and mouth antiseptic spray, spare no effort to make herself a safe obstetrical nurse. Pus in any form, such as an otitis, otopyosis, boils, pustules, T. B., as well as a very recent attack of a contagious disease, most certainly disqualify a nurse. The lesser ills of colds, sore throat, tonsilitis, or bronchitis must be left to a physician to decide. Rather than make a change, it is quite customary for the doctor to permit the nurse to go on duty, but she owes it to herself that every possible care be taken to avoid infecting her patients. The close nursing and the time covered make very possible an unfortunate outcome, unless she fully realizes her duty. This can be met best by observing those rules of personal and gen- eral hygiene which tend to properly preserve her own health. Occasionally nurses lose time waiting for cases, and this forms one of its most objectionable features in the eyes of the 120 A NURSE'S HANDBOOK OF OBSTETRICS. average nurse. Nurses should not be called at the last moment. It is an objectionable custom, as it defeats, oftentimes, the very strongest argument for employing an efficient nurse, namely, through lack of time surgical cleanliness cannot always be se- cured. It is essential that some definite arrangement be made as to the nurse's engagement. The doctor will usually arrange this matter and very properly suggest that payment be made at the usual rate from a certain date, or he may arrange for half pay for the waiting period, the nurse either being on call or at the home of the patient. She even may, with the doctor's permission, accept calls to clean and brief cases, always with the full understanding that she is on call. In any event it is not justice to expect her to lose days, even weeks, without full re- muneration, and usually her doctor will assume direction of affairs and protect her best interests. She must be very careful not to let her cases overlap. Having completed her engagement of her doctor and nurse, the patient will next direct her interest to her own preparations for delivery. The number of patients preferring to be confined in a hospital is rapidly increasing, as a recognition of the many advantages enjoyed is becoming more general. To the average woman who expects to possess comfort and enjoy a feeling of safety, it appeals very strongly. It is cheaper, much safer, and offers every possible convenience. It provides against every emergency, and obviates all interruptions to the domestic routine, other than a temporary absence from the home. Its economy is a strong factor in its favor. A special nurse is more often required for maternity cases than not, if the fastidious, dainty tastes of the patient are to be satisfied. This, of course, with her board is a special expense to the patient, but places a nurse always at her disposal. If such a delivery is not available because of lack of hospital facilities, or the preference is for a home accouchement, the mother will proceed with her own preparations. Beginning at a sufficiently early date in pregnancy to enable her to have all her preparations made at least one month before THE MOTHER'S OUTFIT. I2 i labor is expected to occur, the prospective mother should make ready the articles which will be required at the time of her con- finement. This outfit may be divided into two parts: one consisting of the articles needed for the mother's use, and the other of the supplies which will be required by the infant. In many cases the physician will give the patient a list of the supplies he wishes her to get, but where the matter is left in the hands of the nurse the following outfit will usually prove satisfactory : Six abdominal binders, one and three-quarters yards long by three-quarters yard wide ; made of the cheapest grade of un- bleached muslin. This muslin comes in a width of three-quarters yard, and ten and one-half yards are required to make the neces- sary number of binders. They should be torn in the proper length and then washed and ironed, to make them soft and com- fortable. The cheapest grade of muslin is recommended because the more expensive, and consequently heavier, quality does not take the pins as well and is stiff and uncomfortable when in use. Two obstetrical pads for the bed, each twenty-four inches square and made of cheese-cloth stuffed with cotton batting (not absorbent cotton) until it is three or four inches thick. They should be " tacked " or tufted to keep the cotton from slipping, and are for use under the patient's buttocks during the first few hours after labor when the flow is greatest. One dozen clean towels, preferably old soft ones without fringe. These are to be pinned up in another towel and laid away with the other things. They are for use only about the patient, and are not for the hands of the physician or nurse. New diapers may be used in place of the towels if desired, but old ones may never be employed for this purpose. Fifty yards of gauze or cheese-cloth. Safety-pins, two papers of large and one of small size, in addition to those required for preparing the bed. One new nail-brush for the nurse. The physician should bring his own. The best for this purpose are those with plain wooden backs, costing five or ten cents each. 122 A NURSE'S HANDBOOK OF OBSTETRICS. Four pounds of absorbent cotton. Tincture of green soap, six ounces. Four breast binders, pattern illustrated. Six T-binders. Two pieces of rubber sheeting, each one and one-half yards square. Of this sheeting one piece may as well be of the so-called " enamel cloth " (white) which is often used for cover- ing kitchen table and shelves, and is much less expensive. This piece may be used for covering the bed upon which the patient is delivered, and, afterward, cut into smaller pieces for the baby's bed or bassinette. The other piece, of the regular quality to be had of the druggist, is for use on the patient's bed during the puerperium and, later, by the baby, who will require it for the following three or four years. TWO PAIRS LONG WHITE COTTON STOCKINGS. Two suits white pajamas. To be worn during labor. The trousers to be ripped into two stockings. The seam to be hemmed, the band cut through the back and two wide capes applied. This leaves a wide space before and behind, allowing complete freedom to the doctor and at the same time affording the least exposure to the patient. The nurse may tie a bandage above the knee, keeping any fulness out of the way. The result is an ideal ob- stetrical suit much like the Sloane Maternity stocking so widely used. Sterile towels will, of course, protect the area of opera- tion by being placed over the pajamas. The sterile white cotton stockings and the jacket complete an effective obstetrical outfit. The T-binder preserves the perineal pad in position. One fresh clean dressing gown. Six soft old night dresses. Four pounds cotton batting. Two ounces lysol. One hundred bichloride or biniodide of mercury tablets. Two OUNCES tincture of iodine. Eight ounces saturated solution of boric acid. two ounces albolene. One pint 95 per cent, alcohol. One bed-pan. One covered irrigator with complete attachments. THE MOTHER'S OUTFIT. 123 Two wash-basins, preferably of agate- or enamel-ware ; after boiling, these will be needed for solutions at the time of the labor; afterwards for bathing the patient's genitals during the puerperium ; and still later for use about the infant. One slop-jar or pail with lid, made perfectly clean and used during labor for receiving soiled sponges, towels, as well as any solutions or discharges that can be directed into it. One tub in which to immerse the infant. One bowl, for cracked ice. Six pitchers or vessels, to hold hot and cold water. A good supply of clean towels (in addition to the dozen already mentioned), and plenty of sheets, pillow-cases, and night-gowns for the patient's use. Nothing is more annoying to the physician than to call for a clean sheet or night-gown at such a time, and find that it is not to be had. Clean towels, al- most without number, are needed in the lying-in room. The chapter on The Normal Infant contains a list of the necessary outfit for the infant. TO BE STERILIZED Gauze packing 10-yard length }4-yard wide, sterile, and in sterile jar; for uterine packing. Folr dozen perineal pads of cotton covered with gauze to fit the patient and meet the binder. In packages of three each. One pound of absorbent cotton sponge balls, 3 inches in diameter ; in a preserve jar. Fifty gauze sponges, 4 inches square, for operative use ; in a preserve jar. One test tube containing umbilical tape, with cotton plug and rubber cap. A supply of assorted sizes old linen squares, in a jar. TWO I YARD SQUARES OF MATTRESS PAD MATERIAL. TWO PAIRS OF LONG WHITE COTTON STOCKINGS. Two suits of pajamas, for the patient. One suit of pajamas, for husband. One dozen soft old towels, two dozen towels. 124 A NURSE'S HANDBOOK OF OBSTETRICS. Twelve sheets. Six pillow-cases. two night-dresses. slx abdominal binders. Six T-binders. Six breast binders. two papers of safety-pins. Four brushes, two each in a preserve jar. One-half pint milk bottle, to hold the solution for nurse's forceps. The irrigator, tubing, bed-pan, wash-basin, pitcher, should all be scrubbed, boiled, and wrapped in a sheet and placed away. The dressings can often be made by the patient if she is shown, otherwise they are prepared and sterilized by the nurse. Econ- omy in the use of all supplies is imperatively demanded of the nurse. Much complaint is heard of the great extravagance of many otherwise valuable women. It is usually a simple matter to have the necessary sterilization of supplies done, as a great many hospitals or nurses' directories arrange for this. Usually a small charge is made. Many dif- ferent sets of obstetrical outfits are on the market. These are not always satisfactory, and are expensive. Some hospitals rent very complete obstetrical baskets, the articles outside of the dressings to be returned. This is a very desirable and con- venient arrangement, as the sterilization may be investigated and technic verified. A nurse may possess a small portable sterilizer; several good ones are on the market. Sterilization may be properly done in the patient's home with one of these. Occasionally the nurse may go to the patient's home and in the absence of other facilities proceed, as she has been taught, to boil, steam and dry the small packages, all indelibly marked upon their cotton wrappings. All the surgical dressings and cord dressings, however, must be freshly purchased. Such steriliza- tion is at best not perfect and should not be relied upon for such dressings, XIII Preparations for Labor (continued) These begin with the making or purchase of the supplies described in the preceding chapter, and end with the selection, furnishing, and preparation of the lying-in room. The room in which the confinement is to take place is to be chosen with great care, for it must serve first in the capacity of a hospital operating-room and afterwards meet the requirements of a cheerful and comfortable bedchamber, in which every want of a convalescent patient can be met promptly and satisfactorily. For these reasons there are two prime factors in the choice of the room which can never be safely overlooked. First, it must be scrupulously and surgically clean ; and second, it must be bright, spacious, properly lighted, well heated, and thoroughly ventilated. The nurse is, of course, limited in her selection of a room for this purpose to the possibilities of the house in which the patient resides, but no room is too good for the business in hand, and she is at perfect liberty to make use of even the parlor or dining- room if it seems best suited to her needs. Naturally, the nurse will avoid putting the family to any unnecessary inconvenience, but her first thought must always be in the interest of her patient. The ideal lying-in room is one that is large, sunny, provided with an open fire-place, and with a well-equipped bath-room adjoining, or at least on the same floor. It should be situated in a part of the house that is quiet and as far as possible from the odors of the kitchen and other unpleasant features. The nurse must make sure that the room has not been occu- pied within at least six months by a patient suffering from any contagious, infectious, or suppurative disease, and if such is found to have been the case the room is to be condemned and another, though possibly a less convenient one, chosen in its place. If, for any reason, it is impossible to make use of another 125 126 A NURSE'S HANDBOOK OF OBSTETRICS. room, the infected one is to be thoroughly disinfected in ac- cordance with the rules of the Board of Health with which every nurse should be familiar, and then entirely dismantled, and re- painted and repapered throughout. In any event, the lying-in room is to be thoroughly cleaned and all the wood-work wiped off with damp cloths at least two weeks before the expected date of the labor; and all curtains, draperies, portieres, and other articles that can collect dust are to be banished. In the same way, all unnecessary furniture is to be removed and only enough left to make the room comfortable and cheerful. Carpets should be taken up if possible. When this is not possible, they should be well protected by a large rubber sheet, or by many thicknesses of newspaper covered with sheets and tacked down. Rugs can be easily removed without causing dust and confusion. The patient will need a comfortable chair and a firm single metal bed. These are now very common and are generally found in every home. The doc- tor will need a plain table, from a hall or kitchen. The nurse will need a table for supplies. Another table or chairs will be needed, and the bureau and washstand will occupy the balance of space properly required. All this can be quietly and expeditiously arranged, and the nurse may secure the patient's approbation of this preparation if the matter is intelligently and tactfully presented. In the event of an emergency arising and every second of time being valuable, the wisdom of the arrangement is obvious. The pa- tient may be much interested and assist the nurse in planning the arrangement of furniture and supplies. If this is carefully arranged and the patient made to under- stand what is required, the household will be much less upset than when a sudden demand for instantly required articles is made upon it. In hospitals the details for maternity work are complete. In homes of small means, the economy of the preparations is of vital importance to the patient. The nurse can be most helpful here, by her ability to confine requirements to the limit of effi- THE INFANT'S BED. 127 ciency and safety with the minimum domestic upheaval and expense. In short, the room is to be as clean and free from dust- collecting and germ-breeding articles as it is possible to make it, and the nurse who has been thoroughly drilled in aseptic and antiseptic methods will understand what is required without further argument. The infant should never, under any circumstances, be allowed to sleep with its mother, and its bed may be either the crib that it is to occupy during its childhood or a bassinette designed for use only in its infancy. In emergency cases, where neither of these is at hand, a temporary bed may be made for the baby out of a box, a large trunk-tray, or a bureau drawer ; or it may sleep on a couch or in a large arm-chair. Two ordinary cane-seated chairs, placed against the wall and with a hair pillow or cushion for a mattress, make an excellent temporary bed. Bassinettes may be purchased in any style and at any price to suit the taste and the pocket-book of the purchaser, or a very pretty one may be made at home with a clothes-basket as a basis and barrel hoops wound with ribbon to support the draperies. As a rule, the chief objection to the bassinette is its great depth, and as an infant needs plenty of fresh air it is not; benefited by spending the greater part of its time at the bottom of a deep basket, surrounded and entirely shut in by curtains and hangings. In selecting or designing a bassinette, the top of the infant's bed should never be more than four inches below the top of the basket or framework, and if the nurse finds one ready for use in which this depth is exceeded she should raise the level of the bed by placing under it a folded blanket or a pillow. The bed should be of hair and never of feathers, or the infant will sink down into it and be hot and uncomfortable from the first. These bassinettes are dainty in appearance, but far from desirable. A metal bassinette or crib is better from every point of view. A specially good type is one which can be swung within the mother's reach when necessary. The mother's bed should be the best that the house affords, for the period of convalescence after labor is the more trying to uS A NURSE'S HANDBOOK OF OBSTETRICS. the patient the more nearly it is normal ; and unless her bed is a comfortable one it is often a very difficult matter to persuade her to keep in it for the required number of days. The springs should be good and the mattress firm and solid. Unless it is absolutely necessary this bed should never be the one in which the woman is confined, and for this purpose a single metal bed with a very low foot bar should be provided. The many advantages of a single metal bed have made the latter extremely popular, and few homes are unwilling to purchase one, if their desirability for delivery is properly represented. Their possession in a home is a real economy, as some provision must always be made for the nurse. Couches are often insanitary and generally uncomfortable ; cots are always unsightly as well as uncomfortable, particularly for a heavy patient. If the metal bed purchased be very plain and as high as 28 inches, it will not only serve for the patient's use but later on the nurse may use it. Afterwards it may prove of special service for any member of the family in case of sickness. If the usual double bed with box mattress is encountered, all draperies must be detached, the bed scrubbed with soap and water and washed off with 2 per cent, solution of lysol, and the head- and foot-boards covered with sterile sheets immovably fastened. If the labor takes place in an ordinary double bed, it is ex- tremely difficult for either the physician or the nurse to " get at " the patient conveniently, on account of its width and the pres- ence of the head-board and foot-board; while if any operative work becomes necessary, or an emergency arises, the awkward- ness of the situation is more marked than ever. On the other hand, if a single bed is used the patient is accessible from all sides, and the case can be managed as easily and conveniently as on a hospital operating-table. The preparation of the bed or beds depends upon whether one or two are to be used. If but one bed is provided, it must be so arranged that, after the labor, it can be rearranged quickly and easily and put into a clean and comfortable condition with- out disturbing the patient to any great extent. The best way PREPARATION OF BED FOR LABOR. 129 to accomplish this is to first prepare the bed as it is to be during the puerperium and, then to add the necessary preparations for the labor. The mattress is to be supported from below by means of boards slipped in between it and the springs, so that it will be perfectly firm and level during the labor and not sag down in the slightest degree. Boards may be made expressly for this Fig. 55. — Showing manner of elevating bed, showing draw-sheet and rubber sheet folded back, leaving fresh bed beneath. purpose, or table-leaves or slats from another bed may be used. They are to lie crosswise of the bed, at a point directly under the patient's buttocks, and should be removed at the conclusion of labor. Their use facilitates all the work about the patient, and by keeping the mattress perfectly flat prevents the blood and other discharges from collecting in a pool under the patient's back. The mattress is now to be covered with a piece of rubber 9 130 A NURSE'S HANDBOOK OF OBSTETRICS. sheeting pinned securely at the sides and corners so that it will not slip ; over this is to be placed a white sheet pinned in the same way, and over this a draw-sheet, also carefully pinned. This is the correct arrangement of the sheets for the puer- perium, and they must be protected for the labor by covering them with another rubber sheet or " enamel cloth " and white sheet, both of which are to be pinned securely all around. After the labor is over the uppermost white sheet and rubber sheet are removed, and the patient lies on the white sheet and draw-sheet underneath. If two beds are used, the mattress of the cot on which the labor is to occur is supported with boards, as in the first in- stance, and protected with a rubber sheet covered with a white sheet, both of which are securely pinned on all sides. The other bed is then made ready (in the manner already described) with rubber sheet, white sheet, and draw-sheet. On the draw-sheet should be placed one of the obstetrical pads from the maternity outfit, in such a position that it will come directly under the patient's buttocks when she is laid in bed. Unless the various coverings are carefully and securely pinned they will become greatly disordered by the tossing and turning of the patient, and in protracted cases they may even be torn entirely from the mattress and cast on the floor. The nurse should see that the provisions for lighting the room at night are ample, and that it is warm and comfortable in every way. The hair about the vulva should be closely clipped and the parts shaved. This is part of the ordinary routine in hospitals, and a skilful nurse handling a safety razor occupies a very few minutes at this. These final preparations are usually most distasteful to the patient, but tact and intelligence will usually overcome all objections. If this procedure is strenuously op- posed, the nurse will, of course, withhold argument, and exer- cise great care in the cleansing of the external genitals. Occasionally the doctor prefers not to have the patient shaved or even clipped closely. It is best to be informed of his wishes. The physician should be summoned as soon as labor-pains be- PREPARATION OF PATIENT. 131 gin, unless he has given definite instructions to the contrary. Some physicians prefer not to be called to a case until, in the opinion of the nurse, the first stage is nearly at an end, but even under these circumstances it is better that he should know that the woman is in labor, so that he will be prepared to respond promptly to the second call. After the messenger has been despatched for the doctor the patient should be given an enema of soapsuds, one pint, and spirits of turpentine, one teaspoonful. This will effectually empty the lower bowel, and render the labor not only easier but infinitely more cleanly, and must never be neglected. This may have to be repeated and the nurse must watch closely the move- ments of bowels and urine, reporting promptly failure to secure movement or inability to urinate normally. It is distinctly to be remembered that enemata may be given through a rubber bag. But the bag, even if new, is improper for use in administering an infusion, hypodermoclysis, or sterile douche. It cannot be cleansed properly, and boiling it for twenty minutes soon destroys it. These bags are very apt to be used for many objectionable purposes, even boiling not rendering them safe for sterile obstetrical practice. The use of such bags is a grave and very common fault, and it vitiates the other- wise dependable technic of many doctors and nurses. The same tubing should never be used for sterile treatment and enema. There is rarely time to thoroughly boil it, even granted that there are facilities ; and the risk should never be taken. Enamel covered cans are the safest for a nurse to use. They may be easily and thoroughly cleaned and boiled and leave no doubt as to their aseptic condition. The patient should now receive a thorough general bath with plenty of soap and warm water. After the bath her hair is to be well brushed and braided in two braids, and she is to be dressed in sterile pajamas, sterile stockings, and slippers, over which she will wear a wrapper or bath-robe than can be slipped off and on easily, preferably new, but certainly freshly laundered. While taking the bath, the'patient should be caused to stand in the tub, which is to be partly filled with warm water so that her feet will [ 3 2 A NURSE'S HANDBOOK OF OBSTETRICS. not be chilled, and then given a thorough sponge-bath, after which she may be showered, either with a spray or with water poured over her from a pitcher. This is to be more than ordinarily cleansing. It should in- clude a brisk scrub, using surgeons' soap and crash cloth over the whole body, particularly the area of possible operative ex- posure, and paying special attention to the vulva. This is to be followed by a flushing with warm water, to remove the soap ; then a pitcher of lysol solution, i per cent, is flushed over this area, or 95 per cent, alcohol applied with a sterile sponge. The vulva then receives a final cleansing. Here, as always, the spong- ing is toward the rectum. The patient is given a friction rub. The sterile pad is now put in place and held by a T-binder and the patient is instructed not to touch it. In rural districts or in tenements neither bath-tubs nor showers may be available. The patient must then stand upright in a tub of warm water and the same method be followed. While the patient is occupied with her bath the lying-in chamber is to be prepared for the labor, and the bed or beds prop- erly made up. If the patient has been sleeping in the bed in which she is to be confined, it is to be completely dismantled and supplied with clean bedding throughout. A chair is to be placed at the right side of the bed, facing the head, ^or the physician, and a table (preferably a low cutting-table) covered with sterile white towels should stand within easy reach of his right hand. The slop-jar or pail is to be placed so that the apron of the physi- cian's Kelly pad will drain into it. Many physicians have discarded the Kelly pad in actual ob- stetrical work, on the ground that its use is not practical and on account of the difficulty in properly cleaning and disinfecting it. Where one pad is carried about and used for all purposes its use is vicious. If the doctor prefers to use one, the nurse must see that it is thoroughly scrubbed with a brush, and soap, then rinsed off with a solution of bichloride of mercury 1 : 1000, wrapped in a towel, and boiled for five minutes. From this moment the use of the water-closet must be absolutely forbidoex. Evacuations of urine and faeces are to PREPARATION OF ROOM FOR DELIVERY. 133 be received in a boiled vessel, which is to be removed at once from the room, emptied, cleaned thoroughly, boiled for five minutes, and returned with as little delay as possible. The vulva pad, which must, of course, be removed when the rectum or bladder is emptied, is in every instance to be replaced by a fresh, clean one after the parts have been sponged according to the technic given. The nurse should see that the lying-in room is warm, well lighted, and arranged according to directions ; that all supplies are at hand and in order ; that there is an ample supply of cold boiled water ; that there is a good fire in the kitchen stove, unless a gas stove is available, and that plenty of water is actually boiling ; that the instructions relative to the patient have been conscientiously carried out ; and, lastly, that all children and other unnecessary individuals are out of the way. Unless the doctor requires his help, it is not usual for the husband to remain in the room after the first stage, the doctor usually excusing him. From the moment the nurse comes on duty she will keep a careful record of her patient. This she will continue, however long the case may be. The room will be furnished as follows at time of delivery : A single metal bed, with a firm spring, and made up according to technic for delivery. Small zvooden table with chair, at head of the bed, for anaes- thetist's supplies. Here also will be the hypodermic syringe and needle, tested and ready for instant use. The two 2-quart jars of sterile saline solution, kept warmed by being placed in hot water, ergotole, ergot, tincture of iodine, sterile solution of cam- phor in olive oil, alcohol, pituitrin, or other drugs, asked for by the physician. The tray for the C rede's treatment, and a kidney basin for emesis. All of these should be in instant reach and with no chance for confusion. Doctor s Table. Scrubbed thoroughly, and covered with a sterile towel. Basin containing a 2 per cent, solution of lysol, and cotton sponges, for bathing the vulva. Basin of hand solu- tion of lysol, 1 per cent. Dish or tray with tape, forceps, two 134 A NURSE'S HANDBOOK OF OBSTETRICS. artery clamps, scissors and rubber catheter, pair of rubber gloves pitcher of hot sterile water, and six sterile towels. This must be within reach of his right hand. Bureau for sterile, packages and solution of lysol, 2 per cent., for cleansing vulva. Jar of lysol, 2 per cent, for nurse's forceps, gowns for use of physician and nurse, suits for patient and husband will all be plainly marked and so easily distinguished. Package of gloves for doctor and nurse will be here, unless they were sterilized by boiling for 10 minutes and have been put in a basin of sterile solution on the doctor's table. Washstand for scrub-up technic. Follow the technic of the doctor in attendance. Generally a doctor will prefer to do the preliminary cleansing in the bath-room with running hot water. The boiled tampico fibre brushes will be ready in a sterile 2 per cent, solution of lysol, the covered jars preventing contamination. Tincture of green soap is always used. After scrubbing with care and cleansing around and under finger-nails with file, the hands may be soaked in solution of bichloride of mercury, 1 : 2000, for five minutes, or 95 per cent, alcohol may be sponged over them for five minutes, or lysol, 2 per cent., or carbolic, 1 : 1000, or soda and lime, or permanganate and oxalic acid. Whatever his choice, the solution must be prepared, and an abundance of boiled water must be at command. Small foot or infant bath-tub on chair for resuscitation of infant by immersion with an attached bath thermometer. Basket for infant with hot-water bottle and blanket. Sterile bed-pan. Sterile irrigation outfit for infusions or douches. Abundance of sterile pitchers and vessels. All exposed surfaces on bed, tables, bureau, and washstand must have sterile covers. A covered slop-jar or pail. A hook or bandage on irrigator handle to facilitate attach- ment. A chair for the doctor. The mother's preparation for the infant is outlined in the chapter on " The Ideal Nursery " and will be found to be a conservative guide. XIV The Conduct of Labor Normal labor may be defined as labor which is terminated without artificial assistance and which leaves the mother in good condition, beyond a slight feeling of exhaustion and sense of fatigue. It might perhaps better be termed " unassisted labor," for surely an easy and rapid breech delivery, which occasionally occurs and which is in one sense to be regarded as a distinct abnormality, is to be preferred to a protracted and difficult vertex case which subjects the mother to great suffering and more or less shock. For practical purposes, then, so far as the nurse is concerned, we may regard as normal any labor which is accomplished within a reasonable length of time without manual or instrumental interference. In the cases most likely to come under the care of the trained nurse in private practice she will often be summoned several days or even weeks before the onset of labor, and so will be in a position to observe its phenomena from the very first. It is assumed that all the preparations named have been made, and that everything is in readiness for the expected event. For a varying period before the establishment of true labor- pains the patient will often suffer from so-called " false pains," and the nurse must be able to distinguish between them and effective uterine contractions. False pains may begin as early as three or four weeks before the termination of pregnancy, and they are merely exag- gerations of the intermittent uterine contractions which occur throughout the entire period of gestation, combined with the effects of pressure on the abdominal tissues as the uterus and its contents settle down in the pelvis. They occur at decidedly irregular intervals, are confined chiefly to the lower part of the 135 136 A NURSE'S HANDBOOK OF OBSTETRICS. front and sides of the abdomen and groin, never extending around to the back, and are short and ineffective. They are more annoying than painful, and are never accompanied by any actual " bearing-down" sensation. The primigravida often re- gards them as true labor-pains, and marvels at the ease with which she bears them, but the woman who has borne children or the experienced obstetric nurse is seldom if ever misled by them. True labor-pains occur with a regularity that is almost perfect, and if they are timed by the clock it will be found in the majority of cases that, at the beginning, they will occur at inter- vals of about half an hour and that the periods between them will be exact almost to a minute. In timing the pains in this way the nurse should not let the patient know what she is doing, as the knowledge may have a suggestive influence on their fre- quency. The gradation between false and true pains is an almost im- perceptible one, the first indication of the appearance of true pains being usually the establishment of this regularity in their recurrence. Soon, however, the true pains begin to take on their characteristic qualities. They become longer and somewhat more painful. Beginning in the back they extend around to the front, the sensations in the front of the abdomen remaining after those in the back have ceased, and they are accompanied by a distinct " bearing-down" feeling. True pains cannot be said to be especially painful in the early part of the first stage, but the patient usually realizes fully that her labor has begun, and her face often wears a somewhat anxious expression, with a slight flushing and drawing of the features at the acme of the pain. As soon as the nurse has decided, from the character of the pains, that labor has actually commenced, she should notify the physician in charge of the case. It does not necessarily follow that he will respond personally to this notification, but it is proper that he should know that his patient is in labor, so that he can arrange his time and engagements and be ready to answer promptly the second and peremptory call. If the patient is to TRUE LABOR-PAINS. 137 go to a hospital for confinement, the order to start is usually given by the attending physician ; and the nurse must have matters so ordered that she may start with her patient at a moment's notice. If there is no nurse the patient must be ready to go when the true pains begin. As soon as the physician has been notified the nurse should begin to arrange the room for the labor, being guided as to haste by the frequency of the pains. The room is to be warm (70 to 72 ° F.), well lighted and well ventilated ; hot and cold sterile water and provision for boiling the physician's instruments are to be provided ; and the needed supplies described are to be arranged in a convenient manner and place. The patient is to receive an enema of soap- suds, one pint, and spirits of turpentine, one teaspoonful, and is then given a warm bath, as described, or by sponging, as the circumstances will permit. The external genitals are to be cleansed with special' care, and the pudendal hair, if long and abundant, must be clipped short with scissors or shaved with a safety razor. The patient's hair is to be braided neatly in two braids ; she is dressed in a sterile suit of pajamas arranged as directed for obstetric use, or a pair of woven obstetrical stockings. If no such preparations have been made a clean night-gown with slippers, and bath-robe may suffice ; and a vulva pad is applied and pinned to a band, to protect the parts and absorb any dis- charge that may escape from the vagina. From the beginning of the true pains the patient is not to be allowed to use the water-closet under any circumstances what- ever, and if the enema of soapsuds and turpentine has been effective, she will have no occasion to do so except to empty the bladder. This need, however, will usually be frequent, and the urine is to be voided in a clean vessel, which is to be removed at once from the room, cleaned thoroughly, and returned with as little delay as possible. It will, of course, be necessary to remove the vulva pad when the urine is voided, and after the act has been accomplished the external genitals are to be bathed care- fully and a fresh vulva pad applied. A pad that has once been 138 A NURSE'S HANDBOOK OF ( >BSTETRICS. removed must never be replaced, no matter how clean it may appear to be, and there ean be no exception to this rule because of the danger of carrying infection to the vulva. The woman is to be encouraged to keep on her feet the greater part of the time, to favor descent of the head into the pelvis, and the nurse should endeavor to make this trying ordeal as light as possible by cheering words and a hopeful manner. The patient is to be dissuaded from attempting to help herself by voluntary straining of the abdominal muscles, for such efforts do no good at this time and only exhaust her and' wear out her strength ; and it is even a good plan to keep up her energy during the first stage by providing some light refreshment, such as tea and toast or soda-biscuits, of which she can partake when- ever she feels so disposed. If the membranes rupture in the first stage the danger of prolapse of the cord must be kept in mind, and the physician should be notified immediately, but this should be done without the patient's knowledge, for, especially if it is her first labor, the accident is apt to cause her great alarm. She should be informed at once of the nature of the watery discharge, and assured that it is a perfectly natural phenomenon and of no consequence whatever. If her night-gown or other garments have become soaked wifh amniotic fluid, they must be replaced at once with dry clothing. When the pains occur as often as every five minutes the phy- sician is to be summoned peremptorily, and even sooner than this if he lives at a considerable distance from the patient or in case there is any difficulty in getting word to him. Many phy- sicians give the nurse positive orders as to when they wish to be called, but in the absence of any such explicit directions she may regard the above rule as a safe guide in the majority of cases. This degree of frequency in the occurrence of the pains is a fair indication of the beginning of the second stage of labor, and when the pains take on the characteristic features of those of the second stage the diagnosis of the condition is not at all difficult. The pains of the second stage are longer, much more severe, PRELIMINARY EXAMINATION. 139 and the patient's face is suffused with blood until, at the height of the pain, it is almost cyanotic, while the neck swells and the large blood-vessels stand out like knotted ropes and pulsate violently. As soon as it is apparent that the patient is in or near the second stage of labor she is to be put to bed, for at this time the os uteri is, of course, fully dilated, and if she is allowed to remain on her feet precipitate labor may occur. As a rule, the patient is quite willing to go to bed when this period of labor is reached, and in many cases she is unable to keep up any longer even if she were allowed to do so. The nurse should have ready, on the arrival of the physician, hot water, soap, a nail-brush for the disinfection of his hands, antiseptic solution (usually bichloride solution, 1 to 2000) sterile rubber gloves and solution of lysol, 2 per cent, or lubrichondrin. As many physicians, unfortunately, neglect to provide them- selves with an apron or gown, the nurse should also have in readiness a small clean sheet, which can be pinned around his neck and again about the waist, making a fairly good substitute for an operating-gown. After the arrival of the physician he will, of course, take charge of the further management of the case, and, if the patient is still on her feet, decide when she is to be put to bed. If the case is at all advanced the physician will wish to make a vaginal examination at once, in order to determine the amount of dilatation of the cervix and inform himself as to the progress that the woman has made, and while he is disinfecting his hands the nurse will prepare the patient for examination. The woman is to lie on her back, on the right side of the bed near the edge, covered with two clean sheets, each folded in half and arranged as follows : one sheet is to lie across the bed, covering her lower limbs and extending from the foot-board to a point midway between the patient's knees and hips ; the other, covering the rest of her body, also lies crosswise of the bed and overlaps the first by a few inches (Fig. 56). Before the sheets are finally adjusted the nurse will remove the vulva pad and carefully bathe the external genital organs with warm sterile I 4 o A NURSE'S HANDBOOK OF OBSTETRICS. water and tincture of green soap, and a fresh piece of absorbent cotton, using the sponge in dressing forceps and not in her fingers. When the physician has completed the disinfection of his hands and put on a pair of boiled rubber gloves, the nurse will squeeze some lubrichondrin from a collapsible tube on his index and middle fingers, taking care that neither the tube nor her own hand comes in contact with the examining fingers. The patient should now be directed to draw up and widely separate her knees, while the nurse raises the upper of the two sheets so that the physician can see the vulva, and holds it in such a position that it cannot come in contact with his hands, but serves as a screen to prevent the woman from appreciating the extent to which she is exposed. The writer prefers this method to the older one of covering the limbs and abdomen with a single sheet arranged in " horse- shoe " form which is always getting in the way or becoming disarranged, and which, from the nature and method of its ad- justment, is far more suggestive to the patient than the one described in detail.- If the physician's outfit contains a Kelly pad, it is to be placed under the patient, with its apron draining into the slop- jar or pail, and covered with a clean towel tucked well under the edges of the pad, so that it will not easily slip out of place. The nurse is to see that fresh solutions for the hands are always ready and at a proper temperature (ioo° F.) ; that soiled or bloody towels and sponges are removed at once from the room, or at least kept out of sight as far as possible ; that scissors and tape for tying the umbilical cord and boric acid wipes for the infant's eyes and mouth are ready the moment they are needed ; and that a warm woolen blanket is provided to wrap the baby in as soon as it is born. All the instruments required are, of course, to be provided by the physician, and he will, on his arrival, hand over to the nurse whatever he thinks he may need for the particular case, which are to be boiled at once for fifteen minutes so that they will be ready the moment they are called for. In perfectly nor- mal cases about all that are needed are scissors, catheter, and CONDUCT OF SECOND STAGE. 141 douche-tube, but some physicians add to these a dressing-forceps and a tenaculum or volsellum. In emergency cases, when there is nothing at hand, an ordinary pair of clean scissors and a piece of new white cotton twine may be boiled and used for cutting and tying the cord. During the second stage, when the pains are most severe, the nurse should use every art at her command to encourage the patient with reassuring words and helpful assistance. A great deal can be done to add to the comfort of the patient by holding her hands at the height of the pains and, in the intervals between them, by rubbing her back and legs, which are often lame and cramped. Many women like to have something to pull on as the pains occur, and there is no objection to fastening a twisted sheet to the foot of the bed, on which the patient can brace herself, as it were, when her suffering is most severe. Ether or chloroform is indicated at this stage unless there are positive objections to its use, and in normal cases the duty of ad- ministering the anaesthetic usually falls to the nurse. The patient's face should first be well anointed with vaseline to prevent irrita- tion of the skin by the drug, her clothing is to be loosened about the waist and neck to remove any possible interference with res- piration, and false teeth, chewing gum, or any other foreign sub- stance that may be in the mouth is to be taken out, lest it should be swallowed as the patient loses consciousness. In these cases the chloroform is to be given to the " obstetrical degree " only. That is to say, it is to be administered only at the beginning of each pain and continued only as long as the pain lasts. This will be enough to benumb the nervous system and " take the edge off the suffering," but the patient will at no time be entirely unconscious, and in the intervals between the pains she will be perfectly rational. In operative cases, where complete surgical anaesthesia is required, the nurse should not be expected to shoulder the responsibility of administering the anaesthetic, espe- cially as her services will undoubtedly be needed as direct assist- ant to the operator, and another physician should be called in to act as anaesthetist. 142 A NURSE'S HANDBOOK OF OBSTETRICS. The best method of administering chloroform is with the Esmarch outfit (Fig. 57), which consists of a mask and a dropper bottle. The bottle is filled about half full of chloroform and corked, and when the stoppers are removed from both the little tubes that pass through the cork the contents will escape in a fine stream from the smaller of the two when the bottle is tilted to the proper angle. Before beginning the administration of the anaesthetic the skin of the face must be anointed with vaseline and the eyes shielded with a folded towel as a pro- Fig. 57. — Esmarch outfit for the administration of chloroform. Dropper-bottle and mask. tection against the irritating action of the drug. The mask is placed over the nose and mouth of the patient at the begin- ning of a pain and the material with which it is covered is kept wet with the anaesthetic as long as the pain lasts (Fig. 58). The mask is to be removed from the face at the end of each pain and not replaced until the beginning of the next one, and a close watch must be kept of the patient's pulse and especially of her breathing and the general appearance of her countenance. Irreg- ularity of the pulse, failure of respiration, and sudden pallor are all danger symptoms, and the physician's attention must be called to them at once if they appear. In the absence of the Esmarch inhaler the drug may be administered on a small handkerchief folded square and held over the face about an inch and a half from the nose. Care must CHLOROFORM. 1 43 be taken not to let the handkerchief approach the face closely, for, unlike ether, which is to be inhaled in its full strength, chlo- roform must be diluted with a large proportion of air (ninety per cent.) to be taken with safety. When chloroform is administered at night by either gas- or lamp-light, many persons, including physicians and nurses, suffer from irritation of the larynx of a most severe type, due, probably, Fig. 58. — Administration of chloroform. Patient's eyes protected by folded towel; third finger of nurse's right hand taking pulse at the facial artery under the margin of the jaw. to the disintegration of the drug by the flame and the liberation of chlorine gas. This causes paroxysms of coughing which often make it necessary for the sufferer to leave the room, and in one case at least death has resulted from the violence of the attack. The patient usually escapes because she is anaesthetized to such a degree that the irritating effect of the chlorine is unnoticed by her larynx. 144 A NURSE'S HANDBOOK OF OBSTETRICS. This untoward action of the drug can usually be prevented by keeping a good-sized cloth soaked with ammonia hanging from the chandelier or near the lamp. The ammonia will com- bine with the chlorine to form the bland and unirritating muriate of ammonium. Care must be taken, of course, to avoid over- doing the matter and making the remedy as bad as the disease by rilling the room to suffocation with the fumes of ammonia, but this will not happen if the ammonia cloth is merely kept wet with the liquid. It must hang near the light, and if any irritating effects of the chloroform are felt more ammonia must be used, for a sufficient quantity will almost invariably produce the de- sired result. Until recently ether was rarely used in obstetrical practice, though it has always found favor with certain operators. Chloro- form being much easier to administer, had always been considered (when administered to the obstetrical degree) as attended with little or no danger. This fancied security is disproved by recent investigation and it has been found to be far from possessing innocent freedom from risk. There seems to be a strong leaning toward ether as the less dangerous drug, in cases even suggest- ing involvement of the mother's kidneys or liver. Chloroform is said to produce in susceptible patients a very grave " selective " poisonous effect upon the liver of both infant and mother, resulting in alarming symptoms of toxaemia, and seemingly it is responsible for a serious jaundice in both pa- tients, along with other symptoms. For this reason, the use of ether is more general than formerly. Its use near an open fire- place or gas flame is dangerous. However, if great care is used and the can opened and kept at a considerable distance from the flame, there is said to be no danger. The method of administration of ether differs materially from that of chloroform, and, while ether is in many ways the safer of the two drugs, its proper exhibition calls for greater skill and experience and will not, ordinarily, be required of the nurse unless she has had special training in its use. In emer- gencies, however, the nurse may be called upon to anaesthetize a ETHER. 145 patient with ether instead of chloroform, and a brief description of its administration may be of value in this place. As in chloroform anaesthesia, the patient's clothing must be loosened at every point, so that her respiration will be absolutely unhampered, and any false teeth or other loose objects must be removed from her mouth. The woman lies flat on her back, with no pillow under her head, and during the entire period of anaes- thesia the neck must be extended and the lower jaw held up by pressure against the chin to prevent closure of the epiglottis and interference with respiration. Several towels must be within easy reach, as vomiting is very apt to occur during the inhalation of the drug. Many forms of inhalers, some of them decidedly complicated, have been devised for the administration of ether, but in the emergency cases that may fall to the nurse an improvised " cone," made of folded newspaper covered with a towel or muslin, will usually be employed. The cone may be put together with safety- pins or needle and thread, and the towel or muslin should cover it inside as well as out. It should be of such a size that it will fit snugly over the patient's mouth and nose, and its depth should be from six to seven inches. A piece of absorbent cotton or a crumpled gauze about the size of a lemon is placed inside the cone and saturated with ether, care being taken that it is wedged securely in the inhaler with sufficient space between it and the patient's face to allow free vaporization of the drug. The cone is now placed over the patient's nose and mouth, but a short distance away from her face to avoid the choking sensation caused by the too sudden exhibition of the anaesthetic in its full strength. As soon as the woman's throat and lungs have become ac- customed to the irritating action of the vapor, the cone is to be brought gradually towards her face until it fits over it snugly. The gauze or cotton inside the cone should be kept saturated with the drug, and for this purpose about a drachm of ether must be poured in every two or three minutes. In doing this the bottle or can is to be uncorked and the cone removed for 10 146 A NURSE'S HANDBOOK OF OBSTETRICS. an instant only, as the fresh ether is added, and replaced imme- diately over the face. A very few inspirations of air will be enough to delay the action of the anaesthetic materially. After five or ten minutes, and often when the patient seems to be passing quietly into a state of unconsciousness, she may suddenly begin to struggle violently and use all her strength to tear the cone from her face and get off the table or out of bed. This is due to the primary exhilarating effect of the drug, and is a condition to be watched for in every case. The patient is partly anaesthetized, as will be evident from her incoherent speech and unnatural behavior, and she must be securely held by assistants and fresh ether given freely until she becomes quiet again. The essential point in controlling the struggles of a par- tially anaesthetized patient consists in keeping all her limbs ex- tended at full length so that she cannot get a " purchase" on anything. Her arms must be held straight out at her sides, so that she cannot bend her elbows, and sufficient downward press- ure must be exerted just above her knees to prevent her drawing up her legs. At about this time the patient will often begin to vomit, and at the first sign of retching her head is to be turned as far as possible to one side to allow the vomited matter to escape from her mouth and prevent its possible entrance into the larynx. As this is done the lower jaw is to be drawn upward and for- ward as much as possible, and fresh ether must be administered freely, for the vomiting will stop as soon as the anaesthesia is complete. The mouth must be wiped out frequently with a towel, or with gauze or cotton in an ordinary sponge-holder, and care must be taken that the tongue is well forward and has not fallen back and occluded the throat. Complete anaesthesia will be attained in from ten to twenty minutes after beginning the administration of ether, and it is maintained by adding about a drachm of ether to the cone every four or five minutes. During ether narcosis the patient's face should be slightly ETHER. 147 flushed, but never pale or cyanotic; her respiration deep, pos- sibly stertorous (snoring), but never irregular; and her pulse full, of good quality, fairly rapid, but never intermittent. The nurse should not only watch the respiratory movements of the chest and abdomen, but make sure that respiration is properly carried on by noting that ether vapor actually escapes through the cone with each expiratory act. Fig. 59- — Administration of ether. Cone held snugly over face ; chin raised upward and forward and pulse taken at facial artery. As the patient's wrist is not usually within the reach of the anaesthetist, the pulse may be taken at the facial artery as it passes under the edge of the lower jaw at about the middle; at the temporal artery, just in front of the ear ; or at the posterior temporal artery, directly above the ear at the margin of the hairy scalp (Fig. 59). When, however, there is any doubt as to the character of the pulse taken at these points, it should al- ways be counted at the wrist as well. The open method of ad- ministering ether is simple and quite effective. A wet cotton sponge is placed on each eyelid and the eyes covered with a i 4 8 A NURSE'S 1LAXDHOOK OF OBSTETRICS. folded towel. The Esmarch apparatus is used. A towel folded about its outer margin is brought around either side and crossed. This secures excellent results, as the ether may be slowly dropped without raising the cone. The danger signals in ether anaesthesia are a pallid or cyanotic face, irregularity or shallowness of respiration, and irregularity or extreme rapidity of pulse. In the majority of cases in which the administration of ether will fall to the nurse the physician will first anaesthetize the pa- tient himself, and whenever the nurse is in the slightest doubt as to the subsequent condition of the woman under operation, she should call upon the physician for assistance or advice with- out delay. A nurse should enhance every opportunity to perfect herself in the knowledge of anaesthesia ; if she has a rural prac- tice such knowledge is a rich possession. As soon as the baby is born, the nose and mouth cleared of all mucus, and the cord is tied and cut, the infant, wrapped in a warm blanket, is to be removed to a safe place, out of harm's way, and the nurse is to return at once to the assistance of the physician. From time to time, as opportunities offer, she should glance at the child to make sure that it is breathing properly, that the mouth and nose are free from mucus, and that there is no bleeding from the cord. Some obstetricians do not tie the cord at all, simply clamping it for one-half hour after it is cut. The nurse will do well to look carefully and incessantly after such cases. Again, many doctors tie the cord at the body junction, leaving only a small amount of tissue to retract. If the infant is well wrapped up and in a warm place it needs no further atten- tion until the placenta is delivered and the mother made entirely clean and comfortable. The after-birth is usually expelled in from fifteen to thirty minutes after the birth of the child, and the nurse must have ready for its reception a bowl or other sterile vessel covered with a warm bichloride towel, in zvhich it is to remain until it has been examined by the physician and he has given his consent to its destruction. The importance of this examination of the DELIVERY BY THE NURSE. 149 placenta lies in the fact that it enables the physician to know if any part of it or of the membranes has been left behind in the uterus. The nurse will usually be called upon from time to time to relieve the physician in holding the fundus, and while she is so occupied he will doubtless take advantage of the opportunity to inspect the infant for deformity or malformation of any sort. Every moment that is not occupied with other matters is to be devoted to putting the room in order and making the patient clean and comfortable, so that the evidences of the labor may be gotten out of the way with as little delay as possible. Delivery by the Nurse. — In certain cases the nurse will find it necessary to manage the entire labor herself, either because of precipitate labor or through delay in securing the services of a physician. It is needless to say that such cases progress rapidly, and that almost before any careful preparations can be made the pains are recurring with such frequency and severity that the patient must be put to bed and given the undivided attention of the nurse. It seldom or never happens that the nurse and her patient are entirely alone, and usually the husband, some female relative or friend, or a servant can be called upon to place a small bowl in boiling water, cool quickly, add one bichloride tablet to one quart of water making a 1 : 2000 solution, or prepare some sort of an antiseptic solution, and place it on a chair or table by the side of the patient for the nurse's hands. The boric acid wipes for the infant's eyes and mouth can also be called for, and, as there is never any special hurry about tying and cutting the umbilical cord, there is usually time for the scissors and tape to be boiled in a shallow dish with just enough water to cover them. If the patient is fully dressed, as may be the case in precipi- tate labor, some one should take off her shoes and stockings and remove her clothing as rapidly as possible, but without any show of excitement, by cutting or ripping it if necessary. She should then be helped into a night-gown or, if this cannot be done, 150 A NURSE'S HANDBOOK OF OBSTETRICS. covered with clean sheets and blankets; and a pad or thickly folded sheet should be slipped under her buttocks in an effort tc protect the bedding and carpet from blood and other dis- charges. All these matters may be attended to by the direction of the nurse as she sits or stands by the patient's side and watches carefully the progress of the case, and if she keeps her wits about her and does not lose her head she will have no diffi- culty in securing an immediate mastery of the entire situation. She should leave some one in her place, carefully scrub her hands, use an antiseptic solution, apply her sterile gloves and gown. She should have these articles at hand not expecting for an instant to care for any patient without them. She may, if there is no time to scrub up, put on the sterile gloves. Even precipitous labor does not exempt a nurse from responsibility for results. She will, with cotton sponges, clean the external genitals care- fully, while clean towels placed under the buttocks and about the thighs will do much to prevent the possibility of infection. The room, the bed, and the patient are all to be prepared for the labor as carefully as the time will allow, and in those cases in which the nurse is called upon to conduct the delivery merely because of prolonged delay in the arrival of the physician, she will, of course, have everything in complete readiness. The nurse can deliver the patient and retain more freedom of movement if she is delivered on her side, lying on the left side along the right side of her bed. The nurse will sit on the bed, using her left hand between the limbs and her right free to apply solutions, sponge, etc. This is possible, because the pa- tient's legs are widely separated by two or more pillows folded and covered with a sheet. As the head comes down and begins to distend the perineum the nurse must watch it carefully, and prevent undue stretching of the parts by holding it back at the acme of each pain. This in- terference with the descent of the head to prevent its sudden ex- pulsion through the vulva and consequently laceration of the tissues may be kept up for fifteen minutes or more, or until the DELIVERY BY THE NURSE. 151 parts are stretched to their utmost capacity and the head escapes in spite of every effort to hold it. The essential points are to delay the descent of the head until complete dilatation has taken place and to prevent its sudden delivery if possible and deliver the head between pains. If at any time faeces are expelled from the rectum the same should be deftly received in a towel and sponges and solution used skilfully. The nurse will then change her gloves and solution, arrange fresh towels, and proceed. This will occur less often if enemata have been properly given and ex- pelled, and infection so near the vulva at this time is fraught with great danger. If the membranes have not ruptured, they may, when the case is under the management of the nurse, be left intact until they appear at the vulva, resembling more than anything else in appearance the rounded end of a large bologna sausage. As soon as they protrude in this way and the nurse has convinced herself by careful examination that the presenting object is the amniotic sac filled with fluid, and not any part of the fcetus itself, the patient is to be informed of the nature and harmlessness of the discharge of waters which is about to occur and the sac is to be ruptured. This may be done easily and quickly by cutting through the tissue with the finger-nail at the height of a pain, and after a towel has been placed against the vulva to receive the gush of waters. As soon as the head is born the nurse should feel about the neck for the umbilical cord, and if it is found, it should be drawn gently to one side or the other until it can be slipped over the head. No force should be used in loosening the cord, for fear of injuring it and causing bleeding. The mouth, eyes, nose, and throat of the infant are now to be carefully cleansed from blood and mucus with boric acid solution, and the face must be held up so that it does not lie in the pool of blood and liquor amnii between the mother's thighs. There is no occasion whatever for haste in the delivery of the body, even if the face of the infant becomes distinctly cy- anotic, and the mother and others in the room may be assured [52 A NURSE'S HANDBOOK OF OBSTETRICS. that everything is satisfactory and that there is no danger or cause for alarm. In another moment the uterus will again con- tract and the body of the child will be expelled. If only the shoulders appear there is no harm in passing a finger, which has been carefully rinsed in the antiseptic solu- tion into the axilla and gently extracting the posterior arm. The body will now almost fall out of the vagina, and the infant is to be laid on its right side, between the mother's legs in a sterile towel to cover the cord, and covered with a warm woollen cloth or the nearest substitute for this which can be secured, pre- viously sterilized. If the child does not cry vigorously it may be spanked ener- getically but without too much force, or held up by its heels and slapped sharply on the back four or five times. If this is not successful, a little ice-water may be splashed briskly on its chest, but usually the slapping will suffice. In holding the baby up by its heels care must be taken that no traction is allowed to come on the umbilical cord. The instant the child is bom the nurse, or one of those pres- ent in the room, must place a hand on the patient's abdomen and grasp the fundus firmly (see Fig. 66), and this pressure is to be maintained without interruption for the next full hour, par- ticularly if there is the slightest tendency toward relaxation of the uterine muscles, or the face, pulse or other symptoms indicate possible hemorrhage before any is visible. As this is a very tiresome procedure, it is well for those having the matter in hand to relieve each other at fairly frequent intervals. The correct way to hold the fundus is described in detail. There need be no hurry about tying the umbilical cord, and the nurse may safely wait until the pulsations in it have ceased or grown very faint. The first ligature is to be placed about three inches from the infant's abdomen, to leave room for subse- quent tying in case of hemorrhage, and the second ligature two or three inches from the first. It is a good plan to tie a third tape around the cord, close to the vulva, to serve as a guide to the descent of the placenta. As the after-birth is forced out of TYING THE CORD. 153 the uterus the cord will also escape from the vagina, and the progress of this expulsion can be estimated by watching this third ligature, which at the beginning was as close to the vulva as possible. The ligature should be tied with a " square knot " (Fig. 60), for the ordinary, or so-called " Granny " knot, will almost surely Fig. 60. — Square knot. slip, after a short time, no matter how tightly it may have been drawn when it was applied. The characteristic feature of the " square knot " lies in the fact that both ends pass under the same side of the loop, as shown in the figure, while in the " Granny knot " one end passes under and one over. If hemor- rhage occurs from the cord after it has been tied and the child dies or even is seriously weakened by loss of blood great blame will attach to the nurse, and it will be an extremely difficult mat- ter for her to free herself from the stigma of either neglect or incompetency. Consequently, the nurse who intends to practise obstetrics should make it a point to perfect herself in the method of tying a square knot until she can do so instinctively, and so avoid the possibility of any such accident as has been suggested. It will avail her nothing that the case was an emergency one and that she did her best under most trying and unusual conditions, for people who are desirous of having children allow nothing to escape the fury of their wrath if anything untoward occurs in the conduct of the case, and the fully trained nurse of to-day is regarded by many as the equal of the physician in technical skill. It is a very easy matter to learn to tie the square knot snugly and securely, and when this is done properly there will be no danger of its slipping or of secondary hemorrhage from the cord, 154 A NURSE'S HANDBOOK OF OBSTETRICS. except in the case of feeble or premature children in whom the tendency to bleeding is very great and who must always be watched with the utmost care. As many of the precipitate labors which will fall to the care of the nurse will be cases of premature birth, she must be extremely careful about tying the cord securely, and inspect it for hemorrhage at frequent in- tervals, tying it a second, or even a third time, if necessary. The cord must always be tied in two places and cut between the ligatures, for if this is not done and the case should chance Fig. 6i. — Granny knot. to be one of twins, the unborn child might possibly bleed to death from the maternal end of the severed cord. As soon as the cord is cut and covered with a sterile towel, the infant, wrapped in a blanket, is to be removed to a safe place, and the nurse should take charge of the fundus for a few minutes, at least, to make sure that it is hard and firm. If it is found to be soft and flabby vigorous kneading of the uterus should be practised until it again contracts properly. There need not be the slightest haste about the delivery of the placenta, and while it is usually expelled in from fifteen to thirty minutes after the birth of the child, no harm will result if it is delayed for an hour or more, provided there is no excessive bleeding. It is to be remembered that the uterus is resting during this period, and that when its muscular fibres have recovered from the exhaustion of the labor they will contract firmly and expel the after-birth. Under no circumstances should traction be made on the cord in an effort to pull the placenta out of the vagina, for this will probably result merely in tearing the cord from its attachment, while in rare cases, when the placenta has not entirely separated from the uterine wall, the womb itself may be dragged inside out, causing the condition known as inversion of the uterus. BREECH CASES. 155 In nearly every case, after a reasonable period of time, the woman will have another labor-pain and the placenta will appear at the vulva much like a miniature counterpart of the fetal head. It should be received in the palm of the hand and directed into a sterile bowl held for this purpose, and the string of membranes that trails behind is to be extracted with the utmost gentleness and deliberation, to prevent the detachment of any tags or frag- ments (Fig. 62). The method, formerly advised, of twisting the membranes into a firm cord by turning the placenta over and Pig. 62. — Delivery of placenta and membranes. (Bumm.) No traction should be used, but the membranes allowed to fall out of the vagina by their own weight. over on itself no longer meets with general approval and is not to be recommended. All that is necessary is to extract the mem- branes from the vagina slowly and carefully, taking plenty of time and using no force whatever. The placenta is to be preserved until the arrival of the physi- cian, in order that he may inspect it and make sure that it is intact. In precipitate breech cases, which occur when the infant is small or premature, there are two important points in the management which the nurse must not forget. Traction on the body, after it has passed through the vulva, 56 A NURSE'S HANDBOOK OF OBSTETRICS. must never be made, for it is essential to have the case progress as slowly as possible in order to secure complete dilatation of the parts and afford ample room for the passage of the head. Pressure must be made on the fundus as soon as the nature of the case is recognized, and maintained until the child is born, in order to prevent, if possible, the extension of the arms above the head. Fig. 63. — Delivery of the head in breech cases. The child's body is lifted up and back- ward over the mother's abdomen, and the head is pressed forward, so that the chin, mouth, nose, etc., will be successively delivered. The diagnosis of a breech presentation can often be made by the nurse, without vaginal examination and before the ap- pearance of the infant's buttocks at the vulva, by the escape of meconium in the vaginal discharge. As soon as the body is delivered to the level of the umbilicus the cord is to be secured and gently drawn down a few inches, to prevent traction on it when the head is born, and the extruded PRECIPITATE LABOR. 157 portion of the foetus is to be wrapped in warm towels, which are to be renewed as often as they become cool. This is necessary, not only to prevent chilling the infant, but to avert the danger of respiratory movements while the head is still undelivered, due to the shock of cold air striking the abdomen and chest. The downward pressure on the fundus in the direction of the axis of the pelvic brim is to be kept up, and, when the shoulders have escaped from the vulva, the arm which is the more easily reached is drawn out of the vagina by passing a finger over the infant's shoulder, down the arm to the elbow, and sweeping the forearm and hand across the face and chest into the world. The other arm is delivered in the same way, and then the body of the infant is raised upward and backward until it almost lies on the abdomen of the mother (Fig. 63) to favor the birth of the head. Unless the head can be delivered within five minutes after it has passed into the cavity of the pelvis the life of the child will be in great danger from pressure on the cord, and if there is any delay the nurse may pass one or two fingers into the child's mouth, and with those of the other hand under the symphysis pressing on the occiput, attempt to tip the head forward on the chest while the body of the infant is raised upward and backward and firm downward pressure is made by an assistant through the abdominal wall. Fortunately the cases of breech delivery that will fall to the care of the nurse are seldom attended with any great difficulties, for the very fact of their precipitate character presupposes a small child or a very large pelvis. The chief danger is extension of the arms above the head (Fig. 64), and this can often be avoided by the maintenance of firm pressure on the abdomen throughout the entire course of the labor. After the child is delivered the further management of the case does not differ from that of vertex presentation. Twins are not infrequently delivered precipitately on account of the small size of each infant, and unless they are " locked" in such a way that neither can be expelled without artificial aid (Fig. 65), twin births seldom or never give any trouble to the 158 A NURSE'S HANDBOOK OF OBSTETRICS. medical attendant. As the babies are small, the first is delivered with very little difficulty, and the birth of the second is accom- plished with the utmost ease, because the passages are already dilated fully and there is nothing to interfere with its descent. Fig. 64. — Arms extended in breech delivery. The most serious complication that can arise in the extraction of the after-coming; head. None of the other abnormalities of position and presentation possesses any special interest to the nurse, for, unless they are of such a precipitate character that delivery is accomplished within a very short time, there will be ample opportunity to secure the services of some physician, even if the regular medical attendant cannot be reached. When the nurse finds, on her arrival, that the baby and pos- sibly the- placenta are born and lying in the bed, her first duty is to grasp the fundus with as little delay as possible and see if its contraction is satisfactory, and then make sure that the child is not lying face downward in the blood and discharges and in danger of strangling. As soon as the fundus is firm and solid PRECIPITATE LABOR. 159 the cord may be tied and cut and the infant turned over to some one who will wash its eyes and mouth and wrap it in a warm blanket. Fig. 65.— Locked twins. (R. Barnes.) First child partly born in breech presentation, the second lodged with the face under the chin of the first. In all cases of labor occurring in the absence of the physician the nurse must keep a cool head, for the patient and those about her are usually in a state of great excitement and turmoil, and this may be enough to cause relaxation of the uterus and trouble- some hemorrhage. A level-headed nurse, who shows no trace of nervousness or fear, can often change the entire picture in an instant and bring order and quiet out of chaos with a word and an air of authority and self-confidence. 160 A NURSE'S HANDBOOK OF OBSTETRICS. Analgesia. — An obstetrician discovered chloroform and it was hoped that freedom from suffering at delivery had been found. Ether also offered relief. It has been seen that, in- telligently administered, they produce relief when suffering is at its keenest and may do no damage to mother or child ; but the search for a drug that would diminish pain without narcosis has gone steadily on. Whiskey, chloral, and morphine have been used for this purpose. A mixture of scopolamine and morphine had been used in psychiatry and surgery for years and was first used in obstetrics in 1903. This treatment was developed in some clinics abroad, and an elaborate technic devised by which it is claimed there is a disturbance of thought without loss of consciousness, secured by a combination of drugs adminis- tered in progressive doses as indicated by the patient's psychical perceptions. This was determined by tests, four in number, and has gained widespread publicity among the laity in America. Only the extreme popularity of this subject calls for its mention here. It is essential that a pupil nurse caring for such cases in a hospital obey instructions concerning discussions. From the graduate nurse on private duty intelligent replies are demanded. She is frequently asked, by patients who ap- parently have secured full information about the intricate de- tails, concerning her views and experiences, where such treat- ment may be secured, and its relative safety. If she is interested, and she should be, she will ask her doctor to inform her and refer her to some scientific literature. There is much con- troversy among obstetricians concerning its value, and a nurse displays ignorance who hastens to discuss an obstetrical ques- tion upon the basis of popular information. Her interest lies purely in the nursing of such cases. It may be said that any method that is safe for child and mother must surely come into general use, if at the same time pain and suffering are lessened to a greater degree than is possible with our present means. Dammerschlaf or " twilight sleep " requires conditions of pre- natal care, environment, psychical and physical conditions, and constant medical attendance, that make its widespread use a large question aside from all possible phases of danger (physical ANALGESIA. 161 and mental) to mother and child. Not enough is known of its relative value as yet, for a nurse to assume the responsibility of an argument in its favor or otherwise. Patients are to be met by no expression of opinion whatever from the nurse, and in this, as in every similar instance, they should be referred to their physician. The nursing is done under the constant supervision of a medical attendant. Every preparation must have been made according to routine technic. In addition there is a special en- vironment demanded which must be arranged. As the patient may not be intelligent, no adequate usual warning may be given of the stage of labor and especially close watchfulness is essential. The nurse may have the drugs to administer, scopolamine or one of its derivatives, morphine, codeine, pituitrin, chloroform or thyroid extract. She will prepare for probable forceps delivery and for the resuscitation of the infant from varying degrees of asphyxia. So far these cases have been nursed almost entirely under hospital conditions. XV The Management of the Puerperium The fundus uteri is to be held through the abdominal wall for one full hour after the birth of the child, if the uterus shows the slightest tendency to relax. This duty may be performed by the physician or he may delegate it to the nurse, but it must never be forgotten that it is of far greater importance than anything else that can be done at this time, and the nurse should never begin to put the room in order, bathe the patient, or wash the baby unless some one has a hand on the fundus. If this procedure were conscientiously and systematically followed out in every case, post-partum hemorrhage due to uterine inertia would be practically unknown. The nurse should sit or stand by the side of the patient, facing her feet, and the ulnar edge (the edge on the side of the little finger) of the hand nearest the patient is to be pressed down firmly on the abdominal wall in the median line and at a point at about the level of the umbilicus (Fig. 66). In the relaxed and flabby condition of the abdominal wall after the birth of the child it is quite possible to force it back until the backbone can be felt, and the nurse never should make the mistake of not using suffi- cient pressure. The uterus should now be felt below, and prac- tically in the palm of the hand, as a firm rounded mass about the size and shape of a large cocoanut. If the nurse does not find it at once she should feel around for it, for it may be displaced to one side or it may have relaxed until it has lost its firmness. If this rapid search fails to locate the fundus, she should call at once for the assistance of the physician, or, if she is alone, redouble her efforts, watch for hemorrhage as indicated either by the flow or by the patient's pulse and expression of counte- nance (pallor, etc.), and have some one give the woman one teaspoonful of fluid extract of ergot if it is to be had. The nurse herself should not remove her hand from the abdomen, and the vigorous kneading of the belly caused by her efforts 162 MANAGEMENT OF THE FUNDUS. 163 to find the fundus, especially if assisted by the ergot, will usually be enough to make the uterus again contract firmly so that it can be distinctly felt under the hand. As long as it remains firm and hard it should be let alone, the hand resting against it with sufficient pressure to permit the immediate recognition of any tendency towards relaxation. From time to time this relaxation will occur and the uterus grow soft and slightly flabby, but still perfectly distinct to the touch. On these occasions the fundus should be grasped in the hand and " kneaded " with a rotary motion gently but with in- creasing force until firm contraction occurs and the uterus is again hard and solid. This manoeuvre is not at all unlike that often practised by patronizing adults when they grasp a small boy by the top of his head and while rumpling his hair in a most uncomfortable manner, and digging their finger-tips into his scalp, ask him, solicitously, what he is going to " be " when he is a man. As has been said, this attention to the fundus is to be kept up for one full hour after the birth of the child, by the end of which time the uterus will, in normal cases, have contracted firmly and permanently, and any further danger from hemor- rhage will be very remote. If, however, at the end of the hour the uterus is still relaxed and soft, and cannot be made to stay firmly contracted, the holding and kneading must be kept up until permanent contrac- tion takes place. If the delay is longer than two hours, it would be safer to notify the physician, even though the woman's gen- eral condition seemed to be good. As a rule, the physician prefers to attend to the fundus him- self for at least the first fifteen or twenty minutes, and this gives the nurse an opportunity to attend to the next most im- portant duty of the moment, which consists in " cleaning up " the bed and patient and making things as comfortable as possible. The worst of the blood and discharges should first be washed off with a towel dipped in warm bichloride solution (1 to 1000). Next, the Kelly pad and everything under the patient are to be slipped out and into the pail at the side of the bed. I0 4 A CURSE'S HANDBOOK OF OBSTETRICS. A clean towel is now placed under the patient, a vulva pad applied temporarily, and she is covered with a clean sheet. The pail containing the Kelly pad and all soiled towels and other articles that may have been thrown in it or dropped on the floor are removed from the room, and already the most unpleasant fea- tures of the labor are out of sight. If the patient's night-gown has become soiled, it should be removed by cutting it down the middle in front and taking it off like a coat, for an attempt to bring it over the head will usually result most unpleasantly. If the patient objects par- ticularly to having it torn, it may be slipped off the shoulders, rolled down under the buttocks, and taken off over the feet, but the best and simplest plan is to tear it. As soon as it is removed a fresh warm one should be slipped over the head, on to the arms, and drawn down in front to cover the chest, but the back part of the garment is best left in a roll or soft pile under the shoulders or neck to avoid the possibility of its being soiled before the patient's back has been bathed, or if pajamas have been worn they are easily and quickly removed, and as two suits have been provided and both may not have been used during confinement, a fresh suit may be worn at this time. In like manner, if there are any stains of blood or other matter on the stockings, they should be removed, and fresh, warm ones put on. The nurse should now prepare a warm solution of tincture of green soap and, with fresh pieces of absorbent cotton care- fully wash off any blood or other matter that may be on the ab- domen or thighs, drying the parts immediately with a clean, soft towel. When this is done, the patient is carefully turned on one side and the process is repeated on the back, buttocks, and back of the legs. It may be necessary to turn the patient first to one side and then to the other for this purpose, and as the towel under her will by this time be soaked with blood, it is to be removed and a clean one put in its place, as well as a clean pad over the vulva. A woman after delivery is in great danger from an air- embolus. A patient wearing a proper binder and a snugly ap- THE PATIENT'S TOILET. 165 plied perineal pad will be in less danger, particularly if, in ad- dition, the uterus is firmly held while she is moved. This pos- sibility exists only for a few hours and is possible through the introduction of a douche nozzle, from which air was not ex- pelled, and it is well for the nurse to exercise great care con- cerning the possible inrush of air into the uterus and its circula- tion. The doctor usually helps the nurse in the necessary mov- ing of the patient, as it is not possible for the nurse to do this alone. The patient is now returned to her back and preparations are made for cleansing the external genitals. This should be done according to the technic outlined under " Technic." From this time on it is by error in the nursing technic that infection may occur and it is a good plan to always adhere to one method. A sterile basin is to be placed against the vulva to receive the blood, and when everything is ready the person holding the fundus will draw the covering sheet out of the way, and the pa- tient is told to draw up her knees and separate them as far as possible. The hair covering the mons Veneris and vulva will be found matted together with clotted blood, and if it is at all abundant the greater part should be carefully cut away with scissors. The parts are then to be bathed with the utmost gentle- ness with the warm solution until every vestige of blood is removed and the parts are perfectly clean. The basin is now removed and a fresh vulva pad applied to take up the little stream of fresh blood that constantly trickles down over the perineum. This should be very quickly and efficiently done with no jarring of the patient. If the patient has been confined on a cot, the next step is to remove her to her bed. The bed should be warmed, except, of course, in summer, and on the draw-sheet is to be laid one of the " obstetrical pads " from the maternity outfit. If the patient is a large woman, and those who are to lift her are not very strong, it is better to move the cot up close to the side of the bed on which she is to lie ; she may then be lifted up by two persons (usually the physician and nurse) standing side by side. As soon as she is raised from the cot, a third person draws it quickly 1(56 A NURSE'S HANDBOOK OF OBSTETRICS. out of the way and with one step forward her bearers place her gently in the bed and cover her with the bed-clothes. Unless a full hour after the birth of the child has elapsed she should not be moved except when the uterus is firmly contracted, and the fundus must be grasped again the moment she is laid down. During the brief interval required to change her from one bed to the other the unavoidable exertion to which she will be subjected will act as a sufficient stimulus to the uterine muscle to obviate the necessity of holding the fundus for a few seconds. If she is to remain in the bed in which she was confined, the next step after cleansing the vulva is to unpin and remove the white sheet and rubber sheet on which she is lying, leaving the bedding underneath fresh and clean. At the instant this is done an obstetrical pad is to be slipped under her buttocks to protect the draw-sheet and avoid the necessity of changing it for as long a time as possible. If the full hour for holding the fundus has not yet elapsed, and the nurse is not occupied with this matter herself, she is to put the room in order, as quietly, thoroughly, and expedi- tiously as possible. All soiled articles, basins, pitchers, and the like, are to be removed; towels, sheets, and other articles that are blood-stained are to be thrown into cold water, usually in the bath-tub with the water flowing in and out over them, until all stains are removed ; the physician's instruments are to be scrubbed with nail-brush, soap, and hot water, rinsed in fresh hot water, and dried thoroughly; and the furniture arranged prop- erly and with as little confusion as possible. The irrigator, if it belongs to the physician, is to be emptied, flushed out with hot water, and dried thoroughly, and the Kelly pad must be washed carefully with soap and hot water until it is absolutely clean, then rinsed quickly with scalding water and dried. The air-ring must not be emptied nor the pad folded up until it is absolutely dry, or its opposed surfaces will stick together and ruin it. By this time there will usually be no further need of hold- THE ABDOMINAL BINDER. 167 ing the fundus, and the binder may be applied, so that the pa- tient may be left to herself and allowed to go to sleep. The function of the binder is often misunderstood by the laity, who are apt to suppose that it is used for the purpose of preserving the symmetry of the figure by preventing the lax abdominal walls from bulging outward. This is far from the truth, and in France, where women are supposed to be particu- larly solicitous as to their physical appearance, the obstetrical binder is not used at all. The objects of the binder are two: first, to prevent any tendency to hemorrhage by keeping up a firm and constant press- ure over the uterus; second, to make the woman comfortable by preventing cerebral anaemia, with its accompanying dizziness, headache, and, in some cases, even syncope. The causation of anaemia of the brain after labor will readily be understood when it is remembered that the walls, not only of the abdomen but of the abdominal blood-vessels, are lax and flabby after the comparatively sudden emptying of the cavity and the accompanying loss of from one to two pints of blood. To fill these empty vessels blood comes rushing in from other parts of the body, and unless they are subjected to the firm pressure of the binder, so much blood will be abstracted from other organs and tissues that the result, while not necessarily serious, is bound to be more or less uncomfortable to the patient. After about three days, when the balance of blood-pressure has again become established and the possibility of hemorrhage is past, the binder is no longer necessary, although the patient usually finds it very comfortable to wear it for a week or so more, and then to substitute an abdominal supporter, which she con- tinues to wear for another month, or until involution is complete. Acting on these principles, the author always insists on the use of the binder for the first three days. The perineal pad can be more snugly applied to an abdominal binder than a T, owing to the fact that it can be fitted closer around the groin and spread over a wider area in the back. This prevents an escape of the blood outside the pad. After this he allows the patient to de- cide for herself whether she wishes it used or not. I OS A NURSE'S HANDBOOK OF OBSTETRICS. The binder should be made of unbleached muslin, one and three-quarters yards long and three-quarters yard wide. The selvage may be torn off and the binder washed and ironed to make it soft and comfortable. Not less than six should be pro- vided, so that soiled ones may be changed as often as necessary. Binders should not be hemmed, as the hem is apt to cause un- pleasant pressure, but the edges may be " overcast " if desired. Binders of any other dimensions than those given are not desir- able, and those made of two thicknesses of cloth or in any way " fitted " to the body are very impracticable. In an emergency an excellent binder can be made of a piece of " roller " towelling cut the proper length. In applying the binder its purpose must be kept in mind and never overshadowed by efforts to gain an artistic effect in the arrangement of the pins. This is a common fault in the training that nurses receive in the wards, for not only is the strength and good nature of the private patient often exhausted by delay and fussiness in pinning up a binder, but the binder itself is seldom as snug at every point as it should be. In addition, the patient frequently succumbs to the enthu- siasm of the nurse and rather than disturb the work of art will spend considerable time in real discomfort, waiting to urinate, for instance, until the vulvar dressing is due, or for some other similar reason. Abdominal binders as ordinarily applied make beautiful photographs, but often are only a means of grace to the patient. The binder should be folded about half its length and slipped under the patient in the same way that a draw-sheet is changed. The ends are then held up in the air over the middle of the ab- domen and the binder drawn in one direction or the other until its middle is exactly under the middle of the patient's back, its lower edge well below the hips, and its upper edge at about the free border of the ribs. Beginning now at the lower edge, the two ends, held tightly together, are rolled up as firmly and as snugly as possible until the material at that point is as taut as it can be made. The pin is passed first through the roll and then through the single thickness of cloth on the side opposite the nurse and clasped. Beginning again a little above the first THE ABDOMINAL BINDER. 169 \, Fig. 67. — Abdominal binder. 170 A NURSE'S HANDBOOK OF OBSTETRICS, pin the rolling is repeated in the same way and another pin inserted, and so on till all is done (Fig. 67). When at a point about the level of the umbilicus, a towel, rolled or folded to about the size of a large banana, may be laid crosswise of the abdomen under the binder, to cause extra press- ure on the fundus. A pin should be passed through the binder into the towel on either side to keep it from slipping. There is much danger that the towel may become displaced and harm ensue. This procedure must be done in the right way or not at all. The binder must be changed with sufficient frequency to keep it clean and comfortable at all times, and during the first two days this should be done as often as every four or five hours. Blood trickles down over the perineum and soaks into the binder behind, soon drying and becoming stiff and irritating, so that, no matter how clean and soft the front of the binder may be, frequent changes are none the less necessary. When the soiled binder has been removed the patient should be turned on her side and the buttocks bathed gently with soap and warm water and rubbed with dilute alcohol. The amount of comfort that this affords the patient well repays the slight trouble that it entails. Soiled binders are to be washed immediately after they are removed, and boiled and ironed before used again. The vulva pads must be changed at intervals of not less than every four hours, and, for the first day or two, fresh ones may be required as often as every one or two hours. If, for any reason, an apparently clean pad is taken off, it is never to be replaced, but a new one used in its stead. The reason for this absolute rule is because of the possibility of placing over the vulva that part of the pad which formerly was in direct con- tact with the anus. Soiled pads must be removed at once from the room and destroyed by burning. Under no circumstances should a pad be washed or otherwise cleaned (?) and used a second time. Every time a pad is removed the external genitals are to be bathed carefully and gently with warm green soap solution made up with boiled water. The nurse is to disinfect her hands REMOVAL OF VULVA PADS. 171 and wear rubber gloves for this purpose, bestowing on them as much care as though she were going to make a vaginal examina- tion. Before the hands are disinfected the pad is to be unpinned and left loosely in position and a piece of paper laid on the floor to receive it. The dish containing the solutions and cotton sponges are to be placed on a chair or on the bed within easy reach, and, the parcel of clean pads is opened and laid in a convenient spot ; the forceps in a bottle of lysol, 2 per cent., in reach. After the hands are clean the soiled pad is removed with a thumb- forceps and laid quickly on the paper, out of sight of the patient, to whom its appearance is usually very unpleasant. The cleansing of the parts should begin with the separation of the labia majora with the thumb and forefinger of the left hand and the careful removal of any lochial discharge that may have accumulated in the creases of the vulva. This blood is always more or less irritating and tends to become dry in spots, which adds to the discomfort that it causes. In spite of this, the pa- tient often refrains from speaking of it, on account of her natural disinclination to require of the nurse duties which she knows must be of a somewhat repellant character. The nurse who will attend carefully to this little detail will find her efforts more highly appreciated than would seem to be warranted by the circumstance. This can all be done without variation from the sponge technic given under " Technic." After this has been done the external surfaces of the labia are carefully bathed from above downward, care being taken to remove every vestige of blood from the hair. If stitches have been inserted in the perineum the nurse must take pains not to let the cotton catch and pull on the free ends of the sutures, or she will cause the patient great pain. Sutures must always be carefully dried, and occasionally the doctor may order a dusting with aristol powder. But the nurse is never to apply boric acid or similar powder unless instructed to that effect. If any blood has collected on the buttocks and soaked into the back of the binder these parts must be made perfectly clean and the binder changed, as has already been said. 172 A NURSE'S HANDBOOK OF OBSTETRICS. The pads and draw-sheet under the patient must be removed as often as they become soiled, but if the nurse is particular to change the pads frequently or to keep folded sterile towels over them, the draw-sheet will last for an entire day or possibly a little longer. As a rule, the draw-sheet is to be changed every twenty-four hours, and clean vulva pads must be provided at least as often as every four hours, and oftener if they are much stained, for even when they do not appear to be par- ticularly soiled they always contain, after a few hours, enough of the lochia to serve as an excellent breeding-place for bacteria. If the patient does not void her urine naturally within twelve hours after labor the bladder should be emptied with the cath- eter, and after this she is to be catheterized every six hours until the normal function of urination is re-established. Twelve hours is allowed in the first instance, because the relaxed condition of the bladder and abdomen after the removal of the pressure from the gravid uterus often permits consider- able distention of the bladder with urine before any desire to urinate manifests itself. Every effort should be made to avoid the use of the catheter, because of the danger of infecting the parts at the time of its introduction, and also on account of the fact that its use always tends to delay the time when natural uri- nation can be accomplished. Moreover, if the patient can once be induced to empty her bladder in the normal way, the subse- quent use of the catheter is almost never required. Conse- quently, at the end of the first twelve hours, and thereafter at intervals of six hours, efforts should be made to excite normal urination by the familiar methods of allowing water to run from a faucet, pouring water from one pitcher to another, directing a gentle stream of warm sterile water down over the vulva, or placing under the patient a bed-pan containing hot water and letting the steam from it surround the genitals, occasionally a warm saline enema will relax the urethra or some pungent smell- ing salts may provide the necessary stimulation. With some patients the mere presence of a second person in the room is enough to prevent urination, and, in such cases, the nurse should THE USE OF THE CATHETER. 173 always leave the room on some pretext or other as soon as she has arranged the bed-pan, taking pains to tell the patient that she will not be back for a few minutes. Not infrequently, on her return she will find the bed-pan ready for removal. Per- haps the physician may order the patient to be helped to a sitting posture as there exists a strong prejudice against the catheteriz- ing, except as a, last resource, and he may prefer this to be tried if the patient is in good condition. If, however, all these efforts fail after a reasonable trial, the catheter must be used. This is an operation requiring great dexterity in the case of a woman recently delivered, for the parts are swollen and congested to such a degree that all the usual landmarks are distorted or temporarily destroyed. On several occasions the writer has been called upon to pass the catheter in the first day of the puerperium after nurses of long obstetric experience have failed utterly to find the meatus. The Fig. 68. — Glass catheter. best catheter for the purpose in hand is the ordinary glass one (Fig. 68) about six inches long and slightly bent at the tip. The soft rubber catheter, so often used in the belief that it is less liable to injure the delicate tissues of the parts, is not worth considering, for it possesses no advantages over the glass in- strument and is inserted with much greater difficulty. It is the only one, however, to be used during delivery, as the smooth glass catheter may break or injure the bladder. The preparations for using the catheter in private practice, where there is usually only one nurse on the case, are important, and must be carried out in detail to avoid the danger of infecting the patient. The catheter is to be boiled and the urine should be received in the basin used for boiling the instrument, or in a douche-pan, but never in a urinal which has to be placed in position after the nurse's hands are sterilized. The simplest, and therefore, the best, method is as follows: i; 4 A NURSE'S HANDBOOK OF OBSTETRICS. Boil the catheter in an agate basin of sufficient size to hold all the urine to be drawn oft" and with only enough water to cover the instrument. Prepare tincture of green soap solution and cotton sponges, and have a clean vulva pad within reach. Place a piece of paper on the floor to receive the soiled pad. As a lubricant for the catheter use white vaseline (in a tube) or, what is still better, any one of the preparations of Iceland moss lubricants which may be had of almost any druggist. Remove the screw-top and wrap the tube in sterile or bichloride gauze. Disinfect the hands, as before, with soap and hot water and bichloride solution, and after the patient has raised her knees and separated them as far as possible, take up the basin con- taining the catheter with a wet bichloride towel, pour off as much water as possible without spilling out the catheter and set the basin in the bed as close up to the vulva as possible. Remove the vulva pad with thumb-forceps and cleanse the parts thoroughly according to given technic. Then take up the cathe- ter, which by this time is sufficiently cool, squeeze on it some of the vaseline or other lubricant, and lay it back in the basin out of the water. (The basin can be tilted somewhat so that part of its bottom will be dry.) Now separate the labia as far as possible with the thumb and fingers of the left hand, until the opening of the meatus can be seen. Wipe off the tissues sur- rounding the urethral orifice with a clean cotton sponge dipped in the solution and, with the left hand still keeping the labia widely apart, pick up the catheter with the other and pass it, by the sense of sight, directly through the meatus into the bladder, taking every precaution not to let it touch any of the surround- ing parts (Fig. 69). The basin, if properly placed, will be near enough to the vulva to receive the stream of urine without any difficulty. When the bladder is empty, grasp the catheter between the thumb and second finger and press the forefinger firmly over the tip before withdrawing it (Fig. 70). When it is entirely out and over the basin the forefinger may be raised, and the urine within the tube will escape. This is a small matter of detail, but will often save soiling the bedding or the patient's clothing. THE USE OF THE CATHETER. 175 As has been said, every effort should be made to avoid the use of the catheter, and after the third day the patient may be allowed to sit up in bed to empty the bladder if the case is pro- Fig. 69. — Proper method of inserting catheter. The labia separated and the meatus exposed to view. gressing favorably. This, of course, should only be done with the consent of the physician, and the nurse should make sure that no ill effects follow the exertion. The patient's bowels should have been emptied by enema Fig. 70. — Method of withdrawing catheter. at the beginning of labor, and will not, as a rule, require any attention until the end of the second day. At this time the physi- cian usually orders a mild saline laxative, such as one-half of a bottle of the effervescent solution of the citrate of magnesia, at 170 A NURSE'S HANDBOOK OF OBSTETRICS. night, followed by the other half in the morning, or castor oil ad- ministered in the least objectionable way, either with sarsaparilla, lemon or grape juice, whiskey or sherry wine, in bottom and on top of dose in glass. Lay ice upon tongue first and it is usually easily taken. If this is not successful, a soapsuds enema may be given in the middle of the forenoon, after waiting a reasonable time for the magnesia to act. If the progress of the case up to this time has been perfectly normal, there is usually no objection to letting the patient sit up on the bed-pan to empty the bowels, and if this can be allowed the enema is seldom required. The patient must be well supported by the nurse with the assistance of an abundance of pillows. After this the bowels are to be moved every second day by enema or otherwise, as the physician may direct, unless the natural efforts are effectual. The nurse must exercise care and skill when inserting the rubber rectal tube. Usually there are hemorrhoids and when perineal sutures are present, these must receive special care to prevent tearing. When the patient is on the bed-pan she is to be directed to hold the vulva pad closely against the vulva with her hand to prevent the entrance of fecal matter into the genital canal, and the nurse, in cleansing the parts, must be careful to follow the technic of sponging toward the rectum and discarding the sponges. It is needless to say that no vaginal douche should ever be given by the nurse except in compliance with the express direc- tions of the physician. If the lochial discharge emits a foul odor the physician may order a douche, but the matter must be left entirely with him. The irrigator and nozzle must be boiled before use, and the solution used for douching is to be made of boiled water always. The irrigator should hang about four feet above the level of the patient's bed, and the woman is to lie on a bed-pan covered with a sterile towel. A pillow should be arranged under the back and between the shoulders for support. TEMPERATURE AND PULSE. 177 The nurse should cleanse the genitals as for catheterization and thoroughly irrigate the entrance to the vagina first. Then, changing the soiled tip for a clean one, she makes all necessary preparations of material and patient and then sterilizes her hands in the usual careful way. The greatest care must be taken, in inserting the nozzle, that it does not come in contact with the external surface of the body or with the hair covering the genital organs. She should hold the douche-tube in herrighthand, and with the fingers of the left separate the labia as far as possible so that the entrance to the vagina is clearly in sight. The tube can now be introduced into the genital canal without touching any of the external tissues, and the danger of carrying infection into the vagina is effectually eliminated. The physician will, of course, instruct the nurse as to the solution to be used for the douche and its temperature, but in the absence of any definite directions, as, for example, when he merely leaves word to the nurse while she is out, that the patient is to be douched, she may safely use two quarts of normal salt solution (two drachms to the quart) at a temperature of no° F. If a nurse makes a practice of doing all vaginal work about her patient wearing gloves and using a forceps in contact with sterile sponges and pads, she can be sure, if these articles are freshly boiled and sterile, that she will not infect her patient in that particular way. If she follows sponging technic outlined, she may be equally sure that she carries no infection into the uterus in that way. The temperature and pulse of both mother and child are to be taken every four hours during the first week and after- wards every night and morning unless the case is not doing well, when the four-hour record is to be continued. The tem- peratures of both patients are to be recorded on separate charts, to facilitate a clear understanding of the entire record at one glance. The public is so well educated in the matter of clinical ther- mometry that these charts must be kept out of sight of the mother from the very first, so that in the event of any unex- pected complication she will be ignorant of the amount of her 12 178 A NURSE'S HANDBOOK OF OBSTETRICS. fever and unsuspicious at the withdrawal of the chart from her daily inspection. A pulse of 100 or a temperature of 100. 5 F. is to be re- ported to the physician without delay, as either may indicate the onset of some serious disorder. Every attention must be paid to the comfort of the patient, for the more nearly normal her case, the more tedious is her confinement in bed while awaiting the involution of the uterus Fig. 71. — Proper method of introducing douche-tube. and other generative organs. She should be moved from one side of the bed to the other several times a day, and required to turn frequently from side to side after the first twenty-four hours. Her personal toilet must never be neglected to the slight- est degree, and her face and hands should be washed and her teeth brushed several times daily. Her hair is to be well brushed and combed night and morning, and this is most easily managed by doing it up in two braids, so that there will be no mass of hair directly at the back of the head. A warm general sponge bath with a little soap is to be given once daily, and this is of especial importance on account of the excessive perspiration that DIET IN THE PUERPERIUM. 179 occurs during the puerperium. This bath is best given at night, just before the patient is ready to go to sleep, and but one part of the body should be exposed at a time. After the bath the entire body is to be rubbed with alcohol and water (equal parts), or, on account of the peculiar odor of the lochia, which is often quite distasteful to the patient, cologne or some favorite toilet- water may be used in place of the alcohol. It need not be said that the use of cologne or toilet-water must never be allozved to cover any laxity in the attention paid to the patient's toilet. The nurse must be quick to anticipate any and every need of the patient in the matter of her personal comfort, and never, under any circumstances, make it necessary for her to ask for attentions of this nature that should have been performed as a matter of course. The diet during the puerperium must be of a simple char- acter, but nourishing and sufficiently varied to please the appe- tite of the patient. In ordinary cases the following dietary will be all that is needed. First forty-eight hours: Milk (one and one-half to two pints a day), gruel, soup, one cup of tea a day, toast and butter. Second forty-eight hours : Milk-toast, poached eggs, por- ridge, soup, corn-starch, tapioca, wine-jelly, small raw or stewed oysters, one cup of tea or coffee a day. Third forty-eight hours: Soup, white meat of fowl, mashed potatoes, beets in addition to the above. After the sixth day return cautiously to ordinary light diet ; that is, three meals a day, meat of an easily digested charac- ter at one of them, such as white meat of fowl, tenderloin of beef, etc. Also a glass of milk three times a day, between meals and before going to sleep at night, and a glass in the middle of the night. Since the nurse will have had a more or less thorough course in dietetics, she will be able to give a rational reply to the objections that may be offered when upon the fifth day she gives her patient white meat of fowl or a broiled lamb chop. Eating meat of course will not cause fever, infection alone can do that ; but indigestion will result from over-feeding, as the patient has no great waste of heat and no energy is expended while she is quietly lying in a warm bed. igO A NURSE'S HANDBOOK OF OBSTETRICS. Rich, heavy foods throw too much waste upon the body. The old belief that foods, acid fruits particularly, will insure colic in the infant is now much discredited, though the mother's milk may excrete drugs and a few foods. The diet should consist as before stated of an easily digested and eliminated mixed diet, properly balanced to replace the waste and secretions as well as bodily heat. Under-feeding will decrease the amount of milk secreted in a marked way. Nourishing food with suffi- cient water, on the other hand, is efficacious occasionally in in- creasing the amount. Visitors should be excluded as far as possible during the first two weeks of the puerperium, and, as a rule, none but members of the immediate family should be admitted, and these for not more than five or ten minutes at a time. Friends and distant relatives are usually more interested in the baby than in the mother, and the infant prodigy may be exhibited for a brief interval to such callers in another room. The practice, common even among the better classes, of turning the lying-in chamber into a general meeting-place for conversation and gossip must be distinctly forbidden by the nurse. Flowers, so often sent in great profusion to the puerperal wo- man, may be shown to her as an evidence of the interest of her friends, but should be banished at once to the parlor or dining- room. A few flowers of faint and delicate odor may be placed at the side of the bed or on a table within her sight, but large bouquets of much fragrance are too overpowering for the good of the patient. The room is to be aired freely and with sufficient frequency each day to keep it fresh and sweet, for the lochia, the milk, the discharges of the infant, and the perspiration of the mother all tend to vitiate the atmosphere to a marked degree. In cold weather the patient is to be entirely covered with a sheet and blanket reaching above her head while the windows are opened for the purpose of ventilation. If the arrangement of the house permits, the nurse should always sleep in an adjoining room, to which she can take the baby for the night, and in which, in fact, the infant should spend TIME TO GET OUT OF BED. 181 the greater part of its time. Under no circumstances should the nurse ever sleep with the patient, and if another room is not available she should be provided with a separate bed or cot. Unless the nurse is a very light sleeper, the patient should be given a small bell with which to call her when she is needed. The directions for the care of the infant and the management of its feeding are discussed elsewhere, and must be followed implicitly, and the nurse must keep a sharp watch for soreness or erosions of the nipples and report their occurrence at once to the physician. The time when the patient can get out of bed, or sit up in bed, is a question that always causes her great concern, and the nurse will do best to make no positive statement in this con- nection even in the most favorable cases. Physicians no longer observe any arbitrary rule in keeping a puerperal woman in bed, and each case must be decided on its own merits. As a rule, permission to sit up is granted when involution has progressed to such a point that the fundus uteri can no longer be felt above the symphysis pubis. Even this cannot al- ways be depended upon, and many factors may have to be con- sidered before a definite conclusion is reached. Generally speaking, women of the class likely to come under the care of the graduate nurse are required to spend two weeks in bed, one week on a couch or on the bed, gradually accustoming themselves to the use of an arm-chair, and one week up and about but confined to the same floor. After the fourth week the patient may begin to go up and down stairs slowly once or twice daily, but six weeks in all should elapse after the birth of her child before she can regard herself as entirely freed from all restraint. The fact should be impressed upon her that this pro- tracted period of non-exertion is not required because she is, in any sense, an invalid, but in order to permit involution to go on uninterruptedly. The idea is much the same as that which would hold in the case of a broken leg, where rest would be ab- solutely essential to perfect recovery, although the patient's gen- eral condition would be in no way affected. l82 A NURSE'S HANDBOOK OF OBSTETRICS. A doctor may order massage given in combination with pas- sive movements after the fifth day, to relieve the muscular in- activity, or he may prescribe exercises in bed for the patient. Some physicians lay great stress upon the manner in which these are carried out and give directions in detail. Nurses are more frequently called upon than is a masseuse and the application of this particular form of massage should be made familiar through practice. Whether massage is given or exercises practised, it is generally much enjoyed by the pa- tient, and the great prostration following the quiet of the pre- ceding ten or more days' confinement in bed is largely overcome. XVI Pathology of Pregnancy The disorders of pregnancy are, in many instances, merely exaggerated states of those conditions already described as being, in their milder forms, purely physiological and unavoidable. On the other hand, symptoms appear at times which must be regarded from the very moment of their onset as unnatural and pathological. The properly trained nurse should be able to dis- tinguish accurately between conditions which are mere exag- gerations of true physiological phenomena and those which are entirely pathological and inherently dangerous to the life or health of the patient. Nausea and vomiting, if occurring only in the morning and subsiding by about noon, so that during the latter part of the day the patient is able to enjoy and retain her food, are to be considered as physiological conditions, of importance only as they cause discomfort to the woman. However, about one- third of all pregnant women escape this, and it is believed much further relief could be afforded by the exercise of proper hy- gienic routine. A mental attitude that is absolutely healthy, fresh air and wide interest divert any morbid anticipations of trouble. This is the usual type of the " morning sickness " of pregnancy, and the patient is always able to assimilate enough nourishment each afternoon and evening to suffice for the entire day. In normal cases these symptoms should disappear en- tirely by about the middle of the fourth month, and they call for no medicinal treatment beyond the occasional administration of laxatives to keep the bowels in good condition. The nurse can, however, do much to make the patient comfortable and lessen the annoyance of morning sickness by giving a glass of hot milk or a cup of tea or coffee with toast or biscuits half an hour before the patient arises. This should be taken in the recum- bent position, and the woman should lie still on her back for a 183 184 A NURSE'S HANDBOOK OF OBSTETRICS. full half hour afterwards. When she attempts to arise she should do so slowly and gradually, avoiding any sudden change, to the upright posture. The morning vomiting almost never be- gins until the patient gets out of bed on her feet, and if the stomach can be induced to retain even a small quantity of food in the early morning it will usually continue to do so for the rest of the day. This simple procedure, coupled with careful atten- tion to the condition of the bowels, often affords great relief, and should always be given a fair trial. This vomiting or nausea, if once established, is difficult to overcome, and so it is specially de- sirable to prevent the first attack. In cases which prove more troublesome, without actually becoming serious, the writer frequently prescribes ten grains of sodium bromide dissolved in one tablespoonful of camphor water and given every three or four hours. This remedy is perfectly harmless in the proportions named, and while, as a rule, it is not wise for the nurse to order drugs on her own responsibility, there can be no objection to her availing herself of it in certain cases, as, for example, when she is travelling with a patient and no physician is obtainable. When, however, the vomiting persists throughout the entire day and into the night, so that the patient is not only unable to retain any nourishment whatever, but loses her sleep as well, the condition is wholly different and becomes distinctly patho- logical. Such women lose flesh and strength and quickly be- come emaciated to a startling degree. As the condition ad- vances they develop fever, the so-called " starvation tempera- ture," and unless relief is afforded promptly they lapse into the typhoid state and die of exhaustion. This is, of course, an extreme type, and one that will rarely be encountered, but the passage from the harmless form of vomiting to the variety that may properly be termed pernicious is very insidious, and the nurse must constantly be on the alert lest her patient retain too little nourishment and so begin to lose flesh and strength. As a safe rule of guidance, the nurse should regard with suspicion any vomiting that persists beyond the noon hour, and report the fact to the physician. NAUSEA AND VOMITING. 185 The treatment of the more severe forms of morning sickness lies, of course, with the medical attendant, but the nurse must never forget that the whole affair is of nervous origin and that it is extremely detrimental for her to express before the patient the slightest evidence of apprehension as to the prospect of its ultimate control. So strongly does this psychical factor enter into the causation of the vomiting of pregnancy of whatever type, that it is not unusual for the mere entrance into the pa- tient's room of an eminent consulting physician to bring about an immediate cessation of the symptoms. The vomiting centre in the brain along with the brain tissue is hypersensitive and suffers from the general poor circulation. This has been likened by some obstetricians to a condition re- sembling chronic shock. All the factors entering into the causa- tion of vomiting in pregnancy are still matters for research, but a poor circulation and its effect upon the brain is one generally accepted. It follows logically that proper clothing and elimina- tion may combat the condition. In severe cases all feeding by mouth is usually stopped and rectal medication and alimentation substituted. For drugs, nerve sedatives of the bromide class are usually ordered, and nutrient enemata should consist of peptonized milk, egg-nog, liquid pep- tonoids, panopepton, or matzoon. These patients are usually sent to a hospital for treatment, as the definite routine necessary for their control can be best carried out and the psychical neurotic condition be best met. The family are rarely of much assistance in carrying out the doctor's treatment and unless this is strictly adhered to, the ner- vous condition may not be successfully combated. Before the administration of a nutrient enema, the rectum should be thoroughly washed out with a hot normal salt solution. This not only cleanses the canal and favors absorption, but the salt solution itself is taken up in considerable quantity, supplying fluid to the tissues and relieving the distressing thirst from which the patient always suffers. Not more than eight ounces of nourishment should be used at each feeding, and it should be at the body temperature and injected very slowly and as iS6 A NURSE'S HANDBOOK OF OBSTETRICS. high up in the canal as possible, preferably in the colon itself. As a rule, the rectal feeding should not be given oftener than twice daily, and once in every six hours is the extreme limit. Exclusive rectal alimentation can never be continued with safety for more than two weeks, and if by that time the vomit- ing has not been controlled to such a degree that the stomach will retain at least part of the required nourishment, the physi- cian is justified in adopting more radical measures, which usually consist in the prompt termination of the pregnancy. There is, unfortunately, a class of women who understand full well that the last resort in the treatment of the pernicious vomiting of pregnancy is the induction of abortion, and who, in their anxiety to avoid having children, deliberately keep up and aggravate their symptoms by the surreptitious self-ad- ministration of emetics. Happily, such women are not often en- countered, but the nurse as well as the physician must always be on guard against the successful practice of such criminal im- position. Many other methods of treatment have, of course, been ap- plied from time to time for the control of the vomiting of preg- nancy, and even such a simple procedure as elevating the pa- tient's buttocks to a level above that of her head has been known to succeed, but in general any marked vomiting should be re- ported promptly to the physician and the treatment left in his hands. Occasionally the doctor will relieve the stomach of the accu- mulation due to vomiting and retching, by lavage. The reversed peristalsis results in a condition making this often a great re- lief to the patient. Occasionally it has an excellent tonic effect upon her nervous system. This hyperemesis gravidarum rarely lasts more than three weeks and, if controlled, recovery is gen- erally rapid. Almost every drug in the Pharmacopoeia has been suggested at one time or another as a specific in this condition, but the fact remains that no definite plan of action can be outlined to fit all cases, and treatment that proves almost miraculously success- ful in one instance will, and often does, fail utterly in another. CONSTIPATION. 187 With the general health, and especially the bowels, in good con- dition, the next most important factor in treatment is to gain the entire confidence of the patient and imbue her mind with the idea that the condition is only temporary, and that it will surely be controlled in due course of time. Above all else, the subject of vomiting must never be discussed, or even mentioned in the presence of the patient, for the mildest and most well-inten- tioned inquiries of relatives at the breakfast table will not in- frequently precipitate a severe attack of vomiting that might otherwise have been avoided altogether. In like manner the patient should never be asked what she would like to eat, or if she feels inclined to partake of food, and the nurse must use her wits and ingenuity to learn the caprices of her patient's appetite, so that she can, without comment of any sort, place before her at proper intervals daintily prepared and tempting dishes. It is to be distinctly understood that any vomiting persisting after the fifth month may be of serious import, and that this statement applies especially to that which makes its initial ap- pearance in the latter half of pregnancy after the ordinary " morning sickness " of the early months has ceased. Any such late return of vomiting, however slight, should be reported at once to the medical attendant, for it is usually due to some form of general constitutional poisoning, known as " toxaemia " and is often the forerunner of eclampsia. Constipation is the usual condition of the bowels during pregnancy, and is due largely to impaired peristaltic motion of the intestine caused by pressure from the gravid uterus. The nurse should see that at least one satisfactory movement occurs daily, and, as a routine, it is well to have the patient drink a glass of hot water for this purpose each morning before break- fast. The water should be as hot as can be borne, and a pinch of salt may be added to give it a taste. In the chapter on the Management of Pregnancy, a number of routine suggestions are made, which, if followed, will materially aid in preventing con- stipation from becoming uncontrollable. Proper elimination can- not be too clearly insisted upon, and here daily, normal hygienic habits prove their priceless value. 1 88 A NURSE'S HANDBOOK OF OBSTETRICS. This simple treatment, combined with a largely farinaceous diet, is occasionally all that is necessary, but usually some simple laxative is required in addition. The best preparation in such cases is the fluid extract of cascara sagrada, given at bed time in doses of one-half to one teaspoonful. If the bitter taste of the plain fluid extract is objectionable to the patient, the aromatic extract may be given instead, but it will be necessary to adminis- ter the later preparation in about double the dosage. Starting with half a teaspoonful of the fluid extract (or one teaspoonful of the aromatic extract), either pure or in water as the patient prefers, the dose may be increased or diminished from night to night until the amount necessary to secure one daily evacuation is ascer- tained. In addition to this nightly medication, an occasional glass of Hunyadi water may be given before breakfast, and at times a soapsuds enema will be indicated. Preparations containing aloes in any form should be avoided lest they tend to aggravate the existing tendency toward hemorrhoids. Under no circumstances should the patient be overdosed with cathartics, and the physician should be consulted if the constipa- tion does not yield readily to some such simple plan of treat- ment as the one outlined above. Diarrhcea occasionally occurs during pregnancy, and its onset should be reported at once to the medical attendant. If it is allowed to persist it may result in a miscarriage, either be- cause of severe straining efforts at stool or on account of an ex- tension of the existing intestinal inflammation. Castor oil, so commonly given at the onset of a simple diar- rhcea, cannot be allowed during pregnancy except by direct order of the physician, for it is to be remembered that the abortifacient properties of the drug are so well marked that they have earned for it the unenviable name of " the poor woman's ergot." Dyspncea (difficult breathing) occasionally results from pressure on the diaphragm of the pregnant uterus, and may be sufficient, in the last weeks, to interfere considerably with the patient's sleep and general comfort. It is not a serious condition, but, unfortunately, it cannot be wholly relieved until VARICOSE VEINS. 189 after the birth of the child, when it will disappear spontaneously. It is most troublesome when the patient attempts to lie down, and her comfort may be greatly enhanced by propping her well up in bed with pillows and cushions. In this semi-sitting pos- Fig. 72. — Varicosities of the lower extremities. (Bumm.) ture she will at least sleep better and longer than with her head low. Varicose veixs may occur in the lower extremities (Fig. 72), and at times extend up as high as the external genitals or even into the pelvis itself. A varicosity is an enlargement in the calibre of a vein due to a thinning and stretching of its walls, and may be compared roughly to the bulb in the middle of a David- 190 A NURSE'S HANDBOOK OF OBSTETRICS. son syringe. These distended areas occur at short intervals along the course of the vessel, and give it a knotted appearance. They are caused by pressure in the pelvis from the enlarged uterus, which presses on the great abdominal veins and inter- feres with the return of the blood from the lower limbs. Added to this primary cause, any debilitated condition of the patient favors the formation of varicosities in the veins because of the general flabbiness and lack of tone of the tissues. Naturally, the greater the pressure in the abdomen the greater will be the tendency to this complication, so that in twin pregnancies or in cases of contracted pelvis, where the gravid uterus is relatively much larger than normal, varices are very frequently seen. Also any occupation which keeps the woman constantly on her feet in the latter part of preg- nancy causes an increase in abdominal pressure and so acts as an exciting factor. The most marked case of varicosities ever seen by the writer was in the case of a woman who kept a small bakery and luncheon-room and attended to her duties in the shop up to the hour of her confinement. The first symptom of the development of varices is a dull, aching pain in the limbs due to distention of the deep vessels, and inspection will show a fine purple net-work of superficial veins covering the skin like lace. Later, the true varicosities appear, usually first under the bend of the knee, in a tangled mass of bluish or purplish veins often as large as a lead-pencil and suggesting a strong resemblance to a bunch of fish worms. As the condition advances the varicosities extend up and down the limb along the course of the vessels, and in severe cases affect the veins of the labia majora, the vagina, and the uterus. The treatment consists first and chiefly in the prompt abandonment, at the beginning of pregnancy, of garters, cor- sets, and all other articles of clothing that can cause pressure at any part of the body. If varicosities develop in spite of this precaution, the patient should spend a good part of the time in the recumbent position, and when she is on her feet the legs should be bandaged firmly from the ankles to the hips or fitted with elastic stockings. Where the general condition of the pa- I9i tient is below par the physician will prescribe iron or some other suitable tonic. Constipation is, of course, to be avoided, as an overloaded state of the bowels adds to the existing abdominal pressure. Every effort should be made to prevent the develop- ment of varices, for if they are once formed they never disappear entirely. In slight varicosities covering small areas, strips of adhesive plaster applied over the distention will often relieve the condition ; but care must be taken not to encircle the leg. Hemorrhoids (piles) are nothing more than varicosities of the veins about the lower end of the rectum and the anus, and the little lumps and nodules seen in a mass of hemorrhoids are merely the distended portions of the affected vessels. Like varicosities in other places, they are due to pressure interfering with return venous circulation, and are aggravated by consti- pation. They often cause great distress to the patient, and their prominent symptom is a constant and painful desire to empty the bowel, which is called " rectal tenesmus," and is not relieved, but more often increased, by straining efforts at stool. The treatment consists in relieving the constipation, in the use of hot compresses, and in the application of an ointment containing gallic acid, which can be obtained of any druggist, without a prescription, under the name of " nut-gall ointment." If these measures are not successful the case should be referred to the physician, who will doubtless prescribe suppositories con- taining opium or morphine. (Edema (swelling) of the lower extremities is not of im- portance unless it is associated with albuminuria. If it causes much discomfort it may be relieved by rest in bed, and the wearing of a proper abdominal binder. When the swelling ex- tends to the hands or face it is to be regarded with great sus- picion as a possible forerunner of eclampsia, and the appear- ance of oedema in any part of the body should serve as an in- dication for the immediate examination of the urine. Irritability of the bladder, characterized by frequent and n)2 A NURSE'S HANDBOOK OF OBSTETRICS. often painful efforts at urination ("vesical tenesmus"), may occur at any time during pregnancy, but is usually most trouble- some in the later weeks. The knee and chest position or the Sims position will sometimes afford relief. If it cause great dis- comfort it should be reported to the physician, who may be able to relieve it by the correction of an abnormal position or presen- tation of the foetus or by the administration of vaginal sup- positories containing opium or belladonna. Anaemia, of mild degree, is the normal condition of the blood during pregnancy, but at times it becomes sufficiently severe to call for the most active treatment. In such cases the onset is usually gradual, and unless the patient is carefully watched her condition will become truly alarming before treatment is begun. The symptoms of severe anaemia usually begin with head- ache, and the face becomes colorless and puffy. QEdema of the lower extremities begins and gradually ascends until it covers the entire body, and may even invade the serous cavities. The patient now loses flesh and strength rapidly, and suffers from sleeplessness, dizziness, headache, dyspnoea, and frequent attacks of fainting. The treatment, of course, rests entirely with the physician, although the nurse can do much to prevent the occurrence of this severe type of anaemia by keeping a careful watch over the patient's general condition and encouraging her to exercise freely in the open air throughout the entire period of gesta- tion. No woman who sleeps well, has a good appetite for nourish- ing food, assimilates properly what she eats, and spends a fair portion of the time out of doors is in any danger of becoming markedly anaemic. Diseases of the heart, and especially affections of the mitral valve, are greatly aggravated by pregnancy, and their fatal termination is often hastened from this cause. If the patient has placed herself under medical care at the beginning of gestation, and if the physician has made a proper and thorough examination of all her organs at this time, he will PTYALISM. I93 be in a position to administer such treatment as may be neces- sary. The only thing the nurse can do, when it seems to her probable that the heart is affected, is to report the matter at once to the medical attendant. Personally, the writer believes that these patients should not be allowed to go on in the preg- nant state, but that abortion should be induced at the earliest opportunity after a positive diagnosis has been made. Ascites {dropsy) may affect the extremities and even invade the pleural and peritoneal cavities. It is due to the altered condition of the blood, and the treatment, which should be wholly in the hands of the physician, consists mainly in the relief of the anaemia, the administration of diuretics, rest in bed, and milk diet. Ptyalism, or salivation, while one of the rarer complications of pregnancy, is most annoying to the patient and very stub- born in responding to treatment. It is due entirely to altered enervation, and is characterized by an enormously increased secretion of the saliva. Women have at times been known to discharge as much as two quarts of saliva daily from this cause. Associated with ptyalism is occasionally seen an excessive secretion of tears, and the face becomes swollen and eczematous from being constantly bathed in moisture. This complication, if it occurs at all, usually appears in the early months of pregnancy, and, fortunately, is inclined to cease spontaneously. It is seen in highly nervous women of low vitality and is apt to cause great mental depression and interfere with nutrition. The treatment should be relegated to the physician, and con- sists in building up the general health with iron and arsenic and in the use of astringent mouth-washes accompanied by atropine and bromides, or chloral internally. The treatment is very unsatisfactory and the condition is a most disagreable one, not only for the patient, but for the physician and nurse as well. Insomnia often proves troublesome, and is best relieved by strict hygienic methods, open-air exercise, and massage, sup- plemented by alcohol rubbing after the patient has retired for 13 1 94 A NURSE'S HANDBOOK OF OBSTETRICS. the night. The sleeping- room should, if possible, be large and well ventilated, and so situated that the patient will not be sub- jected to any disturbing influences. If these measures do not enable her to secure a proper amount of natural and refreshing sleep the physician should be consulted, and will doubtless order trional, sulfonal, or some similar drug. Under no circumstances should opium or mor- phine ever be administered in these cases. Palpitation of the heart and syncope (fainting) are of no consequence unless it can be shown that they are associated with, and due to, some organic disease. As a rule, they are purely neurotic manifestations, and usually occur in the early part of a first pregnancy, and when the patient is in a hot, crowded, and badly ventilated room. Neuralgia and headache occurring during pregnancy should be carefully investigated by the physician, and the nurse is to be cautioned against the indiscriminate use of the various popular remedies for these conditions. Neuralgia, if facial, may be due to affections of the teeth, which require the attention of the dentist, and headache, while possibly of purely nervous origin, may be a symptom of severe constitutional disease. In any event, it is safer for the nurse to refer these appar- ently trivial symptoms to the medical attendant than to attempt their treatment herself. Paralysis occurs in certain cases, and may appear either before or after delivery. It may be due to uraemia, to cerebral congestion, or even to purely neurotic causes. Fortunately its outcome is usually favorable, and the treatment, of course, rests entirely with the physician. Cough, unless due to a distinct bronchitis, is ordinarily of reflex origin and is unimportant. In the last months of preg- nancy it may be due to direct pressure of the gravid uterus. Leucorrhcea ("whites") occurs frequently in pregnancy, especially if the patient is debilitated and anaemic, and is char- acterized by a more or less profuse mucous discharge from the vagina. It is often relieved by hot vaginal douches of a solu- PRURITUS. 195 tion of borax (one tablespoonful to the quart), given twice daily, — night and morning. The patient should lie on her back while taking the douche, so that the solution will reach every part of the vaginal canal, and at least two quarts, as hot as can be borne comfortably, should be used. The nurse must keep in mind, however, the possibility of irritating the uterine muscle to contraction by the use of the douche and so causing a miscarriage. This is not likely to happen unless the douche is too hot or administered with too much force, but at the first appearance of pain, or even " bear- ing-down" sensations in the lower abdomen the irrigation should be discontinued at once, the patient kept quietly in bed, and the matter reported to the physician without delay. If this treat- ment is not successful, he may find, on examination, erosions of the cervix or other causes sufficient to keep up the discharge. Pruritus (itching), when confined to the neighborhood of the vulva, is usually due to a coexisting leucorrhoea, and dis- appears when the leucorrhoea is cured. It may be relieved by hot applications or by the use of some preparation containing naphthol, such as " resinol ointment." When the pruritus is general and covers the entire body it is almost always neurotic in character, though it may be due to a gouty diathesis or to diabetes. The treatment in such cases should be in the hands of the physician, and usually consists of rest in bed, regulated diet, the use of bromides in large doses, and the practice of thorough cleanliness, which applies to all degrees of pruritus, however slight. If the patient is gouty or is suffering from diabetes, these conditions will, of course, receive appropriate treatment. Chorea, popularly known as " St. Anthony's," " St. John's," or " St. Vitus's" dance, is, fortunately, one of the rarest com- plications of pregnancy, for it is one of the most serious. It usually occurs in the early months of first pregnancies in very young women, though it may develop at any time. As a rule, the history will show that the patient has suffered previously with the disease. It may begin suddenly or insidiously, and is characterized 196 A NURSE'S HANDBOOK OF OBSTETRICS. by involuntary movements, or twitchings, of the arms and legs, which gradually become more and more marked and extended to other groups of muscles. There are exacerbations and remis- sions of the disease, and the movements regularly cease during sleep, to reappear again when the patient awakes. When the disease develops early in pregnancy the patient usually aborts, and in many cases it is necessary to induce abortion in order to save her life. Any symptoms suggesting chorea should be reported to the physician without delay. Displacements of the uterus may be of old standing or may occur after pregnancy is established. The symptoms of all types of displacement are practically the same, so far as the nurse is concerned, and consist chiefly in marked irritability of the bladder, excessive constipation, pains in the back and loins, and a feeling of weight and " bearing down " in the pelvis. Any such combination of symptoms should be reported promptly to the medical attendant, in order that he may correct the mal- position before the pregnancy is too far advanced. Albuminuria, complicating pregnancy, may be one of several types, and may occur as early as the third month, al- though it usually makes its first appearance at about the sixth month. The diagnostic and only positive symptom is, of course, the presence of albumin in the urine, which should be discovered by the physician in the course of his regular urinary examina- tion. The analysis must be a careful one, including a micro- scopic examination for casts, etc. In properly conducted cases, where analyses of the urine are made systematically and at stated intervals, the discovery of albumin will be made before any other marked symptoms develop, and it often happens that suitable treatment can be instituted with sufficient promptness to ward off the impending attack. Hence it is of the utmost importance for the nurse to attend carefully to the collecting of specimens of urine at regular three-week periods, and forward- ing them to the physician for analysis. If unchecked, the wastes ECLAMPSIA. 197 increase in amount' and a group of certain symptoms show- ing the general toxaemia develop with rapidity. In neglected cases the patient becomes anaemic, suffers from headache, which is chiefly frontal, and develops oedema, first of the ankles and legs, and later of the face and upper extremities. This oedema involves the internal organs as well, the cir- culation being .directly affected by the accumulation of waste in the kidneys. The patient may suffer from this condition in the lung. Ringing in the ears and dizziness soon become annoying symptoms, and disturbances of sight, such as double vision and the appearance of spots floating before the eyes, occur and in- crease as the albuminuria becomes more marked. In severe cases actual blindness may occur. The urine becomes high-colored and scanty and the pulse is hard, small, and rapid. Vomiting persists throughout the entire day, and is especi- ally significant in women whose ordinary " morning sickness " has ceased. In this disturbed state of the digestive system a slight attack of acute indigestion or the occurrence of any other ordinarily trivial disorder is enough to precipitate an eclamptic seizure. A woman in such condition is on the very brink of disaster, and the nurse should send at once for the physician, and while awaiting his coming put the patient in bed, in a dark quiet room, keep her body warm and give her water to drink freely. Put her on an exclusive diet of skimmed milk and move the bowels freely with dessert-spoonful doses of a saturated solution of Rochelle salt, given every fifteen minutes until free catharsis is established. Eclampsia is a disease of pregnancy characterized by the oc- currence of convulsions resembling somewhat those of epilepsy, and appearing, usually, late in pregnancy just at the onset of labor. It may develop, however, at any time during the last three months of utero-gestation, during labor itself, or, rarely, after labor has taken place. The exact cause of eclampsia is not definitely understood, but it is safe to say that it is largely dependent upon deficient i S A NURSE'S HANDBOOK OF OBSTETRICS. elimination of waste products from the maternal organism. Many theories are advanced. According to one theory the liver and kidney disease is caused by the toxaemia which is due to an auto-intoxication from wastes not eliminated ; according to another these poisons are due to the metabolic changes going on in the foetus in utero or due to poisons developed in the in- testinal tract. Its threatened onset is indicated by the presence of albumin in the urine, by insufficient excretion of urea, or by both of these symptoms together. The premonitory symptoms are those which have just been described as characteristic of albuminuria. Eclampsia is very dangerous to the mother and child, and these facts are all the more lamentable when it is remembered that, under proper management and with careful attention to diet and urinary examinations, the disease should be a wholly preventable complication. Carelessness in the management of pregnancy and neglect of the necessary urinary analyses are, unfortunately, so much more often the rule than the exception that, although the writer has never lost a mother from eclampsia in his own practice, he knows of no less than eight deaths from this cause alone, and within the past six years, among his own circle of friends and acquaintances. Of these, one woman was a physician her- self, and another, the mother of several children, had suffered from marked premonitory symptoms of eclampsia in all of her previous pregnancies, in spite of which no urinary examinations whatever were made by her physician and no special diet or treatment was given her. Such lack of management is nothing less than criminal, and the writer hopes and believes that no reader of this book will allow any pregnant woman, no matter how well she may appear to be, to go through her pregnancy without proper urinary analyses, at least during the last three months. After the woman has suffered from albuminuria, and has shown its characteristic symptoms for a varying period, she may, if the case has not been treated, have a miscarriage. This seems to be an effort on the part of nature to relieve her con- ECLAMPSIA. 199 dition, for by the death of the child and its expulsion from her body the strain on her eliminative organs is lessened at least to the extent that she no longer has to excrete the waste prod- ucts of the foetus. More frequently, however, even if the child dies and an attempt at miscarriage occurs, she will pass into the eclamptic state and have the characteristic convulsions of the disease. One attack is practically like another. The patient first complains of dizziness, and then everything grows black before her eyes. Her hands are clinched, with the thumbs drawn in ; her head is drawn backward or to one side ; her face is deathly pale ; the corners of her mouth are drawn down, and the eyes, open but rolled upward so that only the " whites " are visible, give to the countenance a particularly ghastly appearance. Now the large vessels in the neck begin to pulsate violently, the face grows gradually more and more cyanotic until it becomes almost black, and the glottis closes, causing respiration to stop. In this condition the woman remains for from ten to twenty seconds, in a state of complete rigidity, after which, if death does not occur, her muscles gradually relax. Respiration now becomes rapid; she froths at the mouth, and may expel some blood if she has bitten her tongue; her arms and legs begin to twitch, and soon her entire body is in a state of violent con- vulsion. After three or four minutes this gradually ceases and the woman passes into a condition of coma, from which she emerges in a few minutes with no distinct recollection of what has taken place. In severe cases the coma may grow deeper and deeper until death occurs, or she may pass directly from one convulsion to another without regaining consciousness be tween the attacks. These convulsions resemble the uraemic con- vulsions due to kidney disease and found independent of preg- nancy. If the nurse first sees a patient on the occasion of the occur- rence of an eclamptic convulsion it will be necessary for her to make a diagnosis of the cause of the spasm, in order that she may proceed intelligently. Practically the only conditions that might be confused with 200 A NURSE'S HANDBOOK OF OBSTETRICS. eclampsia arc epilepsy and hysteria, and if the following points are borne in mind the nurse will have little difficulty in arriving at a correct opinion. Eclampsia occurs in a woman who is pregnant at least six months. She has suffered during her pregnancy from the symp- toms of albuminuria. Her face is swollen and her entire body is cedematous and puffy. Her friends will tell of her headache, vomiting, visual disturbances, and the like, and often inquiry will reveal the sad fact that her physician (if she has one) has not made any urinary examinations or ordered any special diet for her. Her urine will be scanty and highly colored, and if a little is placed in a teaspoon and boiled over the flame of a match or gas-jet it will turn white and often solid from the coagula- tion of albumin. This test is simple, quick, and absolutely con- clusive, for, w T hile there may have been little or no albumen in the specimen prior to the onset of the attack, it is sure to be present in large amount before many convulsions have occurred. The author can see no objection to the nurse's availing herself of this means of diagnosis unless the physician is close at hand and his presence can be secured without delay. If he has to be summoned from a distance, a positive report as to the highly albuminous state of the urine might be of value to him in making his preparations for the treatment of the case, w r hile such knowl- edge would certainly aid the nurse in her management of the patient while awaiting the arrival of the medical attendant. As she comes out of one convulsion she may pass almost at once into another, and, even without a thermometer, it will be evi- dent that she has considerable fever. She may have only one or two attacks and die, or miscarry and recover, or she may have fifty or sixty at intervals of from a few minutes to a few hours, any one of which may prove fatal. Epilepsy occurs independently of utero- gestation, and if the woman chances to be pregnant it is merely a coincidence. The convulsion is generally ushered in with an outcry, and after it is over the patient passes into a sound sleep which may last for an hour or more. The attack will not be repeated for days, HYSTERIA. 20I at feast, and often it will be weeks or even months before another seizure occurs. There are none of the premonitory symptoms of albuminuria, and the history will show that the patient has long been subject to similar attacks. The nurse must, of course, be on her guard against those rare cases in which eclampsia occurs in a patient known to be an epileptic. The history of the albuminuria and the time of the attack (during the last three months of pregnancy), together with the recurrence of the con- vulsions at short intervals, the appearance of the patient, and the presence of fever, should be enough to settle the question. Hysteria, like epilepsy, occurs independently of pregnancy, and if it happens that the woman is pregnant the hysterical attack may occur at any period of gestation. The convulsion of hysteria is not as severe as that of epilepsy or eclampsia, the patient never loses consciousness completely, fever is not present, and the pulse and respiration are normal or nearly so, and the urine, instead of being scanty, concentrated, highly colored, and albuminous, is pale, of low specific gravity, and excreted in large quantity. It is, of course, to be understood that any convulsion occur- ring during pregnancy is a sufficiently important matter to war- rant the nurse in sending at once for the physician, and if the immediate services of the regular medical attendant cannot be secured she should lose no time in summoning the nearest avail- able practitioner. The treatment of eclampsia begins primarily with those pre- ventive measures which should be instituted by the physician as soon as the pregnant woman comes under his professional care. These consist largely in the adoption of a proper hygienic regime which provides for a nourishing diet with the reduction of meat to once daily, the careful regulation of the bowels, the practice of daily bathing to keep the skin in good working order, the indulgence in regular out-of-door exercise, and the daily ingestion of at least two quarts of pure water to act as a diuretic and otherwise " flush out " the system. When these measures are carefully followed, and the urine is examined at stated intervals for evidences of albuminuria, it should always 202 A NURSE'S HANDBOOK OF OBSTETRICS. be possible to avert a threatened eclamptic attack. Unfortu- nately, this plan can be put in operation only when the patient comes under observation at a comparatively early period of pregnancy, and in many cases the nurse will not be called to a case until shortiy before labor. Her first duty, under these circumstances, will be to ascertain if the patient's pregnancy has been properly managed and if the necessary urinary examinations have been made. This inquiry can always be conducted in a tactful way that will cast no reflec- tion on the behavior of the attending physician, and if the nurse finds that the proper precautions have not been taken she is perfectly justified in making such suggestions as may be indi- cated concerning diet, exercise, and the like, and in securing a specimen of urine and sending it to the physician for analysis. Moreover, during the last two months of pregnancy, she should send a specimen of urine once a week to the medical attendant, whether it is asked for or not. This should be done entirely as a matter of course, for, in the light of modern obstetrics, no physician would dare to find fault with such a procedure, even if he belonged to that happily small class of men who do not bother to make urinary analyses at these times. If the patient shows any general symptoms of threatened eclampsia, such as headache, visual disturbances, severe vomiting, and marked oedema, the physician should be sent for at once and his atten- tion explicitly directed to her condition. Occasionally the nurse will encounter the patient for the first time when she is in a convulsion, or the woman will have an eclamptic seizure shortly after the nurse's arrival or at some other time when there is no physician at hand. After sending at once for the nearest medical man and as- suring herself, from the character of the convulsion, the history of the case, the bloated appearance of the patient, and the al- buminous state of the urine, that the attack is really due to eclampsia, the nurse may proceed as follows until assistance arrives. Let the patient be lifted without jar into a warm bed ; insist upon absolute quiet in the room and the avoidance of all excitement ; no anaesthetic must be given by the nurse. No HYSTERIA. 203 matter what the first cause, the kidneys are almost without ex- ception involved and chloroform has been shown to produce very serious toxic effects upon the liver of mother and child. The liver has the work of breaking up poisons preparatory to their excretion by the kidneys. Ether, with as large an admixture of oxygen as possible, may be ordered to control the typical convul- sions. Remove all the patient's clothing, cutting the garments with scissors, and wrap her entire body (arms and legs separately) in a hot wet pack and cover her with warm blankets; empty the bladder with the catheter, disturbing the patient as little as possible ; as soon as she can swallow give two drops of croton oil in one teaspoonful of sweet oil, if it can be obtained ; whether the croton oil is given or not, make a saturated solution of Ro- chelle salt and give a dessert-spoonful every fifteen minutes until the bowels move freely. Prepare saline solution for intravenous injection or hypodermoclysis, as these are usually demanded. Oxygen is often given with excellent effect upon the cyanosis and respiration. When the convulsion ceases insist upon ab- solute quiet, and do not allow so much as a whisper in the room ; disturb the patient as little as possible and only for the necessary purposes mentioned above. The time to treat this culmination of symptoms known as an eclamptic convulsion is before the toxaemia has developed to this alarming stage. The tongue must be protected from being bitten by placing a spoon or clothespin covered with a cloth or napkin to prevent damage to the teeth themselves. This must be within instant reach to be of use. The nurse will, of course, remove all false teeth. If convulsions con- tinue uncontrolled, the child is usually born. If alive, tie and cut the cord and remove it to another room ; if it is dead, leave it alone, to avoid disturbing the patient, but in any case keep a hand on the fundus, under the hot pack, as a preventive against hemorrhage. If there is bound to be a considerable delay in securing the attendance of a physician, get thirty grains of chloral hydrate and forty grains of sodium bromide and give it by rectum. Beyond this : Darken the room. 204 A NURSE'S HANDBOOK OF OBSTETRICS. Maintain absolute quiet. Keep up the hot pack. Keep ice-bag to head and throat. Observe closely to prevent burns from external heat applied. Do not disturb the patient under any circumstances. Secure medical aid as soon as possible. Wait till the physician arrives before doing anything else. Do NOT LOSE YOUR HEAD. As the patient is unconscious or much dazed, the nurse must not leave the irresponsible woman alone and must be able to secure and maintain the absolute quiet prescribed. Upon the doctor's arrival he may hasten to empty the uterus if this has not already occurred and the nurse must make the necessary preparations, or he may adopt elimination and seda- tives as he sees fit. The effect of these sedatives, given usually by rectum must be very carefully observed. Morphine or veratrum viride may be ordered. Hemorrhage from the uterus may occur at any time during pregnancy, and while it may be due to high arterial tension or to erosions or ulcers of the cervix, and so be of no special con- sequence, it may, on the other hand, be of serious import; and all attacks of bleeding should be reported at once to the physi- cian. In the early months of pregnancy hemorrhage may be due to a beginning abortion or the case may be one of ectopic gesta- tion. In the later months the bleeding may indicate placenta praevia or be due to the separation of a normally situated pla- centa from the uterine wall. These four conditions will be described in detail later on, but so far as the nurse is concerned the general treatment of hemorrhage occurring during pregnancy is the same in every case : send at once for the physician ; put the patient in bed and make her lie still on her back ; elevate her bed at the foot ; reassure her in every way possible, and avoid all noise and every suspicion of excitement on the part of her friends and relatives ; if she is very nervous or if the hemorrhage ECTOPIC PREGNANCY. 205 seems at all severe, give one-sixth grain of morphine hypo- dermically. If the bleeding continues, a sharp watch must be kept for symptoms of acute anaemia, and it may be necessary to send for the nearest physician available instead of waiting for the arrival of the regular medical attendant. When the blood escapes into the bed, as in the case of placenta praevia, the amount of the flow should be enough to indicate the proper course to pursue, but it must be remembered that in certain instances, as, for example, when a normally situated placenta becomes detached from the uterus, the woman may bleed to death inside of her own body and little or no blood escape from the vagina. In such a case the symptoms indicative of danger would be those of severe hemorrhage from any other cause. The patient would be pale, and her pallor would increase as the bleeding continued ; she would be extremely nervous and restless, and her face, bathed in a cold sweat, would have an anxious and " wild" expression ; her pulse would grow more and more rapid and feeble, and finally would disappear entirely at the wrist ; her thirst would be extreme, and she would soon complain of ringing in the ears, dizziness, spots before the eyes, and at last total blindness ; towards the end would be seen that horrible condition known as " air hunger," in which the patient literally tries to bite the air as she would a solid substance, so great is her need of oxygen. Under these circumstances the nurse can do nothing beyond getting medical aid as soon as possible and preparing for the probability of a surgical operation, with plenty of hot water and hot, sterile, normal salt solution for infusion. Pain in the region of the uterus may be merely neuralgic in character and of no consequence beyond the discomfort that it causes, but its occurrence should always be reported to the medical attendant, as it is one of the symptoms of abortion, of ectopic gestation, of concealed hemorrhage, and of many of the diseases that may complicate pregnancy, such as appendicitis and various other disturbances of the abdominal organs. Ectopic gestation, occasionally and incorrectly termed 20 6 A NURSE'S HANDBOOK OF OBSTETRICS. " extra-uterine pregnancy," means, literally, a pregnancy that is " out of place." In the chapter on Fetal Development it was said that the ovum is usually impregnated by the male element while it is still in the Fallopian tube, after which it passes on into the uterus. If, now, anything occurs to prevent its passage into the uterine cavity, it will either develop where it is or else, in very rare instances, fall out of the open trumpet-shaped end of the tube and develop in the cavity of the abdomen. If its prog- ress towards the uterus were not interfered with until it reached that portion of the tube which lies within the uterine wall, it would be in the uterus, although decidedly ectopic or " out of place," which explains the incorrectness of the general term " extra-uterine pregnancy." This accident may be caused by a narrowing of the tube due to a constriction within itself; to folds or twists of the tube which may be the result of accident or disease ; to pressure from pelvic organs or tumors ; or it may occur with a very long tube or when the impregnation takes place close to the ovarian ex- tremity, so that before the ovum reaches the uterus it has developed to such a size that it is too large for the canal through which it is supposed to travel. In any event it becomes firmly lodged at some point and development proceeds, up to a certain stage, as though it were safe within the uterine cavity. The most common form of ectopic gestation is that which goes on in the tube itself, and is called " tubal pregnancy" (Fig. 73) ; the next most frequent type occurs in that portion of the tube which lies within the uterine wall, and is termed "inter- stitial pregnancy;" and the rarest form of all is known as " ab- dominal pregnancy," in which the ovum develops in the abdomi- nal cavity. Neither tubal nor interstitial pregnancy ever goes on to the full development of a living child, but occasionally, when the ovum falls into the cavity of the abdomen, the placenta attaches itself to some viscus and the foetus develops to full term and is removed by abdominal section. In all cases of ectopic gestation the woman exhibits, to a certain degree, the usual early symptoms of pregnancy, and, as ECTOPIC PREGNANCY. 207 a rule, regards herself as being normally pregnant. The uterus enlarges somewhat, the irritability of the bladder and the breast symptoms appear, and the patient suffers more or less from " morning sickness." Her menstruation may cease entirely, but there is usually a slight flow at each monthly period due to con- gestion of the lining membrane of the uterus. This may be only enough to stain the napkin for one day, and although such a " show" may occur in the early part of a normal pregnancy, it is entirely unnatural and sufficiently suspicious to warrant the Pig. 73. — Ectopic gestation. Tubal variety, ruptured at the end of the third month. A, uterus from behind with several small fibroid tumors in its wall; B, right ovary; C, ruptured tube ; D, left ovary; E, foetus. nurse in sending for the physician or at least advising him of its appearance. As the ectopic gestation advances there will be considerable pain of a sharp, shooting character on the side of the affected tube and extending down the leg. This pain is due to the stretching of the tissues of the tube or uterine wall, and any such combination of pain and slight bleeding should be brought to the notice of the medical attendant without delay. In abdominal pregnancy the condition may not be recognized 2oS A NURSE'S HANDBOOK OF OBSTETRICS. until the case has gone on to full term, when, as labor does not occur, a careful examination will disclose the true state of affairs. In unrecognized abdominal pregnancy the child will die, and may cause death of mother from peritonitis, or it may become mummified and remain in the belly indefinitely or else adhere to the abdominal wall and later slough out as an abscess. Cases of tubal and interstitial pregnancy, unless recognized and operated upon, will rupture into the abdomen sooner or later (usually between the first and third months), and the patient may bleed to death or die of peritonitis or shock. A ruptured ectopic sac would be diagnosed by the history of the early symptoms of pregnancy, the excruciating pain at the time of the rupture, the occurrence of collapse, and the rapid onset of signs of severe internal bleeding. The nurse can only send at once for surgical aid, lower the patient's head, elevate the foot of the bed, keep the patient surrounded with hot packs and perfectly quiet, and prepare for an abdominal section. While it is possible that the hemorrhage will stop and the products of conception be absorbed, bleeding is usually severe, and only the most energetic action saves the life of the patient. Placenta previa (Fig. 74) signifies an attachment of the placenta directly over, or in the immediate neighborhood of the cervix instead of at its usual site near the fundus of the uterus. When the placenta completely covers the internal os the condi- tion is known as " central placenta prcevia; " when merely the edge of the placenta extends over the opening it is termed "mar- ginal placenta prcevia; " and when the placenta is simply attached low down on the uterine wall, near the os but not overlapping it, it is called " lateral placenta prcevia." In any case the condition forms a distinct obstruction to de- livery, and the first symptom is a sudden discharge of bright red blood without any pain and apparently for no particular reason. The first hemorrhage is rarely fatal, but any subsequent one may result in the death of the mother before any surgical assistance can be obtained. At the first appearance of bleeding of this character the nurse should send the patient to bed, give one- PLACENTA PREVIA. 20Ci sixth grain of morphine hypodcrmically, summon the physician, and prepare for an immediate operative delivery, — usually a ver- sion. It is needless to say that all preparations for labor should be made without the patient's knowledge, to avoid the possi- bility of causing her any alarm. Fig. 74. — Placental attachment. A, normal attachment at the fundus; B, lateral placenta praevia ; C, marginal placenta prsevia; D, complete, or central, placenta praevia. Hemorrhage due to the detachment of a normally situated placenta may show itself externally or it may be entirely con- cealed, the blood remaining in the uterus and finding room for itself by collecting between the fetal sac and the uterine wall (see Fig. 74). In such a case the only symptoms would be those of severe internal hemorrhage already described, together with excruciating pain located at the point of placental separation. These cases of concealed hemorrhage are often very difficult to 14 210 A NURSE'S HANDBOOK OF OBSTETRICS. diagnose, but the nurse would at least know that something serious was the matter, and in putting the patient to bed, giving morphine for the pain, and sending at once for the physician she would relieve herself of further responsibility. The symptoms of concealed hemorrhage from placental separation are practi- cally the same as those caused by rupture of the uterus, but when it is remembered that the placental detachment always occurs before, and the rupture of the uterus during, labor, it will not be a difficult matter to distinguish between the two conditions. Nose-Bleed occasionally occurs late in pregnancy or early in labor, and is due to the existing hydremic condition of the blood, coupled with a congested state of the nasal mucosa. It is seldom troublesome, but, in certain rare cases, it proves very intractable, and may persist until the patient loses an alarming quantity of blood. Such cases are, of course, very unusual, but the possibility of their occurrence should be kept in mind, and any profuse hemorrhage from the nose should be reported to the physician. Slight hemorrhages from the stomach or lungs, also due to the existing hydremia and from areas of local congestion, are occasionally met with late in pregnancy, and, unless it can be shown that they are due to other causes, such as a gastric ulcer or pulmonary tuberculosis, they are seldom of any moment. They are, however, usually more alarming to the patient than would be a really serious nose-bleed, and, of course, they should be reported to the medical attendant at once. While awaiting his arrival or advice the patient should lie quietly on her back and take small bits of cracked ice at frequent intervals. The eruptive fevers, when affecting a pregnant woman, are always exceptionally severe, and if the temperature is at all high, abortion or miscarriage is almost certain to occur. Scarlet fever is particularly fatal during pregnancy, and very little hope can be offered to the woman who contracts the disease at this time. Pneumonia in pregnancy is usually very fatal to both mother and child, although, when abortion occurs, as it often does, the maternal chances are somewhat improved. SYPHILIS. 211 Tuberculosis shows apparent improvement during preg- nancy, but its fatal outcome is probably hastened, for the woman's decline is usually very rapid after the birth of the child. Malaria is very apt to cause abortion, either by reason of its high temperature or because of the large doses of quinine given for its control. It must be said, however, that physicfans practising in malarial districts give quinine to pregnant women without any regard to its oxytocic properties, and claim that under these conditions — that is, when given to a pregnant woman who is actually suffering from malaria — it has no tendency to cause miscarriage. In any event, the physician is between two horns of a dilemma when he encounters severe malaria com- plicating pregnancy, for if quinine is not given, through fear of causing abortion, the high temperature of the disease will most probably do so. Syphilis is the most common cause of all abortions, and a syphilitic patient should be under active treatment from the very beginning of gestation is she wishes to be at all certain of going to term and giving birth to a living child. The nurse should remember that syphilis is often encountered where it is least expected, and that her professional acquaintance with the disease will by no means be limited to her hospital training. Syphilis is defined as a chronic, infectious disease (which may also be hereditary, inducing cutaneous and other lesions), due to a specific germ the Treponema pallidum. The primary or first stage is marked by chancre and indolent bubo. This may appear almost anywhere and need not be of venereal origin at all. The secondary or second stage is characterized by skin erup- tions, glandular swellings, and mucous patches. These two stages are highly infectious, and follow each other within two or three months. The tertiary or third stage is marked by gumma and severe skin lesions. The gumma attests the degree of damage suffered by all tissues of the body. It develops after a lapse of years. Syphilis is curable and Osier and Churchman state that syphilitics may marry with safety after they have undergone 212 A NURSE'S HANDBOOK OF OBSTETRICS. three years of thorough treatment and been free from symptoms for a year after the last treatment. Paternal transmission of the disease is usually during the first and second stages. A patient who has tertiary lesions may have healthy children ; but more often pregnaney results in a dead and typically maeerated foetus or an infant afiiieted with the disease. It is a disease transmitted from man to man and there is no intermediate host. The knowledge concerning it is widespread. It is a communicable, preventable disease, and stands unequalled in its destruction of human life. Being, as has been said, the most common cause of all abor- tions, it leads as a factor in causing infant mortality. Nowhere will pre-natal care secure more definite results. A positive diag- nosis and treatment will lessen the damage to the child. Mercury, in the form of baths, inunctions, subcutaneous injections and internal administration, is usually ordered to control the condi- tion during pregnancy. Potassium iodide is often administered in conjunction with mercury. Salvarsan treatment early in syphilis will prevent the further spread of infection. A nurse may use her knowledge wisely and report symptoms observed in a patient and so save the life of the infant. A new-born infected babe will show a typical snuffle, a gen- eral eruption, ulcers on the mucous surfaces, and marasmus. Beaumes' or Colles law: " that a child born of a mother who is without obvious venereal symptoms, and which, without being exposed to any infection, subsequent to its birth, shows this disease when a few weeks old, this child will infect the most healthy nurse, whether she suckle it or merely handle and dress it, and yet this child is never known to infect its own mother, even though she suckle it while it has venereal ulcers of the lips and tongue." The nurse may recognize some of the symptoms and will im- mediately take steps to prevent the highly communicable infec- tion from spreading. She will report the matter to the doctor and use every precaution that will protect the household and herself. She will nurse the patient as she would any contagious disease. Wear a gown and rubber gloves. As fast as possible GONORRHOEA. 213 destroy all discharges, by burning. Strictly individual articles must be used and kept inside the patient's room. Plenty of running water and antiseptic solution will be needed. A nurse will do well in caring for what is called a venereal disease to remember that many are innocent victims and her patient is under no circumstances to be told she has such an affliction. Her condition and symptoms must not be discussed or mentioned. The nurse must hold close to her school version of the Hip- pocratic oath and hold inviolate her knowledge of the patient's life. If she fails in this trust imposed upon her, she has failed in her whole life work ; and she should never forget that a word, or even a look, may inaugurate a domestic cataclysm. Gonorrhoea is said to be even more prevalent than syphilis. The point of infection first shows the reaction to be gonococcus. It invades the genital tract, causes inflammation, produces nu- merous complications in male and female, and has a most serious consequence, sterility. It sometimes invades the blood and a general septicaemia and pyaemia result. It may produce an arthritis and acute endocarditis, and what chiefly concerns the obstetrical nurse is the possible infection of the baby's eyes either at birth or later through the lack of care by the nurse. The patient usually suffers intensely ; and the nurse, always remembering the case to be of an infectious nature, will give all nursing care, such as douches, treatment, tampons, etc., with scrupulous regard for technic. The doctor concentrates or- dinarily upon controlling the acute manifestations of the disease before confinement, and should a puerperal peritonitis follow, the measures for relief of the pelvic pain are usually a peritonitis bed and ice-caps to pelvis, with liquid diet. These cases require the best of intelligent care and absolutely perfect technic to avoid infection of the infant's eyes, navel or genitalia. The doctor may use injections of serum to control the infection. All of the eruptive fevers, syphilis, tuberculosis, malaria, and lead and sewer-gas poisoning may directly affect the foetus in utero ; and although the last two conditions do not cause any very serious disturbances if the child lives, they are very apt to cause abortion at an early period. XVII Operative Delivery Operative delivery may be either instrumental or non- instrumental. Instrumental delivery may be further divided into three classes, — cutting operations, non-cutting operations, and muti- lation of the foetus. The non-instrumental form of delivery consists in turning the foetus with the hands from an undesirable into a desirable position in the uterus. This operation is termed version, and may be performed in any one of three ways, — by external ma- nipulation through the abdominal wall alone, called " external Fig. 75.— Internal version. (Garrigues.) Entire hand in the uterus grasping a foot. As the foot is drawn down the protruding arm will be drawn up into the womb, and the child will be delivered by the breech. version ;" by internal manipulation through the vagina alone, called "internal version" (Fig. 75); and by a combination of these two methods, in which one hand is placed on the abdo- men of the mother and the other in the vagina with the finger- 214 VERSION. 215 tips in the uterus, called " combined version" or the " Brax- ton-Hicks Method" (Fig. 76). Pig. 76. — Combined or bipolar version. (Garrigues.) The finger in the vagina is assisted by the other hand on the abdominal wall. External version can only be performed before labor has begun, or immediately after and before the membranes have ruptured. It is often employed to convert a breech or trans- verse presentation into that of the vertex when the abnormality is recognized at a sufficiently early date to admit of the neces- sary manipulation. The combined, bipolar, or Braxton-Hicks method has a not much wider field of usefulness than the external method, and must also be done before or very early in labor. The finger- tips in the uterus push the undesired presenting part to one side, while the other hand of the operator presses through the abdom- inal wall and forces the desired fetal pole into the pelvis. The operation requires considerable skill and great patience and perseverance, and really amounts to turning the fcetus around in the uterus and passing it along in a gradual, jerky way over the finger-tips until it is in a proper position. Neither external nor combined version call for the admin- 2l6 A NURSE'S HANDBOOK OF OBSTETRICS. istration of an anaesthetic unless the patient is in an extremely nervous condition or her abdominal wall is rigid and unyielding. The operation is not at all painful, but is often unsuccessful, either because it proves to be entirely impossible, or, as is more often the case, because the foetus returns to its original position within a few hours. Fig. 77. — " External version. The patient is to lie on her back, with her knees drawn up enough to relax the abdomen, and as soon as the fetal position has been corrected a firm binder should be applied with long pads on each side of the belly to prevent any change of position. In these two forms of version the head of the foetus is almost invariably the part that is brought into the pelvis, and frequently, as soon as this is accomplished, the physician will rupture the FORCEPS OPERATIONS. 217 membrane artificially and allow labor to proceed at once. When internal version is performed the entire hand is introduced into the uterus, and instead of the head, as in the external and combined methods, a foot is grasped and brought down into the vagina, or even out of the vulva, converting the case into one of breech delivery (see Fig. 75). The patient is to be placed on her back in the lithotomy position, with her legs elevated and held by assistants or sup- ported in a leg-holder. Anaesthesia is always necessary, and should be carried to the degree of complete unconsciousness. The os uteri must be dilated sufficiently to admit the closed fist of the operator before the operation is begun, or rupture of the uterus may result ; the membranes must, of course, be ruptured, in order that the surgeon may grasp a foot, and the bladder must always be empty. While external and combined version carry no danger what- ever to either mother or child except, in the latter variety, through possible infection of the uterus by a surgically unclean operator, internal version is extremely dangerous to the infant, and to the mother is one of the most perilous operations of sur- gery, not excepting those which necessitate opening the abdomi- nal cavity. Of the non-cutting instrumental operations, the most com- mon is FORCEPS DELIVERY. Forceps are merely metal substitutes for hands, which can grasp the sides of the fetal head, or rarely the breech, and draw it down and out of the pelvis (Fig. 78). Forceps operations are divided into three classes, — high, medium, and low. The high operation is done when the head is at or above the pelvic brim. It is extremely dangerous to the mother on account of the possibility of rupture of the uterus, and may be even more serious than version. The medium operation is done when the head has passed through the brim but lies in the vagina and does not yet distend the perineum. The low operation is done when the head lies well down on the perineum and pushes forward the vulva so that it is, in many cases, in plain sight. 2i8 A NURSE'S HANDBOOK OF OBSTETRICS. Fig. 78.-Forceps applied to head of brim. (Gafrigues.) Fig. 7 » Oj ^—^ 8a- >v - <*5 5 _/ <** ^ _ 7 •n f fir S5 t _ 7 c* S, _ I ^1- . t J5 r Q N *Tl- .. r : °r> 3$ t . 1\ te- t _ Jo *•% _r _ : t L-*-* t <** t-t : 1 — - -^ _ 1 i 2 i 1^17 ? i vb « /? A M JJ )f ) ?h t < 9 PUERPERAL INSANITY. 287 in deep-seated infections by the the use of the Bier congestion bell. This is applied as often as is ordered for short periods of time, but because of the pain involved in comparison with the treatment outlined, it is but little used in practice. If the treatment outlined above is unsuccessful and the case goes on to suppuration, the treatment is necessarily surgical, and the nurse can only follow the directions of the medical at- tendant. Local anaesthesia is generally given and the incision made as small as possible. Evacuation of the pus is sometimes difficult to secure. The drain is perhaps a small wick or may be some form of suction cup, depending upon the area involved. This implies the necessity at times for an anaesthetic at dressings. It is not necessary to repeat the caution concerning the handling of such pus. Gloves and gown to protect nurse and both pa- tients ; cleanliness and good technic are demanded. It may be said that the cases of mastitis that develop during the first month after labor seldom go on to suppuration, but those appearing later in the puerperium are very likely to do so unless they can be checked in the manner described. Syphilitic lesions may be found on the nipple, either primary from the bite of a syphilitic child, or of the tertiary type in a wo- man who is suffering from the disease in its advanced stage. The matter would, of course, be brought at once to the attention of the physician, and the treatment is the same as it would be under any other condition. Eczema of the nipple and areola, and occasionally extending over the entire breast, is a rare complication that may arise during the puerperium. Its treatment is both local and general, and can only be carried out by the physician. Insanity may occur at any time after conception and disap- pear within a few days or even hours, or it may continue through- out the entire pregnancy, into the puerperium, and even through the whole period of lactation. The insanity of pregnancy is usually melancholia, and is often so slight that it is entirely unnoticed, but it may, on the other hand, be very pronounced, with a marked suicidal tendency. 2 88 A NURSE'S HANDBOOK OF OBSTETRICS. The insanity of the pnerperimn, called "puerperal insanity," is most often of the maniacal type, and is the most common of the three varieties. The mania usually appears within a month after delivery, either following the melancholia of pregnancy or without any warning whatever. The patient is at first restless and disagreeable, and soon evinces a marked dislike for her husband and others who are most nearly related to her, or else the mania develops suddenly with no premonitory symptoms. The woman becomes noisy, talkative, and incoherent, and her mind may dwell on religious subjects, or she may be profane, obscene, and vulgar, with an absolute loss of all sense of decency or modesty. The tendency to suicide or murder is always strongly marked, and the patient must be most carefully watched. The insanity of lactation is usually of the melancholic type, like that of pregnancy, and is most commonly seen in multipara? who have borne many children in rapid succession and whose general condition is greatly impaired. The causes of insanity cannot be stated very definitely, but may be supposed to include all conditions that greatly under- mine the general health of the patient. This would comprise severe injuries, mental disturbances, albuminuria, eclampsia, chorea, hemorrhages, septic infection, pronounced anaemia, and painful or prolonged labors. Heredity seems to play an im- portant part in the causation of this condition, and illegitimacy often exerts a sufficient effect on the mother to account for the insanity of pregnancy or of the puerperium among unmarried women. These cases are seldom fatal except through personal injury inflicted by the patient herself, but quite a number die eventually of exhaustion, and others become chronically and hopelessly in- sane. Unless the patient recovers entirely within a year it is almost certain that she will remain permanently demented, but the majority of cases do not last more than a few weeks or a month. There is a sudden transitory mania which sometimes occurs during labor, but it is probably an hysterical manifestation due to the severity of the pain, and disappears within a few minutes. PUERPERAL INSANITY. 289 The treatment of these cases lies entirely with the physician, and consists chiefly in building up the shattered constitution with nourishing and easily digested food, fresh air, good hygienic surroundings, and careful nursing and attendance. The maniacal cases should be placed in an asylum, unless the circumstances warrant the employment of a sufficient num- ber of nurses for both day and night duty to keep the patient under constant surveillance, and even in the melancholic cases the suicidal and homicidal tendencies must be kept in mind at all times. XXI The Care of the Normal Infant As soon as the mother has been given the attention neces- sary to secure cleanliness and comfort, the nurse may, after as- suring herself that she is in good condition, direct her attention to the infant. The infant was wrapped in a sterile towel, to protect the umbilicus from infection, and a warm flannel blanket, and laid in a safe place at the time of its birth, and has been examined occasionally by the nurse to see that its breathing is satisfactory and that there is no bleeding from the cord. If the room is cold or the child is not warm and rosy, it should be surrounded with hot-water bottles filled with water no hotter than 120 ° ■ F. and covered to prevent the possibility of burning its delicate skin. The physician will, when the opportunity offers, inspect the in- fant's body carefully for deformity, injury, or abnormality of any sort, and, if it is perfectly developed, inform the mother of its satisfactory condition. If deformity or injury is found, it is best to keep the knowledge from the mother for as long a period as possible by giving more or less non-committal replies to her interrogations, but as soon as she begins to suspect in the slightest degree that she is being deceived as to the child's con- dition the doctor must be notified. The obstetrician will direct the nurse as he sees fit. Usually the father will be told at once and the mother informed by him or the doctor. The nurse rarely has this painful duty to meet. The baby's eyes first receive attention. The doctor usually gives this by washing the eyes from the inner angle toward the outer with a boric acid solution. He will take every care to prevent any contamination of the eye from foreign matter and when they have been thoroughly cleansed he will open them and use Crede's treatment or some similar 290 OILING AND DRESSING THE NEW-BORN INFANT. 291 Fig- 137. — Oiling and dressing the new-born infant. All articles are within reach. The table is warmed with hot-water bottles. 2 () 2 \ NURSE'S HANDBOOK OF OBSTETRICS. method. If nitrate of silver solution, i or 2 per cent, is used, one drop in each eye, he may neutralize this with normal salt solution or a 2 per cent, boric acid solution. He may prefer argyrdl, 25 per cent., or protargol, 15 per cent. Occasionally he leaves this to the nurse. She must take especial precautions against allowing vernix or blood to get into the eyes, and against any silver solution dropping upon the face. The infant must have warmth and protection from strong light and draughts. The nurse will soon find time to anoint the baby carefully with warm sweet oil or albolene, and to remove the vernix caseosa which covers the body. The oil is poured into a glass or cup, which is placed in a vessel and allowed to stand until it is thoroughly warm. The nurse will have a small table prepared to receive the infant and will never be guilty of placing it upon her lap when this can pos- sibly be avoided. No lap can properly support an infant when the person is continuously reaching for required articles and altering the position of her knees. It is entirely unnecessary and nurses should begin to grasp the fact that this ancient custom leaves very much to be desired in the way of comfort and effi- ciency to .both nurse and infant. The method has nothing to recommend it save custom. The infant should be handled as little as possible. This can best be done by always placing it upon a table. Care can be given more expeditiously and efficiently in this way. In a hospital the op- portunity for infection through bathing a number of infants upon the nurse's lap is obvious. Some hospitals have instituted a system of spraying the in- fant upon a slab to avoid this source of very real danger. The general objections to the lap method occur to the mind at once. Any table covered with a blanket and a towel will suffice for the first anointing of the baby. Secure warmth beneath by a hot-water bottle, and, turning the infant upon its face, apply albolene gently but rapidly with a cotton sponge, going care- fully in all creases at knee, buttocks, neck and back of the ears where the vernix is most abundant. DRESSING THE CORD. 293 Take care that nothing comes in contact with the cord and that no oil enters the eye. The head usually requires a thorough anointing. Dry with a warmed soft towel. The infant is then turned over, and the anterior portion of the body anointed in the same manner, particular attention being given to the armpits and creases in the elbows, groin, and under the chin. Dry thoroughly. Doctors rarely dress the cord, but a nurse will be wise if she asks for orders as to method before assuming responsibility. It should be done with especial care and especially clean hands to avoid infection. The cord and surrounding area may be washed thoroughly, particularly the point of insertion, with 95 per cent, alcohol, and a wet gauze dressing of 95 per cent, alcohol applied, or it may be cleansed thoroughly with 95 per cent, al- cohol and a dry sterile gauze dressing applied. Never use powder. It is not sufficiently antiseptic, and it forms crusts This dressing can best be done by using forceps to handle the dressings. The dressing is the usual one in shape. A pad of gauze or cotton is cut with a hole in the centre through which the stump protrudes. The corners are folded over the stump, allowing it to take the direction of least resistance. Over this is placed a sterile gauze sponge and then the binder is applied. After the temperature is taken and diaper applied, the baby should be dressed rapidly and put in a warm crib. Children should not receive a tub bath until the cord has be- come detached. The cord dressing is not to be disturbed unless it becomes soiled, when the same surgical care is to be shown in its renewal. Unless the dressing becomes soiled with urine or otherwise, it may be allowed to come off with the cord some time between the fifth and eighth day. If it is necessary to remove it, only such of the cotton as can easily be freed from the cord need be taken away and the fresh dressing applied exactly as in the first instance. The little tags and fibres of cotton that adhere to the cord will be sufficiently sterilized by the application of the fresh alcohol. 294 A NURSE'S HANDBOOK OF OBSTETRICS. The Umbilical Cord. — This usually becomes detached from the body between the fifth and eighth day after birth, but its de- tachment may be delayed until the tenth, twelfth, or even the fourteenth day without causing any harm unless signs of inflam- mation appear. The nurse will usually find the cord in the um- bilical dressing when she removes the binder to bathe the infant, and there may be a slight stain of blood. If the bleeding con- tinues, as it may in very rare instances, the physician should be notified. In most cases the navel will be depressed somewhat and absolutely free from any evidence of inflammation. No further treatment is required except to keep the part clean and dry. Fig. 138. — Method of dressing the umbilical cord. The clinical record of a normal infant should show a varia- tion in pulse of from no to 150. Only experience can teach a nurse to accurately count an infant's pulse-rate. Touching its wrist will generally startle and noticeably accelerate its heart beat. It can always be felt at the temporal artery to best ad- vantage, particularly when sleeping. The temperature may vary a whole degree, from 98 to 99 F. A feeble infant will have a temperature below this, from 97 to 98 . Sleep. — The newly born infant requires a great deal of sleep and is to be kept in its crib except when it is removed for some special purpose, such as nursing or bathing. The infant will, during the first few weeks of its life, sleep practically all SLEEP. 295 the time, but it must be expected to cry vigorously for at least half an hour each day in order to expand its lungs and develop the muscles of its chest and abdomen. It should be laid down at once so that it may go to sleep and digest its food properly, and if it cries and examination shows that it is perfectly dry and comfortable, it should be left alone to stop of its own accord, and must never be patted, rocked, or walked about. If at all possible the child should be kept in a room away from the mother until after the puerperium, in order that this process of disciplining may not disturb her. Systematic training of this kind during the first few weeks of the puerperium, coupled with a regular hour for undressing the baby and putting it to bed in a dark room for the night, will teach any child to go to sleep the moment it is laid in bed and the habit will cling to it as long as the rule is enforced. If the plan is to be successful, it must be adhered to ab- solutely, and friends and relatives must understand clearly that they cannot see the baby under any circumstances after five o'clock. There is not a healthy child living who has to be rocked or otherwise cajoled to sleep whose parents or nurses are not di- rectly responsible for the whole matter, and while it may be very entertaining to ignore the welfare of the infant entirely and make a toy of it at first, the constant care and attention become most trying as the years go by, and especially so if other children are born and a similar program is followed. A child can be made a comfort just as easily as a trial and a burden ; and people whose children are up at all hours of the night, have to be rocked to sleep and stayed with for hours each evening, and protected from bogie men and other terrors of the nursery, have absolutely no one to blame but themselves. In these matters of discipline the nurse can only advise the parents as to the best course to pursue for their own personal comfort and the good of the child, but if they prefer to make themselves and every one about them miserable for a number of years rather than forego an ill-timed frolic with the baby, they cannot be denied the pleasure of doing so. 296 A NURSE'S HANDBOOK OF OBSTETRICS. Infant's Cries. — After the child is born and has cried lust- ily, it becomes quiet and at once sleeps. After the eyes, navel and skin have received the necessary care it is dressed and placed in a warm crib, and it will not cry unless it is wet, hungry, or ill. A nurse should learn to distinguish an infant's condition and needs from the character of its cry, which all nurse's text- books describe — a loud insistent cry with drawing up and kick- ing of the leg, denoting colic, either intestinal or due to the pass- age of red uric acid deposit from the bladder. Sometimes this point may be decided by finding this red stain upon the diaper. A fretful cry if due to indigestion will be accompanied by green stools and passing of gas. A child's whining cry is noticeable when the infant is ill, premature or very frail. A fretful, hungry cry, with fingers in mouth, is easily known. A peculiar sharp, sounding cry is emitted where there has been any injury suggesting a cerebral condition. A nurse should make every effort to recognize any deviation from the usual manner in which an infant announces his normal requirements. Adherent Foreskin. — In a male child adhesions between the prepuce and the glans penis are very common. The fore- skin may be extended beyond the glans. A very small opening is spoken of as a phimosis. A curdy secretion, called smegma, may form in considerable amount and collect under the prepuce behind the glans ; small amounts of urine may also be retained and all of these conditions favor irritation. The doctor will perform the delicate operation of separating the adhesions. A nurse must never attempt it. It should be left alone and in no way manipulated by unskilled hands, or a serious condition known as paraphimosis may result. The doctor will sometimes expect the nurse to do the daily dressing, following a dilatation and retraction and will direct her. The manipulation will be difficult at first and must be done quickly. But the use of the probe is rarely expected of a nurse, a cotton sponge, the gentlest pressure with sterile vaseline for the lubricant generally serving the purpose. Soapy water should never be used to bathe this denuded tissue. Use sterile warm salt solution. Similar adhesions are often found about the WEIGHT. 297 clitoris in female infants, but then destruction is not so easily accomplished and should be left entirely to the physician. Oc- casionally a slight bloody discharge may come from the vagina. It may be due to injury or is apparently menstrual in character. It rarely reappears and needs only cleanliness for treatment. Chafing, Scalding or Eczema Intertrigo. — This is due to moisture and the irritation of adjacent surfaces. In the female infant there is not infrequently a vaginitis with the usual swell- ing and purulent discharge. Practically all genital infection is the result of neglect and careless handling. It may be brought to the area by the nurse in the same manner she may infect the mother. It may be due to contaminated lochia or pus ; neglect for a few hours is enough to start up irritation. All irritation of the genitalia must be treated with absolute cleanliness and the parts must be kept dry. This applies to all conditions not due to specific constitutional infections. Soap and water are to be discontinued at once, and the infant should be patted clean with olive oil and dusted with stearate of zinc or talcum powder, as commercial toilet powders nearly all contain boric acid powder which burns and irritates. Removal of the cause by eliminating pressure, with rest, cleanliness, and preventing moisture of the tissues, will usually check the inflammation. No properly quali- fied nurse will permit such a condition to arise in a child under her care. Properly fashioned, washed and ironed diapers used only once will be a large factor in preventing its occurrence. Weight. — The normal weight of a male child at birth is seven pounds and eight ounces, while that of a female infant is six pounds and eight ounces, or one pound less. These are the usual, average weights of normal infants, and two-pound mites or twelve-pound boys are as rare as Siamese twins, despite the marvelous tales of proud parents and ignorant midwives. During the first few days of life the infant normally loses in weight, until about the sixth or seventh day, it has dropped ten ounces below its birth-weight. This is because its digestive ap- paratus is barely learning to functionate at this time and the child assimilates little if any of the very small quantities of material which enter its stomach. For nearly a week it lives almost en- 298 \ NURSE'S HANDBOOK OF OBSTETRICS. tirely on its own subcutaneous fat and gives off in meconium, urine, perspiration, and otherwise far more matter than it takes in by mouth. About the time that the meconium begins to disap- pear from the stools the weight commences to increase and, in normal cases, does so regularly until, by the tenth day of life, it equals the birth-weight ; after which, if all goes well, it continues to increase until, at six months, it is double the birth-weight. For example, a child which weighs seven pounds and eight ounces at birth should be expected to drop to six pounds and fourteen ounces by the fifth or sixth day, increase to its original weight of seven pounds and eight ounces by the tenth day, and weigh fifteen pounds when it is six months old. Any marked deviation from this course should be reported to the physician. Directions for nursing are given and it must not be for- gotten that the baby requires a drink of tepid boiled water several times daily. This amount should be increased if a red deposit is found upon the diaper, following an attack of crying. The nurse must know with certainty whether the infant has urinated. If no urination occurs during the first twenty-four hours (an unusual condition) a cause must be looked for and an obstruction will probably be found. A prompt report should be made of the condition. The sterile water should never be given with a medicine dropper. The danger of injury to the mouth through careless administration is great. A small boiled bottle and nipple are better for the purpose. The needs of the baby and the ideal nursery will be included in the next chapter. XXII The Ideal Nursery and Layette THE IDEAL NURSERY As a guide to the nurse in answering the many questions an inexperienced mother will put concerning the infant's wardrobe, nursery and accessories, this chapter is added. The change from the old to the new order as applied to the hygiene of the baby is nowhere else shown to be so great. For the nursery, which is to be a home for a child, theoreti- cally the only logical reason for the maintenance of a home itself, a room flooded with sunshine and properly ventilated is the best. The proper sort of nursery should be secured if it is at all possible. Families might change a cramped dark apart- ment for a more desirable residence if the baby was considered as he deserves. Necessities for the child's health, comfort and freedom, as well as his protection from infections and accidents, can all be secured by the exercise of intelligent common sense, ordinary foresight, and economy as well. Quiet, sunshine, simplicity, warmth and ventilation are es- sentials for the baby. A neutral washable brown or green paint upon the walls and window shades of tan or dark green are suitable. Window hangings may be dispensed with. Eye hy- giene must be carefully observed and the infant never be ex- posed to a light shining into his eyes. The room should be kept quiet and freshly aired at all times. Usually the heating system must be accepted and will need watchful control. The nursery temperature should be about 66° to 70 ° F. during the day and 6o° by night, and if the child con- tinues strong a much lower temperature can be safely borne by night. The chief point to remember is to afford the necessary protection of the child's body from the cold air. This is ab- solutely essential and can be accomplished by the use of proper sleeping apparel and a proper method of crib making, using 299 3oo A NURSE'S HANDBOOK OF OBSTETRICS. coverings (such as wool or down) that give warmth with the least weight. The hlankets should immediately cover the infant. Gas and oil heaters exhaust air rapidly, and if it is necessary to use them, they must be carefully watched, and the moisture in the atmosphere supplied, in a measure, by a large vessel containing water, always on the stove. The floor should be bare, with washable rugs or covered Fig. 139. — Infant's crib with adjustable sides. with linoleum. The bed is sometimes a clothes-hamper set upon two chairs, but should be a child's metal crib. This should have a hair mattress. Where this is not possible, many substitutes can be found. Mattress padding, four thicknesses deep, table felt- ing or a straw or southern moss may be used and covered with a quilted pad. Care and cleanliness by frequent washings and airing are essential and a rubber sheet is always necessary for PREPARATIONS FOR THE BATH. 301 protection if the mattress is to continue in use. The infant must never lie directly upon a rubber sheet, but always upon a dry pad. Babies require no pillows, breathing more easily lying upon the abdomen. When the infant is older a flat hair pillow may be used. Down is too heating for use at any time. In addition, the furniture, which should all be plain and washable, consists of : I. A table fenced on all sides and divided through the centre. Fig. 140. — Practical infant's crib. It may be raised and swung over bed of mother if desired. This is to be covered with rubber sheeting or oil-cloth, then a pad, and finally a towel or soft blanket for one half, two thick- nesses of padding for the dressing half. The infant is to be bathed on one compartment and dried. Then laid upon the other compartment for its careful toilet. This nursery furniture is a stock article abroad, but the fashion persists very strongly here of bathing, dressing and handling the infant upon the mother's knees. This is very undesirable. It is awkward for the mother, however low her chair and table of supplies. It results in much 302 A NURSE'S HANDBOOK OF OBSTETRICS. unnecessary handling of the infant, much more time is consumed than need be, and unless every detail of the bath and toilet has Fig. 141. — Double wash-basin. been remembered, it means the placing of the infant in some convenient spot until the mother returns with the forgotten article, pins, hot water, etc. When the baby is to be tubbed, the process of undressing, washing the head, nose, and ears, soaping Ihe body, can all be 1 m Fig. 142. -Paper bags pinned together. One for soiled clothing to be for articles to be destroyed. •ashed ; the other very expeditiously accomplished upon such a table and, with the tub beside it, all stooping is avoided. The dressing proceeds rapidly on the dry end of the table. Any small table 28 inches high may be so divided and fenced for protection. PREPARATIONS FOR THE BATH. 303 2. An infant's dressing screen is now on the market which does away with the insanitary exposure of the most personal toilet articles of the infant. This screen, which closes upon itself, has shelves, drawers, towel rack, and may be exceedingly elaborate with glass shelves, covering tufted satin, or plain wood. It may be made with a wooden frame and backed with linoleum or any washable material or most daintily fashioned. Every article belonging to the baby should find its place inside this screen, instead of the discredited baby basket which is invariably dirty. The soap should always be in a shaker, as are some shaving soaps. Nothing that the baby uses is quite so dirty as the usual cake of castile soap. Sea sponges, long discarded Fig. 143 A. — Infant's dressing screen. Holds all required articles and protects table. Fig. 143 B. — Infant's dressing table. One half for bath and change; one half for use after infant has been bathed and dried. in surgery, are equally insanitary for the use of the baby. Clean rags boiled often are far better. Cotton sponges in one piece may be shaped to cleanse the ears and nose. Never use cotton upon a tooth pick to cleanse nostrils. The danger of detachment is a real one and ears may be seriously injured by the manipulation of such an applicator. 3^4 A NURSE'S HANDBOOK OF OBSTETRICS. The shelves will hold the double basin, two pitchers, hot- water bottle and all toilet accessories. This screen opens, is light and on rollers, and is to be placed around the nursery table. This avoids a draught and places within immediate reach all the articles which are required. 3. A chair without arms for the mother or nurse. 4. A metal bed for the nurse. 5. An infant's wardrobe or chiffonniere. 0. A table to hold scales and any other article. 7. A low table or flat chair to hold the bath-tub. 8. An armless rocker for visitors. 9. Infant's bath-tub. These articles may be as exquisitely dainty or severely plain as the mother may wish. But the infant thrives best where it has quiet, sunshine, cleanliness, and an equable temperature. If the nursery has an adjoining bath-room as well as a screened porch many steps may be saved. A board over one end of the bath-tub may serve instead of the nursery table. It is low, however, and inconvenient because of the number of times in the day the infant requires attention and appropriates the bath-room. Much has been written to popularize the long-recognized scientific fact that clothing and environment produce definite effects upon the baby's physical and mental development. Pins, tight bands, rough seams, weighty clothing, scratchy laces, insuffi- cient diapers, noise, unnecessary handling, bootees and a host of other sufferings to which the infant has long been subjected have now a great light thrown upon them, and mothers are asked, on all sides, to consider these matters and to remedy the defects. The National Children's Bureau of the U. S. Department of Labor has published two monographs on Pre-natal Care and Care of the Infant which are very valuable. Mothers are ad- vised to secure them. The diaper is quickest made in the old way. twice as long as broad, in two sizes 20 X 40 inches and 26 X 52 inches. The first used should be still smaller, 36 inches square and folded four deep. PREPARATIONS FOR THE BATH. 305 Pins are required to adjust these diapers. They reach too high up the back and should be replaced by the shaped dia- per now so strongly recom- mended. The pattern is shown and explains itself. It is time the diaper pin dis- appeared from use. It has nothing in its favor except undisputed sway. Tapes that do not twist and straps not easily torn consume no more time in adjusting than does the finding, opening and applying the pins. The diaper is more comfortable when shaped, it allows more freedom to the limb, and, if properly fitted, it af- fords equal protection. An inside absorbent pad must al- ways be used, for the econ- omy is obvious. An oblong or towel-shaped diaper is excellent for larger chil- dren. The diaper is folded down from the top to double the thickness under the seat and the long end drawn up between the legs and fastened in four places. The tapes are to supersede the safety-pins where these are used. The fairly com- mon accident of swallowing safety-pins would be rare if the infant's clothing could be fashioned to dispense with their use. Being " stuck " with the point of a pin is only one of the possible discomforts to which the infant is subjected. There is 20 Fig. 144. — Method to secure air for infant in a city apartment. 306 A NURSE'S HANDBOOK OF OBSTETRICS. at all times more or less pressure of the small body upon them. Again, the large ill-fitting diaper between the thighs may result in a slight deformity to the femurs, and the delicate genitalia may be injured by the same pressure. The infant's temperature should be taken by rectum, and with proper training the bowels may be evacuated before the morning bath is begun. It is to be given according to a schedule. All necessary articles are to be within reach. The temperature Fig. 145. — Another view of Fig. 144. of the room should be about 70°to 75 ° F. All draughts are to be excluded and entrance to or egress from the room is not to be permitted unless the same temperature is maintained outside. The tub may be enamel, which is expensive but indestruct- ible ; a rubber tub, which it is impossible to scrub quite clean ; a papier mache or a tin tub. These last are usually painted and will serve very well for at least one year. The temperature of the bath may vary somewhat accord- INFANT'S CLOTHING. 307 / Fig. 146. — Diaper shaped according to pattern. No pins required. 308 A NURSE'S HANDBOOK OF OBSTETRICS. ing to the age and strength of the infant, but it must never be cold enough to cause shivering or blueness of the extremities, and must invariably be gauged by the thermometer and not "guessed at " by the nurse. In a general way the following table, given by Rotch, will meet the requirements of most infants, but the effect on the child must be watched carefully and the temperature raised if necessary. TEMPERATURE OF THE BATH FOR DIFFERENT AGES Age Temperature At birth 98 F. During the first three or four weeks 95 F. One to six months 93 F. From six to twelve months 90 F. Twelve to twenty-four months 86° F. Then gradually reduce in summer to 8o° F. In third or fourth year, if possible, reduce to 75° F. The infant is to be laid upon the bath end of the table, its clothing removed excepting its band and diaper. A cotton sponge should be saturated in a 2 per cent, solution of warm boric acid or boiled water, and used for washing the exterior of the eye. Care must be taken that no fluid escapes into the eye. Washing the healthy eye can do no possible good and may do much harm, the solution being often contaminated and old. The ears and nostrils are to be washed with small shaped pledgets of absorbent cotton. Toothpicks with cotton or sponge attached have no place in nursery. There is a great reaction against wash- ing the baby's mouth frequently ; all pediatricians seem to agree that this has been overdone in the past, and so now the avoidance of this source of danger for the introduction of germs and in- jury to the very delicate structure of the surface is strongly advised. Once a day the tongue may be cleansed with a 2 per cent, solution of warm boric acid. A piece of cotton should be ap- plied, most gently, with a surgically clean little finger. This is better than the cotton on a toothpick, so often used as an ap- plicator. If food is vomited, curds may be removed in this way. Separate pledgets must always be used for the mouth, ear, and TEMPERATURE OF THE BATH. 309 eyes. Paper bags may receive the articles to be destroyed and another those for the laundry. The head and the face are to be washed. The child's body is now to be soaped thoroughly and quickly with the sponge and water from the proper side of the double basin, and as soon as this is done the infant is lifted carefully into the tub and allowed to kick and splash for a few seconds. If the cord has not yet separated, the infant is not put into the bath. Nearly every baby will thoroughly enjoy its daily bath if it is begun before the child is old enough to know the meaning of fear, but when the tub bath is not commenced until the infant is several weeks old, or if it is ever dropped or otherwise fright- ened or injured in the bath, it may require great patience and perseverance to overcome the little one's terror of the water. The nurse must make sure that the water is of the proper temperature, and the baby is to be held firmly and dipped in the water slowly and carefully so as to avoid any sudden shock. When the child is, for any reason, actually afraid of the water, a thin towel may be laid across the top of the tub, covering it entirely, and the baby held over the towel and then lowered very slowly and carefully into the water. A few baths given in this way may be successful in reassuring the infant and over- coming its fear. After a few seconds in the tub the child is returned to the table, covered at once with a warm towel, and " spatted " softly until it is dry. A small soft towel is then used for drying the creases of the body and the armpits, groin, and buttocks, and talcum powder is applied lightly to all folds of the skin and places where moisture might collect. Remember that the baby is to be soaped and washed on the table, and not in the tub until it is old enough to sit up ; that separate sponges, wash-cloths, and water are to be used for the body, buttocks and face. The infant, wrapped in the towel, is now laid in the scales and the weight carefully noted and recorded on the weight chart after the bath. Before recording the weight the towel is to be 3io A XURSE'S HANDBOOK OF OBSTETRICS. weighed and its weight deducted from that of the infant and towel together. If the cord dressing has been removed it is replaced in the manner already described and the binder sewed carefully over it or tied. The diaper, folded in triangular shape, is laid well up under the buttocks and on it is placed a square of folded gauze, lintine, or old soft pieces of napkins or table-cloths, which will absorb a good part of the urine and take up all the discharges from the bowels. These are to be changed and destroyed as soon as they become soiled, and their use will effect a great saving in washing. The diaper is now tied carefully and fastened to the binder in front, and the infant's socks are put on. The outer clothing consists of three pieces, — an undershirt of stockinet with sleeves, a flannel petticoat without sleeves, and a muslin slip. These garments are all made so that they can be fitted into each other before the infant is bathed and all slipped on at once. They should be drawn up over the feet and never put on over the head, for fear of frightening the baby, and after the sleeves are adjusted properly the child is turned on its face and the three layers of clothing closed in the back. It will be seen that this method of dressing the child causes no pressure on the chest or elsewhere, and allows perfect free- dom of movement to all its muscles. As the infant is turned over but once in the entire process of dressing, it is not tired or excited as when the old-fashioned style of clothing is used. On this account it is not at all fretful, but more or less drowsy, after its bath, and quite inclined to nurse and go to sleep at once, to the great comfort of every one concerned. A folded diaper may be laid loosely under its buttocks, be- tween its body and the undershirt, to protect its clothing, and its diapers must be changed the instant they are wet or soiled. The whole process of bathing, drying, powdering and dress- ing the infant must be carried on with the keenest realization of the care which the delicate body requires. Roughness insures abrasions, and abrasions insure infections. The skin becomes dry after the infant is about four days old, and about half of them show, during the first fifteen days, THE INFANT'S LAYETTE. 311 a jaundice known as icterus neonatorum. The exact cause is not clear. It is no doubt due to a number of causes, but generally it disappears and needs no treatment, but it may be due to an in- fected navel and it is best that the dressing be carefully inspected for the assurance that this source may be eliminated, always re- membering that the point of union of the cord with the body is the point of possible infection. The gall-duct may be affected or there may be a congenital stricture. This demands the immediate care of the doctor. Carelessness in cleansing the scalp will result in the condition known as seborrhcea capitis, which consists of an over-secretion of the sebaceous glands, mixed with dirt, forming a yellowish- brown, waxy-looking crust on the head. This will never occur if the child is properly cared for, and when the condition is en- countered the crusts should be gradually softened with warm sweet oil and removed as gently as possible, after which, if the head is kept clean there will be no return of the trouble. The time when the baby can go out of doors depends upon the time of year, the weather, and the climate of the place of its birth. Babies born in the summer or in a warm climate may usually go out on dry, pleasant days when they are four or five weeks old, provided they are kept in the sun with their faces shielded from the light. Infants born in the winter or in a severe climate are better off in the house, even up to the fourth and fifth month, but they should receive fresh air once or twice daily by being bundled up warmly and carried into a good-sized room with open windows, where they may remain for ten or fifteen minutes. THE INFANT'S LAYETTE Twelve plain slips of nainsook, crepe, dimity or long cloth (linen is objectionable) 27 inches from shoulder to hem. Six sack gowns, sleeveless, opening in back, folding over at bottom; for the first two weeks. Made of part wool flannel for winter, lighter weight for summer. Popular in hospitals and difficult to improve upon for first clothing. May be utilized later as sleeping robes. Six part wool flannel petticoats made Gertrude fashion. For 3 i2 A NURSE'S HANDBOOK OF OBSTETRICS. summer wear should have cotton waists. Always close with snaps at shoulders. Six shirts, loosely woven mesh silk and wool for winter, or Six shirts, loosely woven mesh cotton or silk and cotton for summer. Unless the infant is quite small, purchase the second size. Two dozen cheese-cloth diapers. The softest and most ab- sorbent for use the first two months. Cut one yard square and stitch into one-quarter yard square diaper pads. Use later for inside pads. Four dozen diapers of cotton birdseye, domett flannel or terry cloth, size 20 X 40 inches and 26 X 52 inches. These are better when shaped according to pattern and made same size. Best of all are the soft absorbent knit diapers so widely ad- vertised, but they are expensive because of the number required. These are more absorbent than any woven goods. But whatever is used must first be boiled to become shrunken and absorbent and changed as soon as known to be damp. Six straight bands, 6 inches wide and 22 inches long. These will be used to keep the umbilical dressing in place. If the doctor advises the wearing of a band after the first month these will be needed : Six knit bands fastened with straps. These have shoulder- straps and tabs for. attaching to the diaper, and in summer may replace the shirt. Six knit straight bands fastened with tapes, of silk and wool or cotton. Six night-dresses of light soft flannel or crepon. Tapes applied flat at neck and wrists. Snaps down front and across bottom which is closed by being folded forward. Pinning blankets imprisons the legs, interferes with activity ; are unneces- sary and objectionable. Six pairs cotton and wool long stockings, for winter. Six pairs cotton socks for summer. Avoid all kid shoes or knitted bootees. They are a source of irritation. THE INFANT'S LAYETTE. 313 314 A NURSE'S HANDBOOK OF OBSTETRICS. THE INFANT'S LAYETTE. 315 If the child has cold feet apply external heat. When covered with clothing the feet should have nothing at all upon them unless a soft pair of stockings are worn. Six bibs of fine absorbent Turkish towelling. A number of jackets are essential. These may be of dif- ferent weights. The body is often not protected in proportion Fig. 149. — Band and shirt fastened with tapes. Band should be sewed if necessary. Pins should not be used. to the lower limbs. This must be met by a more or less warm jacket of flannel or a knitted sack. A number of blankets for baby's use. The best size is a yard or yard and a half square. This outfit is enough to start with and does not leave the mother swamped with hopelessness upon the nurse's departure. The amount could profitably be doubled. If laundering can be promptly done four of each article with ten slips and four dozen diapers may be made to serve. Out- door garments may be secured later. All clothing must be changed night and morning. All articles 3 i6 A NURSE'S HANDBOOK OF OBSTETRICS. worn by the baby as well as its bed must be thoroughly aired every day. The care of the shirts and bands is a part of the nurse's duty, and it is essential that she know how to supervise their washing, as they are expensive and easily ruined. They should be washed in soft water with a wool soap, and are best dried on a stretcher. Diapers must be promptly placed in cold water, rinsed, boiled and again rinsed. The soap used must have no free alkali and must be carefully rinsed out ; chafing and serious irritation may result if this is neglected. Xo diaper may ever be used a second time. Less expensive outer apparel and an unlimited supply of diapers is the part of common-sense. The infant's toilet screen will be fitted with: Four soft bath towels. Two dozen soft wash-cloths of old linen. One-half pound of absorbent cotton. One soft hair-brush. One small nail-scissors. One box talcum powder. Use cotton sponge instead of puff. One bath thermometer. One hot-water bottle. One box of castile soap in shaker. One tube plain vaseline. Six ounces 95 per cent, alcohol. Six ounces sterile boric acid solution. Six ounces olive oil or benzoinated lard. Four dozen paper bags for waste. One double basin. Two pitchers. One cake white castile soap for the shaker. XXIII The Accidents, Injuries, and Diseases of the New-Born The accidents that may occur at or shortly after birth in- clude aspJiyxia and hemorrhage from the cord. Asphyxia neonatorum (asphyxia of newly born infants) may result from injury during manual or instrumental de- livery ; from compression or torsion of the umbilical cord, shut- ting off the fetal blood-current ; or from protracted labor alone. Any one of these conditions should be enough to suggest the probability that the child will be born in a state of suspended animation, and preparations for its resuscitation should be made, if possible, before the termination of the labor, so that there will be no delay whatever. It may be asphyxiated with or without mucus in its throat. The nurse should have ready one large foot tub containing hot water (105 F.) and a basin of ice water and a good sized piece of ice. These should be placed side by side on chairs or on a low table at a distance from the mother's bed, or even in another room. In addition there should be a gum elastic catheter, No. 8, for withdrawing mucus from the infant's throat, and a number of pieces of gauze, about eight inches square, for wiping out the mouth or for placing over the face if it is deemed neces- sary to blow air directly into the baby's lungs. At least two warm soft pieces of flannel blanket are required, as well as hot-water bottles and a pitcher of hot water to maintain a temperature of io5°-iio° F. for the bath. There are two types of asphyxia neonatorum. In one the baby's face and even its entire body are of a livid hue, and the vessels of the umbilical cord are gorged with blood (asphyxia livida) ; in the other the child's face and body are of a death-like pallor and the vessels of the cord are empty (asphyxia pallida). The livid cases usually recover, for the lividity only indicates an early stage of asphyxiation ; but while the pallid infants may 3i7 3 i8 A NURSE'S HANDBOOK OF OBSTETRICS. Fig. ISO. — Slapping upon the back to induce respiration after removing mucus and blood from the nose and throat. ASPHYXIA NEONATORUM. 319 Fig. is 1. — Snapping the finger upon the soles of the feet, to stimulate respiration after removal of blood and mucus from nose and throat. 320 A NURSE'S HANDBOOK OF OBSTETRICS. occasionally be made to breathe after prolonged efforts, the majority of them die at once or after a few days. If a child is born in an asphyxiated condition the cord should be tied and cut at once, so that there will be no interference with the performance of artificial respiration and also to permit the adoption of immediate measures towards its resuscitation. No time is to be wasted in determining whether it is dead or alive. It is always to be assumed that the child is living, for often it is over an hour before breathing can be established, and cases are on record where success has followed efforts extend- ing over the enormous period of seven or eight hours. More- over, even if the child is dead, it is a satisfaction and comfort to its parents to know that every possible effort was made to save it. There are several methods of performing artificial respiration on the newly born infant, but a description of one, and its clear understanding by the nurse, is all that is necessary in this place. The first thing to do is to hold the infant up by its heels, slap it sharply on its back and chest, and insert a finger in its mouth to the back of its throat and remove any mucus or blood that may be there. If the child does not breathe it should be laid on its back, its tongue brought forward and the Xo. 8 catheter inserted and the mucus aspirated. The tube is blown clean and again inserted. Respiration may now be excited by a brisk rubbing up and down the infant's spine while suspended by the feet in the left hand. If this is unsuccessful the child should next be dipped up to its neck in the hot water, held there for a moment or two, and then transferred to the cold water for an instant, or generously sprinkled with ice water upon the chest and back (many doctors object to the immersion of the infant in ice water as unnecessary), and back to the hot. While it is still in the hot water artificial respiration should be practised in the following manner. The child is held with the right hand of the nurse under its shoulders and its neck lying in the cleft between the thumb and forefinger, with the head falling loosely backward. The left hand of the nurse supports its thighs, and its entire body, with the exception of its head, is submerged in the hot water. ASPHYXIA NEONATORUM. 321 Fig. 152. — Byrd's method of resuscitation. First movement. Expiration. 21 322 A NURSE'S HANDBOOK OF OBSTETRICS. Fig. 153.— Byrd's method of resuscitation. Second movement. Inspi ASPHYXIA NEONATORUM. 323 This means, of course, that the nurse's hands are both under water. Expiration is now affected by doubling up the body of the infant until its knees almost, if not quite, touch its chest. It is held a moment in this position, and then inspiration is caused by separating the hands and bending the body backward as far as possible. This process is repeated about twelve times a minute, or once in every five seconds, and by placing her ear close to the baby's mouth when the movement of expiration is performed, the nurse can tell if the manipulation is effective and air is actually being forced in and out of the lungs. Every few minutes the child is to be plunged into the cold water and returned instantly to the hot, in the hope that the shock will stimulate natural respiratory movements of the chest, and from time to time a finger is to be passed into its mouth to free it from mucus or other obstructing substance. It is highly important that the child be kept warm as possible. Receive it from the warm bath into a warmed blanket and if the artificial respiration practised be Marshall Hall or Sylvester method, the extreme need to preserve the body heat is apparent. Whiskey may be rubbed along its spine. This routine of hot bath, removal of mucus, ice water, tongue traction, artificial respiration is to be repeated. Asphyxia means really lack of pulse, apncea meaning lack of breathing. If the infant's heart action is very feeble or irregular, or if no beats at all can be heard by placing the ear in close con- tact with the chest wall, a hypodermic injection of whiskey (ten minims) should be given, and if no air can be made to enter and leave the lungs when the artificial respiration is performed the air passages may be expanded by laying a piece of gauze over the infant's face and, with the lips in close contact with its mouth, blowing a short, sharp blast down its throat. The air must be prevented from entering the stomach and bowels by placing pressure directly upon it with the hand. The air is expelled from the chest by compression and the manoeuvre repeated. Too much air must not be thrown into the lungs, as their delicate structure may be ruptured. The artificial respiration is to be resumed and continued for at least an hour in the manner already described. 324 A NURSE'S HANDBOOK OF OBSTETRICS. Fig. 154. — Artificial respiration. Sylvester's method. First movement. Expiration. ASPHYXIA NEONATORUM. 325 Fig. 155. — Artificial respiration. Sylvester's method. Second movement. Inspiration 326 A NURSE'S HANDBOOK OF OBSTETRICS. The combination of the Byrd and Sylvester methods of in- ducing artificial respiration combined with a hot bath and the Laborde method tongue traction, alternated by the insufflation of air into the lungs, may be followed by the Schultze swinging method ; usually a last resort. This may be repeated a dozen times when warmth must again be applied. This is considered a most efficient method and it is said that when properly done this method will inflate the lungs even if the child be dead. If at the end of this time there are still no signs of life, it is hardly probable that anything further can be accomplished, but it is usually wiser to continue the efforts for a somewhat longer period, if for no other reason than to satisfy the family. A pulmotor, if available, is sometimes used with success. The physician will, of course, attend to this matter of resuscitating the infant if the condition of the mother is such that he can leave her with safety, but often the task will fall to the nurse, and, in some cases, even after the physician has officially pronounced the child dead, the family will be grati- fied at further efforts to save it, futile though they be. Hemorrhage from the cord may be primary, due to the slipping or loosening of the ligature, or secondary from the base of the cord when it separates from the body. In the first instance the bleeding is from the end of the cord and not from its base, and can be controlled by the proper application of a fresh liga- ture. The secondary hemorrhage, from the base of the cord, occurs at about the fifth to the eighth day when separation takes place. It is often preceded by a slight jaundice, and is not an actual flow of blood but a persistent oozing, which frequently resists every form of treatment until the infant dies in a con- dition of exsanguination. This variety of hemorrhage is of rare occurrence, and may be due to that peculiar condition known as the " hemorrhagic diathesis," in which the individual's blood shows no disposition to coagulate, and bleeding from any denuded surface is persistent and often profuse; or the child may be the subject of a syphilitic taint. The treatment by the nurse of secondary hemorrhage from the cord consists in the application to the bleeding surface of a ASPHYXIA NEONATORUM. 327 Fig. 156. — Sylvester's method combined with tongue traction. i 2 8 A NURSE'S HANDBOOK OF OBSTETRICS. Pllll V\ Fig. 157. — Schultze's swinging method. First movement. Expiration. ASPHYXIA NEONATORUM. 329 piece of cotton saturated with liquor ferri subsulphatis (solution of the subsulphate of iron, to be had of any druggist). The physician should be notified promptly, and if by the time he arrives the use of the styptic has not effectually controlled the oozing, he will doubtless pass two long needles at right angles to each other through the base of the umbilicus and apply a tight "figure-of-eight" ligature (see Fig. 131). The needles must be removed at the end of six or eight hours and an anti- septic dressing applied. If this form of bleeding is at all severe and persistent, recoveries seldom take place and even if the um- bilical hemorrhage is controlled, bleeding may appear in the nose, mouth, stomach, intestines, or abdominal cavity ; or the infant's body may develop purpuric spots at various points. The injuries to the new-born infant are those which occur during labor, either from pressure or from manual or instru- mental assistance to delivery. Fracture of a long bone or dislocation of an extremity may be the result of a version, or may occur in a breech case with the arms extended above the head when they are brought down into the vagina. Fracture of the clavicle (" collar bone ") or of the jaw, or dislocation of either of these bones, may follow for- cible efforts to extract the after-coming head in cases of breech presentation. These cases, of course, can only occur when the physician is present, and their treatment rests with him entirely. Fractures in the new-born infant usually heal rapidly, but it is often difficult to Iceep.the parts in good position during repair. Dislocation should be reduced at once, or there will be great danger of permanent deformity in the joint Injuries to the head caused by the forceps usually disappear within a few days, even when they are quite marked at first. If there is actual laceration of tissue, which will only occur when the instrument slips, or if there is a destruction of 'tissue- vitality from very prolonged pressure, it is quite probable that perma- nent scars will remain. Neither of these injuries will happen when the instruments are judiciously used, and any scar that may result will be so small and faintly marked by the time the child is five or six years old that it will be scarcely noticeable. 330 A NURSE'S HANDBOOK OF OBSTETRICS. Fig. 158. — Schultze's swinging method. Second movement. Inspiration. ASPHYXIA NEONATORUM. 331 . / i ' : ~ •Fig. 159- — Removal of mucus with aspirating cacueter. 33^ A NURSE'S HANDBOOK OF OBSTETRICS. Pressure from forceps may seriously affect the brain-tissue, causing paralysis of certain groups of muscles (Fig. 161), or an acute traumatic meningitis may develop; and the same con- ditions may occur when no instruments are used. Prolonged pressure on the head during a protracted first Fig. 160. — Warm bath combined with tongue traction. stage, where the membranes rupture before the os is fully dilated, causes a swelling of the scalp at the point where it is encircled by the cervix. This is called "caput succedaneum" (Fig. 162), and in its milder forms is very common. It is due INJURIES TO THE NEW-BORN INFANT. 333 to an extravasation of serum into the tissues of the scalp at the portion surrounded by the os and free from pressure, and V Fig. 161. — Facial paralysis of new-born child. (Ahlfeld.) it is the more marked the longer the first stage is delayed. The portion of scalp rendered cedematous in this manner varies, of W Fig. 162. — Caput succedaneum. Male, two hours old. (Rotch.) course, with the position and presentation, and the condition always disappears in a day or two without treatment of any sort, 334 A NURSE'S HANDBOOK OF OBSTETRICS. Another swelling of the sealp which resembles caput succe- daneum in certain respects is caused by an effusion of blood between the parietal bone of one side and the overlying scalp. This is seldom present when the child is born, and may not be noticed for two or three days, when the existence of a swelling will be observed, and it will be seen to increase gradually in size until about the seventh day after labor, when it remains stationary for a time and then slowly disappears. This condi- tion is termed "cephalhematoma" (Fig. 163), and usually Fig. "163. — Double cephalhematoma. Infant four days old. (Retch.) ends in recovery without treatment. It may be due to pres- sure in normal labor, or by forceps, but it is also occasionally seen in breech cases in which no instruments were used nor pro- longed pressure exerted on the after-coming head. These cases are not common, and require no further mention. The diseases of the new-born infant are ophthalmia, icterus, spina bifida, mastitis, vaginal hemorrhage in female infants, umbilical hernia, umbilical vegetations, congenital cyanosis, and tetanus. OPHTHALMIA NEONATORUM. 335 Ophthalmia neonatorum is a disease of the eyes char- acterized by a profuse, purulent discharge due to infection generally from the genital canal at the time of birth and usually of gonorrhceal origin. This is not always the case, how- ever. The lack of proper hygiene by the doctor or nurse or mother may carry the germ to the eyes of the infant. From 25 to 30 per cent, of all children in schools for the blind are the result of a gonorrhceal infection. Pus, syphilis, trachoma, acci- dents, etc., are the other causes of preventable blindness. The disease appears two or three days after birth, provided the infection occurred at this time, but as the septic matter may be introduced into the eye at a later period by dirty cloths and by neglect of the proper care of the child, the onset of the trouble may be much later. Both eyes are usually affected, and they are first suffused with a watery discharge and somewhat con- gested. Within twenty-four hours the lids are very much swollen, and a thick, creamy, greenish pus is found under them. Later the swelling becomes so marked that the eyes cannot be opened, opacities of the cornea occur, the conjunctiva is ulcer- ated and then perforated, and the eye collapses and atrophies. The treatment consists, first in Crede's method or in the use of a 5 per cent, solution of protargol dropped into the eyes im- mediately after the labor, and this should always be done as a preventive measure. If the disease develops in spite of this prophylactic treatment, the infant is to be kept in a dark room and the eyes bathed at intervals of from twenty to thirty minutes with sterile ice-cold saturated solution of boric acid. Iced cloths must be kept constantly on the eyes until the inflammation has subsided, and when the boric acid solution is used the lids must be separated so that it will flow freely into the eye and reach every part of the diseased tissues. Whenever the iced cloths are changed or the boric acid is used, fresh pieces of gauze must be employed and the old ones destroyed at once by burning. If opacities appear on the cornea in the form of small milky-white spots, the physician must be notified immediately, for, unless the most energetic measures are adopted without delay, the sight will be destroyed. A NURSE'S HANDBOOK OF OBSTETRICS. OPHTHALMIA NEONATORUM. 337 The nurse must remember that this is a distinctly infectious disease, and that there is extreme danger of conveying it to others and of setting up an acute infection in the maternal genital tract. Even the eyes of the nurse herself may become infected unless she is most painstaking in her methods. Gloves, cap, gown, and glasses must be worn by the nurse. The pa- tient is placed upon a table and the nurse seated at its head. She must handle all dressings with forceps. If one eye only is in- fected the sound one must be protected by a Buller shield fastened to the face by an adhesive strip, and must be inspected at least twice a day for possible infection. Every article used by doctor, nurse, and patient must be absolutely diverted from use to other purposes. The ice-pads should be of soft lintine, quaker flannel or some such material and cut into one-inch squares. These should be placed upon a cake of ice, and applied (three to the minute) upon the eye ; irrigations are done with a medicine dropper or syringe from the inner angle of the eye outward. The pus must be entirely removed while the eyelids are separated. Pro- longed irrigation of large amounts of solution over a surface already freed from pus is not so much ordered as formerly. The prescribed douches may be of boric acid, or bichloride mercury solution i : 10,000, saline or permanganate of potas- sium solution ; the temperature should be tested by a ther- mometer and must not exceed 75 ° F. Care must be taken not to direct the stream from an irrigator directly against the child's eye. The child's head must be lowered and the solution drain into a kidney basin. If such a solution is used a small Kelly pad or an improvised one of stork sheeting or rubber may be employed, care being taken not to infect the ear with the solution ; but the infant must never be picked up or placed upon the lap of the nurse. The doctor in charge issues orders as to drops, method of irrigation, solution, schedule of ice applications, etc. He may vary this treatment with hot applications. These can be ap- plied in the same manner, an electric or alcohol stove supply- ing heat for the solution. 22 338 A NURSE'S HANDBOOK OF OBSTETRICS. Fig. 165. — Technic of irrigating eye with medicine dropper and permanganate solu- tion. The child must be drawn to the head of the table and its body elevated if large amounts of solution are used. A small Kelly pad or rubber must be placed under the lowered head and empty into a pail. OPHTHALMIA NEONATORUM. 339 These cases always require two nurses. The feeding, bath- ing, proper disinfection of discharges and linen, preparation of dressings, treatments, etc., demand the utmost care in technic, and the care of the mother becomes a grave matter to prevent further infection. They require strict isolation, if an epidemic is to be averted, in a home, institution, or hospital, and the responsibility for 1 ft) 1) o n 4 iijjiii!!! 1 4 Fig. i66. — Thumb forceps. spreading infection rests most often with the nurse. The dis- ease may last for weeks or may be of a less virulent type. Ophthalmia neonatorum is a serious condition which may result in total blindness, but if suitable treatment is adopted at the very outset of the disease and intelligently carried out the sight can usually be saved. The entire treatment is, of course, under the direct supervision of the physician, and in severe cases he will often deem it best to call an oculist in consultation. 340 A NURSE'S HANDBOOK OF OBSTETRICS. Icterus neonatorum (jaundice of the new-born) is a fairly common condition of somewhat uncertain origin, but be- lieved by many to be due to infection of the umbilicus. It often appears in its milder forms among strong, healthy infants, the yellow color of the skin showing first on the second or third day and increasing in intensity until the ninth or tenth, when it begins to disappear. No treatment is required unless the in- fant shows symptoms of severe constitutional disturbance, and in the vast majority of cases a favorable outcome may be ex- pected. Winckei/s Disease. — This is a very rare and fatal septic Fig. 167. — Spina bifida of dorsal lumbar region. Infant forty-eight hours old. Died when ten days old. (Rotch.) disease of new-born infants, marked by icterus, hemorrhage, bloody urine and cyanosis with malignant jaundice. The cause is not clearly known. The poisons which cause these symptoms are said to be connected with the rapid metabolism of labor. The symptoms resemble pernicious vomiting or acute atrophy of the liver. The intense jaundice is found with hemorrhage or fatty degeneration. Among other causes suggested are over- doses of chloroform to the mother, and asphyxia, which is usually associated with it. The nurse by close observation of symptoms may secure immediate orders, and prompt measures may possibly prevent the development of this condition. Spina bifida (Fig. 167) is due to the congenital absence of SPINA BIFIDA. 341 one or more vertebral arches, usually at the lower part of the spine. This allows the membranes covering the spinal cord to bulge outward, forming a soft fluctuating tumor filled with Fig. 168. — Spina bifida. Spontaneous cure. Male, four and one-half years old. (Rotch. ) cerebrospinal fluid. The tumor is diminished by pressure and enlarges when the infant cries. The disease is usually fatal, al- though a certain few cases have been cured (Fig. 168). The most common outcome is ulceration of the sac followed by it's 342 A NURSE'S HANDBOOK OF OBSTETRICS. rupture and the escape of its contents. Convulsions then occur, and death follows within a few hours. When the tumor is very small and shows no signs of increas- ing in size, it may merely be protected from injury and infec- tion by carefully applied dressings, but the more severe cases are treated surgically if at all. Mastitis (inflammation of the breast) is occasionally seen in very young infants of either sex. The affected breast be- comes swollen, tense, hot, red, and painful, and the disease usually appears during the first two or three weeks of life. The breast is to be anointed gently with camphorated oil and pro- tected from injury by a soft, loose, cotton dressing. In other respects it is to be left severely alone, and under no circum- stances should it be squeezed, rubbed, or massaged. Nearly all cases will recover without any trouble, but if, as may pos- sibly happen, an abscess should form, it is to be treated sur- gically. A vaginal discharge of blood is not an uncommon oc- currence among female infants, the flow appearing a few days after birth, and usually causing the parents considerable anxiety. It is of no consequence whatever, and will disappear of itself in a few days without any treatment. Umbilical hernia (rupture at the umbilicus) may appear during the first few weeks of life, but usually not until a later period. The tumor may be made to disappear entirely on pres- sure but reappears when the pressure is removed and the child cries. This is due to a weakness in the navel opening of the ab- dominal wall caused by non-union of the recti muscles. The condition usually disappears spontaneously, but should the pro- trusion of omentum persist a two-inch strip of adhesive plaster will close the opening. Hernia buttons act as a wedge and pre- vent the reduction of this hernia. A pasteboard circle, one inch in diameter, covered with gauze may be placed under the strip, over the protrusion. Other hernias occasionally are observed. They require pres- sure applied and are usually outgrown. CONGENITAL CYANOSIS. 343 Umbilical vegetations are sometimes seen after the cord has separated, in the form of little red friable tubercles varying in size from that of a pin-head to that of a large pea. The vege- tations bleed readily, and are merely redundant granulations and of no special consequence. The physician can usually cure them promptly by removal with scissors or cauterization with nitrate of silver ("lunar caustic"). Constipation should be early recognized. It is not often met with. If the bowels have not moved in two days a saline enema is usually ordered. The nurse will know if there is a malformation, or whether the rectum is impacted. If malforma- tion is the cause, the constipation is not relieved by enemata of saline two ounces at a time, or an injection of two ounces of olive oil. This condition is a very serious matter. Hirsch- sprung's disease, an idiopathic dilatation of the colon, may be the cause. This condition, as well as the absence of an anus, require surgical treatment if the infant's life is to be saved. Castor oil or a laxative is usually ordered to clear the intestinal tract of the meconium and mucus. This generally solves the question of the cause of constipation. Water in sufficient amount with proper nursing and an occasional saline enema will soon establish a habit movement. Massage must not be given until after the cord is lost. The physician gives ample instructions concerning the treatment, whatever the cause. Congenital cyanosis occurs in those cases known popularly as " blue babies," and manifests itself at any time from a few hours to a few weeks after birth. The infant's body and, es- pecially, its face and extremities acquire a dusky bluish or purplish hue, which may be almost imperceptible when the child is resting, but which is very marked after exertion of any kind. The condition is due to a congenital defect in the circulatory apparatus, usually in the heart itself, which interferes with the flow of blood through the lungs, and so deprives the infant of its proper amount of oxygen. Most of the cases die in early infancy, although some may live to be ten or twelve years old. The only treatment is that directed towards the comfort of 344 A NURSE'S HANDBOOK OF OBSTETRICS. the little sufferer, and consists of inhalations of oxygen to re- lieve urgent symptoms, and rest, quiet, good hygienic surround- ings, and nourishing food of a simple character. Brandy or other stimulant may be given when the dyspnoea is severe, but no treatment can have any curative effect, and the disease will al- ways prove fatal eventually. Atelectasis, often present in premature infants, is due to several causes, general feeble defective tissues, particularly those of the nerve centres and lungs. It is taught by some that the special causes are hepatization, injuries to the brain, and pleural effusion. Frequent altering of position, artificial respira- tion, shaking, alternate cold and hot baths, holding the nose and mouth closed, and oxygen are said to be beneficial. In short, the Fig. 169. — Opisthotonos. The characteristic convulsion of tetanus. methods used to combat asphyxia are indicated in the treatment of atelectasis. The development of its muscles must be a very gradual process and every effort made to save the child from all forms of strain. To survive, it will need to be under the con- stant direction of a physician. Tetanus is a very rare disease in this country. It is due to the action of a special germ, the Bacillus tetani, which in the newly born infant enters the system through the umbilicus. The disease begins between the third and tenth day after delivery, and the first symptom noticed is a stiffness of the muscles of the face and an inability to nurse or swallow. This is followed by a contraction of the muscles that control the jaw, causing trismus or " lockjaw," and within ten or twelve hours the spasm extends to the muscles of the neck and back, caus- ing opisthotonos, or a rigid arching backward of the body so that DIARRHCEA. 345 it can rest on the neck and heels with the trunk and limbs above the level of the bed (Fig. 169). As a rule, death occurs within twenty-four hours, but if the child can be made to live for a few days it may possibly recover. If an epidemic of tetanus is prevalent in any locality, it is best for a prospective mother to go to some other place which is free from the disease, for her confinement. The treatment rests wholly with the physician, and, as the patient is unable to swallow, all drugs must be given hypoder- mically. The child must be disturbed as little as possible, for any sound or movement aggravates the condition. Tetanus antitoxin, if it can be secured, combined with stimu- lants and opiates, and chloroform by inhalation when the spasms occur, are the only means we have for combating the disease. Suffocation. — Nurses will always endeavor to arrange for separate sleeping quarters of mother and child. The tempera- ture required by the infant is between 65 ° and 70 ° F. The mother requires a cooler atmosphere than this and separate rooms are most desirable for many reasons. Either by malice or accident a very considerable number of infants are overlain. In London alone, in 1900, there were 615 such cases. Mothers showing mental symptoms must be closely watched and the oc- currence is always preventable if the nurse removes the infant from the mother's bed after each feeding. Diarrhcea. — Normally the new-born infant has perhaps two or four stools per day. The colostrum acts as an agent to- ward emptying the bowel of meconium. Some physicians as a routine order castor oil to hasten this process. Occasionally the baby has a movement after each nursing and unless the yellow liquid stools become green and there is mucus and a strong odor with marked excoriation of the buttocks, it is usually quickly controlled when the cause has been found. The fault is most often with the feeding. If the infant is not nursed the oppor- tunity for infection is of course greater than in the breast-fed babies. The doctor usually orders nursing to be discontinued for twenty- four hours, and water or barley water is given ; at the same time a dose of castor oil with saline enemas or some 346 A NURSE'S HANDBOOK OF OBSTETRICS. similar treatment is ordered. Nurses must strictly observe the character of the stools and note the same on the chart. The irritated genitalia must be carefully cleansed and kept perfectly dry. Colic. — -Most infants suffer from colic at times. The par- oxysm may be more or less acute. If intestinal, an enema of warm salt solution, a warm bath, a hot drink, a hot-water bottle to the abdomen, a few drops of some carminative such as peppermint or wintergreen, or lying upon its abdomen, will generally afford relief to the infant. If the colic is recurrent it should be reported. The doctor may order treatment such as colon irrigation, massage or lavage with external heat, or medi- cines such as castor oil or broken doses of calomel, usually V20 or V40 grain doses. By this treatment the cause of the indigestion is usually removed unless there is an infection. If inflammation is present there will be tenderness of the abdo- men upon pressure and green stools with mucus, lumps, froth, and a foul odor. If the colic is urinary, hemorrhage and nephritis as well as colic may be present. It is to be relieved by removing the cause. The fever and general auto-intoxication often present may cause cerebral disturbance and convulsions. In this case prompt action is called for, and the doctor is to be notified at the first rise of the child's temperature. Nurses frequently overstep proper bounds in their efforts to relieve colic. No drugs or teas must be administered by the nurse. A colic is always a symptom either of digestive or renal disturbance, and whether simple or not, during the first two weeks of life, calls for an avoidance of drugs that may dis- guise the condition, and the faithful administration of as large a quantity of boiled water as the infant will take. If convulsions appear, the nurse will observe the first painful twitching of muscles of the eyes, face, and body following a general rigidity. The doctor must be promptly notified, and the infant should receive a warm bath, ice cloths to the head and quiet. The temperature of the bath should be ioo° F., and this is gradu- ally raised to no° to secure relaxation. A thermometer should COLIC. 347 be used and extreme excitement avoided. The child should not be immersed for a longer period than twenty minutes ; and the ice application to the face and head must be continued. Upon the doctor's arrival, sedatives or stimulation may be ordered ac- cording to his view of the causative agent. In a new-born baby this may be tetanus, already referred to, injuries received during labor, pneumonia of the new-born, or some other infection. XXIV The Premature and Feeble Infant There are three essential factors in the management of an infant that is puny and feeble whether its low vitality is due to prematurity or to other causes operating on a full-term child. These are : to maintain its body temperature ; to provide nourish- ment which it can assimilate readily; and to insure its absolute rest and quiet at all times. The best indication of an infant's ability to fight its own battles after birth is its weight. The mere fact that the child is born prematurely is of little consequence when compared with the number of pounds that it weighs, and a premature infant of five pounds will, in general, require no more care and attention than a full-term baby that weighs the same. The routine of encasing all feeble, small infants in a cotton jacket and the anointing with warm olive oil, seems to be losing favor with a large number of obstetricians; it is claimed that the body heat is not maintained but the infant on the contrary is refrigerated. The newer teaching anoints the infant, if this is done at all, with benzoinated lard. Aside from a soft diaper, its band, Warren slip and coverings are all wool. The infant lies in absorbent cotton or eiderdown, either in a bassinette or incubator, depending upon the degree of prematurity, and prac- tical possibilities. As a safe general rule for guidance it may be said that babies weighing between four and a half and five and a half pounds are to be kept warm by flannel garments and coverings, in- stead of being regularly dressed, while those weighing less than four and a half pounds should be placed in the incubator; and even larger children whose temperature is subnormal often do better if wool clothing and coverings are used. As soon as a small, feeble child is born it should be well 348 CARE OF PREMATURE INFANT. 349 anointed with warm albolene or benzoinated lard, wrapped in warm flannel and surrounded with hot-water bottles. The cord must be tied with special care, and is to be inspected for bleeding at frequent intervals, for there is a well-marked tendency to secondary hemorrhage in this class of cases. A very warm bed for the infant in the baby basket is pro- vided by using soft pillows, and an even, warm surface is secured by the use of a number of hot-water bottles. Pure wool cover- ings should be obtained if possible, and every effort must be made to prevent a drop in the body temperature. This means great care at birth and immediately afterward. The shock, lack of fat, lack of lung expansion, and radiation all tend to send the body heat rapidly to 93 ° F. or even less. This, unless arrested by a warm bath, incubator or substitute, will quickly cause death. Large maternity hospitals all receive premature infants and provide efficient care generally. The infant is transported in an incubator ambulance, a small portable contrivance devised by Dr. J. B. DeLee. If no incubator station is within one hundred miles, arrangements can be made and the child successfully in- cubated and nursed at home, especially if mother's milk can be procured. If the child weighs four and one half pounds, or more, it need only be clothed and kept warm in a basket or box as described. The temperature is to be maintained about 85 ° F., and ventila- tion, moisture and complete freedom from draughts must be secured. Gas or electricity heated incubators are generally installed in the large hospitals. Some stations, however, use no incubators, but a specially constructed incubating room where the tempera- ture, moisture and ventilation are under perfect control. A small room in a private house answering these demands is ideal. In its absence, if the baby weighs less than four and a half pounds an incubator may be rented or purchased and the child (dressed as mentioned above) placed in it at the earliest possible moment. The principle of all incubators is the same, the only differ- ence being in the construction of the various kinds. It has long been known that the air surrounding a premature infant must 350 A NURSE'S HANDBOOK OF OBSTETRICS. || Hi Fig. 170. — Electrically heated infant incubator. INCUBATOR. 351 be kept exceptionally warm, and formerly this was accomp- lished by heating the room occupied by the child to a stifling temperature, to the great discomfort of the nurse or other at- tendant. Fig. 172 shows an incubator designed in 1880. Warmth may be supplied by the use of hot-water bottles, water tank, hot air, steam, gas, or electricity. The incubator is nothing but a miniature room in which the infant can lie, and is so arranged that its temperature can be regulated to any desired degree, while the interior can always be inspected through a glass in the top. Beyond this ability to con- trol the temperature perfectly, the only other essential feature of a satisfactory incubator is the apparatus which provides for its thorough ventilation. The incubator is usually heated by means of hot water, and this either circulates through a system of pipes, one portion of which is exposed to a gas or alcohol flame, or the hot water is placed in tanks or bottles in the lower part of the incubator and renewed as often as it cools. In hospitals there may be found installed elaborate electrically or gas heated incubators with more or less perfect devices for securing a continually changing cir- culation with the proper proportions of moisture, heat and fresh air ; but in private practice a movable incubator must neces- sarily be used, the principle being always the same. The child lies on a shelf or platform, padded thickly with eiderdown or absorbent cotton, about six inches from the floor of the box and directly over the coil of pipe or the cans containing the hot water, or a large tank. Fresh air enters at the bottom, circulates around the heating apparatus, where it is raised to the proper temperature, passes over the shelf on which the infant rests, and escapes through a ventilator at the top. This ventilator is provided with an ane- mometer, or small revolving fan, to show whether or not there is a free circulation of air. As the warm air escapes from the ventilator at the top of the incubator it will cause the anemometer to revolve, and this revolution will be continuous unless the cir- culation of air is interfered with or the anemometer is out of j 5 2 A NURSE'S HANDBOOK OF OBSTETRICS. 8 Fig. 171. — Gas heated infant incubator. INCUBATOR. 353 order. Consequently it must be most carefully watched, and if the motion of the little fan ceases or becomes irregular a prompt investigation must be made ; the mechanical device must be kept clean and well oiled. Another method of keeping track of the circulation of air within the incubator depends upon the appearance of the glass which covers the top. This should be clean and dry at all times, and if it becomes moist and cloudy on the inside it is positive proof that the ventilation is not good. A wet sponge (which must be kept wet, and its use alter- nated with another sponge so that the first one may be steri- Fig. 172. — Tarnier's incubator, interior. E, wet sponge; P, partition between lower ana upper compartments ; A, tube for escape p f air; T, M, V, Z>, b, as in Fig. 151. lized) is to be kept in the incubator to moisten the air, but there must be a sufficiently rapid circulation to prevent any of the moisture from collecting on the glass A thermometer, of sufficient size to be read easily, is to be placed by the side of the infant in such a position that it can be seen clearly through the glass, and the temperature of the in- terior must be kept between 88° and 92 F., and with as little variation as possible. It is best to start at 92 , and then reduce the temperature very gradually and evenly to 88°, reaching this 23 354 A NURSE'S HANDBOOK OF OBSTETRICS. point by the end of about a week and holding to it for several weeks longer, as the physician may direct. The electric and gas heated incubators which are found in large hospitals require the same intelligent watchfulness and care to avoid chilling or, what is equally fatal, overheating the infant. Sudden changes in temperature must be avoided absolutely, and thermometer and anemometer be watched constantly, whether the heat control is automatic or not. As the cry of a premature infant is very feeble at best, it is often quite inaudible when the child is shut up in an incubator, and the closest attention must be paid to the condition of the baby at all times. Many persons are of the impression that once the child is placed in a good incubator no further special precautions need be taken, but this is a most mistaken idea. Premature or under- developed infants require the most solicitous care in every way, and to merely keep them at a proper temperature will avail noth- ing unless the other details of their management are carefully carried out. Rest is a most important factor in the rearing of such chil- dren, and they must be shielded from excitement and every dis- turbing influence. Visitors invariably flock to see an unusually small child, and an " incubator baby " will be sure to attract a crowd of curiosity-seekers as soon as its existence becomes known. The nurse must positively refuse to let any one see the child except the members of its immediate family, and these favored few can only be allowed occasional and very short glimpses. All manipulations of the baby must be avoided except for absolutely necessary purposes, such as changing its clothing, ad- ministering nourishment, altering its position, or cleansing its body. The child requires an application of albolene or ben- zoinated lard as the doctor may order, twice a day. The lard, infant, and blanket must be very warm, and all exposure is to be avoided. Occasionally a physician will order gentle passive movements to improve the circulation of the extremities. FOOD FOR THE PREMATURE INFANT. 355 Light is to be curtailed by placing a shawl or other piece of dark cloth over the glass top of the incubator, and loud or sud- den noises must be forbidden. The skin, in these cases, is extremely delicate and tender, and diapers must be changed the instant they become wet or soiled. The child is not to be bathed except as is necessary for cleanli- ness, and when the diapers are changed the buttocks must not be washed with soap and water, but wiped carefully with cotton dipped in warm oil or albolene and then dried with cotton alone. If the child flourishes the doctor may order it taken from the incubator by day and returned at night, also an immersion, for a moment, in water warmer than its body heat, about 105 F. The cotton jacket is to be changed twice daily, care being taken that the fresh one is warm and ready for instant use the moment the old one is removed, if this treatment has been ordered. If the infant is wearing a Warren gown, and flannel coverlets are used, they must be changed every twelve hours to be properly sunned and aired. The weight and temperature of the child are both matters of the greatest importance, for, as in the case of any baby, if the child loses weight and its temperature goes up, it is an evidence that its food is either insufficient or of improper quality. The temperature is to be taken in the rectum and recorded on a chart every night and morning, and the weight is to be taken and carefully recorded once a day, at the time when the infant is changed. It is unnecessary to say that any rise in tempera- ture or loss of weight must be reported at once to the attend- ing physician. The best food for a premature baby is mother's milk, not only because it is especially adapted by nature to the needs of the child, but because it is very desirable to keep up the secretion of the mammary glands, so that, when the baby grows older and stronger, it can nurse directly from the breast. The milk may be expressed from the breast with the hands or with a breast-pump, and is to be received into a perfectly clean cup and fed at once, before it has had time to cool. 356 A NURSE'S HANDBOOK OF ORSTETRICS. The only breast -pump worth considering is that known as the "English breast-pump" (Fig. 173). This must be kept scrupulously clean and free from any curds or particles of sour milk, and should be boiled each time it is used. The nurse must be very gentle in applying the breast-pump to the nipple, or the delicate tissues may be injured and much trouble result. After the nipple has been thoroughly cleansed, as for a nursing baby, the air is to be forced out of the bulb of the breast-pump and the bell placed gently but firmly against the breast so that the nipple comes exactly in the centre of the opening. The bulb is now al- lowed to expand slowly and gradually, and in a moment or two the milk will be seen to spurt out in two or three very fine jets. Fig. 173. — English breast-pump. As soon as the bulb is fully expanded and full of air the pump is to be lifted from the breast, the bulb again compressed, and the bell again pressed firmly over the nipple as before. If for any reason it becomes necessary to remove the pump from the breast while it is still exerting suction on the gland, a little com- pression of the bulb will restore the pressure within the pump and it will come off of itself. Under no circumstances should it ever be pulled forcibly from the breast, and the use of the breast-pump should never at any time be painful to the mother. In some cases it will be found necessary to combine massage of the breast with the use of the pump, and if the milk does not flow freely when the pump is used the gland should be stroked gently and firmly with the finger-tips from the edges towards FOOD FOR THE PREMATURE INFANT. 357 the nipple. Both breasts should be emptied at each feeding-time and the milk poured into a cup which stands in a basin of hot water, until enough is collected for one meal. It seldom happens that a premature baby is strong enough to nurse from a bottle and the milk must be fed with a spoon, Fig. 174- — Feeder for premature infant. (Rotch.) a medicine dropper, or some other appliance that will do away with all effort on the part of the child. Dr. Breck has devised a " feeder " for premature infants (Fig. 174) consisting of a graduated glass tube with a small rub- ber nipple at the smaller end and a rubber finger-cot at the larger. The cot serves as an air reservoir, and, when the nipple 358 A NURSE'S HANDBOOK OF OBSTETRICS. is placed in the infant's month, slight intermittent pressure on the cot will enahle the child to get the milk without any effort whatever beyond that of swallowing. To fill the " feeder " the nipple and cot are removed, a cork fitted snugly in the smaller end, and the proper quantity of milk poured in through the larger opening. The cot is then attached to the top, the " feeder " inverted, and after the cork is removed, the nipple is slipped over the smaller end. The care of the breast-pump and nursing-bottle, or " feeder," whichever is used, is of the utmost importance, for, if germs of any sort are allowed to collect in them, the milk will be contaminated and the life of the infant will be greatly endan- gered. The cot and nipple are to be cleansed with soap and water inside and out, rinsed thoroughly, and boiled for five minutes before each feeding. The bottle, or glass portion of the " feeder " or breast-pump, must also be cleansed with the greatest care by scrubbing, rinsing, and boiling. It is well to have a number of " feeders," bottles, nipples, and cots, so that several of each may be boiled at one time and kept in sterile jars until they are needed. When mother's milk cannot be secured, cow's milk, modi- fied in the manner described in Chapter XXV, must be given, but no effort must be spared to secure human milk from some other source. This is generally possible and only as a last resource is artificial food to be considered. The physician must always regulate the strength and quantity of the food, for the problem of feeding a premature child with artificial nourish- ment presents many difficulties, and is too serious a matter for the nurse to undertake on her own responsibility. In general it may be said that the premature baby is to re- ceive food of half the strength and in half the amount, but twice as often as would be given to a full-term child. The feeding by mouth does not require the infant to be taken from the incubator. The babe may not be able to suck or even swallow. It may require feeding by a catheter or by drop- ping from the nipple of the feeder. Medicine droppers are to be avoided. Elaborate tables have been devised to guide in the Fig. 175.— Infant premature at thirty weeks. Birth- weight, four and one-quarter pounds. Treated in incubator sixty-four days. Age, nine months. Weight, seventeen and one-half pounds. (Rotch.) FOOD FOR THE PREMATURE INFANT. 359 amount and times the infant is to be fed. The physician will at all times give definite orders, as over-feeding a premature in- fant is easily done. On the other hand, starvation is often the cause of its death and is evidenced by a steady loss in weight and vitality along with increased stupor. The feeding in every case must be regulated to meet the needs of the particular baby under treatment, but if the manage- ment is at all successful at the outset it will not be long before milk of the usual strength for a normal infant of corresponding age can be given with safety. The beginning may be made with one-half to one drachm every hour, day and night, the time and amount gradually in- creasing. The first few days it may be ordered diluted with water. When nursing is begun, persistence is required to induce the tiny babe to take the breast. A shield with small nipple may be used or the use of a teterelle may be ordered. It must be fed boiled water at regular intervals. The infant may be overcome by exhaustion or regurgitation. It may require that oxygen be given to prevent asphyxiation. It requires ceaseless vigilance on the part of a nurse at all times and the history notes must be complete. The nurse will often be asked if a premature infant will ever develop as well and be as strong and sturdy as one born at term. If it escapes asphyxia, atelectasis, starvation, pneumonia and other infections, and can be made to live and thrive during the first few weeks, there is no reason why it should not ultimately be as robust and healthy as any other baby. Licetus, Helmholtz, Goethe and Kant are said to have been premature infants. XXV Infant Feeding The best food for a baby is that designed for it by nature, — breast milk. The best breast milk is that furnished by the infant's own mother, and the next best is that from another woman acting as a wet-nurse. If the child's mother is unable to supply milk of a proper quality and in sufficient amount for its needs, and if the services of a suitable wet-nurse cannot be secured, the next best food is cow's milk, properly modified to meet the requirements of the child. Whenever the mother is able to do so she should nurse her infant as far as she can, and then make up the deficiency with modified cow's milk ; for even a limited quantity of breast milk is better for the child than none at all, and the effect of nursing not only stimulates the breasts to the production of better milk from day to day, but greatly aids the process of involution by which the uterus and other pelvic organs return to their normal condi- tion after labor. Breast milk is to be preferred to any modified milk, no matter how carefully prepared, for the reason that it is exactly what the child requires, while the other is at best only an imitation; it is absolutely free from germs, while cow's milk always contains a certain number of bacteria; it is delivered to the child in proper quantity and at a proper temperature, while bottle food may escape through the nipple either too rapidly or too slowly, and is often too hot at the beginning of a feeding and too cold at the end. Moreover, the bottles and nipples are apt to become sour even when the utmost attention is given to their care ; the quality of the milk is always liable to vary ; and errors not infrequently occur in the preparation of the food. Hence we have to consider four distinct methods of feeding, named below in the order of their respective values : 360 MOTHER'S MILK. 361 1. Mother's milk. 2. Wet-nurse. 3. Mixed feeding. (Partly breast milk and partly modified cow's milk.) 4. Artificial feeding. (Modified cow's milk exclusively.) Mother's Milk. — Before we can expect a mother to furnish good milk for her infant we must see to it that her breasts are in the best of condition for performing their functions (Fig. 176). This necessitates the adoption of measures early in preg- Fig. 176. — 'Soft, flabby breasts. Not well adapted to nursing. nancy that will prepare the mammary glands for the work that lies before them. These measures have already been discussed in the chapter on the Management of Pregnancy, but will be reviewed here briefly. The breasts should be bathed night and morning with soap and tepid water, to keep the skin in good condition, and rinsed after each morning bathing with cool or even cold water, accord- ing to its effect on the patient, to stimulate the activity of the glands. During the last two months of pregnancy the nipples are to be anointed with white vaseline or albolene every night, and this is to be washed off carefully in the morning to remove 362 A NURSE'S HANDBOOK OF OBSTETRICS. any crusts of dried colostrum that may have formed. This dry- ing of colostrum on the nipples is one of the most potent factors in the causation of soreness or tenderness of these organs, and the daily application of the vaseline or albolene effectually pre- vents the colostrum from " crusting" and so irritating the deli- cate tissues of the parts. If the nipples are short or flattened, they should be drawn out with the thumb and forefinger every night and morning and held in this position for at least five minutes. This simple procedure, practised regularly twice daily during the last eight or ten weeks of gestation, will often work wonders with nipples so small or flat that nursing is, at first, apparently out of the question. The condition of the woman's general health has much to do with her ability to furnish good milk, and it goes without saying that corsets or other garments that compress the chest will inter- fere seriously with the development of the breasts. Assuming that everything is favorable for nursing, the child is not to be put to the breast until the mother has had a good rest from the effect of her labor, and, if possible, not until after she has had a nap of a few hours. Usually the baby can begin its nursing about four or five hours after birth, after which it is to be put to the breast regularly, every four hours, day and night for the first two days. During this time the breast secretes nothing but colostrum, a laxative substance containing prac- tically no nourishment whatever. If the infant does not seem satisfied with this diet of colostrum, the nurse may give it a five per cent, solution of milk-sugar made up with boiled water. One teaspoonful of sugar to twenty of water makes the solution in the required proportion, and it is best given in an ordinary two-ounce vial fitted with a small rubber nipple (Fig. 177)- If a small enough nipple cannot be obtained, one may be impro- vised by taking the rubber cap of a medicine dropper and piercing it with a good-sized needle. At or about the end of forty-eight hours the true milk begins to appear in the breast, and the infant should now be nursed every two hours from six a.m. to ten p.m., with one night feed- ing at two a.m. This plan gives the mother two uninterrupted HOURS FOR NURSING. 363 periods of four hours each for sleep, and it is to be adhered to until the child is six weeks old, after which the intervals Fig. 1 7 7.— Two-ounce vial with nipple. For administering nourishment, water, or sugai solution to a very young infant. between the feedings can be increased gradually until the fourth month is reached, when the night feeding can often be omitted entirely. For convenience of reference the hours for nursing may be tabulated as below : First two days Every four hours. 2, 6, 8, 10, 12 A.M. Third day to sixth week. 2, 4, 6, 8, 10 p.m Six weeks to ten weeks { 2 -*°> 7 > 9-3o, I2 AM - l 2.3o, 5, 7.30, IO P.M. Ten weeks to four months f 2.30, 7, 10 a.m. C I, 4, 7, IO P.M. Four months to nine months { 7 ' IO A - M - 1 1, 4, 7, 10 P.M. Of course, different meal-times might be chosen with the same intervals between, but the hours given are those which are least likely to interfere with the meals and other affairs of the 364 A NURSE'S HANDBOOK OF OBSTETRICS. household. Nurses, and physicians as well, will find it a great convenience to adopt the same feeding hours for all normal infants coming under their professional care, for this plan will do away entirely with the possibility of any confusion or mis- understanding as they go from one family to another. The child can easily be " started " at six o'clock every morning for the first six weeks, and this will bring the other meal-times right for the entire day. Afterwards the mother may be allowed to sleep until seven o'clock before the regular daily programme is begun. Some physicians may vary this routine according to the special needs of the infant. The feeding period is lengthened to two and a half, three, or even four hours if the child is large and steadily gains in weight. At least four ounces per week or over is the normal gain. If this gain is not shown by an accurate weight chart the food is not sufficient. Immediately before and after each nursing the entire breast is to be bathed gently with tepid water and a little castile soap, and the nipple washed off with alcohol (95 per cent.). The utmost gentleness must be exercised in cleansing the infant's mouth, for the tissues are extremely delicate, and if any force is used abrasions may be caused which may afterwards serve as starting-points for infection. For this reason a sterile wipe of cotton or linen saturated in a borax solution or plain boiled water may be used to remove particles regurgitated upon the gums or tongue. The danger from injury is greater than that from food ; and the mouth cleansed carefully in the morning needs no further swabbing out, except to remove particles of food. The effect of the warm water on the breast is to favor the flow of the milk in the first instance, and after the nursing is over it adds greatly to the comfort of the patient by removing any of the secretion that may have trickled down over the skin. The alcohol (itself an antiseptic) sterilizes and probably tough- ens the nipple, and as it evaporates almost instantly it cannot exert any harmful effect on the infant as might be the case with ordinary antiseptic solutions made up of more or less CARE OF THE BREASTS. 365 poisonous drugs. The breasts should have an application of sterile lanolin at night. Both the alcohol and lanolin are to be applied with sterile cotton sponges on applicators. The Cleans- ing of the infant's mouth is for the purpose of removing any curds or other substances that might, by decomposition, infect the nipple or cause trouble to the child. When the true milk begins to appear in the breast (about the second or third day), the patient is apt to suffer somewhat from a. feeling of fulness and tenderness in the distended organs. This can be relieved by the application of a well-fitted and fairly snug breast-binder, so adjusted that it will raise the breasts up on the front of the chest and prevent them from hanging down at the sides and " dragging." After the binder has been placed in position under the patient's back and is ready for pinning, the breast on one side is to be raised up as high as possible over the chest wall, a pad of absorbent cotton about the size of the hand placed at its outer side, and held in this position by the patient herself while the other breast is treated in the same way. This will bring. the two breasts close together in the median line, with a deep furrow between them, and it is well to place a small strip of absorbent cotton in this depression be- tween the organs to absorb perspiration and any possible excess in the secretion of milk. The milk at this time and for the next few days is apt to flow very freely and in much greater amount than is needed by the child, and other little pads of absorbent cotton should be placed over the nipples to take up the overflow and keep the clothing sweet and clean. These pads must be changed at very frequent intervals, for if any sour milk is allowed to collect it will not only tend to make the nipples sore, but it may seriously affect the child as well. The binder is, of course, to be unpinned for each nursing and replaced again as soon as the child is through and the breasts have been thor- oughly cleansed. It can usually be discarded entirely after a few days, and it must be remembered that its only purpose is to support the breasts, and that if too snugly pinned it will compress the organs and interfere with their functions. If the child is to nurse properly it must be properly held by 366 A NURSE'S HANDBOOK OF OBSTETRICS. the mother, and while most women seem to know instinctively how to support an infant at the breast, many are so awkward about it that definite instructions must be given them. First of all, the baby must be comfortable, and so placed that it can reach the nipple without any effort. Its head and shoulders should rest on the arm corresponding to the breast to be nursed, and the mother's other arm should reach over the child's body so that the hand can support its back. This is much more easily managed when the woman is sitting up, but during the early days of the puerperium the patient is, of course, on her back in bed. At this time a small pillow placed under her elbow is of great assistance to her in supporting the weight of the child, and when she is able to be up she should use a chair with arms, on which she can rest her elbow or upon which a pillow or cushion can be placed when the infant is at its meal. Feeding too rapidly, too slowly, allowing the infant's position to interfere with his breathing are points to be guarded against by the mother. The child should be made to understand that it is to begin nursing as soon as it is put to the breast, and it should con- tinue to nurse vigorously, with occasional brief rests for breath- ing, until its meal is finished, when it is to be removed at once and laid in its bed. A baby that " dawdles " at the breast, or one that is fretful and peevish, either is not hungry or there is some fault with the milk, the nipples, or with its own ability to nurse. In any event, such a child should be taken from its mother's arms as soon as a fair trial shows that it is not going to nurse properly, for it is the worst possible policy to keep a crying child at the breast for a long period when it is obviously unwilling or unable to take its nourishment. It should be kept away for a full interval, or until another feeding time comes round, when it will probably have learned what is expected of it and proceed to its duty properly and without delay. If, however, it continues to refuse the breast after this has been done, the physician should be consulted. He may find that the quality or quantity of the milk is at fault, that there is trouble VOMITING AND REGURGITATION. 367 with the nipples, or that the infant itself is ailing in some way. Possibly the infant may be found to be suffering from tongue- tie, cleft-palate, thrush, or Bednar's aphtha. If everything is satisfactory the baby should nurse heartily at its regular meal-times, which, of course, grow farther and farther apart as the child's age increases. It should be hungry as each feeding time comes round, satisfy itself in at least twenty minutes, and at the end of the meal fall into a comfortable, drowsy condition or even drop off to sleep. The infant should be weighed every day and its weight ac- curately recorded in pounds and ounces. It will be found that during the first few days of its life it will lose weight in every case, because its food, being chiefly colostrum, contains very little nourishment and it is obliged to live on its own fat. This initial loss in weight is always to be expected, and usually amounts to about ten ounces, after which the child begins to gain, and should be back to its original birth-weight by the time it is ten days old. Thus there is a normal initial loss of ten ounces in weight, normally regained in ten days' time. From this time on the child should gain steadily from day to day, until at the age of six months it should weigh twice as much as it did at birth. Besides gaining regularly in weight and strength, a baby should be happy and good-natured when awake, but inclined to sleep a good part of the time between nursings. It should be hungry at its proper nursing times, but not before, and its diges- tion should be perfect, as evidenced by the absence of vomiting and the passage of smooth, bright yellow stools entirely free from curds or mucus. Vomiting must not be confused with " regurgitation," which is a purely normal process by which the stomach gets -rid of an overload of food. Vomiting is always accompanied by the symp- toms of nausea. It may occur at any time, but usually long after nursing. The child cries, grows pale, and even blue, about the mouth, develops a cold sweat on the forehead, and, with more or less effort, expels a quantity of sour, bad-smelling, 368 A NURSE'S HANDBOOK OF OBSTETRICS. curdled milk from the stomach. This process may be repeated at frequent intervals, and the child is evidently sick. Regurgi- tation occurs immediately after nursing and at no other time. The baby is bright and happy, and merely opens his mouth and lets the excess of milk run out on his dress. It is, in other words, nothing more than an overflow, and, far from doing the baby any harm, does him good by relieving his distended stomach. The milk is not sour, and the baby is obviously perfectly well. Occasionally a child appears to be hungry between feeding- times, when in reality it is only thirsty, and it should be given small sips of tepid boiled water until it has satisfied its thirst. There is no danger of giving it too much water, and it should be allowed to drink until it stops of its own accord. In this way loss of weight may be controlled to a slight degree. In no case should the baby be put to the breast more fre- quently than at the regular feeding-hours already named, for a young infant requires nearly two hours in which to digest its food, and if it is nursed too often one meal will be taken into the stomach before the preceding one is digested, with the result that vomiting and indigestion will occur. As the child grows older it takes more milk at a nursing, and a longer period is required for the digestion of its food, so that the intervals between the nursings are necessarily lengthened. The point is to give its feedings far enough apart to allow the stomach a short period of rest before each nursing. Usually the milk from one breast will be enough for a very young infant, in which case alternate breasts should be used for each nursing, but as the child grows older it will be neces- sary to put it to both breasts at every feeding. There is no harm in doing this at any time, provided the milk of one breast alone does not seem to be in sufficient quantity to satisfy the child. The baby should never be played with or disturbed soon after a nursing, for such excitement will almost surely inter- fere with digestion and cause vomiting and other disorders of a INSUFFICIENCY OF MILK. 369 serious nature. In fact, a child should never be played with at all until it is past six months old, but allowed to devote all its energies to eating, sleeping, and developing in every way. When, after every precaution has been taken to secure proper milk for the child, the food is still not digested, the trouble, if not with the child itself or with the condition of the nipples, can usually be traced to alterations in the quantity or the quality of the breast milk. If the quantity is at fault, and the baby is not receiving enough nourishment (a condition known as agalactia), the fol- lowing signs will serve to indicate the nature of the trouble. 1. The baby will wake before its regular nursing time and be obviously hungry. It will cry and fret, refuse water with apparent disgust, and, when nursing is permitted, seize the nipple ravenously and nurse with great vigor. 2. It will continue to nurse long after the breast is empty, in its effort to secure enough food, and will cling to its mother and cry in a fretful way when an attempt is made to remove it from her arms. As has been said, a normal child, receiving normal milk, should be perfectly satisfied within twenty minutes at the most, after which it should drop the nipple of its own accord. 3. The breast itself, when examined just before a nursing hour, will not be full of milk as it should be, and on prolonged palpation it may be impossible to express any milk at all from the nipple. When the meal-time arrives the breasts should, under normal conditions, be firm and tense but never painful, and very slight pressure should be enough to cause the milk to escape in fine jets. 4. The child's weight will go down and its temperature will go up. In the chapter on the Care of the Normal Infant stress was laid on the importance of keeping a careful daily record of its morning and evening temperature taken in the rectum, for the onset of fever, coupled with a loss of weight, is one of the most significant indications that the amount of nourishment is not sufficient. With these four points in mind, the nurse should have no 24 370 A NURSE'S HANDBOOK OF OBSTETRICS. difficulty in knowing when the amount of milk secreted is too small. To increase the milk flow the condition of the mother's health should be looked into carefully, and she is to be shielded as much as possible from worry, grief, overwork, or other causes of low vitality. If coffee is included in her diet, it should be stopped entirely, for this beverage has a decided ten- dency to diminish milk secretion. She should drink milk, or cocoa, in its place, and extra milk should be taken between meals and at night before retiring. It must be remembered, however, that too much milk is apt to upset the stomach, especially in certain individuals, and lime water or vichy should be added to each glassful as a preventive against this form of gastric dis- turbance. If symptoms of indigestion develop, the milk should be stopped at once, and dispensed with until the stomach is again in good working order. There is great uncertainty regarding the value of any special foods to stimulate the milk secretion. Many foods on the markets have strong advocates among physicians, but the final value to the mother is questionable. If the milk taken cannot be properly digested, a starchy diet with large amounts of fluid may be given. Beets and all kinds of shell fish, noticeably crabs, are said to increase the quantity of milk to a marked degree. The tendency at present is to place the strongest hope upon stimulations of the body and the gland itself. Massage with cool baths and dry rubs, electricity, and breast massage may affect the amount secreted. Great patience is often required before the mother is re- warded. The present-day teaching is so overwhelmingly in favor of a woman nursing her infant that the nurse is urged to carry out with every faithfulness all orders that will make this possible. The infant's chances for life are doubled. The doctor will decide if the gland cannot secrete, or is diseased, or if further stimulation is unadvisable. An excessive flow of milk (or galactorrnoca) is of rare oc- currence after lactation is fully established, but when it does occur to such an extent that it soils the patient's clothing and CHEMISTRY OF MILK. 371 keeps her in a constantly uncomfortable condition, it may often be checked by the administration of one or two cups daily of strong black coffee. This may be varied with the usual with- drawal of fluid and elimination. If belladonna is applied ex- ternally the effect must be closely watched. If the quality of milk is at fault the case will probably have to be referred to the physician. Up to this time no mention has been made of the chemical constituents of milk, but unless a nurse has a fair knowledge of these matters she cannot understand the subject of infant feed- ing in an intelligent way. Milk is a natural emulsion, and consists, roughly speaking, of 13 per cent, of solids and 87 per cent, of water. The solid substances are fat, sugar, proteids, and salts, and of these it is only necessary to consider the first three, for the salts are unimportant in many ways and never vary much. The fat of milk is the cream, the sugar is the kind known as " lactose/' or " milk-sugar/' and the proteids make up the curd. In good specimens of mother's milk there is, approximately, four per cent, of fat, seven per cent, of sugar, and two per cent, of proteid. It will be seen that this makes up the entire thirteen per cent, of solid matter, but, as a matter of fact, the true proportions are slightly less than the round numbers given, leaving room for a small percentage of salts. Normal mother's milk, as it leaves the breast, is a sterile fluid, absolutely free from germs, blood-corpuscles, or pus-cells. It should have an alkaline, possibly neutral, but never an acid, reaction, and its specific gravity should be from 1027 to 1032. Colostrum cells should be absent after the twelfth day, and the fat cells should be small, numerous, and of uniform size. The proteids of milk vary directly with the specific gravity, — that is, the higher the specific gravity the higher the proteids, and vice versa. If we know the amount of cream in a given specimen of milk, it is possible to make a fair estimate of the proteids in a very simple way. Professor Holt, of the College of Physicians and Surgeons, has devised a little apparatus, con- sisting of an hydrometer and jar, for ascertaining the specific 372 A NURSE'S HANDBOOK OF OBSTETRICS. gravity of milk, a pipette, and two long graduated cylinders with glass stoppers, for estimating the percentage of fat. The milk to be examined is to be taken from the middle of a nursing, or, if it is removed from the breast artificially, after about half the entire amount has been extracted. This milk is put into one of the glass cylinders with the pipette and should fill it exactly to the graduation marked O. If specimens from both breasts are to be examined at the same time, both cylinders are used. The cylinders, properly filled and securely corked, are set away in a temperature of 70 ° F. and left undisturbed for twenty-four hours, after which time the cream line will be distinctly visible and the percentage may be read on the scale. But this, is cream and not fat, which is to the cream as 3 is to 5. Thus, if a specimen of milk shows seven per cent, of cream, we have : Fat : 7 : : 3 : 5, or four and one- fifth per cent, of fat. The estimation of the proteids is not quite so simple, but it is by no means difficult. We can determine accurately the amount of fat in a given specimen, and fat, being the lightest part of the milk, tends to lower the specific gravity; so that the more fat in a specimen the lower the specific gravity would naturally be. Proteid, on the other hand, is the heaviest part of the milk, and the greater the percentage of proteid, the higher will be the specific gravity. Hence : (a) If both fat and specific gravity are high the proteids must also be high, or the amount of fat will bring down the specific gravity. (b) If the fat is low and specific gravity high, the proteids are probably about normal, the high specific gravity being due to the small amount of fat in the specimen. (c) If the fat is high and the specific gravity low, the pro- teids are again probably about normal, the low specific gravity being due to the large amount of fat. (d) If both fat and specific gravity are low, the proteids must also be low, for otherwise the small amount of fat would make the specific gravity high. VARIATIONS IN QUALITY. 373 In collecting the milk for examination great care must be taken to handle it as little as possible, and the glass cylinders for making the cream tests must be scrupulously clean, or the milk may sour before the cream has had time to rise. If at the end of twenty-four hours the cream line is not sharply defined, the specimen may be allowed to stand six hours longer before the percentage is recorded. Any marked variations in the proportions of fat and proteids, and the presence of any foreign substances in the milk, such as blood or pus, will cause, in the infant, indigestion of a more or less serious degree. The most common form of disturbance is that due to an increased percentage of proteids, and is evi- denced by constipation and the presence of curds in the stools. If the condition is not corrected promptly, serious illness may result. When fat is present to an excessive degree the infant vomits and has diarrhoea. It is not difficult to keep these two sets of symptoms in mind when it is remembered that the pro- teids, being the curd of the milk, would, if in excess, naturally cause curds in the stools ; and that the fat, being an oil, would, if in too great amount, tend to the production of diarrhoea. Both fat and proteids are increased by a diet that is largely of animal food and diminished by one consisting chiefly of vegetables. In cases where the proteids are in too great amount it might be possible to remedy the matter by putting the woman on a vegetable diet and then, if necessary, making up the de- ficiency in fat by giving her cream to drink. Fright, worry, pain, or any other nervous shock, increases the proteids in the milk, and the patient must be shielded from these disturbances as far as possible. Menstruation increases the proteids, but the increase depends largely upon the amount of pain that the woman suffers at this time. Not long ago it was thought best to stop nursing entirely if the menstrual function returned during lactation, but it has been found wiser to be governed by the amount of suffering that the woman undergoes, and not take the child from the breast unless the mother's pain is extreme and the infant plainly shows the effect of the change in the milk. Ordinarily it is better to 374 A NURSE'S HANDBOOK OF OBSTETRICS. let the baby undertake the extra digestive strain for a few days each month than to risk an entire change in diet. The presence of blood or pus in the milk is an absolute indication for stopping all nursing at the affected breast. This condition is usually due to injury or inflammation of the breast, and if the milk remains after an apparent cure, the child must not lie allowed to nurse until, by microscopic examination, it is known that all evidences of suppuration have entirely disappeared. Pregnancy, when occurring during lactation, causes a marked decrease in the percentage of fat. It is another, and the only other, positive indication to stop nursing entirely. The milk is not good for the child, and the mother cannot properly nourish herself, her baby, and the foetus in utero, while the reflex connection between the breasts and the uterus would make nursing under such conditions a very probable cause of abortion. As has been said, the presence of blood or pus in the milk and the occurrence of pregnancy are positive contraindications to nursing; and of the other conditions may or may not be, according as they can or cannot be corrected by diet or other treatment ; and lastly, there are some women whose milk is apparently perfect in every respect and yet who cannot nurse their children because, from some unknown reason, the milk does not and cannot be made to " agree." Wet-Nurse. — Theoretically the wet-nurse is the best substi- tute for mother's milk, but practically it is usually better to try " mixed feeding " or adopt artificial feeding entirely. The wet- nurse is not easily secured ; she is expensive, and usually an ex- treme care, causing trouble with other servants and making her- self generally unpleasant in her assurance that the family will put up with anything rather than have the baby's food changed again. The majority of wet-nurses are unmarried women secured from some public maternity hospital, as women with homes and husbands are not apt to neglect their own children in this way, and the probable, if not actual, lack of morality in the nurse is an added reason for making her an undesirable member of the family. Aside from this, however, an unmarried woman usually makes the best wet-nurse, not only because she parts with her MIXED FEEDING. 375 own baby with little or no regret, but she has no husband to appear at frequent intervals and demand her wages or upset the entire household by threatening to take her away. In selecting a wet-nurse a woman should be chosen whose baby is as nearly as possible of the age of the baby for whom her services are required. She should be a woman of neat and cleanly habits, and, preferably, one of more or less phlegmatic disposition, and both she and her child should be examined by the physician for evidences of disease of any and every sort. As has been said, a single woman usually makes a better nurse than one who is married, and the fact that the married woman has lost her infant through death does not help matters any, for her grief will usually be enough to spoil her milk. If the unmarried woman is physically all that could be de- sired, she should be given the preference, for the essential thing is to secure a good food for the baby. The question is often asked if there is not danger that the baby will acquire the disposition and character of the wet-nurse, and the best answer is that the proba- bilities are exactly the same as that a bottle baby will take on the manners and morals of a cow. Milk is milk, and if it agrees with the baby its source is a matter of no consequence whatever. After the nurse has been selected and the baby given into her charge the general directions governing the feeding are the same as when the infant nurses at its mother's breast. Mixed Feeding. — This is the method to be adopted when the mother has some milk, of good quality, but not in sufficient quantity to, fully satisfy the child. The hours for feeding, according to the age of the child, are the same whether the baby is at the breast or on the bottle, and if the mother has not milk enough to satisfy her infant at every feeding she can often skip one or two nursing hours and give modified milk in place of the omitted breast feedings. This plan should always be tried when the quantity of breast milk is below normal and its quality is good, for, as has been said, it is better for both mother and child to have the breast milk utilized as far as possible. 376 A NURSE'S HANDBOOK OF OBSTETRICS. rhe modified milk to be used in mixed feeding is prepared in the proportions suited to the age of the child and given in the same quantity that would be allowed if the baby were exclusively on the bottle. Artificial Feeding, — This is a most important subject and one that can only be considered here as it may be applied to a normal and perfectly healthy infant. The various patented baby foods will not be discussed in any way. Directions for their use go with every bottle, and while each one claims to be better than all the others, and proves its claims by the publication of pictures of fat and usually rhachitic babies, they are all more or less bad and of no real value except in certain cases where they may be used by the physician's direc- tion to tide over a period of travel or to increase the carbohy- drates in a food greatly diluted to remove its proteids. Condensed milk, like the patented foods, contains too much sugar and too little fat to give it any value except on occasions, and while it also makes fat babies, these children, like those fed exclusively on the advertised baby foods, have no real honest strength and are liable to break down in childhood at the first attack of any serious disease. Mothers often point with pride to healthy grown children, and state that they w^ere brought up on this, that, or the other food, but the fact remains that if they had been attacked by any serious disease of infancy they would have died, when babies fed on modified cow's milk might have weathered the gale without difficulty. The explanation is that these children were fortunate enough to escape any severe disease until they had been on a general diet long enough to enable them to resist it. That the " baby-food babies " are fat is merely because sugar makes fat, and these foods are chiefly composed of sugar, which is necessary as a preservative, just as the housewife adds sugar to her " preserves " to keep them from spoiling. Goat's milk and ass's milk are not worthy of consideration, although it is true that their constituents approach more nearly the proportions of breast milk than do those of cow's milk. The objection to their use lies in the fact that they are not ARTIFICIAL FEEDING. 377 exactly the same as mother's milk and must be modified with as much care and attention as is paid to the preparation of cow's milk. The only milk worthy of serious consideration as a substi- tute for breast feeding is that obtained from a herd of healthy cows. The milk from one cow, so long regarded as best for bottle feeding, is no longer used. It was formerly supposed that " one cow's milk " was less liable to change than that from mixed milkings, but it is now known that while the milk from a herd preserves a very constant average of quality, that from one cow is always subject to marked change. Laboratories exist in all large cities, which fill prescriptions for modified milk. They are known to be reliable and the doctor is assured there will be no error in the product. For this reason, where available, the feedings are purchased as ordered. Some hospitals maintain a diet kitchen service for the benefit of physicians requiring such a convenience. Occasionally one will be maintained in connection with a Nurses' Directory. All milk stations give instruction in milk modification, and such instruction is an important feature in the work of a Public Health Nurse. It is, however, quite possible for mothers to do this properly in the home and if systematized this consumes but little time. Where bottled milk is unattainable, cream may be removed from a pan with care and fat free milk siphoned from the bottom. The milk sold in bottles in the cities is usually of fairly good quality, owing to existing laws regulating the management of dairies and the shipment and sale of milk. The best bottled milk to be had in New York is that known as " certified" or "'guaranteed," milk and sold by certain dealers only. This dif- fers from ordinary bottled milk only in that it is milked, shipped, and sold strictly in accordance with suggestions made by a committee appointed by the New York County Medical Society to investigate the milk supply of the city. Ordinary bottled milk may be up to all the requirements of a good food, or it may not, but certified milk can always be relied upon in every way. If the child is at all feeble, or, in any event, if the parents can 378 A NURSE'S HANDBOOK OF OBSTETRICS. afford the slightly additional expense, certified milk should be used instead of the ordinary kind. It has been said that mother's milk contains, approximately, four per cent, of fat, seven per cent, of sugar, and two per cent, of protcids. Mixed cow's milk — that is, milk which has been stirred up, so that any cream which may have risen is thoroughly mixed with the rest of the milk — contains, approximately, four per cent, of fat, four per cent, of sugar, and four per cent, of protcids. At first sight it would seem that the only necessary step in modifying cow's milk to meet the requirements of an infant would be to dilute it one-half with water, giving fat, two per cent. ; sugar, two per cent. ; and proteids, two per cent. ; and then adding two per cent, of fat and five per cent, of sugar to make the formula read, fat, four per cent.; sugar, seven per cent. ; proteids, two per cent. This formula, from a chemical stand-point, is exactly the same as that of mother's milk, and it would be a proper food for the baby were it not for the fact that the proteids of cow's milk differ materially in point of digesti- bility from those of breast milk and must be greatly diluted before a young infant can assimilate them. By the time the child is about three months old its system has become accus- tomed to the proteids of cow's milk, the proportions of which have been gradually increased from day to day until, by this time, the formula is the same as that of mother's milk. To prepare milk for an infant under three months of age we find that it is most convenient to use, as a basis, cow's milk containing twelve per cent, of fat, four per cent, of sugar, and four per cent, of proteids. This is called " twelve per cent, milk," or " 12-4-4 milk." To prepare food for a baby between the ages of three and nine months it is most convenient to use cow's milk containing eight per cent, of fat, four per cent, of sugar, and four per cent, of proteids. This is called " eight per cent, milk," or " 8-4-4 milk." Ordinary mixed cow's milk, containing, as has been said, ARTIFICIAL FEEDING. 379 four per cent, each of fat, sugar, and proteids, is called "four per cent, milk," or " 4-4-4 milk." To make " eight per cent." or " twelve per cent.", milk it is only necessary to add to ordinary mixed (4-4-4) milk the re- quired amount of fat in the form of cream. Cream is nothing more than milk containing an excess of fat, and is of two kinds, — " gravity" cream and " centrifugal" cream. " Gravity" cream is that which rises to the top of a milk- bottle, or which, in the country, may be skimmed from the milk- pans. It contains fat, sixteen per cent. ; sugar, four per cent. ,* proteids, four per cent. " Centrifugal" cream is that made with a centrifugal machine, and is sold in the cities in small sealed bottles as " cream." It is about as thick as honey, and contains fat, twenty per cent. ; sugar, four per cent. ; proteids, four per cent. The problem now is to make either " eight per cent." or " twelve per cent." milk by the addition of the proper quantity of either " gravity" or " centrifugal" cream to ordinary mixed (4-4-4) milk. These various formulas may seem a trifle confusing until they are placed in order, thus : Fat. 4 per cent. 8 " Sugar. 4 per cent. 4 " Proteids. 4 per cent. 4 " 12 16 4 4 " 4 " 4 " 20 " 4 ' 4 It will now be seen that nothing varies but the fat, and that the fat varies only in the perfectly regular progression of 4, 8, 12, 16, 20. The first formula is that of ordinary mixed milk, and the next two are those of the desired products for use as the basis of the baby's food ; while the last two are those of the perfectly familiar kinds of cream in every-day use. In addition to the method of making " eight per cent." or " twelve per cent." milk by mixing cream and ordinary milk in proper proportions, the same results can be obtained by removing a definite amount of milk from the top of an ordinary quart 380 A NURSE'S HANDBOOK OF OBSTETRICS. milk-bottle in which cream has had time to rise. The method of removing this " top milk" and the amount to be removed will be taken up later. Thus we have three methods at our disposal, — the use of " gravity" cream, of " centrifugal" cream, or of " top milk." If " twelve per cent." milk is desired, it is made as follows : From gravity cream, by adding one part of 4-4-4 milk to two parts of gravity cream, thus : Fat. Sugar. Proteids. 16 4 4 16 4 4 4 4 4 •36 12 12 From centrifugal cream, by mixing equal parts of 4-4-4 milk and centrifugal cream, thus : Fat. Sugar. Proteids. 20 4 4 4 4 4 2)24 12 From top milk, by taking nine ounces from the top of the bottle as it comes from the dairy. The best way to remove the top milk is with the little dipper, holding exactly one fluid ounce, devised by Dr. Henry Dwight Chapin and known as the " Chapin dipper." The first dipperful is to be taken off with a teaspoon, or the milk will be lost when the dipper is lowered into the bottle. It is, of course, distinctly understood that the milk is to be dipped out and not poured, for any tipping of the bottle will disturb the cream and alter the proportion of fat in the top milk. This " twelve per cent." milk is now to be modified for the infant's use, and it is most convenient to prepare twenty ounces of food each time in order to make the proportions come right. It has been said, in speaking of breast milk, that it should be ARTIFICIAL FEEDING. 38l alkaline or neutral in reaction, but never acid. Cow's milk, as it reaches the consumer, is always acid, so that it must be made alkaline by the addition of lime water or sodium bicar- bonate before it is fit for the baby's use. The sugar in cow's milk (four per cent.) is normally much less than that in mother's milk (seven per cent.), and the addi- tion of water, necessary to bring the fat and proteids down to a proper amount, reduces the sugar to almost nothing, so that sugar must be added to give sufficient sweetness to the food. With " twelve per cent." milk as a basis, it is only necessary, in preparing food for an infant under three months of age, to add lime water, or sodium bicarbonate, milk-sugar, and water in proper proportions. The amounts of lime water or sodium bi- carbonate and sugar do not change at all, but the milk is in- creased and the water proportionately diminished from day to day as the child grows older and is able to take stronger food. Twenty ounces of food are made at each time, and for this amount one ounce each of lime water and milk-sugar are re- quired, or sodium bicarbonate, 10 grains (or one-half grain to one ounce). When the amount of "twelve per cent." milk suited to the age of the child has been added, enough boiled water is poured in to make the total amount of food exactly twenty ounces and the work is done, thus : — bo oii 13 U 5 §5 00 n-£r-ve'shon) . Weakness ; languor ; lack of nerve stimulus. Ensiform (en' si-iovm.) . Like a sword; sword-shaped. E. Appendix, Cartilage, or Process, the extremity of the ster- num or breast-bone. Epidemic (>p-f-dcs"cri-m£n-U'sh'us) . Belonging to excrement. Excrete (^cs-crit'). To separate from the bodily tissues useless matter which is to be cast out of the system. Excretion (Vcs-cri'shon). 1. The separation of those fluids from the blood which are supposed to be useless, as urine, perspiration, etc. 2. Any such fluid itself. Exostosis (^c-sos-to'sis). An exuberant growth of bony matter on the surface of a bone. Expiration (ecs-pi-re'shon). The act of breathing out or expelling air from the lungs. Expiratory (ecs-pair'e-to-n). Relating to or of the nature of expiration. Expire (n'*'-tal). 1. Belonging to generation. 2. Relating to the genital organs. Genupectoral (jmsh'us). Baleful; deleterious; highly dangerous : as pernicious anaemia, or pernicious vomiting. Perspiration (p^r-spi-re'shon). [Latin, perspirare, to breathe every- where.] i. Sweat. 2. The process or function of sweating. Pessary (p72> Straining during labor, 259 Strangling, danger of, 158 Streptococcus infection, 277 Striae, abdominal, cause of, 68 gravidarum, 67, 68 in skin of breasts, 69 Stricture, congenital, 311 Study, excessive, 45 Subinvolution, 81 Sublamin, 401 Suckling as cause of uterine con- tractions, 41, 113 discomfort from, 283 impossible, 344 interference with, 279, 283 position for, 366 prevention of, 114 Suffering, puerperal, 25 Suffocation of infant, 345 Sugar, fat-producing, 376 in milk, 378, 381 in urine, 73 Suicide, tendency to, 278, 288 Sunshine for baby, 299, 304 Supervision of pregnancy, 26 Supplies needed by nurse, 396 renting of, 124 Suppression of menstruation, 45 Suppuration of breast, 283, 287, 342 Surgery in ectopic pregnancy, 208 Surgical dressings, 124 Suspended animation, 317 Sutures of cranium, 58, 59, 60 perineal, 171, 176 Swabbing the mouth, 364 Swallowing pins, 305 Sylvester's method, 327 Symphyseotomy, 31, 234, 236 Symphysis pubis, 28, 30, 33 Syncope, 192, 194, 253 Syphilis as cause of abortion, 211 transmission of, 212 INDEX. 473 Syphilitic infection, 212, 213 nipples, 287 Table, dressmaker's, 247 for dressing baby, 303, 309 Tampico fibre brush, 134, 402 Tamponing, 266, 268 Tape for cord, 395 fastenings, 305 Tarnier basiotribe, 239 forceps, 223 Tarnier's incubator, 353 Tarry discharge from vagina, 97 T-binder, 132 Tears, excessive secretion of, 193 Technic, hand preparation, 401 Teeth, care of, 108 false, 141, 145, 203 Temperature after labor, 81 charts, 177, 394 in puerperal fever, 275 of incubator, 349, 351, 353 of infant, 294, 306 of nursery, 299 of operating room, 233 of premature baby, 355 subnormal, 348, 349 Tenesmus, rectal, 191 Tennis, 106 Terror of water, 309 Terrors of nursery, 295 Test meal, 400 Tetanus, 344 Teterelle, 359 Thermometry, clinical, 177, 394 Third stage of labor, yy, yg Thirst from hemorrhage, 205, 255 of baby, 298, 359, 368 relief of, 185 Threatened miscarriage, 256 Throat, mucus in, 317, 318, 319 Thrombus, 271 Time for labor, 75 Tissue, injury of, 329 Toilet of mother, 178 screen, contents of, 316 Tongue, biting of, 203 bleeding from, 199 cleansing of, '308 traction, 320, 323, 326, 332 Toothache, 108 Top milk, 380, 382 Towels, clean, 121, 123 Toxaemia, eclamptic, no general, 187, 197, 198 indicated by vomiting, 86, 187 of liver, 203 Traction on body during delivery, 155 Training of infant, 295, 306 Transverse presentation, 99, 101, 215 Tray for care of breasts, 279 Trendelenburg position, 261 Treponema pallidum, 211 Triplets, 65, 66 Tub-bath for baby, 293, 302, 304 for baby, temperature of, 306, 308 in pregnancy, 108 Tubal pregnancy, 206, 208 Tuberculosis in pregnancy, 211, 213 Tubes, removal of, 234 Tucker-McLane forceps, 223 Tumor, abdominal, 228 of spina bifida, 341 Turpentine enema, 137 Twelve per cent, milk, 378, 380, 384 Twentieth century civilization, 27 Twilight sleep 160 Twin, decapitation of, 238 pregnancies, 76, 190 Twins, abdomen containing, 68 causation of, 65 delivery of, 157, 158 locked, 157, 159, 238 474 INDEX. Twins, precautions concerning, 154 umbilical cords of, 66 Typhoid state, 184 Tubercles of Montgomery, 69, 87 Ulcer, syphilitic, 211, 212 Ulceration of tumor, 341 Umbilical cord, 53, 116 compression of, 317 cutting of, 65 detachment of, 294 prolapse of, 259 shortness of, 258 tying of, 66 hemorrhage, 326, 329 hernia, 342 vegetations, 343 Umbilicus, 53. See also Navel infection of, 340 protrusion of, 68, 69 Unavoidable hemorrhage, 253, 254 Unconscious patient, 204 Under-feeding, 180 Uniforms for nurse, 394 Uraemia, 194 convulsions of, 199 Urea, excretion of, 198 Urethra, 35 Uric acid deposit, 296 Urinary colic, 346 Urination in new-born, 298 stimulation of, 172 Urine, examination of, 113, 118, 196, 198, 200, 202 in hysteria, 201 of eclampsia 200 of pregnancy, 73 retention of, 83 voiding of, 172 Uterine dilator, 247, 248 inertia, 222, 264 Uterus as a nest, 117 bleeding from, 154 bleeding into, 254 Uterus, cancer of, 412 contraction of, 41, 81, 83, 85, 242 enlargement of, 89 infection of, 21 inversion of, 154 mucous membrane of, 49 openings of, 39 packing of, 252 palpation of, 101 pregnant, 36, 67 pressure of, upon lungs, 70 relaxed, 81, 162 removal of, 226, 228, 234 rupture of, 217, 257 sinking of, 76 tilting of, 38, 86 virgin state of, 35, 81 Vagina, 34 aseptic state of, 35 irrigation of, 177 Vagina of infant, bloody discharge from, 297 packing of, 243, 252 secretion of, 21, 69, 137 violet hue of, 69, 85, 89 Vaginal discharge after meno- pause, 412 meconium in, 156 douche, 35, 176, 194 examination, 139, 403 mucous membrane, 89 operation, 219 secretion a lubricant, 69 walls, return of, to normal, 82 Vaginitis, 297 Varicose veins, 104, 189, 191 Vegetations, umbilical, 343 Veins, clot in, 277 Ventilation, 180 of incubator, 351, 353 Vernix caseosa, 58, 292 INDEX. 475 Version, external, 214, 215 indications for, 222, 243 operation of, 101, 209 internal, 214, 217 Vertex presentation, 91, 93 Vesical tenesmus, 191 Virgin state of uterus, 81 Vision, double, 197 Visiting nursing, 406, 408 Visitors, 80, 180 to incubator baby, 354 Vital resources, conservation of, 19 Vomiting due to ether, 146 during labor, yy, 78 morning, 85, 86, 183 of albuminuria, 197 of infants, 367 of pregnancy, 70, 86 pernicious, 186 relieved by bromide, 184 uncontrollable, 186 Vulva, 34 cleansing of, 132, 171, 251, 403 infection of, 138 pads, 23, 133, 137, 170 Waist, pressure about, 103 Waiting, time lost by, 119 Walcher posture, 218, 220 Walking during pregnancy, 105, 106 Wansbrough's shield, 282, 283 Wash-basin, double, 302, 309 Washing of baby's clothing, 316 Washrags, 303, 309 Water, boiled, for baby, 298, 359, 368 for colic, 346 intake of, 112 sterilization of, 401 Water-closet, non-use of, during labor, 132, 1 37 Weather and out-door exercise, 105 Weight chart, 309 of baby, 309, 348, 394 doubled, 367 loss of, 368 new-born, 297 normal increase in, 298, 364 Wet-nurse, milk of, 360 mortality of, 374 selection of, 374, 375 Wharton's jelly, 55 Whiskey by hypodermic, 323 " Whites," 194 Winckel's disease, 340 Windows, protection of, 250 Wipes, burning of, 170, 213, 335 "Wobbly" gait, y3 position of head, 96 Womb, 35. See Uterus. Wool flannel for baby, 311 Woolen underwear in pregnancy, 103 Yellow crust on head, 311 Yellowness of skin, 340 Zone, temperate, puberty in, 45 Zoolak, 397