Mother, Nurse and Infant / A Manual Especially Adapted for the Guidance of Mothers and Monthly Nurses, Comprising Full Instruction in Regard To Pregnancy, Preparation for Child-birth, and the Care of Mother and Child, and Designed to Impart so Much Knowledge of Anatomy, Physiology, Midwifery, and the Proper Use of Medicines as Will Serve Intelligently to Direct the Wife, Mother and Nurse in All Emergencies.

PART IV. SKILLED NURSING AND MIDWIFERY.

CHAPTER I.
PRELIMINARY INSTRUCTION TO THE NURSE MIDWIFE.

It is my design in giving the following instructions to prepare the student of this work to be a skilled or skillful nurse, not to be simply a midwife; to act in conjunction with, not in opposition to, physicians; to conform to, and not to violate laws which regulate the practice of medicine; to officiate in cases of easy, natural labor sometimes, but never in cases requiring the use of instruments; to be prepared to act in emergencies until the doctor can come and take the case; not to treat the case when the services of a physician can be obtained and is desired or needed; in short to act intelligently in all cases in which women now act perhaps blindly, hurriedly and ignorantly.

The present state of feeling among our people, and especially among the medical profession in this country, would not sanction an effort to educate women solely as midwives.

But there is a general feeling or sentiment that every young lady ought to have that kind of education which may render her useful; that she should be prepared in some way to minister to the desires, wants and needs of her fellow creatures, and that some part of that knowledge or skill should be of that kind which would be available if these persons were thrown on their own resources; hence I would have some of you to be, not only nurses of the sick, but skilled nurses of lying-in women. And should some young lady after studying this work, decide to pursue the study of medicine thoroughly and become a physician, the knowledge here obtained would be available.

PRELIMINARY INSTRUCTIONS.

1. Do not stop short of a thorough knowledge of this book, every part of it.

2. Endeavor here to get a knowledge of midwifery that will qualify you to attend ordinary cases of natural labor, and enable you sometimes to give medicine when needed, and when there are no physicians in attendance; but understand that there are many times when the only proper thing for you to do is to send for a physician or experienced accoucheur.

3. Do not hesitate to seek knowledge and experience and instruction from any source where you think that you can obtain it. Physicians will be willing to aid you, and I think the time is coming when he will regard the educated nurse as his friend, and not as his natural enemy.

4. I do not think it best that you should call yourself a midwife, because if you do it will excite misapprehension and prejudice. Seek in every way to be skillful as a nurse, and seek to have a corresponding reputation.

5. Do not undervalue your position, if you have the wisdom and courage and perseverance necessary to prepare you to minister to your sex in their time of greatest suffering and trial. Do not doubt that your mission is an honorable one. And even if you do not minister very often to the sick in labor, except as the right arm of the medical man, you may help to raise the standard qualifications of the nurses of our land. Do not suppose that I am complaining harshly of our present supply of nurses. Women have shown a wonderful adaptability to the needs and exigencies of their suffering friends in nursing and caring for them. And it is because they are so ready to receive instruction that I endeavor here to furnish good instruction for them.

6. Do not suppose that your knowledge obtained by study is sufficient to enable you to act as midwife (except in an emergency), unless your studies are supplemented by observation, as mother nurse, &c.

7. Do not be unwilling to minister to women who are poor. The young physician is willing to do something in this way to gain experience and for the sake of humanity, and this will be your opportunity to gain experience without coming in competition with rivals.

8. The nurse as well as the medical man, must study the phenomena of labor at the bedside of the patient. No one can be qualified by mere reading for the duties of a midwife, and no woman that is diligent and observing can attend a case of labor without some addition to her knowledge.

INSTRUCTION TO THE NURSE MIDWIFE.

When I use the term nurse midwife I mean a nurse that has some knowledge of midwifery, that can be called to attend to women near the time that she expects to be confined, and that can remain in attendance for two weeks or more if it is desired or necessary. Sometimes a woman would, if possible, have a skilled nurse with her a week or more before confinement, especially because she would thereby avoid sending for the physician unnecessarily, and because she would be less likely to detain him for a long period of time.

If the nurse midwife understands her business she will in some cases do better for the woman than a physician in the commencement of labor. For instance, suppose that a doctor is called a distance of five miles and away from his home and his other patients, and when he examines the case the pains seem to be of the character of false labor pains. He knows that the real good of the patient might require that she should take an opiate, but the doctor would be unwilling to give it lest it might protract a real labor, and subject all parties to the inconveniences of a prolonged labor including unnecessary visits of the doctor. The nurse who can remain with the patient, if the labor should not be concluded in several days, would be more likely to do just what the good of the woman requires. And in such a case a skilled nurse would be peculiarly acceptable to a physician if he chanced to be called, because he would be much more at liberty to leave his patient if it seemed necessary to do so.

When a nurse midwife is called to attend a case, she should carry with her besides disinfectants, a male catheter, some laudanum or other opiate, quinine, and extract ergot, in order to be prepared for emergencies. Ordinary cases may require no medicine, but some cases do.

CHAPTER II.
THE NATURAL LABOR.

A NATURAL LABOR has been described as one “in which the head presents, and descends regularly into the pelvis; where the progress is uncomplicated, and concluded by the natural powers within twenty-four hours, (each stage being of due proportion), with safety to the mother and child, and in which the placenta is expelled in due time.”

A skillful, careful examination in the commencement of labor will enable you perhaps to decide whether the labor will be natural or otherwise. But it may be your duty first to know if your patient is in ordinary health, or if she have any fever or organic disease, and you should enquire about the bodily functions generally, the condition of the pulse, skin, &c. Before making a digital examination you should notice the character of the pains, their frequency, force and regularity, the amount of voluntary effort, the character of the outcry, &c. From these enquiries you probably will be able to decide whether she is suffering from real labor, or false pains.

She will, however, probably not object to a digital examination and your opinion will be founded principally upon that. The modern practice is to wash the hands in antiseptic soap or some solution before making an examination.

We are directed by most writers to have the patient lie upon her left side near the edge of the bed when we examine her. The fore finger of the right hand (sometimes the left) after being well oiled or soaped should be passed along the perineum into the vaginal orifice, and is to be pressed upward and backward towards the promontory of the sacrum until the os uteri or the presenting part is found. Sometimes this is not reached without an effort. When reached endeavor to find the foetal head or to determine what is the presenting part—feel sufficiently to distinguish the lips of the os uteri from the presenting portion of the foetus. Do not be hasty in making the examination; wait till you examine sufficiently to know if the child is forced down; observe both during the time of a pain and during an interval, and observe if the pains dilate the os. Sometimes during a natural labor there may be a severe pain, and when the pain is hardest, the os contracts. By waiting to take a number of pains you will learn if there is real progress. When examining, note the calibre, heat and moisture of the vagina; the general condition of the cervix; the dilatability of the os uteri and the actual dilatation by the bag of waters or the foetal head during a pain. If the head presents you can best learn the particular position when the pain is off; and after the membranes are ruptured you can decide better than previously. Ordinarily the sagittal suture can be felt, and perhaps both fontanelles, but you must not be discouraged at all if you cannot determine the exact position. Doctors ordinarily do not deem it necessary.

If you can decide that it is a head presentation and that the woman is undoubtedly in labor, you may probably decide that the labor will be natural, and you may properly tell the friends so, adding perhaps, that it will depend upon the character of the ensuing pains whether the labor will be protracted or short.

Various circumstances of which you are possibly not yet cognizant may make your case of labor a tedious or difficult one. You have decided, perhaps, that there is no obstruction to the passage of the child, no deformity of the pelvis, scirrhus or other tumors in the vagina, no cystocele, no prolapsed ovary, and that there is not a rigid perineum or imperforate vagina. If there is, you need to have a medical man present, but should none be obtained you will need to repeat your examination from time to time. Observe if each pain presses down the bag of waters and dilates the mouth of the womb, and if the soft parts are in a relaxed state, and if there is a show. Even if the appearances are thus promising, the labor may be slow and tedious from various causes.

1. Possibly hardened feces maybe in the rectum; if they are you may be assured of the fact when you make a digital examination, as they seem like tumors posterior to the vagina. The remedies are physic, enemas, rest—possibly opium.

2. Inefficient pains may be due to a bladder distended with urine. When this is suspected we should observe whether there is abdominal swelling (not tympanitic) low down; pain on pressure which gives rise to a desire to urinate; a constant desire to pass water though the patient has just performed the act, or a dribbling of water from the parts. If the bladder cannot otherwise be relieved a catheter should be used, and as a precaution to avoid wetting the bedclothes it is well to have a catheter made long enough by affixing a piece of India rubber tubing to the end of it to reach a vessel at the side of the bed. Never use force in passing a catheter in. It is very seldom that it is necessary to use it at all during labor.

3. If there is a hernial protrusion of the bowel, or a calculus of the bladder falling down in the passage you will probably have a medical man to officiate. But I may say that if there is need of your doing anything to replace them, or if it is necessary to return a prolapsed bladder, you can best do it when your patient is in the knee-chest position.

4. The lack of expulsive power is sometimes due to the want of sleep. If the first stage, that of dilatation, is prolonged the subsequent uterine contractions seem to want efficiency. In such cases if the patient can have a dose of opium or morphine administered to induce sleep it acts favorably. Where there is nervous excitement particularly, the efficiency of the pains are increased if we give opium and first procure a period of rest.

5. The uterus may be greatly distended and its expulsory power thereby weakened. In such cases there may be a suspension of the action of the uterus for several hours although the labor before that had made considerable progress. If pains of labor are feeble or slow or suspended, no harm can come to the mother or child (in such cases) except that the mother is compelled to bear them for a longer time. The only remedy that I would suggest is that the distention be relieved by the rupture of the membranes and discharge of water. If more efficient pains did not come on, then I would give a dose of morphine, which would either increase the pains, or give a period of rest.

6. Sometimes there are vehement and cramp-like pains in the abdomen producing no effect that is good and adequate, caused by partial irregular or spasmodic contractions of the uterus—usually what are called hour-glass contractions. If the bowels have been evacuated and there is no improvement, I would give one-fourth grain of morphine which will enable the woman to go through her labor more easily, and perhaps quite as quickly.

7. It is generally believed that a cord being very short and being around the neck of the child may protract a labor. I do not deny that this may possibly occur, and when the child’s head is born, and I find that there is a coil of the funis on its neck I loosen it.

8. Weakness of the constitution when the general health of the woman is below the natural proper standard may be a cause why the uterine contractions are not severe. But in such cases the parts are not rigid, and nothing more than a dose of four or five grains of quinine is needed to make the pains effectual.

9. A want of irritability in the constitution frequently observed in fat and inactive women, or in those who are exceedingly timid, will sometimes be a cause of slow and lingering labor. Fear often lessens the energy of all the powers of the constitution, and diminishes or wholly suppresses for a time the action of all the parts concerned in parturition. Attendants should endeavor to inspire such patients with activity and resolution, and remove all fear from their minds. These cases are not dangerous but I have often found it necessary in this kind of cases to apply forceps. The skilled nurse might perhaps give eight or ten grains of quinine, if no physician has charge of the case.

10. Every woman is expected to suffer greater pain and to have a more tedious labor with her first child, and if a woman be advanced in age at the time of having her first child the difficulty attending her labor may be somewhat greater. A longer time may be required for the completion of the labor than in ordinary cases, but I do not advise giving any medicine unless it is perhaps a dose of quinine. There may be a little more need of assistance by instruments, &c.

11. An oblique position of the os uteri, it being projected on one side or the other of the center of the superior strait, or so far backwards that it cannot be felt for several hours after labor has begun, is a cause of delay. The presenting part may be found pressing against the walls of the pelvis at one point, instead of keeping its course in the center of the pelvic cavity. You should endeavor to place the patient so as to remedy this condition. When the presenting part is found to one side, it will be found that the fundus of the womb is lying to the opposite side; this should be remedied by a proper support of the abdominal tumor or by holding it up by the hands. For example, if the os uteri be projected to the left side, she ought to rest on the right side and have a pillow placed under her body; some physicians would prefer that she lay on the left side, but without the pillow under her.

12. Extreme rigidity of the os uteri is a cause of tedious and very painful labors. It sometimes happens that the os is dilatable, but the pains are not sufficiently expulsive. Perhaps at the same time the os is found far back towards the promontory of the sacrum, and the head appears not to be driven directly into the os so as to aid in its dilatation, but rather presses against the anterior wall of the cervix. In such a case the end of the finger can be hooked into the anterior lip of the os uteri so as to aid in the dilatation, and also to help correct the displacement of the os. In other cases we may help dilate the os by a firm and gentle sweep of the finger around the advancing part of the child’s head within the os. But we cannot always do this, because we may be afraid of rupturing the membranes prematurely. If the membranes have been already ruptured, we may act more boldly, but we must never make any great efforts to dilate it artificially lest we excite inflammation. In many cases it is best to give ¼ gr. of morphine, and inform the suffering woman that she cannot possibly get through her labor in a short time, but if you can give her an hours’ rest, the os, which is rigid, will be more relaxed and pains more effectual.

13. In first labors there is sometimes unusual rigidity of the soft parts, which are external. Where the perineum is rigid it may require several hours continuance of the pains before it is sufficiently stretched to allow the head of the child to pass. But the difficulty can hardly be relieved by our interposition. We should generally wait the due time, as we must also if the os coccygis is anchylosed with the sacrum.

14. The head of the child may be comparatively large when the pelvis is of the ordinary form and size. This may be a cause of delay though it may perhaps cause nothing more than prolonged, tedious labor. In such cases you have time to send for a doctor, even if he lives at a distance. After the woman has been a long time in labor he will think it best to apply the forceps.

You will be importuned in cases of slow and tedious labor to administer ergot, but any one who knows the action of the drug would never give it in any of the following cases: 1. Where the os is not well dilated. 2. When any mechanical obstacle exists to the passage of the child, or when there is a tendency to convulsions, and you should never give ergot except for hemorrhage; and when you have much reason to fear it, you may in such cases give one or two twenty drop doses of the fluid extract very near the termination of labor. Quinine may be given as an oxytocic with safety. Morphine is liable to render the pains weak for a time, but it often increases their efficiency.

I will now enumerate your duties when you act as accoucheur.

1. Ascertain if the lady is really in labor. Make a digital examination. If the os is high up so as to be reached with difficulty, slightly patulous and rigid, and the pains are felt in front, there is reason to believe that the labor has not yet commenced—that she only has false labor pains. At this time attend to the bowels; give perhaps paregoric or morphine to relieve her of what is to her useless and exhausting agony, and enjoin rest. You may at this time properly give her an enema containing ¼ of a grain of morphine or fifteen grains of chloral dissolved in gruel or starch or mucilage.

2. When you make an examination and find that the pains are efficient in producing a dilatation of the os uteri, that the parts are soft and relaxed, if there is a secretion called the show, if there is a favorable presentation, and the labor is making some progress, the patient should be told of all that is favorable in the case.

3. Be careful in making early examinations to, first, if possible, reach the os with the finger. When your finger presses against the cervix it will hurt her considerably more than it will when it presses against the presenting part of the child. 2. Avoid rupturing the membranes. 3. Notice if there is anything observable to hinder the progress of the labor. 4. Note any progress of the labor.

4. If everything is favorable, assure the patient of the fact; if you have doubts and fears upon some point, you need not express all your fear, but do not delay to send for a physician.

5. You may in the early stage of labor, permit the patient to move about as she wishes, and she may rest on the sofa when tired. She may have her usual diet, but not any stimulants.

6. From time to time make an examination. If the os is dilatable you need not fear that the membranes may then be ruptured. Learn as fully as possible the presentation and position, and if you press your finger against the child’s head you may thereby reinforce weak pains.

7. Do not annoy the patient by pressing upon the back or anywhere during a pain if she requests you not to, but when she does not object you can make such pressure as will reinforce the action of the abdominal muscles. When she is lying on her back with her shoulders elevated so that she is in an almost vertical position, you can stand beside her with your back towards her head, and make the necessary palpation by pressing with your hands on her abdomen, one of them on each side. Do this only when there is no tenderness, when the os is dilated, when there is a normal pelvic canal and a low position of the presenting part. Seek in thus pressing to move the uterus to the axis of the pelvic brim, then with the palms of your hands to the sides or fundus of the uterus press gradually downward, increasing the pressure for six or eight seconds, and then gradually diminishing. You may repeat this as often as she has a pain, and with an increasing force, and if the patient assents, you may make such pressure unremitting.

8. When the os uteri is fully dilated or soft and dilatable, the membranes may be broken by pressing with the end of your finger against it, or if this does not suffice, the finger nail previously nicked may open it.

9. When free hemorrhage occurs prior to delivery, it may depend upon placenta previa; that is, upon the placenta being attached very near or over the mouth of the womb; in such a case obtain a physician to take charge of the case if possible. You may yourself give half a teaspoonful of extract of ergot in the emergency.

10. During the progress of the labor you must always remember that the unassisted, natural powers are in most instances fully sufficient to bring the labor to a safe termination, and whatever you do should be of the kind that is not harmful. The important thing for the attendants to possess is gentleness and patience, and it is a good thing for the patient if she can be kept tranquil and cheerful.

11. A little light food may be offered the patient at any time during labor.

12. During the first stage of labor the patient must not strain or bear down to the pains, but it is my practice when I examine my patient and find that the head has not yet entered the pelvis, at the same time that the touch stimulates the uterus to contract, I direct the patient to bear down during each pain. After the head is fully engaged in the bones, no stimulus to pain is needed; however, as the bearing down pains come on, she should be advised to strain or press down.

13. Towards the last, when she is in great pain, if she be inclined to cry out, let her do so; never reprove her.

14. I approve of giving chloroform in some cases, but I do not advise the skilled nurse to give it except when a physician is present to direct its use.

15. During the latter part of the labor the only assistance you can render the woman is to support the back, and to give her something to pull upon if she is so inclined. A sheet tied to the foot of the bed may be useful for this purpose. At the very last, bearing down efforts should be discouraged.

16. When the head is about to be expelled we always fear there may be slight or severe lacerations of the perineum. Do not in any way hasten the expulsion, even if there should be a number of pains in which a part of the head presents externally during the pain, and then recedes when the pain goes off. I have not always been able to prevent laceration, but the following directions are the best that I can give: Endeavor to have the patient extend her legs, and do not have her knees drawn up close to the body at the last. When the perineum is put on the stretch, place the thumb and forefinger of the right hand on either side of the perineum, and press so as to aid the stretching or distention. When the perineum is distended and protruding you may cover the hand with a soft napkin and apply it across the perineum, also by the sides of the vulva, and make firm, moderate pressure during the pain. Endeavor to have the pressure equable around the head of the child.

17. When the head is expelled an attendant should make steady gentle pressure upon the uterus and follow it down, keeping her hand firmly upon it for several minutes, perhaps for half an hour, or if you have given a little attention to the child, you yourself may put your hand on the contracted uterus and firmly knead it for ten minutes.

18. It is not necessary to extract the body immediately after the expulsion of the head. It is better to wait three or four minutes for the return of a pain before making any traction.

19. Although a little traction can be made on the head, it is a better way while an attendant presses on the uterus, and while you hold on to the child’s head with one hand, insert a finger of the other hand into the axilla, (under the child’s arm) and gently extract the body.

20. The child may be born apparently asphyxiated—its face swollen—and of a dark livid color, and at first make only feeble and gasping efforts at respiration; if there is the least beating of the heart can be perceived, there is fair hopes of its recovery. The cord should at once be tied and the child removed from the mother. If one or two slaps on its body does not make it cry, try immediately artificial respiration by the Sylvester method perhaps, not omitting at first and afterwards to throw a little cold water on its body. If these efforts fail I would try to induce respiration by placing my hand over its nostrils and blowing into its mouth, and immediately afterwards compressing its lungs.

21. As soon as the child cries, as it most generally will as soon as it is born, proceed to tie and separate the cord. Tie the cord tight, so that it is thoroughly compressed and the vessels obliterated, applying the ligature about one and a half inches from the child, and then cut the cord one inch further from the child. The child can be rolled in flannel and removed, and you can attend to the mother and to the removal of the afterbirth.

22. In only a very few cases I have had post partem hemorrhage or adherent placenta to trouble me, and I commend to you the method that I have used for the removal of the placenta. I do not tie the cord until circulation has ceased in it. I then sever it, and usually two or three ounces of blood may flow from it. This I suffer to run into some vessel to avoid soiling the bed uselessly, and then wind the cord around my right hand so that I can hold it. If I cannot have an attendant to make proper pressure on the uterus, I immediately endeavor to compress it as much as I possibly can with my left hand, but I make very little traction on the cord. I usually instruct some one else to make strong and firm pressure upon the uterus, and I pass two fingers of one hand into the vagina, and learn thereby when the placenta descends, and if necessary assist in its removal. Although we should never hurry in removing the afterbirth, I believe that it always is easily removed if we make the effort very soon after the child is born, and if it is necessary for you to pass your hand into the uterus you can do so then better than at any other time. Judging from my own experience in cases of retained placenta, if you pass your hand along the cord into the uterus, you will find that an hour-glass contraction retains the afterbirth (whether adherent or not) in the fundus. You will have to press your fingers through the constricted portion and grasp it, and you can remove it steadily and slowly, but not stopping to give it “one or two turns in the vagina.”

23. Post partem hemorrhage is liable to occur; when it does, obtain a physician as soon as you can, but some things must be done immediately. 1. Some one must grasp and compress the womb continually. 2. Remove the pillows and raise the foot of the bed so that the patient’s body lies higher than her head. 3. If you have it, give a small teaspoonful of extract of ergot, or twenty drops spirits turpentine or (F. 96.) 4. Examine to know if possible, the source of the hemorrhage; if it comes from the vagina or perineum where there is laceration, it is not very dangerous. Inject hot water of the temperature of 115° into the uterus, and apply a dry cotton cloth, heated as hot as possible, to the abdomen externally. 5. Before using the injections remove all clots from the vagina. 6. Quinine and stimulants may be exhibited if there is sinking, and ice may be applied to the abdomen and to the internal surface of the uterus, if the bleeding continues. I will here direct another thing which is very effectual, and which might be used at first in preference to anything else. 7. After removing the clots take a handkerchief or piece of muslin, saturated with vinegar, in your hand, pass it entirely into the uterus, and let it remain there 15 or 20 minutes, and your hand also. Your hand will compress the open blood vessels, and keep a clot in the mouth of them, and the vinegar will act as the best astringent that can be used. In one case of violent flooding I simply held my hand still in the uterus for five minutes, and the flow ceased. After the hemorrhage subsides you must be careful not to raise the patient’s head above the level suddenly; her life may be put in jeopardy by suddenly raising her so that she sits up.

After pains are very seldom severe in primapara cases, and they are less likely to be severe if the proper manipulations have compelled the womb to close completely, expelling all clots, &c. But sometimes there is a peculiar irritability or neuralgic condition of the womb which gives rise to excruciating pains. Ordinarily you may use Tully’s powder. (F. 123, 93, 95, 107.)

Retention of urine in some cases necessitates repeated visits of the physician, and he will appreciate a nurse who can introduce the catheter. If the patient cannot at first void the urine, perhaps the application of a hot wet sponge over the pubis may enable her to do so. But it may be necessary to introduce a catheter two or three times a day until she regains her power over her bladder, or until the swelling of the urethra subsides.

It is well for the nurse to know that owing to the distensible state of the abdominal parietes, the patient will lay twelve or fourteen hours, perhaps, after the child is born, without manifesting a desire to void the urine, though her bladder may be very full, and you should remind her of the necessity of passing the water, lest it produce cystitis. In some instances the urethra and neck of the bladder are extremely irritable, causing strangury, and there may be some difficulty in passing the catheter, but the urine must be evacuated, and afterwards it may be necessary to use ergot, laxatives, opiates and fomentations. (F. 125, 126, 162.)

CHAPTER III.
CONVALESCENCE.

Variations from ordinary convalescence will, under ordinary circumstances, receive necessary attention from the physician, but the skilled nurse should know as much about them as possible, and I here make a brief reference to some of them.

The NERVOUS SHOCK, caused by the last pains of labor, in some cases is very severe. This is indicated not only by the exhaustion, but by the countenance which is expressive of suffering, anxiety and oppression. The pulse may be very slow or unusually rapid, the breathing may be panting. Opium is the best remedy, and this may be given in small doses repeated, or a teaspoonful of paragoric may be given, also aromatic ammonia, and 3 or 4 drops of spirits of camphor.

The STATE OF THE PULSE after a natural labor soon comes down to near the ordinary standard; if it remains above a hundred it is because there is some special cause. It will be quick if there are very hard afterpains, a tendency to flooding, diarrhoea or disturbance of the stomach, and it is quickened also when lactation commences.

The LOCHIAL DISCHARGE ordinarily continues about three weeks, at first of pure blood mixed with coagula, and if good uterine contraction has not been secured, coagula may be expelled for several days after the delivery. Sometimes there is a SUDDEN DECREASE OF THE LOCHIA, perhaps on the fifth and sixth day, and at the same time an increased bulk of the womb, and increased frequency of the pulse. Apply hot fomentations to the abdomen, and probably some clots will be expelled, but at the same time give purgative enemata; and if there is abdominal tenderness give an aromatic purgative and laudanum. (F. 108, 122). There are remarkable differences in the QUANTITY, QUALITY AND ODOR OF THE LOCHIA without any morbid affection of the uterus or vagina. But when the lochia are acrid, the vagina, labia and external parts become excoriated, and smarting or itching is caused. Try extreme cleanliness, frequent bathing, lead lotions, black wash, vaginal injections of warm water, and F. 153, 154.

If the discharge ceases a few hours after birth, or if it continues the usual time, but in very small quantity, or if it is prolonged beyond the usual period, or if it is excessive at first, and if at the same time all the other symptoms are favorable, there is not occasion for much medicine, though it may be necessary to give the patient a better diet, possibly some tonics. (F. 174, 175). It sometimes occurs that the lochia is suddenly discharged in double quantity after the patient is permitted to sit up or walk about. In such cases enjoin extra rest.

If the red discharge continues longer than usual, or if it return after yellow or greenish discharges, you should be on your guard against HEMORRHAGE. Enjoin rest in a horizontal position under light clothing.

Occasionally the LOCHIA HAVE A VERY FETID ODOR. It is not very rare to observe a very disagreeable odor in the lochia without any bad results, but this often indicates the retention and putrefaction of coagula or a small portion of the placenta or membranes. Syringe out the vagina freely night and morning with Labaraques solution or some other antiseptic wash, (F. 153) and once or twice a day with warm milk and water. A weak solution of carbolic acid 1 in 50 may be used, and it may be proper to throw it into the uterus.

The SECRETION OF MILK generally becomes established in about forty-eight hours, and very often on the third day the breasts become turgid, hot and painful. There may, or may not, be some general disturbance, fever, chills, &c., but if there is it will usually be relieved after the milk is drawn out. It is customary on the morning of the third day to secure an action of the bowels, and this generally allays the vascular action if it is excessive. But very trivial causes may set up INFLAMMATION OF THE BREAST, and this is always liable to end in suppuration, which may be long continued and distressing.

The MAMMARY INFLAMMATION may follow exposure to cold, a blow or other injury on the breast, some temporary engorgement of the lacteal tubes, or sudden and depressing mental emotions, and it often follows from fissures and erosions of the nipples. To prevent the formation of an abscess, endeavor to remove the engorgement of the lacteal ducts by gentle hand friction with oil or F. 209, 202. Moderate the inflammation by giving five drops of the extract Phytolacca decandra (Poke root) every two hours—give saline cathartics, minute doses of aconite, and perhaps a large dose of quinine. Keep the patient in bed and have the affected breast supported by a suspensory bandage. Apply hot fomentations containing a solution of carbolic acid, or poultices containing it, and the breasts may be smeared with belladonna extract rubbed down with glycerine; or belladonna liniment or ointment may be applied (F. 201). Belladonna plasters or diachylon plasters may be useful. Give 15 grains bromide potassa.

When pus has formed notwithstanding efforts made to cure the inflammation, as soon as it is near the surface so that it can be detected by the fluctuation, the abscess should be opened. During the last few years careful surgeons have been unwilling to make any incision or lance even an ordinary abscess without employing some antiseptic method, such perhaps as the following:

The patient’s skin where the incision is to be made, is first to be washed in 1 to 1000 bichloride of mercury solution—hands and instruments employed in the work must touch nothing that is not sterilized; hands must be washed in the same solution before operating—sponges that are used must be cleaned and stored in a 1 to 20 carbolic acid solution, and instruments must be soaked in the same for 15 minutes before being used, and some apply a large wad of bichloride of cotton or gauze to catch the exuded pus.

The following is Lister’s antiseptic method which he first directed, to prevent the introduction of air containing living germs:

“A solution of one part of crystalized carbolic acid in four parts of boiled linseed oil having been prepared, a piece of rag from four to six inches square is dipped into the oily mixture and laid upon the skin where the incision is to be made. The lower edge of the rag being then raised a scalpel or bistoury dipped in the oil is plunged into the abscess and an opening about three-quarters of an inch in length is made, and the instant the knife is withdrawn the rag is dropped upon the skin as an antiseptic curtain, beneath which the pus flows out into a vessel placed to receive it, and all the pus should be pressed out as near as may be. For a dressing afterward Playfair recommends the following: About six teaspoonfuls of the above mentioned solution of carbolic acid in linseed oil is mixed up with common whiting to the consistence of firm paste; this is spread upon a piece of tin foil about six inches square, so as to form a layer about a quarter of an inch thick; the tin-foil thus spread with putty is placed upon the skin, so that the middle of it corresponds to the position of the incision, the antiseptic rag used in making the incision being removed the instant before. The tin-foil is then fixed securely by adhesive straps, the lower edge being left free for the escape of the discharge into a folded towel placed over it, and secured by a bandage. The dressing is changed once in twenty-four hours, as a general rule, and must be methodically done. A second similar piece of tin-foil having been spread with the putty, a piece of rag is dipped in the oily solution and placed on the incision the moment the first tin is removed. This prevents mischief during the cleaning of the skin with a dry cloth, and pressing out the discharge from the cavity.”

The same author directs methodical strapping of the breast with adhesive plaster, in cases of long continued suppuration, and he adds that “much attention must be paid to general treatment, and abundance of nourishing food, appropriate stimulants and such medicine as iron and quinine will be indicated.”

I give on the authority of another the following as good treatment for SORE NIPPLES:

“1. Keep everything that will irritate, whether clothing or medicine, away from the nipple, and have the excess of milk drawn from the breast in the easiest way possible. 2. Keep the excoriated nipple thickly covered with sub-nitrate of bismuth. 3. When the nipples are cracked at the base keep the cracks filled with bismuth, and put on a round piece of adhesive plaster starred in the centre, and just large enough to slip over the nipple and extend around its base an inch or more every way. When this is loosened it must be reapplied.” (F. 231, 243).

There are certain accidents of parturition so grave in their nature, and attended by symptoms so alarming and urgent that no nurse would attempt to treat the patient except under the direction of a physician. I only refer to them because it is believed that some of these serious cases might have been prevented by early proper action on the part of the midwife or other attendant.

Inversion of the uterus sometimes occurs, though but rarely. If it is in the practice of a midwife, and if she be at the time pulling on the cord, that will be assigned as the cause of the accident. Inversion consists essentially in the enlarged and empty uterus being either partially or entirely turned inside out. The immediate symptoms are those of shock or collapse—fainting, small, rapid and feeble pulse, possibly convulsions, or vomiting, and a cold, clammy skin. The countenance becomes deadly pale, the voice weak, and other symptoms indicates sudden exhaustion or sinking. In cases of partial inversion the symptoms are not so striking. Hemorrhage to a large amount, frequently but not always occurs. In more than half the cases no mechanical cause can be traced, but as it is sometimes attributed to pulling on the cord, to pressure with the hand on the fundus, and also to the patient straining forcibly, these combined causes should be avoided. When the symptoms named are present, you can give the patient some aromatic ammonia or other stimulant; always obtain a physician as soon as possible.

Puerperal mania is nearly always preceded by restlessness, want of sleep, and other premonitory symptoms. When the mania first comes on there is usually causeless dislike to those around her, and as the child may be the object of suspicion, the nurse must be extremely careful that the patient does not have an opportunity to seriously injure it. The course of treatment must be mainly directed to the maintenance of the strength of the patient, and the two things most needful are a sufficient quantity of suitable food and sleep. Possibly your efforts in this direction before the disease is fully developed, may ward off the disease.

Puerperal septicemia was formerly called puerperal fever; as its nature is now better understood than formerly, we hope to do more than was formerly done to prevent it. This fever is now very generally believed to be produced by the absorption of septic matter into the system, through some tear or laceration in the generative tract such as exists after labor.

This septic matter may be from within the patient such as coagula, or membrane, or placenta partly decomposed; or from without as might be on the hands of physician and nurse, or in the air from cases of erysipelas, &c., or in some way from puerperal patients.

The notion that puerperal fever and septicemia is produced by BACTERIA has now become an established doctrine, and has given rise to a rational treatment based thereon, especially for their prevention.

As prophylactic means may be mentioned, the use of a carbolic solution 1 in 30 which the practitioner or nurse applies before touching any case, the use of carbolized oil 1 in 8 for lubricating the fingers, catheter, forceps, &c.; syringing out the vagina with diluted Condy’s fluid, rigid attention to cleanliness in napkins, &c. The nurse should use antiseptics to only a very limited extent without the advice of a physician.

CHAPTER IV.
CARE OF INFANT CHILDREN.

Infants sometimes require treatment for ailments either slight or severe when the advice of a physician cannot be obtained.

The NAVAL is sometimes a little sore after the naval string comes away. It may be dressed by putting a little simple cerate or vaseline or carbolized cosmoline on lint or a linen rag, and applying it to the part affected every morning, and a bread poultice every night until it is quite healed.

A RUPTURE OF THE NAVAL is sometimes caused by much crying, and it may be occasioned by the nurse pulling on the cord to remove it before it will readily separate from the infant’s body.

The best treatment is a piece of adhesive plaster as large as the top of a tumbler, with a properly adjusted pad made of several folds of muslin fastened on the plaster, which will keep the bowels from protruding. The bandage or belly band can be put on over this.

If the infant have a GROIN RUPTURE the only proper treatment is to keep on it day and night if it cry much, a well fitting truss. In applying the truss be careful to return the rupture thoroughly, and endeavor to have it well adjusted or it will chafe and will not effectually cure.

If the child is TONGUE TIED so that it cannot apply its tongue to the nipple to suck, the frenum may be cut, but it will not be necessary to make more than a small nick or a slight cut in it.

Milk in the breasts of new born infants, or a serous fluid resembling it, is often found, and sometimes there is considerable swelling both of the breasts of male and female children. It is not the better way to apply plasters or to squeeze or press them, but the milk may be drawn out by putting an open top thimble over the nipple and drawing on it.

Chafings may be caused by inattention to cleanliness. Fat babies are subject to them, and when there is disorder of the bowels or kidneys they cannot at all times be prevented. Thoroughly sponge the parts with tepid rain water, allowing the water from a well filled sponge to stream over them, then carefully dry with a soft towel, and perhaps dust over them sub-nitrate of bismuth. (F. 202.)

Diarrhoea and DYSENTERY and also COSTIVENESS are among the ailments with which infants may be afflicted. I wish to be particular in giving directions, that these may generally be avoided, but I must again repeat that the nurse should never be influenced by my advice to do any thing contrary to the directions of the attending physician.

To avoid the subsequent necessity of giving medicine you must be very careful in their administration at first. It is indeed necessary that the meconium should be purged off at first, but nature in general provides such physic as is required, and if the child is applied to the mother’s breast, it obtains in the colostrum such medicine as it needs. Where the infant cannot obtain anything from the breast a gentle aperient may be given, and I name the following as being suitable: either molasses and water, raw sugar, a solution of manna in warm water, a teaspoonful of sweet oil, or of simple syrup of rhubarb, or in more obstinate cases, of castor oil, or one-fourth teaspoonful compound licorice powder, (F. 108.) but you must never give a drastic purgative, and you must not repeat the aperient if the discharges become yellow and natural. A young infant ought to have from three to six motions in the twenty-four hours, the color ought to be of a bright yellow or orange, and of the consistency of mustard as ordinarily prepared for the table, and there ought not to be any lumps or curds in its motions. A mother or nurse ought to be very observant of the state of the bladder and bowels—should inspect motions daily and see that they are not slimy, or curdled, or green. If they are she should be very careful, especially in regard to what the mother eats and drinks. If the bowels are costive she must avoid the frequent repetition of opening medicine, however gentle and well selected the aperients may be. They interfere with digestion, often irritate the bowels, and render them more costive. For the sake of the child as well as herself, the mother may vary her diet considerably after the first week, she may eat boiled and stewed, broiled and roast meats, mutton, lamb, and beef, fish, game, and chickens, potatoes, turnips, spinach, celery, peas, beans, figs, bananas, prunes, baked apples, &c. (F. 45 to 60.) The bowels of the child that nurses generally (not always) keep pace with those of the mother, and she must endeavor both for her own sake and that of the child, to keep her bowels loose by means of diet. If necessary she must take physic. (F. 107, 108, 109.)

If the constipated child nurses the mother and the mother constantly pays proper attention to her own health, and especially to her diet, the child will very seldom require physic. Indeed I would not give active physic when the child seemed well, if it did not have a passage oftener than once a week. If it has cow’s milk or other food besides the mother’s milk, do not boil the milk and you can add to the cow’s milk, corn starch, or the following: Make a thin mush by boiling a small quantity at a time of unbolted wheat flour in water and straining it through a sieve while hot. The child may sometimes be fed with this alone, a little sweetened. Molasses may be given freely, or molasses and soda. The child should be watched, and if there is occasional costiveness, and at the time any indisposition, make a suppository of common soap about an inch in length and a quarter of an inch thick, dip it in water and pass it into the rectum. Or give an injection of less than a gill of water with perhaps a teaspoonful of molasses and a pinch of salt. But I would avoid the practice of giving an enema daily, as tending to get up a bad habit in the system. Should the costiveness have provoked fever, induced pain, or excited convulsions, active physic may be given, either castor oil, magnesia, calomel, or F. 108. But be sure that costiveness is not brought on by giving paregoric or other opiates, and let a child drink freely of pure cold and fresh water. The water may be boiled to destroy germs, and then cooled in a refrigerator; it should always be boiled before being used when there is an epidemic of bowel complaint prevailing.

In DYSENTERY there is a specific inflammation and ulceration of the mucous membrane of the colon, especially of the lower part, and of the rectum—there is generally some fever, frequent and bloody stools, tenesmus, and griping pains. Sometimes it attacks an infant or a delicate child, there being at first for several days diarrhoea, the motions being slimy and frothy like frogspawn, afterward entirely mucous and blood. The child is dreadfully griped, strains violently, and screams, and twists about every time it has a motion, and there is vomiting and great prostration.

You should in treating the child at the breast still keep him to it, and give it no other food. If the mother’s milk is not good, procure if possible a healthy wet nurse. If the child must be fed give it cow’s milk from one healthy cow—fresh from the cow—small quantities at a time and frequently, mixed with gum arabic water. In the commencement a warm bath may be used, or as a substitute you may wrap the child in a blanket that has been previously wrung out of hot water; over this put a dry blanket and keep the child thus enveloped for twenty or thirty minutes.

Formula 74 and 99 may be used, but the dose for a young child must be small to accord with its age.

Cholera infantum is more prevalent in the United States than in any other country. The continued heat of summer is a predisposing cause, and improprieties in diet and clothing, worms, premature weaning, and teething are exciting causes.

You may treat this disease in the initial stage by giving F. 80, and also for a child a year old, injections of a gill of warm water in which a teaspoonful of common salt has been dissolved, allowing the patient three or four times a draught of warm water, as much as it desires to drink. Perhaps the drink will be immediately vomited, but it will at least remove irritating matter from the stomach. The injection, too, may operate immediately, but it may bring with it a fecal or bilious discharge, and if several times repeated, its effects will be salutary. A muslin cloth heated almost to scorching and applied once or twice dry to the neck, may stop vomiting, and draughts applied to the extremities may also be of much benefit. After using injections of warm soft water, anodyne injections may be given three or four times a day; but cases of this kind are too serious for any nurse or mother to treat, if the services of a physician can be obtained; and I will only mention one or two things more. When the extremities are cold put the child for a few minutes in a warm bath of mustard water, and then employ friction to the skin.

I have found chicken tea made by boiling the chicken very soon after it is killed, very useful in checking the vomiting and curing the child.

Of course a physician will be obtained in these serious cases if possible.

Retention of urine in the newly born infant if slight is easily removed by giving two or three drops of spirits of nitre once an hour in a little sweetened water, or if obstinate it may be aided by castor oil and the warm bath. A little pumpkin seed or parsley root tea also succeeds remarkably well.

ApthÆ is usually called the baby’s sore mouth. It generally begins on the inner part of the lower lip or corner of the mouth, as a small white speck which resembles a coagulum of milk. These aphthous white pustules soon appear over the inside of the cheeks and on the tongue and gums. The eruption is very white and looks as if whey or curds were spread over the mouth, which is hot and painful, and the disease sometimes does, and at other times does not cause fever. I regard this complaint as being one of the germ diseases, although the fact has not yet been demonstrated. The children fed upon farinaceous food are most liable to this disease, and during its continuance, if the child is not at the breast it should be kept entirely to the milk of one cow. Medicine should be given with regard to the stomach and bowels. If the passages from the bowels are green, magnesia is a proper kind of physic, and when there is diarrhoea use formula 80, 77, 81.

Genuine jaundice may attack a young child, but this is to be distinguished from those cases where there is only a generally diffused YELLOW COLOR OF THE SKIN. In the latter class of cases there are no symptoms indicating any serious disease; the yellowness may continue for several days, and this disappears without the aid of any medicine and without leaving any evil behind. But in jaundice the whites of the eyes and the tears are tinged yellow, and, besides, the feces are paler than they should be, the urine is yellow, and other serious symptoms are added. If the bowels be costive, or irritated to frequent efforts, if the abdomen swells and becomes tense, if the child is uneasy and inclined to vomit, if it refuse the breast and frequently moans as if in pain, if it emaciate rapidly, jaundice in a bad form is present, and there is probable disease of the liver. Call the doctor.

I need not continue my instructions any farther in regard to the diseases of infancy, as you are expected to act as far as you can under the directions of a physician. But I must again advise you as to how you are to treat your medical advisor. Give him your entire confidence. Be truthful and candid with him. Have no reservations; give him a plain statement of the symptoms. Be prepared to state the exact time the child showed any illness. Tell him if the child had a chill; if there be any eruption on the skin, note the quantity and appearance of the urine, the number, color, &c., of the stools—all the symptoms of the disease. Strictly obey the doctor’s orders in diet, in medicine, in everything, and never omit any of his suggestions. If the case be severe, never call a second physician without first consulting and advising with the one first chosen; speak in the presence of children with respect and reverence of the doctor, and endeavor to have them like him. Send for the doctor when practicable early in the morning, as the daylight is most favorable for making the examination, but if the illness come in the night do not delay on that account; if you do not know what to do, it is better that the doctor be called early than late.

CHAPTER V.
CASES OF DIFFICULT LABOR.

I wish to give you so much instruction in regard to cases of difficult labor that you may at least be prepared to decide in any case when the services of a physician is indispensably necessary, to decide whether the parturition in a given case is a natural one that does not need any assistance, or an unnatural one requiring the assistance of the art of midwifery, scientific or manual, for the relief of irregularities and difficulties. In general I shall adopt Churchill’s divisions and definitions as I think they are very concise and correct.

“Definition. The head of the child presents and the labor is terminated without manual or instrumental assistance, but it is prolonged beyond twenty-four hours from causes which occasion delay in the first stage.”

Prolongation of labor is of comparatively small consequence when the membranes are still intact, as they serve to protect the soft parts of the mother as well as the body of the child from injurious pressure, but the mere lengthening of the labor may become a serious thing when the head has entered the pelvis, when the uterus is strongly excited by reflex stimulation, and when the maternal soft parts as well as the foetus and cord are exposed to severe pressure. When we find no evil resulting from the delay we need not interfere, but when we can remove the cause of it we are bound to do so.

In tedious labors the woman becomes fatigued, the loss of sleep is much felt, her spirits become depressed, and the stomach is more or less disturbed, but when the other bodily functions are performed regularly, the skin is cool, the pulse quiet, the tongue clean and moist, there is no headache, and the pains recur tolerably regularly, the condition of the patient is favorable, though the pains are inefficient and vary in their duration and frequency. There is usually loud outcry during the pain in the first stage of labor, but there is often sufficient remission of the suffering for the woman to get some quiet sleep, and generally there is progress to the labor.

Inefficient action of the uterus occurs most commonly in women confined for the first time, and sometimes we can ascribe it to no cause but constitutional peculiarity, or a deranged state of the digestive organs, or mental depression; in other cases it may be caused by irritation of the os and cervex uteri.

The skilled nurse may properly send for a medical man, though he is not indispensably necessary in such cases. The best thing which she can give in such cases is a quarter grain dose of morphine to suspend the pains and induce sleep, or if this is not thought best it may be proper to give physic or stimulating enemata. Never give ergot to increase the pains, but it may be proper to give several grains of quinine. However, giving medicine must be left as much as possible to the physician.

Excessive amount of liquor amnii with undue distention of the uterus in some cases renders the pains inefficient. The unusually large size, and the fluctuation of the abdominal tumor may be obvious, but although an accoucheur might deem it advisable to evacuate the waters, the skilled nurse who could not be certain that there was a favorable presentation, should not do it. She must exercise patience herself and encourage the patient to do so, and time will probably do the work, though it is better to commit the case to a doctor.

An undilatable os uteri, which remains rigid although the pains are severe, may sometimes be felt with its edges thin and stretched over the head, and sometimes thick and tough. In the majority of cases patience and time may overcome the obstacle, but as it is best in some cases to give chloroform, chloral, &c., and in some instances to use local means to relax or dilate the os, the physician should be sent for. The nurse may properly give the patient a hip bath.

Premature escape of the liquor amnii and OBLIQUITY OF THE UTERUS are both causes of tedious labor, but not cause for apprehension or special interference. I have already given some hints in regard to the treatment of the latter class of cases.

The posterior lip of the cervix uteri in some instances is retracted while the anterior is drawn tightly over the crown of the head. In such cases it has been my practice to draw with my finger the anterior lip forward, and during the time of the pain to press my finger against the head of the child. I do this believing that the anterior lip is caught between the head and symphasis pubis, and that it will be better retracted while support is given to the head.

POWERLESS LABOR.

“Definition. The labor is prolonged in the second stage by causes which act on the uterine powers primarily or secondarily, rendering the pains feeble and inefficient or totally suppressing them.” In consequence of the stage at which the delay takes place, certain symptoms arise which render speedy delivery imperative.

The second stage may continue twenty hours or more without any bad symptoms, but usually if it exceeds twelve hours some of the following symptoms may be observed: The pains become irregular as to recurrence and force—perhaps become weaker—there may be rigors or shiverings—the vomiting may be distressing—there may be constant restlessness and fever—the vagina and uterus may be hot and tender to the touch—and the pressure of the child’s head may prevent the evacuation of the bladder. The same causes (weak constitution, mental emotion, disease, &c.), which in the first stage rendered the labor tedious without bad symptoms, now occasion these and perhaps even more alarming indications. If an experienced accoucheur now arrives to take charge of the case he will be likely to apply the forceps, but it would have been better if he had been there and applied them sooner, before the patient had undergone so much suffering; and the midwife who attends a woman in the first stage of the labor should ascertain if any of the following causes of powerless labor exists: Is there a weak constitution or one exhausted by disease? Is it a first labor and the woman of advanced age? Has the patient had very many children? Is there excess of liquor amnii? Is there malposition of the uterus? No midwife should undertake to manage such a case alone.

OBSTRUCTED LABOR.

“Definition. The progress of the labor is impeded by some mechanical obstruction in the passages connected with the soft parts, which by causing delay in the second stage leads to the developement of symptoms of powerless labor.”

The symptoms that arise and that cause anxiety are the same as in a case of powerless labor, except that while in the latter kind the pains are feeble, in the case of obstructed labor the pains may be vigorous and severe but ineffective in consequence of obstacles. I may say, however, that these obstacles have not been often met with in my practice. Since I commenced the practice of midwifery three thousand cases of pregnancy have been under my observation for treatment, and I have not yet met with any of the following causes of obstructed labor: Occlusion of the os uteri, cancer of the os uteri, undilatable vagina, tumors in the pelvis, or diseased ovary, stone in the bladder, imperforate hymen, hernial protrusion into the vagina, or blood effusions, or swelling of the soft parts. I have met with one case of excessive oedematous effusion of the vulva, which I relieved by puncturing the skin; one case of cystocele which I relieved by first drawing the water and then returning the bladder, before the head of the child descended into the pelvis; one case of ovarian tumor that was not at that time in the pelvis; one case of small fibrous tumor on the neck of the uterus, which did not much obstruct the labor; and numerous cases where hardened feces in the rectum was an obstacle until they were removed by the use of enemata. In cases of obstructed labor the skilled nurse will show her wisdom by detecting the obstructions and sending for an accoucheur.

DEFORMED PELVIS.

“Definition. The progress of the labor impeded by abnormal deviations in the form of the pelvis, giving rise to delay in the second stage, or rendering the descent of the child impossible without assistance, or altogether impracticable. The symptoms are those of powerless labor.”

The EQUALLY ENLARGED PELVIS, enlarged in all its parts, is not often met with, and is of no obstetric importance. If in any case this condition is diagnosed preceding or during labor, the patient should be watched by the nurse lest labor close so precipitately that the child falls to the ground.

The equally contracted pelvis—equally contracted in all its diameters, generally renders the labor difficult and tedious but not impracticable, by the natural powers. Other distortions such as has often been caused by rickets, &c., offer great obstruction to the passage of the child. In some cases a modification of the position of the child allows it to descend, but in many cases it is necessary to interfere and terminate the labor artificially. The nurse should not wait for unfavorable symptoms to appear before she sends for a man that is able to use the forceps, &c.

MALPOSITION AND MALPRESENTATION OF THE CHILD.

Unnatural or abnormal labor may be caused by some peculiarity on the part of the child, in the position or presentation. These cases demand the services of the skilled accoucheur, and I do not intend to hint that the nurse should ever attempt to do what an educated physician should be called to do in these cases.

Face presentations sometimes retard the labor so much in the second stage as to give rise to unfavorable symptoms. In cases where the action of the uterus is so energetic as to finally expel the child, the sufferings of the mother are severe and prolonged. I have in my practice met with four cases, three of which were delivered by the natural powers, the children living; in one case craniotomy was performed. The mothers all lived. The diagnoses of face presentations is not easy at an early stage of labor. The finger first touches the forehead, which may be mistaken for the vertex. When the membranes are ruptured we may be able to make out the presentation. We may distinguish the edges of the orbits, the prominence of the nose, the mouth, &c. The bridge of the nose is the best guide, it being prominent, firm, and unlike any part of the breech or vertex. The face becomes tumefied during the labor, and the cheeks pressed together to resemble the nates, and it may be mistaken for a breech presentation. But in either presentation the proper course for the nurse is to leave the case alone in the expectation that the natural efforts will be sufficient to complete delivery. The child when born has a frightful appearance from the swelling and discoloration of one cheek, &c., but the injuries pass away in a day or two.

The forehead towards the arch of the pelvis at the time of delivery is not favorable, but unless the pelvis is proportionately small no interference is necessary.

The BREECH may present at the brim in different positions, and the breech is distinguished by its roundness and softness, by the cleft between the buttocks, by the arms and by the organs of generation. In some cases the labor is concluded as quickly as if the head descended, in others it is more tedious. The results as regards the mother are as favorable as in head presentations. The danger to the child is in direct proportion to the length of time between the birth of the body and that of the head.

When the body is expelled so far as the umbilicus, the danger to the child commences, for at this time the cord may be pressed between the body of the child and the pelvic walls. A loop of the cord should be pulled down, and if it freely pulsates the child can probably be delivered alive. Generally a judicious traction on the part of the accoucheur, combined with firm pressure through the abdomen applied by an assistant, will effect delivery of the head before the delay has had time to prove injurious to the child. If the arms of the child are above at the side of the head, the doctor will bring one down by passing a finger over the shoulder as near as possible to the elbow, and then drawing it across the face and chest until it arrives at the external orifice, but all this time it is the part of the nurse to continue to make effective pressure upon the abdomen of the mother—also while he delivers the shoulders—and while he perhaps introduces two fingers into the vagina of the mother to reach the upper jaw of the child and make pressure upon it, so as to depress the chin and facilitate the expulsion of the head.

Presentation of the knees and PRESENTATION OF THE FEET is identical in its progress with breech cases, and the treatment of breech cases applies to footling presentations, but it is best to avoid pulling on the foot or feet that come down, as it is safer for the child if the lower part of the body is delivered quite slowly. Even if the nurse should in an emergency deliver the child, she should help principally by pressure on the mother’s abdomen.

The only rule that I would have the skilled nurse adopt in regard to these cases, is that it is necessary that she should discover as early as possible if the labor is not a natural one, and if it is unnatural, should obtain the services of a physician as soon as possible. The same rule applies to cases of placenta previa hemorrhage, but I shall have more to say of these hereafter. A case of compound presentation where the hand and arm presents with the head, or in which the feet and hands, or one of each present together, also imperatively demand the services of an experienced accoucheur without delay. The nurse will be impotent to give any efficient help until the doctor arrives.

Presentation of the SUPERIOR EXTREMITIES will receive from me a full and complete description, because I believe that under certain circumstances the nurse should be prepared to operate by turning. As this radical opinion may perhaps be opposed by my medical brethren, I offer the following reasons for it which I consider a sufficient justification.

1. Cases of this class commence with the ordinary symptoms of labor; their peculiar character cannot usually be distinguished until the os is well dilated, and this is the only favorable time to perform the operation of turning.

2. Although in cities and villages generally, a physician’s services can in most instances be immediately obtained, in the country it is not always practicable to obtain them within an hour or two of time.

3. Such knowledge as is necessary for the performance of this operation may be obtained from such description and instruction as can be given in books.

4. There are some women who possess the necessary traits of character, the complete exercise of their faculties, with the perfect coolness which is demanded of the operator in such a case.

5. I do not advocate trusting the operation to a nurse when the services of an accoucheur can possibly be obtained within the proper time.

6. The services of a physician, if obtained one or two hours after the arm is first thrust down in the vagina, may not be of any use because the time for turning is passed.

7. The operation of turning, performed by a properly instructed nurse, does not involve the least danger to the mother or child.

8. The only danger connected with this operation arises from the size of the hand of the operator, and the woman’s hand is small.

9. It is a historical fact that at one period practitioners overrated the performance of turning, and extended its use to unsuitable cases, and after the invention of the forceps, they fell into an opposite error. It is possible that we may be in error if we hold that the nurse cannot be instructed to perform the operation of turning.

10. I do not advise that the nurse should ever attempt to turn in those cases in which the membranes have been long ruptured—the shoulder and arm pressed down into the pelvis, and the uterus contracted around the body of the child. I once succeeded in a case that two experienced physicians had tried in vain for several hours to turn, and I never had very much difficulty in turning, but there have been many cases where excellent operators could not succeed in turning.

In cases of PRESENTATION OF SHOULDER, ARM OR TRUNK, delivery by the natural powers is quite exceptional, though the natural powers have occasionally succeeded in expelling the child. The safety of the mother and child depend upon the early detection of the abnormal position of the foetus, and upon their receiving proper treatment before labor has been long in progress.

The position of the child is one intermediate between the long and transverse diameters. It may lie with its back towards the abdomen of the mother or with the back towards the spine of the mother, and the head of the child may be towards the right or the left of the mother.

The existence of a shoulder presentation is not commonly suspected until the first examination is made during labor. Suspicion will arise from finding on examination that we are not able to reach the presenting part, and that the os uteri does not dilate as usual, and that when it becomes dilated the bag of membranes protrude of a conical form, but this is common to all malpresentations. When the shoulder has descended a little it is recognized as a round, smooth prominence, rounder than the elbow, and we may be able to reach the axilla, &c. The elbow may be recognized by the sharp prominence of the bone, and the hand can be distinguished from the foot by the fingers being wider apart and more readily separated from each other than the toes, and by the thumb which can be carried across the palm. The situation of the thumb and the aspect of the palm of the hand will mark whether it is the right hand or the left.

As soon as the nurse ascertains or suspects from an external palpation or a vaginal examination, that it is a cross birth she should send for the doctor, who ought to be there as soon as the membranes are ruptured, and the nurse must not be very persistent in making examinations lest she rupture the membranes prematurely. She may perhaps give a small dose of morphine, but I would not advise that she give chloroform as it is not necessary.

The right time to turn the child is when the os uteri is dilated, either before or immediately after the rupture of the membranes, and if a doctor cannot be soon obtained, it is better that a skilled nurse should turn the child, and if she is properly instructed, she should do it carefully and slowly, but without any fear and confidently. She can assure the patient that she will be able in a short time to relieve her sufferings.

In England the ordinary position for turning is on the left side. I prefer that the patient be placed across the bed on her back with her legs drawn up and supported by assistants. I now describe my own mode of operating.

I bare my right arm and hand (sometimes the left), lubricating it freely. If the waters have only recently escaped, and the os be dilated, the operation is performed with ease, especially after we have determined the position of the child.

I press the fingers together in the form of a cone, the thumb between the fingers—slowly and carefully press them into the vagina in an interval between the pains, and constantly and slowly press the hand in, only when the contractions of the uterus remit; never using any force, gently pass the fingers into the os; gently open the fingers a little occasionally to dilate the os sufficiently, and when it is expanded pass the hand into the uterus, make out the presentation accurately, so as to keep my hand to the abdomen of the child; always keep the hand still during a pain; when there is an interval between the pains, carefully search for the feet; when one of the feet is found, clasp the leg at the knee with one finger; flex the leg at the knee so that the finger has a good hold of it, draw it down in the absence of a pain; as the knee approaches the os when it is drawn down over the abdomen of the child, the shoulders and head recede towards the fundus, and when the head has reached the fundus and the knee is brought through the os, the case is converted into a knee presentation, and I deliver slowly but without needless delay—making a little traction during each pain, the management being conducted as in feet presentations, and the whole process being assisted by pressure made on the uterus by my left hand, or by the hand of an assistant.

Possibly these directions will be better understood if I use the language of another who directs:

1. That the patient be placed on her left side near the edge of the bed.

2. The os externum is then to be dilated with the fingers reduced into a conical form, acting with a semi rotary motion of the hand.

3. When the hand is passed through the os externum it must be slowly conducted to the os uteri. We may perforate the membranes with the finger if they are not broken.

4. The hand must then be passed along the thighs and legs of the child until we come to the feet. If both the feet lie together we must grasp them firmly with one hand, but if they are distant from each other we may deliver by one foot.

5. Before we begin to extract we must be sure that we do not mistake a hand for a foot. The feet must be brought down with a slow, waving motion into the pelvis, when we are to wait till the uterus contracts, still retaining them in the hand.

6. The feet are to be brought down with each return of the pain, and the labor may be finished partly by the efforts of the mother and partly by art.

7. If the toes are turned towards the pubis the back of the child is towards the back of the mother which is an unfavorable position.

8. If the toes are towards the sacrum, the back of the child is towards the abdomen of the mother, and this position is advantageous when the head comes to be extracted.

9. When the feet of the child has passed through the os externum, wrap them in a cloth and holding them firm wait till there is a pain, during the continuance of which gently draw down the feet. When the pain ceases we must rest, we merely assisting the efforts of the patient.

10. When the child is brought so low that the funis reaches the os externum, a small portion of it is to be brought out to slacken it, and from this time the operation is to be finished as speedily as it can be with safety, but if the circulation of the funis be undisturbed, there is no occasion for haste as the child is in safety.

11. If the child should stick at the shoulders the arms must be successively brought down.

12. When both the arms are brought down the body of the child must be supported upon our left arm and hand, the fingers on each side of the neck, and if the head should not come easily away, we must introduce the forefinger of one hand into the mouth of the child to render the position of the head more convenient for passing.

12. When a child has been extracted by the feet, the placenta usually separates very easily, but in the management we are to be guided by the general rules.

13. In these cases the child usually needs to be resuscitated, and the nurse should arrange so that hot and cold water may be at hand if required.

In these descriptions of the operation I have mentioned both the back and side as good positions for the mother, because some accoucheurs prefer one position and some the other. Some prefer to have the patient on the hands and knees. But if the nurse have the instructions here given well in her mind, she can operate in either position. If she ascertains at first how the child lies she may sometime reach its abdomen better if she introduces her left hand, but the main point is to proceed slowly and carefully. She should be careful in passing in her hand to change the direction of it in accordance with the pelvic axis, and should not use much force at any time. The danger to the mother is very small indeed; the danger to the child arises, as in breech presentations, from the compression of the funis, which commences about the time the buttocks appear at the os externum. But the safety is only when the operation is performed at the proper time. The nurse must never operate if the services of a physician can be obtained at that time, but when it is necessary she may proceed to turn, doing it slowly and properly, but fearlessly and confidently. If the doctor that is sent for is informed before he arrives that it is a case of hand presentation, he will come dreading the difficulties that he may encounter, and if he can have the satisfaction of knowing when he comes that the woman is safely delivered, he will be exceedingly glad.

CHAPTER VI.
CONCLUDING INSTRUCTIONS IN MIDWIFERY.

What I shall say of PLURAL BIRTHS, and MONSTERS, of CHILDREN AFFECTED WITH HYDROCEPHALUS, OR ASCITES, of EXCESSIVE SIZE OF THE FŒTUS, of DEFECTS IN THE FORMATION OF THE FŒTUS, of PROLAPSE OF THE FUNIS, &c., will be compressed in a few words. I am not instructing the nurse to attempt to conduct a case of even natural labor without having a physician if he can be obtained, but she should consider the services of a trained practitioner imperatively necessary in these unusual cases. In either instance there may be a safe delivery by the natural powers alone, and the nurse may act in an emergency, but it would not be consistent with the plan of this work for me to describe in detail the various operations that are sometimes performed in these several cases, or to give instructions in the use of instruments, which I advise the nurse never to use.

In regard to those instances where it seems as if it would be necessary to use instruments, I quote the following rules adopted by accoucheurs: 1. Meddlesome midwifery is always bad. 2. In no case need we interfere when the obstacles to be overcome can be overcome in a reasonable time by nature or without an operation. 3. Cases in which instruments are to be used are exceptions to the general rule, and no instrument should be used in a clandestine manner. 4. We should not have such an aversion to the use of instruments that we too long delay that assistance we have the power of affording with them.

PLACENTAL PRESENTATION.

Placenta previa will never be treated by the nurse, but she should know its nature, know that it is this that causes unavoidable hemorrhage, and she should not fail to obtain a skillful physician early, to attend the case. The flooding is the necessary consequence of the dilatation of the os uteri, by which the connection between the placenta and uterus is separated, and the more the labor advances, the greater the disruption, and the more excessive the hemorrhage.

The woman usually passes through the early part of pregnancy without any sign that denotes the peculiar attachment, but the placenta can easily be distinguished from the membranes or coagulated blood as soon as the os uteri is a little opened. When a hemorrhage comes on from this cause the patient is never free from danger till she be delivered. Often the medical man is obliged to free the patient from imminent danger by artificial delivery, but I can conceive of no circumstance in which a nurse would be justified in turning for unavoidable hemorrhage.

Before, during, and after the delivery, the appliances used in other cases of hemorrhage may be used with some advantage, but I would hardly advise the nurse to do any thing before the doctor arrives.

ACCIDENTAL HEMORRHAGE.

That form of FLOODING that arises from a partial and accidental separation of the placenta which occupies its usual position, must here be briefly referred to, as the nurse may be called on to do something in an emergency. The immediate cause of the flow is the separation of some portion of the placenta from the womb, and the laceration of the vessels. The hemorrhage is at first internal, is accompanied with dull pain at the spot where it takes place, it generally becomes external, it may or may not be attended with the discharge of coagula from the os uteri, and when the discharge commences it varies in quantity from a few ounces to an amount that is alarming. It is generally necessary to make a digital examination, to distinguish the accidental from the unavoidable hemorrhage.

Until the doctor arrives the patient should be kept in bed on a hard mattrass and very lightly covered with bed clothes. The temperature of the room should be kept very low, and nothing but cold water allowed.

The danger from hemorrhages that occur at or near the full period of utero gestation, may often be estimated by the absence or degree of pain, as well as from the quantity of the discharge. Hemorrhages are much more dangerous with sudden than with slow discharges of blood, and women are always in greater danger when they are not accompanied with pain. Puerperal convulsions, whether of the hysteric, epileptiform, or apoplectic variety will always demand and almost always receive the prompt attention of the physician.

While the nurse is waiting for the doctor to arrive she might possibly administer a cathartic, thirty grains of bromide of potash, and an enema, but as a general rule she should not give anything. She might insert a wedge or roll of linen between the teeth to prevent injury to the tongue, and she should remove every thing out of the way, by striking against which, the patient might hurt herself.

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CHAPTER I. PRELIMINARY INSTRUCTION TO THE NURSE MIDWIFE.