Obstetrical Nursing / A Text-Book on the Nursing Care of the Expectant Mother, the Woman in Labor, the Young Mother and Her Baby

PART IV The Birth of the Baby

CHAPTER X. PRESENTATION AND POSITION OF THE FETUS. Breech, Head, Face, and Vertex Presentations. Longitudinal and Transverse Presentations. Position of Fetus. Time of Engagement. Methods of Ascertaining Position and Presentation of Fetus. Abdominal Palpation. Vaginal Examination. Rectal Examination. Auscultation of the Fetal Heart.

CHAPTER XI. SYMPTOMS, COURSE, AND MECHANISM OF NORMAL LABOR. Onset of Labor. Three Stages of Labor.

CHAPTER XII. NURSE’S DUTIES DURING LABOR. General Principles of Treatment and Nursing Care. Psychology of the Patient. Preparation for Vaginal Examination or Delivery. Nurse’s Duties during First Stage. Second Stage. Maintaining of Surgical Cleanliness. Immediate Care of the Child. Resuscitation of New-born Child. Third Stage. Immediate Aftercare of the Patient. Nurse’s Duties if the Doctor Is Delayed. Prolapsed Cord. Post-partum Hemorrhage. Obstetrical Anesthesia: Chloroform. Ether. Nitrous Oxide Gas Analgesia. Twilight Sleep. Complete Anesthesia.

CHAPTER XIII. OBSTETRICAL OPERATIONS AND COMPLICATED LABORS. Conditions Giving Rise to Operations. Preparation for Operation in the Home. Perineal Lacerations. Episiotomy. Breech Extraction. Version. The Use of Forceps. Symphysiotomy. Vaginal Hysterotomy. Cesarean Section. Ruptured Uterus. Destructive Operations. Induced Abortions and Premature Labors. Accouchement ForcÉ.

CHAPTER X
PRESENTATION AND POSITION OF THE FETUS

Fig. 50.—Most frequent attitude of fetus in uterine cavity, at term.

Returning for a moment to the pregnant uterus at term, we find it to be a thin-walled, muscular sac containing the mature fetus, attached by means of the umbilical cord to the placenta and floating in the amniotic fluid, which is contained within a sac formed by the amniotic and chorionic membranes.

The average fetus at term is about 50 centimetres long, weighs about 3250 grams and is curved and folded upon itself into an ovoid mass, occupying the smallest possible space. (Fig. 50.) Its most frequent attitude is with the back arched; the head bent forward, with chin resting upon chest; arms crossed upon chest below chin; thighs flexed upon abdomen and knees bent.

Fig. 51.—Illustrations from the first textbook on obstetrics, Roesslin’s “Rosengarten,” 1513, which gives an amusing impression of early ideas of the position of the fetus in utero.

With a few exceptions the long axis of the fetus is parallel to the long axis of the mother, and most frequently the head is downward. It was formerly believed that the child stood upright in the uterus until toward the end of pregnancy and then somersaulted to the position it occupied immediately before birth. (Fig. 51.) But it is now known that though the fetus may move about and change its position during the early part of pregnancy, it is not likely greatly to alter its relation to the mother’s body during the tenth lunar month.

Fig. 52.—Attitude of fetus in breech presentation.

It seems advisable to define here certain terms which are in common use in discussing patients in labor, and which will be employed in the following pages.

A nullipara (0–para) is a woman who has not had children.

A primigravida is a woman who is pregnant for the first time.

A primipara (1–para) applies to a woman during her first labor and until the beginning of her second labor.

2–para, 3–para and 4–para apply to women in succeeding labors which correspond to the numerals used.

A multipara is a woman who has had more than one child.

There is also a terminology, with abbreviations, which is fairly generally used in this country and England to designate the position which the child, about to be born, occupies in relation to its mother’s body. A diagnosis of this position is, of course, absolutely necessary to a skilful management of labor, and the nurse should understand the meanings of the terms used, and also their distinctions and subdivisions.

Fig. 53.—Attitude of fetus in vertex presentation.

The presentation of the fetus is the term which is employed to indicate the part of the baby’s body which is at the brim of the mother’s pelvis. Thus the part of the fetus which is lowermost is designated as the presenting part and gives the presentation its name. If the breech is downward, therefore, it is a breech presentation (Fig. 52), and if the head is the lower pole it is termed a head, or cephalic presentation. (Fig. 53.) The head presentations are divided into two main groups, which are designated, respectively, as face and vertex presentations. For example, if the baby’s neck is so arched that the chin rests upon the chest, the crown of its head, or the vertex, is the part that is lowest in the birth canal and is the part that will be seen first at the vaginal outlet. Therefore, this is called a vertex, or occipital presentation. But if the neck is bent sharply backward, the face becomes the presenting part and we have a face presentation.

The breech, face and vertex presentations are sometimes referred to as longitudinal presentations since in these instances the long axes of the bodies of mother and child are parallel. In transverse presentations, however, the child lies across the uterus, with one side or the other at the pelvic brim.

The transverse presentations are infrequent, occurring once in about 250 cases, and are regarded as abnormal because spontaneous delivery under such circumstances is extremely rare. They are more likely to be seen, when they do occur, among multiparÆ and women who have contracted pelves.

The longitudinal presentations, however, constitute something over 99 per cent. of all cases and are regarded as normal, since the child occupying this relationship may be born spontaneously. In about 3 per cent. of the longitudinal presentation the breech is the presenting part and in about 97 per cent. it is the head. Of these, the vertex presentation is the one most commonly seen and is the one in which the child is most easily delivered. Face presentations are very rare, occurring in only a fraction of 1 per cent. of all cases.

In addition to the child’s presentation, there is also its position, which is an entirely different matter, for in each longitudinal presentation the presenting part may occupy any one of six positions.

By position is meant the relation of some arbitrarily chosen point on the presenting part of the fetus, to the right or left side of the mother, and to the front (anterior), side (transverse) or back (posterior) segment of that side.

Taking these up in turn, we find, that in transverse presentations the shoulder, acromion process, is the point on the baby’s body which is chosen, to give the four possible positions their names.

In breech presentations the sacrum is the arbitrarily chosen point.

In face presentations it is the chin, or mentum, while in vertex presentations the occiput is the point chosen.

Presentation, then, describes the relation of the long axis of the entire fetal body to the mother’s body, while position describes the relation between the baby’s shoulder, sacrum, face or occiput to the mother’s pelvis.

If the child is so placed in the uterus that the head is the presenting part; the neck arched with chin on chest, and the occiput directed toward the mother’s left side, and more to the front than to the side, the presentation would be longitudinal, of the vertex variety, and the position would be a left-occipito-anterior. The arbitrarily chosen point on the child’s body (the occiput) would be directed toward the left, anterior segment of the mother’s pelvis. This is the situation most commonly seen and the description of this presentation and position are abbreviated, by taking the first letter of each word, into L. O. A.

Fig. 54.—Diagram showing the six possible positions in a vertex presentation.

If the occiput were turned directly toward the mother’s left side, neither to the front nor the back, we should have a left-occipito-transverse, L. O. T., and if it were directed toward the left posterior segment of the pelvis the position would be left-occipito-posterior, or L. O. P. As there are three corresponding positions on the right side, anterior, transverse and posterior, there are six possible positions for the child to occupy in the vertex, or occipital presentations, as follows:

Left-occipito-anterior, abbreviated to L.O.A.
Left-occipito-transverse, abbreviated to L.O.T.
Right-occipito-posterior, abbreviated to L.O.P.
Right-occipito-anterior, abbreviated to R.O.A.
Right-occipito-transverse, abbreviated to R.O.T.
Right-occipito-posterior, abbreviated to R.O.P. (Fig. 54.)

Similarly there are six face (Fig. 55) and six breech (Fig. 56) presentations. Thus, if the chin (mentum) is resting in the left anterior segment of the mother’s pelvis, the position would be left-mento-anterior, or L. M. A. If the breech presents and the sacrum is in that relation the position is left-sacro-anterior, or L. S. A.

Fig. 55.—Diagram showing the six possible positions in a face presentation.

In describing the transverse presentations, four words, instead of three are used; thus, left-acromio-dorso-anterior, or L. A. D. A.

There are but four varieties of transverse presentations, since the shoulder is either anterior or posterior: thus left-acromio-dorso-anterior, left-acromio-dorso-posterior and the two corresponding positions on the right side.

Fig. 56.—Diagram showing the six possible positions in a breech presentation.

During the last two to four weeks of pregnancy, particularly among the primiparÆ, the top of the fundus settles to the level which it reached at about the eighth month, and the lower part of the abdomen becomes more pendulous than formerly. The patient usually breathes much more comfortably after this change in contour takes place, but, at the same time, she may have cramps in her legs as a result of the increased pressure; more difficulty in walking; frequent micturition and desire to empty her bowels, while the vaginal discharge may be considerably increased. It is at this time that the presenting part enters the superior strait and is spoken of as being “engaged.”

The time at which engagement takes place depends upon three factors: Whether the patient is a multipara or a primipara; the size and normality of the pelvis; the size and position of the fetus. It is often helpful to the obstetrician in planning for the delivery to know whether or not the presenting part is engaged, particularly in primiparÆ.

Although in primiparÆ engagement usually occurs about four weeks before labor begins, it does not normally take place in multiparÆ until immediately before labor. This difference is accounted for in the increased tonicity of the uterine and abdominal muscles of primiparous women. In certain abnormalities, or marked disproportion between the diameters of the child’s head and mother’s pelvis, engagement may not take place until labor is well advanced, or possibly not at all.

The presentation and position of the fetus are ascertained by means of abdominal palpation, vaginal examination, rectal examination and auscultation of the fetal heart.

Palpation of the child’s body through the mother’s abdominal wall is possible under ordinary conditions, because the uterine and abdominal muscles are so stretched and thinned that the various parts may be made out through them. But it is sometimes difficult in hydramnios and is practically impossible in very fat patients or in the case of a ruptured uterus when the fetal outline is obscured by hemorrhage. This procedure has been practiced only during comparatively recent years, and is regarded by many obstetricians as one of the most important factors in reducing the frequency of puerperal infections and thus in decreasing maternal deaths. The explanation is that in general the dangers of puerperal infection are believed to increase in direct proportion to the number of times a patient is examined vaginally; and since it has been known how to diagnose the child’s position by means of abdominal palpation, the necessity for vaginal examinations is not so great and they are accordingly made less frequently.

Fig. 57.—First maneuver in abdominal palpation to discover position of fetus.

Rectal examinations may also be regarded as a factor in preventing infection, for, since much the same information may be obtained by means of them as by vaginal examinations, after the onset of labor, they often replace direct exploration of the easily infected birth canal.

Abdominal palpation, as usually practiced, consists of four maneuvers, with the patient lying flat and squarely on her back with the abdomen exposed. The nurse should bear in mind that successful palpation requires even pressure. Cold hands applied to the abdomen or quick, jabbing motions with the fingers will usually stimulate the muscles lying beneath them to contract, thus somewhat obscuring the outline of the child. Such palpation is also very uncomfortable for the patient; but firm, even pressure, started gently, with warm hands, does not hurt.

Fig. 58.—Second maneuver in abdominal palpation.

First Maneuver. The purpose of the first maneuver is to ascertain what is in the fundus; this is usually either the head or the breech. The nurse should stand facing the patient and gently apply the entire tactile surface of the fingers of both hands to the upper part of the abdomen, on opposite sides and somewhat curved about the fundus. (Fig. 57.) In this way the outline of the pole of the fetus which occupies the fundus may be made out. If the head is uppermost, it will be felt as a hard, round object which is movable or ballottable between the two hands, and if the breech, it will be felt as a softer, less movable, less regularly shaped body.

Fig. 59.—Third maneuver in abdominal palpation.

Second Maneuver. Having determined whether the head or the breech is in the fundus, the next step is to locate the child’s back and the small parts in their relation to the right and left sides of the mother. This is accomplished by slipping the hands down to a slightly lower position on the sides of the abdomen than they occupy in the first maneuver, and making firm, even pressure with the entire palmar surface of both hands. The back is felt as a smooth, hard surface under the palm and fingers of one hand, and the small parts, or hands, feet and knees, as irregular knobs or lumps, under the hand on the opposite side. (Fig. 58.)

Fig. 60.—Fourth maneuver in abdominal palpation. (This series of pictures is from photographs taken at Johns Hopkins Hospital.)

Third Maneuver. Unless the presenting part is engaged, the third maneuver virtually amounts to a confirmation of the impression gained by the first maneuver, by showing which pole is directed toward the pelvis. The thumb and fingers of one hand are spread as widely apart as possible, applied to the abdomen just above the symphysis and then brought together to grasp the part of the fetus which lies between them. If not engaged, the head will be felt as hard, round and movable, while the breech will be less clearly defined. (Fig. 59.)

Fig. 61.—Diagrams showing relation of nurse’s hands to fetus in the four maneuvers of abdominal palpation.

Fourth Maneuver. The fourth maneuver is of particular value after the presenting part has become engaged. The nurse faces the patient’s feet in this position, and directs the first three fingers of each hand down into the pelvis, on either side of the fetus, to ascertain whether it is a face or vertex presentation, by discovering whether chin or occiput is the higher cephalic prominence in the mother’s pelvis. (Fig. 60.) If it is a vertex presentation, the neck will be flexed, with the chin on the chest and consequently higher in the pelvis than the occiput. The nurse’s fingers of one hand will accordingly come in contact with the chin on the side opposite to the child’s back, before the fingers of the other hand reach the occiput. If, however, it is a face presentation, the neck will be bent sharply backward and the nurse’s fingers will feel the occiput first, and on the same side as the baby’s back. This maneuver tells, also, how far into the pelvis the presenting part has descended.

Fig. 62.—Diagram showing method of ascertaining position of fetus by means of rectal examination. Examining finger palpates head through recto-vaginal septum.

Vaginal Examination. The information obtained by vaginal examination, before the cervix is dilated, is rather uncertain since the child’s presenting part must be palpated through the fornix. But after complete, or even partial dilatation, the exploring finger is able to feel the sagittal suture and one fontanelle, in a vertex presentation, and diagnose the position by discovering the direction of the suture and whether it is the anterior or posterior fontanelle that is felt. The anterior fontanelle, it will be remembered, is relatively large and four-sided, while the posterior is small and more nearly triangular in shape. In a face presentation, the features may be felt; in a breech the examining finger can palpate the buttocks and genital crease.

Because of the possible danger of introducing infective material into the birth canal, the tendency is to make fewer and fewer vaginal examinations, and then only after the most painstaking preparation which will be described presently. Needless to state, vaginal examinations are not within the province of the nurse.

Rectal Examinations. More and more frequently rectal examinations are being employed to obtain information about the child’s position, as the examining finger is able to feel the surface of the presenting part through the recto-vaginal septum, after the cervix is dilated, and there is no danger of infecting the birth canal while so doing. For this reason nurses are frequently taught to make rectal examinations, thereby increasing the value of their assistance to the doctor in watching the progress of labor. (Fig. 62.)

Auscultation of the fetal heart is valuable in confirming the diagnosis of presentation and position which has been made by palpation. In vertex and breech presentations the heartbeat is best heard through the baby’s back and in face presentations it is transmitted through the chest, which presents a convex surface in this case and fits into the curve of the uterine wall. In anterior vertex presentations the heart is heard a little to the side and below the umbilicus; in transverse, further to the side, and in posterior, well toward the back.

CHAPTER XI
SYMPTOMS, COURSE AND MECHANISM OF NORMAL LABOR

Labor may be defined as the process by means of which the product of conception is separated and expelled from the mother’s body. It ordinarily occurs about 280 days from the beginning of the last menstrual period. (See p. 93.)

The cause of labor is not known. Many theories have been advanced to explain why the uterine contractions, which have occurred painlessly throughout pregnancy, and without expulsive force, finally become painful at the end of the tenth month and so changed in character as to extrude the uterine contents; but as yet, none is wholly satisfactory nor generally accepted. Nor is it known why some labors are premature and some delayed.

The onset of labor is usually marked by the patient’s becoming conscious of the uterine contractions through dragging pains which may be felt first in the back and then in the lower part of the abdomen and the thighs. At first the pains are feeble and infrequent, but they gradually grow more severe and more frequent. Intestinal colic is sometimes mistaken for labor pains, but when the paroxysms are rhythmical and the uterus is felt, through the abdominal wall, to grow hard as the pain increases and soft as it subsides, there can be no doubt but that the patient is in labor. The first signs of labor may be a gush of amniotic fluid, caused by the rupture of the membranes, or of blood, but these are not typical.

For purposes of convenience, labor is usually described as consisting of three periods or stages. The first stage begins with the onset of labor and lasts until the cervix is completely dilated; the second stage begins with the complete dilatation of the cervix and lasts until the child is born; the third stage begins with the birth of the child and lasts until the placenta is expelled.

The entire duration of labor may vary from a few moments, comprising a few pains, to several days of severe and exhausting pain, but the average length of the first labor is 18 hours and of subsequent labors about 12 hours, divided respectively into the three periods as follows:

	1st stage.	2nd stage.	3rd stage.	Total.
Primipara	16 hours	1¾ hours	15 minutes	18 hours.
Multipara	11 hours	45 minutes	15 minutes	12 hours.

The longer labor in primiparous women is due to the greater tone, and thus the greater resistance offered by the muscles of the cervix and perineum. Elderly primiparÆ are likely to have longer labors than young primiparÆ.

First Stage. This is frequently called the stage of dilatation. During this period the contractions of the uterine muscles make pressure upon the amniotic sac of fluid, forcing it gradually down and into the cervix as a water wedge, widening the internal os first, then the external os, until the entire canal is fully dilated (thinned out); shortened to about one-half inch in length and finally obliterated so that it is uninterruptedly continuous with the lower uterine segment. (Figs. 63, 64, 65, 66.)

The first stage pains begin by being mild and occurring at intervals of from 15 to 30 minutes, but they gradually increase in frequency and intensity until at the end of 14 to 16 hours they are very severe and recur every three or four minutes, each pain lasting about one minute. The pains begin in the back, pass slowly forward to the abdomen and down into the thighs.

The patient is entirely comfortable, as a rule, between pains and until they become very frequent will usually feel able, in fact prefer, to be up and about, but if she is on her feet when a contraction begins she will usually seek relief by assuming a characteristic leaning position (Fig. 67) or by sitting down, until the pain subsides. As dilatation advances, the patient has an increasing, sometimes persistent, desire to empty the bowels and bladder because of encroachment upon these two organs by the descending head. She may vomit, also, when the cervix becomes nearly or quite dilated.

Fig. 63.

Fig. 64.

Fig. 65.

Fig. 66.

Figs. 63, 64, 65, and 66 are diagrams showing stages of dilatation and obliteration of cervix during labor.

In the course of this stretching process, the cervix sustains many tiny lesions, from which blood oozes and tinges the vaginal discharge. This blood-stained secretion is often called the “show” and usually appears toward the end of the first stage.

Fig. 67.—Characteristic position which patient often assumes during pains in first stage.

As a rule, when the cervix is fully dilated the membranes rupture and there is a sudden gush of that part of the fluid which was below the fetus in the amniotic sac, but the rupture of the membranes does not necessarily mark the end of the first stage. In some instances they rupture before the cervix is fully dilated; in others, though not often, before the patient goes into labor, thus producing what is known as a “dry” labor.

The abdominal muscles do not contract very forcibly during the first stage, the expulsive force in this period coming almost entirely from the uterine contractions. The patient’s cries at this time are sharp and complaining in contrast to the groans and grunts which accompany the second stage.

Complete dilatation of the cervix marks the termination of the first stage.

Fig. 68.—Diagram indicating the rotation and pivoting of baby’s head during birth.

Second Stage. The second stage is sometimes called the stage of descent, or expulsion, of the fetus. The patient should and is usually quite willing to be in bed throughout the second stage, during which she should not be left alone. The pains are now regular, occurring at intervals of about two minutes from the beginning of one to the beginning of the pain following, and as the contractions last about one minute and are excruciatingly painful, the patient has very little respite from her suffering. Her face is flushed and she may perspire freely.

The abdominal and respiratory muscles are brought into active use during the second stage, contracting simultaneously with the uterine muscles and increasing their expulsive force. These are apparently controlled by the patient’s will at first, and she is able somewhat to increase their power by taking a deep breath, closing her lips, bracing her feet, pulling against something with her hands, straining with all her might and “bearing down.” Finally, however, the whole bearing down process becomes involuntary, is accompanied by intense pain and the deep grunting sound, which is characteristic of the well-advanced second stage. Under normal conditions, the child descends a little farther into the pelvis with each contraction, and finally the presenting part begins to distend the perineum and to separate the labia advancing at the height of each pain and slipping back a little as it subsides.

Fig. 69.—Anterior shoulder being slipped from under symphysis to facilitate birth of posterior shoulder.

The baby descends into and through the mother’s pelvis by means of a series of twisting and curving motions, accommodating the long axes of its head to the long diameters of the pelvis. The head being somewhat compressible and mouldable, because of imperfect ossification, is capable of a good deal of accommodation to the mother’s pelvis.

The mechanism of labor, therefore, is virtually a series of adaptations of the size, shape and mouldability of the baby’s head to the size and shape of the mother’s pelvis. If the head passes through the inlet satisfactorily, the rest of the labor will usually be accomplished with comparative safety. But a marked disproportion between the diameters of the head and pelvis may interfere with the engagement or descent of the head and produce a serious complication.

Fig. 70.—Delivery of posterior shoulder.

The long diameter of the head must first conform to one of the long diameters of the inlet, usually oblique, and then turn so that the length of the head is lying antero-posterior in conformity to the long diameter of the outlet through which it next passes. As the head descends and rotates it also describes an arc because the posterior wall of the pelvis, consisting of the sacrum and coccyx, is about three times as deep as the anterior wall formed by the symphysis. That part of the baby’s head which passes down the posterior wall of the pelvis must therefore travel three times as far in a given time as the part which simply slips under the short symphysis pubis.

Fig. 71.—Diagrams showing Duncan and Schultze mechanisms of placental separation.

In a vertex presentation, left-occipito-anterior position, while the occiput passes under the symphysis and appears at the distending vaginal outlet, the face passes down the posterior wall and along the floor of the pelvis. As pressure is exerted by the rapidly succeeding contractions, the head pivots about the pubis, thus extending the neck and pushing the face farther downward and forward. After emergence of the back and top of the head below the symphysis, the forehead appears over the posterior margin of the vagina, then the brow, eyes, nose, mouth and chin in turn, and the entire head is born. (Fig. 68.) The baby’s head then drops forward, in relation to its own body, with its face toward the mother’s rectum and the occiput in front of the pubis, but soon the occiput rotates toward the mother’s left side, resuming the relation that it bore to the inner aspect of her pelvis before expulsion. The undelivered shoulders are now antero-posterior, one under the pubis and the other resting on the perineum. (Fig. 69.) The lower, or posterior shoulder is born first (Fig. 70), followed quickly by the anterior shoulder and the rest of the body, and the amniotic fluid which was behind the child’s body. Thus is the second stage completed.

Fig. 72.—Longitudinal section through uterus showing thinness of uterine wall before expulsion of fetus, contrasting sharply with thickened wall in Fig. 73. (From photograph of specimen, to which twin placentÆ are still adherent in upper segment, in the obstetrical laboratory, Johns Hopkins Hospital.)

Third Stage. The third stage, sometimes termed the placental stage, is that period following the birth of the child, during which the placenta is delivered. For a few moments after the baby is born the tired mother lies quietly and free from pain, as there is a temporary cessation of the uterine contractions, and she often sleeps as a result of the anesthetic given during the second stage.

Fig. 73.—Longitudinal section through uterus, immediately after labor, showing marked thickening of wall as a result of muscular contraction. (From photograph of specimen in the obstetrical laboratory, Johns Hopkins Hospital.)

The uterus has greatly decreased in size, the fundus now lying below the umbilicus where it may be felt as a firm, solid mass. The uterine contractions are resumed in the course of a few moments and as they persist, the uterus grows smaller, thereby greatly decreasing the area of placental attachment. As the placenta is non-contractile it cannot accommodate itself to this decreased area of attachment, and so is literally squeezed from its moorings. It is then gradually forced down into the lower uterine segment where it may be located by the distension of the abdominal wall which it produces just above the symphysis. After the separation of the placenta is complete the uterus rises in the abdominal cavity until the fundus is felt above the umbilicus. The placenta, finally, may be completely expelled spontaneously, or expressed by slight pressure made upon the fundus by the accoucheur.

The placental detachment may begin at the centre, the area of separation spreading to the margin, or the detachment may start at the margin of the placenta and extend toward the centre. Either is normal. These two modes of placental separation are named the Schultze and the Duncan, respectively, from the men who first described them. (Fig. 71.)

In the Schultze mechanism, which occurs most frequently, the separating process begins at the centre of the placenta and the glistening fetal surface appears at the vaginal outlet. In this case there is practically no bleeding during the third stage as the inverted placenta blocks the vagina and holds back the blood.

In Duncan’s mechanism the detachment begins at the margin, the placenta rolls upon itself and presents at the outlet by its roughened maternal surface and there is usually slight but continuous bleeding from the time the separation begins. When the placenta is delivered, the collapsed membranes trail after it like a tapering cord. A good deal of blood is lost at the time of the placental expulsion and immediately afterwards, but this profuse bleeding usually subsides in a few moments. Although the loss of blood may be as much as 500 cubic centimetres without its being regarded as serious, the average amount is about 350 cubic centimetres.

The patient has been through a severe ordeal and at the end of the third stage of labor she is usually tired out and cold.

CHAPTER XII
THE NURSE’S DUTIES DURING LABOR

The extent of the nurse’s helpfulness during labor, both to the patient and to the doctor, will depend very largely upon the intelligence with which she grasps what is taking place and upon her own attitude, as an individual, toward the patient and the miraculous event which approaches. Important as is the preparation of the room and dressings, this other factor is almost equally influential.

It will be wiser, therefore, for the nurse to try to picture the process of labor in each instance, and to be guided by a few broad principles that apply to all cases under all conditions, rather than to try to memorize the details of her duties and of the desirable equipment and preparation.

The process of labor we have just described.

As to the general principles: If there is any time in a nurse’s career when she should give scrupulous attention to establishing and maintaining asepsis, it is during labor, for the patient’s life may, and often does depend upon it. If there is any time when she should be watchful for developments and for symptoms of complications, it is during labor, for again the patient’s life may depend upon this.

Her powers of adaptability to doctor, patient and surroundings may be severely tried, for though they all may be infinitely varied, the nurse must invariably be clear-headed and efficient and the adequacy of her service must never fail.

The sympathetic insight, which should constantly underlie the work of the obstetrical nurse, will be needed at this crucial time of labor in the fullest and finest and completest sense. This is almost her test as a nurse and as a womanly woman, for she needs to be both, supremely.

Perhaps she had better imagine for a moment what this occurrence, that we baldly term labor, may mean to the patient and look at it as nearly as possible from the standpoint of the patient herself. It is one of the most stirring and momentous experiences of her life, particularly if the expected baby is her first child. She is about to realize the sweetest and tenderest of dreams—that of motherhood—cherished throughout nine long months. She is also approaching a period of excruciating pain, and knows it, with her eyes wide open to the possibility of not surviving it; and an event so amazing in its mystery and wonder that to only the most stolid can it fail to be a deeply emotional experience.

And so, the young woman, to whom we refer so impersonally as “the patient,” is an intensely personal being at this time, experiencing a number of the most poignant of the human emotions: awe, expectancy, doubt, uncertainty, dread and in some cases fear amounting almost to terror. And through it all her body is being racked and exhausted with pain that grows harder and harder to bear.

It is known that the ravaging effects of pain, coupled with great emotional stress, such as fear, worry, doubt, anger or apprehension, upon the physical well-being of surgical patients, is such that death itself may be caused by excessive fear and suffering. Accordingly, many careful surgeons take elaborate precautions to tranquillize a patient who is about to be operated upon, if for no other reason than to increase his chance for recovery.

There can be no doubt that nervous and emotional disturbances are detrimental to the physical well-being of the patient in labor, also, and this fact alone is enough to warrant an effort to avert them. If the nurse appreciates the significance of the emotional influence and shapes her attitude and conduct accordingly, she will thereby help to increase the ease and safety of the actual delivery. Just what that attitude shall be, no one can say, for it must be developed, in each case, in such a way as to win the confidence and meet the needs of that particular patient.

But in all cases the nurse should impress her patient with her sincere sympathy and appreciation of the fact that she, the patient, is going through a difficult time. Through it all the nurse must be cheerful, encouraging and optimistic; very gentle; very calm and reassuring in all that she does in preparing for the delivery. She must steadily increase the patient’s realization of the part which she herself must play in the effort which is being made to carry the event through to a happy issue.

The occasion need not, should not, be a mournful one but it is often a very sacred one to the patient, and the nurse should be dignified, almost reverential in her bearing.

If the patient feels secure in the belief that her ordeal is not being taken lightly; that it is being regarded seriously, as it merits, and that every known precaution is being taken, and taken confidently, to safeguard her and her baby’s welfare, her actual physical condition will be favorably affected by the condition of mind thus produced. And her patience and courage will often be strengthened if the nurse will explain, from time to time, the cause of certain conditions that normally arise, and which otherwise might give her alarm. It is the mysterious events, the unexpected and unexplained that so often terrify.

This giving of comfort and strength to the variety of temperaments and mentalities which the nurse meets among her patients will involve a very sensitive adjustment of manner on her part, but it is one aspect of her duty, none the less, and one which will give her great satisfaction.

FIRST STAGE

Happily, the onset of labor is usually gradual, as has been described, and there is accordingly ample time during the first stage for deliberate and unhurried preparation for the birth of the baby. The character of the preparation and of the nurse’s assistance will vary greatly according to the wishes of the attending doctor; the duration of labor; the circumstances and condition of the patient, and whether she is at home or in a hospital.

It is a fairly general routine, at present, both in hospitals and in the home, to give the patient a soap-suds enema and a shower or sponge bath, at the onset of labor; to braid her hair in two braids and dress her in freshly laundered stockings and nightgown and a dressing gown. The enema is given to empty the rectum of material which might be expelled during labor and contaminate the field. For this reason, enemata are often given until the fluid returns clear, virtually irrigating the rectum, and are repeated every six or eight hours during the first stage. The enema should be given to the patient in bed and expelled into a bed-pan, as it is not wise for her to use the toilet after labor has begun. Sometimes the vulva and perineal region are shaved and scrubbed at the onset of labor, either before or immediately after the bath and enema. But the time and sequence of the different steps in the preparation for labor are governed entirely by the wishes of the individual doctor, to which the nurse may very easily adjust herself.

The patient should be given a bed-pan and encouraged to void every four hours. If she is unable to do so, and the bladder becomes distended, the doctor will usually wish to have her catheterized, and with a rubber catheter. This distension is not uncommon, and in extreme cases the bladder may reach to the umbilicus. The nurse should therefore observe the amount of urine which the patient voids and also watch the lower abdomen for bladder distension, which may be observed easily, excepting in very fat patients.

The seriousness of a distended bladder lies in the fact that it may markedly retard labor, partly by interfering with the descent of the baby’s head and partly through reflex inhibition of the uterine contractions. The prevention of a distended bladder during labor, therefore, is of considerable importance.

As the pains are infrequent and not severe at first, the patient will usually prefer to be up and about, most of the time during the first stage, when it occurs in the daytime, and many doctors think it important that she should be. They feel that patients tend to stay in bed too much during the first stage, since being on their feet would really promote their comfort and also have a tendency to make the pains more regular and efficient. But, on the other hand, the patient must be cautioned against tiring herself, and should, therefore, lie down often enough and long enough to avert fatigue. When labor begins at night, it is well to advise the patient to stay in bed and to sleep as much as possible until morning. Even though her sleep be disturbed and broken by the labor pains, she will be much less tired in the morning than if she had gotten up and had no sleep at all.

The patient should also be advised against trying to hasten labor by bearing down during first stage pains, since the only result at this time will be to waste her strength which will be needed later. This is one of the points that the nurse will do well to explain; that no voluntary effort on the patient’s part, during the first stage, will advance labor and if she tires herself by making such efforts before the second stage pains begin she will not be able to use them as effectively as she would were she in a rested condition.

Bearing in mind the importance of conserving all of her forces, it is usually advisable for a patient in labor to have no visitors, particularly the type of person who would be likely to offer advice and gratuitous information.

She should drink water freely and take some kind of light nourishment about every four hours. As pain of any kind tends to retard digestion, the diet during labor is usually restricted to fluids, such as broths, weak tea or coffee and sometimes milk or cocoa; while occasionally crackers and crisp toast are allowed. Whatever nourishment is given must be very light because of the probability of the patient’s vomiting and the possibility of her having to be given complete anesthesia before the termination of labor.

The maternal temperature, pulse and respirations should be taken every two or four hours and the fetal heart rate from every hour to every two hours, according to the wishes of the doctor.

The time at which the nurse should call the doctor is the subject of considerable discussion. Doctors never want to be called too late, neither do they wish to be called unnecessarily early, though they prefer to have the nurse err on that side, if at all. On general principles the doctor should be notified as soon as the patient goes into labor, in order that he may make his various plans with the pending delivery in mind. But if the nurse remembers that in primiparÆ the first stage of labor usually lasts about sixteen hours and in multiparÆ about eleven hours, she will realize that if the pains begin between the hours of eleven p.m. and seven a.m., and are of average character, mild and infrequent, she is not warranted in disturbing the doctor’s much needed sleep, unless he has explicitly requested her to do so. But under average conditions he should be notified by seven o’clock in the morning that the patient is in labor; at what hour the pains began; their character and frequency at the time of the report; the patient’s temperature, pulse and respirations and general condition and the fetal heart rate.

During the early hours of the first stage the nurse should begin to arrange the room and bed for delivery. She will need two, or preferably, three tables, though the top of a bureau may be used in place of one table. A washstand or the bathroom should be equipped for the doctor with soap; two sterile brushes; nail scissors or clippers and file or orange stick; hot water; alcohol and a solution of bichlorid 1–1000, biniodid 1–5000, lysol 2 per cent. or any solution that he may wish; sterile gloves and sterile vaseline or albolene to lubricate his hands. In short, an equipment which will enable him to prepare his hands exactly as he would for performing a major operation.

A large receptacle of water may be boiled, covered and set aside to cool; a boiler or large kettle placed in readiness for boiling instruments or other appliances that the doctor may bring; the room may be given a final cleaning: floor wiped up, furniture and all small articles wiped with a damp cloth; the unopened packages of dressings, sterile douche pan, irrigation-bag and basins may be placed on the tables, ready to be opened when needed, together with the other articles which have been prepared.

In preparing the bed in a patient’s home, it is practically always advisable to make it firm by slipping a board, or the leaves from a dining-table, between the mattress and springs. The bed should be made up with three freshly laundered sheets, the entire mattress being protected by means of a rubber placed under the lower sheet; next a rubber draw sheet, covered by one of muslin, while the top sheet, light blanket and counterpane should be left free at the foot. A flat hair pillow is better than one of feathers.

If the doctor wishes to make a vaginal examination, it devolves upon the nurse to prepare the patient with the most scrupulous care, as it is by means of vaginal examinations, made without careful preparation, that so many parturient women are infected. In fact, even the most conscientious preparation sometimes seems to be an inadequate safeguard, for infection has been known to follow in its wake. For this reason, some obstetricians prefer to make no vaginal examination during labor, when previous inspection has indicated that the case is normal, depending rather upon rectal examinations for guiding information.

The patient should be placed in bed, on a douche pan, with knees flexed and well separated; gown tucked up under her arms; draped with a sheet or the bedding folded down to her knees according to the extent of the area to be prepared; and the articles needed for the preparation arranged on a table at the bedside. The nurse should trim her nails, scrub her hands with soap and hot water; shave the vulva, supra-pubic region and inner surface of the thighs and rinse with sterile water. In shaving the vulva, the strokes should be from above downward, greatest care being taken not to allow hair, soap or water to enter the vaginal opening. She should then scrub her hands vigorously for three minutes, scrubbing about the nails with especial thoroughness. Some obstetricians have the entire area from the umbilicus to the knees prepared as for an operation, while others prepare only the supra-pubic region, inner surface of the thighs and the vulva. The number and kind of solutions which are used in this preparation also vary greatly, but in general the shaving is followed by a thorough scrubbing, by clean hands, with green soap and sterile water, then iodin, lysol or alcohol and bichlorid or biniodid solution, according to the custom of the doctor. (Fig. 74.)

But the kind and number of the solutions are probably not so important as the nurse’s technique. Throughout the entire course of the preparation she must apply the principles of what she was taught about the technique of preparing the skin for an operation and regard the perineal region in the same light as she would the field which was being prepared for a major operation; scrubbing from the centre toward the periphery, always, in order not to carry infective material from an unclean to a clean area, which in this case is the vaginal outlet.

Fig. 74.—Bathing the vulva preparatory to vaginal examination or delivery. (From photograph taken at Johns Hopkins Hospital.)

The supra-pubic region and abdomen are scrubbed across, back and forth, working up from the symphysis; the strokes on the thighs are up and down; in the groin, down toward the rectum, and away from the vagina, never toward it, and fluids poured upon the vulval region must never run into the vagina from over surrounding skin. A sponge or scrub ball must be discarded after approaching the rectum, or stroking away from the vagina in any direction. Some obstetricians instruct the nurse to place a firm, sterile cotton pad or scrub ball between the labia, against the vaginal opening while scrubbing and flushing the adjacent areas, to preclude the possibility of introducing fluids. But with a painstaking nurse this is scarcely necessary.

Fig. 75.—Patient draped for vaginal examination; vulva covered with sterile towel. (From photograph taken at Johns Hopkins Hospital.)

After the surrounding areas have been prepared, the labia are separated and the inner surfaces scrubbed, first across, then from above downward, and flushed by pouring the solution directly between the folds. After the patient has been given this preparation, a dry sterile towel or pad is placed over the vulva; the douche pan is removed, the back and hips are dried, after which the patient is so draped with a clean sheet that only the perineal region is exposed, and a sterile towel is slipped under the buttocks. (Fig. 75.)

To summarize the preparation for vaginal examination or delivery:

1.: Trim nails and scrub hands with soap and hot water.
2.: Shave vulva.
3.: Scrub and soak hands.
4.: Scrub vulva, inner surface of thighs and lower abdomen with green soap and sterile water, alcohol, 70%, and lastly bichloride 1–1000 or lysol 1% or 2%, using sterile sponges and taking care not to contaminate vulva from surrounding fields.
5.: Cover vulva with sterile towel or pad.

This may be taken as a description of a fairly typical method of preparing a patient for vaginal examination or for delivery, which is widely employed and with satisfactory results. But it is by no means the only satisfactory procedure, for many other and different methods of preparation also are followed by excellent results, as measured by the patient’s temperature during the puerperium.

The details of preparation vary so greatly, even among different doctors in the same hospital, that the nurse will simply have to bear in mind the general principles of asepsis and antisepsis, and adjust herself to the practices of the individual doctor. And she must remember that in spite of the best planning, there will be emergencies and precipitate labors, when the preparation will necessarily be modified, and sometimes so curtailed that even the bath and enema are omitted.

But in all cases the nurse can, and must, bear in mind that on one point there is virtually no difference of opinion among obstetricians of to-day; and that is the imperative necessity of having everything sterile that is brought to the perineal region or used in any way in connection with the delivery, or as nearly sterile as is possible under the circumstances.

By many doctors this is considered the most important factor, as to surgical cleanliness, in the entire preparation. In their opinion the local preparation of the patient may, with safety, be restricted to clipping the pubic hairs (instead of shaving), and scrubbing the vulva with only soap and water. But these doctors believe at the same time that the patient is dangerously susceptible to infection which may be conveyed to her from without, and accordingly they do not permit vaginal examinations to be made during labor, and make the most exacting demands concerning the maintenance of perfect surgical technique, by all who assist with the delivery.

Fig. 76.—Wrong and right methods of boiling gloves. Note that gloves in basin at the left are partly above the surface of the water and therefore will not be sterilized. Those in basin at the right are kept below the surface by the weight of the towel and will be sterilized by the boiling water.

In this connection, much depends upon the actual sterilization of the rubber gloves, either by boiling or by steam under pressure; and the method of putting on the gloves, in order that once having been sterilized, they may be kept so. It is useless to attempt to sterilize gloves by boiling, if they are thrown loosely into a kettle of water. There will practically always be enough air in the fingers to keep at least a part of the gloves out of the water, and consequently unaffected by its heat. They should be put into a covered wire basket that will be entirely submerged, or they may be wrapped in a towel, the weight of which will carry them below the surface of the water (Fig. 76), and insure their being completely covered while boiling, which should continue for ten to fifteen minutes. The doctor will usually want boiled gloves placed in a large basin of bichlorid solution, 1–1,000, or lysol 2 per cent., from which he may remove them after scrubbing his hands. If dry gloves are used, there should be in readiness a sterile towel and powder with which to dry and powder the hands before putting on the gloves. (Fig. 77.)

Fig. 77.—Powdering hands before putting on dry gloves. (From photograph taken at the Brooklyn Hospital.)

Whether boiled or steamed, the cuffs of the gloves should first be turned up toward the hand, to make it possible to put them on without touching the glove fingers with ungloved hands. (Fig. 78.) For no matter how long and carefully the hands are scrubbed and soaked, they cannot be made absolutely sterile, and therefore, in relation to the gloves which are sterile, the bare hands must always be regarded as unclean. Too much thought and attention cannot be given to the sterilization and handling of the gloves, for the patient’s very life may depend upon their aseptic condition.

After the doctor has seen the patient, the nurse will make observations and communicate with him in accordance with instructions which she must make sure to obtain from him at that time. Many doctors wish to be with a primipara continuously from the time the cervix is completely dilated, and with multiparÆ after it is half dilated. But that, of course, is a matter which each doctor decides for himself. The nurse’s responsibility is to learn his wishes.

Fig. 78.—Successive steps in proper method of putting on sterile gloves to avoid contaminating outside of gloves with bare fingers. (From photographs taken at the Long Island College Hospital.)

Watchfulness, then, is of extreme importance; watching for symptoms of complications or change in the patient’s condition, and watching the progress of labor in order to keep the doctor fully informed about his patient’s condition. Nurses are very frequently taught to make rectal examinations for the sake of increasing the value of their assistance in this respect.

Although unexpected symptoms do not, as a rule, develop suddenly during the first stage, the nurse must be none the less vigilant for them. The doctor should be notified if the pains suddenly grow either more or less frequent, or more or less severe; if there is any bulging of the perineum; if the membranes rupture; if there is any bleeding or a prolapsed cord; if there is extreme restlessness or any evidence of unusual distress; a rising temperature or pulse; a temperature of 100° F. or a pulse of more than 100 or less than 60; a fetal heart rate of more than 150 or less than 116, or any marked change of any kind in the patient’s condition.

During the latter part of the first stage, and during the second stage, the patient has an almost continuous desire to empty her bowels, because of pressure made upon the rectum by the descending head. This is another point which the nurse explain to her patient, in assuring her that frequent attempts to use the bed-pan will give no relief.

The end of the first stage is reached when the cervix is fully dilated, at which time the pains occur about every two minutes, are stronger and more severe, and the patient begins to feel like bearing down. The membranes frequently rupture at this point and the vaginal discharge is blood tinged. The patient should remain in bed and not be left alone from this time on.

To sum up the nurse’s duties during the first stage of labor, when the patient is almost entirely in the nurse’s care:

1.: She must be a sympathetic, encouraging friend to the patient.
2.: She must help the patient to preserve her strength by giving her light nourishment about every four hours; by advising her not to bear down; not to exhaust herself by walking about too much but to lie down when tired.
3.: She must watch the progress of labor and watch for symptoms of complications.
4.: She must employ strictest aseptic and antiseptic methods.
5.: She must prepare for the birth of the baby.

SECOND STAGE

The second stage is shorter, harder and more perilous than the first. The uterine contractions are stronger; more frequent and more expulsive, and the baby steadily curves and rotates its way down through the birth canal.

With the onset of the second stage the nurse should complete the preparations for the baby’s birth, bearing in mind that with a primipara the baby probably will not come for an hour and a half or two hours, but may come in half an hour or less if the patient is a multipara. Everything which is to be used should be conveniently placed, but the packages are not necessarily opened at this time.

In addition to the sterile dressings, basins, gloves, instruments and various other articles which have been enumerated, the nurse must remember that there should be for the baby a box or basket lined with a blanket and containing one, or preferably two, hot-water bottles at 125° F.; in hospitals, an adhesive strip for the baby’s name or a name necklace; a binder of flannel or sterile gauze, according to the custom of the doctor; sterile olive oil or albolene for the first oiling and one or two tubs, in case the baby needs to be resuscitated.

There will be needed, also, a covered basin for the placenta; chloroform and an inhaler; Wassermann tubes, for those doctors who make this test as a routine; hypodermic syringe and needles, with pituitrin, ergotole and drugs for stimulation which the doctor may specify. (Figs. 79, 80.)

In the meantime, the force and frequency of the pains should be noted, and some doctors require a record of both the fetal and maternal pulse rate every half hour, and notification if the baby’s is over 150 or below 116, or the mother’s over 100 or below 60. Extreme restlessness, distress, vaginal bleeding, prolapsed cord, a temperature of 100° F., or any marked change must be communicated to the doctor immediately, if it occurs before he has started for his patient.

The patient may complain of intense pain in her back and cramps in her legs during the second stage. Pressure made by the nurse’s hand, or a small pillow slipped under the small of the back will frequently relieve the backache, while cramps in the legs may be relieved by straightening, and slightly elevating the leg, and rubbing it while in that position. As these pains are usually due to pressure they have no serious significance and subside as soon as the child is born.

Fig. 79.—Bed and simple equipment in readiness for normal delivery. (From photograph taken at Johns Hopkins Hospital.)

On table by bed:
Sterile: cover.
towels, 6.
bag of sponges.
delivery pad.
pair of leggings.
delivery sheet.
doctor’s gown.
perineal pads.
cord ligatures.
Lower shelf: douche pan.

Window sill:
Baby box with hot-water bag
at 125° F., and blanket.
Chloroform dropper and inhaler.
Sterile albolene for baby.
Alcohol.
Baby band.
Wassermann tubes.

Second table:
Basin of instruments.
Basin of bichloride, 1–1,000 with pair
of gloves.
Sponge sticks in alcohol.
Hypo, tray: pituitary liquid.
ergotole.
syringe and needles.
alcohol.
pledgets.
Lower shelf: 2 tubs for resuscitating baby.
Covered placenta basin.
Dressing basin.

Head of bed:
Nightgown.
Sheet.
Stockings.
Towel.

The nurse may find herself in any one of three situations during the second stage. The doctor may arrive in ample time to conduct the delivery; he may be slightly delayed and the nurse endeavor to retard labor, according to instructions; or the baby may be born, with or without the expulsion of the placenta, before his arrival.

When the doctor arrives at the onset of, or during the second stage of labor, the nurse acts solely under his direction, the nature of her offices depending somewhat upon the condition and surroundings of the patient, and whether or not the nurse is the only person at hand to give assistance. In any case, the gloves, and instruments for repairing a tear should be boiled and in readiness; the dressings and other articles to be used are to be conveniently arranged upon the tables and opened at the proper time.

Fig. 80.—Instruments for normal delivery shown in boiling basin on table in Fig. 79: Needle holder. Blunt hook. Blunt scissors. 2 small Kelly clamps. Mouse tooth forceps. 4 towel clips. 2 large perineal needles and 2 cervical needles in gauze sponge.

After having everything ready and at hand for the delivery, the nurse may be called upon to clean up and act as an assistant, or to give the anesthetic. If she cleans up, she should wear a sterile gown and gloves, and if it is the doctor’s custom, a cap and mask as well, having prepared her hands somewhat as follows:^[6]

1.: Scrub hands and arms with hot water and green soap for five minutes, paying especial attention to the fingers and nails.
2.: Clean and trim nails and scrub again for five minutes.

Fig. 81.—Old prints illustrating early ideas of suitable methods of making examinations and conducting deliveries, furnishing interesting contrast with present-day methods. Concern seems to be divided between the patient and the signs of the Zodiac in the picture at the right.
3.: Soak and scrub hands and forearms in alcohol, 70%, for two minutes.
4.: Soak in bichloride solution, 1–1000, for five minutes.
5.: Put on gloves out of second bichloride solution, avoiding contact with fingers of ungloved hand. (See Fig. 78.)

Fig. 82.—Patient draped with sterile towels, leggings, sheet and delivery pad for delivery. (From photograph taken at Johns Hopkins Hospital.)

The patient is given a final scrubbing with green soap and sterile water and an antiseptic solution, by some one with clean hands, and is further protected by means of sterile leggings, a sterile towel across the abdomen and one covering the inner surface of each thigh, held in place by sterile clips or safety pins. The lower half of the bed is covered with a sterile sheet while a sterile delivery pad is slipped under the patient’s hips. (Fig. 82.)

If the delivery is made with the patient lying on her side, the sterile dressings are so arranged as to cover all but the perineal region after she is placed in the desired position.

This brings up the question of the nurse’s obligation to protect her patient from the embarrassment of unnecessary exposure at any time during labor. The field which is prepared must be uncovered temporarily, and while the patient is being draped for examination or delivery a certain amount of exposure is unavoidable; but there are many little ways in which the nurse may show her consideration for the patient in this connection and the patient always appreciates the protection.

During the second stage, the preservation of asepsis, watching the progress of labor and watching for unfavorable symptoms, are of even greater importance than during the first stage. After the patient has been prepared and draped with sterile dressings, neither they nor the perineal region should be touched with anything unsterile.

If for any reason it has not been possible to sterilize sheets and towels, or more are needed after the prepared supply has been exhausted, the inner surfaces of towels and sheets that have been ironed either by hand or machinery, and folded with the ironed surfaces inside without being touched, may be regarded as practically sterile.

As the second stage advances, the patient may greatly aid the progress of labor by voluntarily bearing down during pains, and the nurse in turn may be called upon to help by encouraging her and explaining just what she should do. At the beginning of a pain the patient should take a deep breath, close her lips, brace her feet and strain with all her strength. If she opens her mouth and cries out, she fails to use her pains to the best advantage. The effect of this bearing down may be increased by providing the patient with straps, attached to the foot of the bed, upon which she may pull during the contractions, as she bears down. (Fig. 83.) Or, what is often a great comfort to her, she may pull upon the nurse’s hands as the latter braces herself so as to offer strong resistance. If the nurse can be spared from other duties to give this kind of assistance, it is indeed a comfort to the patient, who appears to derive from it both a moral and physical sense of being helped in her struggle. It is also important to assure the patient, between pains, that she is doing well, and that her efforts are advancing the baby, if this is true; and if not, she may under ordinary conditions be urged to make greater effort.

Fig. 83.—Patient pulling on straps while bearing down during second stage pains. (From photograph taken at Johns Hopkins Hospital.)

Before the head can be seen at the outlet or its advance noted by perineal bulging, the stage of its descent is often ascertained by palpating through the perineum, the fingers of a gloved hand pressing upward, on one side of the vulva. (Fig. 84. See Figs. 85, 86, 87, and 88 for appearance, advance and birth of head during normal delivery.)

Immediately after the birth of the head, and before the birth of the body, the nurse is frequently asked to wipe the baby’s mouth and eyes and sometimes to drop nitrate of silver into the eyes. In such a case she should wipe out the mouth very gently with a bit of sterile gauze, wet with boric, wrapped about her little finger, reaching well back into the throat; the eyes should be wiped from the nose outward, a separate wipe being used for each eye. The purpose of these maneuvers, when they are employed, is to favor respiration from the beginning by removing mucus that might impede it and to remove possible infective material from the lashes before it is spread to the conjunctivÆ by the baby’s winking. The silver solution is to destroy germs that may have gotten into the eye.

Fig. 84.—Palpating through the perineum to ascertain the stage of descent of the baby’s head. (From photograph taken at Johns Hopkins Hospital.)

As soon as the baby is completely born a sterile douche pan should be slipped under the patient or a small sterile basin placed close to the perineum, to receive the blood which escapes during the third stage. This is partly to protect the bed, but chiefly that the blood may be measured, as in no other way can it be ascertained how much the patient loses. A loss of 600 cubic centimetres or more is regarded as a hemorrhage.

Fig. 85.—Baby’s head appearing at the vulva at the height of a pain. (This and succeeding pictures of a normal delivery are from photographs taken at Johns Hopkins Hospital.)

Fig. 86.—Advance of the head indicated by stretching of the vulva and perineum.

Fig. 87.—Holding back the head at the height of a pain to prevent a perineal tear.

Fig. 88.—Birth of the head immediately followed by external rotation.

Fig. 89.—Wiping mucus from baby’s mouth with gauze wrapped about little finger.

Immediate Care of the Child. After the baby has been brought safely into the world, it is of greatest possible importance to make sure that it begins its separate existence by crying lustily, in order fully to expand its lungs. This provides for oxygenation of its blood, which has taken place, until now, through the placental circulation. In many cases the baby cries satisfactorily without aid, but not infrequently must be stimulated to do so. In all instances the first step is to clear the air passages of the mucus lodged in the mouth and throat, by some one of the many approved methods. One is by means of a piece of wet sterile gauze wrapped about the little finger, and wiped gently about in the back part of the baby’s mouth (Fig. 89), though many doctors object to this procedure for fear of abrading the very delicate mucous membrane, no matter how lightly it is done. They prefer to hold the baby by its feet, with the head hanging down and the neck sharply curved backward, when by gravity the mucus will drop out of the mouth; or, holding the baby by the feet, to run the thumb and forefinger along the neck on either side of the trachea, toward the mouth, and force out the mucus in that way. If the baby does not cry well after the mucus is removed, it may usually be stimulated to do so if held by the feet, head downward, and the back gently rubbed (Fig. 90) or the face stroked or the buttocks spanked two or three times. When holding the baby in this position the nurse should slip one finger between the ankles and grasp them firmly.

Fig. 90.—Stroking baby’s back to stimulate respirations.

After the baby has cried well it may be laid on the foot of its mother’s bed. At this juncture it seems pertinent to stress two points which must be remembered throughout the entire routine of the baby’s care, namely: the importance of protecting it from infection and from being chilled. As the baby lies on the mother’s bed, before the cord is cut, it finds itself in a room which is many degrees cooler than the very warm habitat from which it has just emerged; it is struggling to establish its functions, which are suddenly deprived of the mother’s help, chief of which at the moment are respiration and the circulation. Body warmth is one of the most valuable aids in promoting an even circulation, and accordingly the baby should be kept warm from the beginning. For this purpose there should be a small sterile blanket, or piece of flannel, in readiness to protect the little body as it lies on the bed, awaiting further developments. The hands and feet of the newborn baby that lies uncovered for even a quarter of an hour, or more, are nearly always cold, and as this must be guarded against in an older, more securely established baby, it cannot be desirable for the newly born.

Fig. 91.—Showing two clamps on cord after pulsation has ceased.

Fig. 92.—Wrong and right method of tying knot in cord ligature. A will slip. B will not.

As soon as the cord ceases to pulsate, it is usually clamped with two clamps about two inches apart (Fig. 91) and cut between the clamps. The scissors should have blunt points, in order not to scratch or cut the baby, who may be wriggling vigorously by this time. The cord is tied tightly with a sterile cord ligature, in a square knot that will not slip (Fig. 92), about an inch from the abdominal wall. It is considered a safe precaution, after removing the clamp, to bend the cord back upon itself and tie it a second time with the same ligature, as the danger of hemorrhage from a loosely tied cord is serious when the baby is kept sufficiently warm. The placental end of the cord is also tied, or it remains clamped until the placenta is expelled, because of the possibility of there being another child in the uterus and the danger of its bleeding to death through the open cord.

Some doctors do not tie the cord, but crush the vessels with a clamp which is left on the cord for about half an hour and then permanently removed, but this should not be done by a nurse upon her own responsibility.

Very often the person who performs the delivery removes the blood, mucus and vernix from the baby’s body, as soon as the cord is tied, by sponging it thoroughly with albolene or olive oil; wraps the cord stump with a sterile, dry or alcohol sponge and applies the abdominal binder while an assistant holds the baby by the feet, head down. It is also very common simply to oil the baby with unsterile lard, oil or vaseline, cover the cord with sterile gauze and leave the bath, cord-dressing and binder to be attended to later.

If the delivery takes place in a hospital the baby must be marked before it is taken from the delivery room, with adhesive plaster, upon which its mother’s name is plainly printed, or with the name necklace, now so frequently used.

The baby is once more wrapped in a warm blanket and placed, with a hot-water bottle, at 125° F., in the basket or box, which was prepared for it. Although the baby should be well covered, care must be taken to leave the face fully exposed as a young baby is easily suffocated. It was formerly customary to lay the new baby on its right side, but with the present fuller knowledge of the fetal circulation and the changes which take place after birth, this practice has been largely done away with.

Resuscitation of the Newborn Baby. If the baby breathes feebly, or even if it does not cry vigorously, the effort to stimulate the respirations may have to be continued for an hour or more after the cord is tied. In addition to the simple methods, previously described, which are very commonly employed at the time of labor, such as stroking the baby’s back or holding him by the feet and spanking him (Fig. 93), the following measures are sometimes resorted to if the baby’s condition demands it:

Fig. 93.—Stimulating respirations by holding the baby head downward and sharply spanking him. Note the method of grasping the baby’s ankles with one finger between them to prevent his slipping from the nurse’s hand.

One method is to hold the baby with its chest resting on the palm of one hand, with head, legs and arms hanging forward, thus compressing the chest wall and favoring expiration (Fig. 94), and then turning it over on its back, in the other hand, in which position the head, legs and arms hang backward, thus expanding the chest and favoring an inspiratory movement. (See Fig. 95.) Alternate repetitions of these positions, about twelve times a minute, will often stimulate the child to breathe satisfactorily.

Fig. 94. (See also Fig. 95.)
Figs. 94 and 95 show method of stimulating respirations by resting the baby alternately on his chest and back on the nurse’s hands. (From photographs taken at Bellevue Hospital.)

Another method is alternately to plunge the baby into tubs of hot and cold water. But as there is doubt about the wisdom of chilling the entire surface of the baby’s body, the cold plunge is forbidden by many doctors, who, instead, dash a little cold water upon the face and chest, while the body is immersed in water at about 110° F.

Fig. 95.—Resuscitating the baby. (See also Fig. 94.)

A widely used and efficacious method is to hold the baby continuously in a tub of water at about 110° F., and alternately extend and fold its body, thus keeping it warm while stimulating inspiration and expiration. (Figs. 96, 97.)

Direct insufflation may be employed while the baby is in the warm water, by protecting its face with clean dry gauze and blowing directly into its mouth at intervals corresponding to those of normal inspiration. (Fig. 98.)

Fig. 96. (See also Fig. 97.)
Figs. 96 and 97 show method of resuscitating the baby by alternately
extending and folding his body under warm water. (From photographs
taken at Johns Hopkins Hospital.)

Another procedure is to hold the baby by the shoulders, with its body hanging down, thus expanding the chest, and then to toss it quickly upwards, folding the legs upon the chest to compress it. This method is objected to by many obstetricians on the ground that it both exhausts and chills the baby.

Fig. 97.—Resuscitating the baby. (See also Fig. 96.)

The outstanding requirements in resuscitating a baby are to stimulate its respiratory movements, by alternately expanding and contracting the chest; to promote its circulation by keeping it warm, and to avoid exhausting the very frail little body. Gentle handling, therefore, is important.

THIRD STAGE

After the birth of the baby, some doctors request the nurse to rest one hand on the mother’s abdomen in order to feel the fundus as it rises while expelling the placenta, and to keep him informed concerning its consistency. Others regard this as a dangerous practice and forbid it.

As a rule, there is little bleeding until the placenta has separated. If bleeding does occur, it is the practice of some doctors to have the uterus gently massaged through the abdominal wall, to stimulate contractions, while others consider this inadvisable.

Fig. 98.—Stimulating respiration by means of direct insufflation, the baby’s face being covered with clean gauze. (From photograph taken at Johns Hopkins Hospital.)

After the placenta separates and descends into the lower uterine segment, it produces a bulging just above the symphysis, while the fundus may be felt as a firm, hard mass above the umbilicus. Since the placenta is entirely separated from the uterus at this time, its complete expulsion is usually aided, when it does not occur spontaneously, by gentle pressure upon the fundus. The accoucheur holds his hand just below the vaginal outlet, to receive the placenta (Fig. 99), which he turns over and over in his hands, thus twisting the membranes, and gradually draws it away from the mother, the membranes trailing after in the form of a tapering cord. (Fig. 100.) It is important that the placenta and membranes be carefully examined to make sure that they are intact, for if fragments of either are retained within the uterus they will prevent its firm contraction and thus may be a cause of post-partum hemorrhage. For this reason, only very gentle pressure and traction are used in expressing the placenta and withdrawing the membranes, for the use of force might leave small particles adhering to the uterine lining, which would otherwise separate with the rest, in due time, as a result of the uterine contractions.

Fig. 99.—Delivery of the placenta.

Having been inspected, the placenta should be placed in a covered receptacle to be disposed of as the doctor directs, as many physicians make a routine laboratory examination of the placenta and wish to have it kept for this purpose.

With the birth of the placenta comes a gush of blood, as the uterine vessels, some of which are as large as a lead pencil at this time, are left wide and gaping. The bleeding usually subsides very shortly, however, as the blood vessels are closed by involuntary contraction of the network of uterine muscle fibres in which they are enmeshed, and which are sometimes referred to as “living ligatures.” If the bleeding continues, these contractions should be stimulated by massage. This is done by grasping the uterus through the abdominal wall firmly with one hand and kneading vigorously. Rubbing the top of the fundus with the fingers usually is not enough. The fundus should be grasped by the entire hand; the thumb curved across the anterior surface and the fingers, directed deep into the abdomen, behind it. (Fig. 101.)

Pituitrin or ergot, or both, are frequently given to further stimulate contractions of the uterine muscles. Since the action of pituitrin is quick, but evanescent, and the effect of ergot is slower and more lasting, both a quick and lasting effect is obtained by giving them together.

Fig. 100.—Twisting the membranes while withdrawing them from uterus.

The expulsion of the placenta ends the third stage and completes the process of labor.

Fig. 101.—Grasping fundus through abdominal wall in giving massage to stimulate uterine contractions.

Immediate After-care of the Patient. The patient should be bathed and dried about the thighs and buttocks, the vulva being bathed with alcohol or an antiseptic solution, and a sterile perineal pad applied. The douche-pan, wet towels, delivery pad and draw sheet are replaced by a dry draw-sheet and a towel or pad slipped under the patient’s hips, while a fresh nightgown is put on if the one worn during labor is wet or soiled. The perineal pad is very commonly held in place by a T. binder, with which all nurses are familiar, but some doctors prefer an abdominal binder to which a perineal strap is attached. This abdominal support may be a straight swathe or a Scultetus bandage, varying with the wishes of the doctor, and it may or may not be used in conjunction with a pad, so applied as to make pressure over the fundus. Other doctors forbid the application of any kind of a perineal dressing from the time of delivery, but instead, have a large, sterile pad slipped under the patient to receive the discharge.

The patient is usually tired and cold at the conclusion of labor, and may even have a nervous chill. Although this chill is not serious, the patient is none the less uncomfortable, and she should be warmly covered, be given something hot to drink, and a hot-water bag placed at her feet.

All possible effort must now be made to secure for her rest, quiet, and an opportunity to sleep. Every one but the doctor and the nurse had better be excluded from the room, which should be absolutely quiet, somewhat darkened and well ventilated. In addition to this, the majority of doctors now require that either they or the nurse shall stay with the patient and keep one hand resting on the fundus for at least an hour after delivery as a safeguard against post-partum hemorrhage. As long as the fundus is felt through the abdominal wall as a firm, hard mass, its irregularly arranged muscle fibres are contracted upon the blood vessels, and will prevent an escape of blood. But if the fundus feels soft and boggy, its muscles are relaxed, the constrictions are somewhat released from the open vessels, and serious bleeding may occur unless they are stimulated to contract again.

If the Doctor Is Delayed. It sometimes happens that labor progresses with unexpected rapidity, or that the doctor is delayed in his arrival and the nurse is accordingly confronted with the emergency of being alone with the patient during part or all of the delivery.

When the baby is making such rapid descent that the nurse fears it may be born before the doctor’s arrival, she may somewhat retard labor by covering her hand with a folded, sterile towel, if she has not had time enough to put on gloves, and hold back the head by pressing against the perineum during pains, at the same time instructing the patient to open her mouth, breathe deeply and try not to bear down. It is sometimes easier for the patient not to bear down if she lies on her side.

If by mischance, or in spite of her efforts, the baby so far descends that the brow appears before the doctor’s arrival, the nurse cannot safely hold it back longer because of the danger of the baby becoming asphyxiated. She should, up to this point, hold the head back during pains in order that the perineum may be stretched slowly, with the hope of preventing a tear. (See Fig. 87.) It is the sudden distension of the perineum and expulsion of the baby’s head at the height of a pain that frequently causes lacerations. If fecal matter is expressed during pains, the field should be wiped, downward, with sterile sponges and bathed with the antiseptic solution at hand.

After the brow is born, the nurse may gradually release the pressure and allow the head to emerge, and remembering the position of the child and the mechanism of its birth, assist Nature in its complete delivery. After the head is born, it drops down toward the mother’s rectum, after which external rotation, or restitution, takes place. (See Fig. 88.) A finger should be slipped around the neck in search of coils of cord, which, if felt, should be slipped over the baby’s head. Otherwise, pressure upon the cord in that unnatural position might so interfere with the circulation as to asphyxiate the baby.

The shoulders may be born spontaneously or the nurse may grasp the head with both hands, curving the fingers of one hand under the baby’s chin, and of the other, under the occiput, and make gentle, downward traction (See Fig. 69.) in order to slip the anterior shoulder from under the symphysis; and then pull gently upward, to deliver the lower or posterior shoulder (see Fig. 70.), after which the rest of the body follows easily.

This description of how a nurse may conduct a normal delivery by fairly typical and generally approved methods is only intended to guide her in an emergency, when there has been no understanding between her and the doctor about what she should do in event of his absence; or when he has authorized her to use her best judgment in safeguarding the lives of mother and baby.

It is obviously of extreme importance for the nurse to ascertain definitely the doctor’s wishes in this connection, as he sometimes will be unwilling to have the nurse give any attention to either mother or baby, even to tie the cord, before his arrival.

Prolapsed Cord. If the umbilical cord should prolapse at any time during labor, in the absence of the doctor, or lacking instructions, the nurse should elevate the patient’s hips, in order that gravity may lessen the pressure on the cord as it lies between the presenting part and the pelvic brim. Otherwise, the interference with the placental circulation may result in asphyxiation of the baby. (Fig. 102.)

Fig. 102.—Drawing showing how prolapsed cord may be pressed between baby’s head and pelvic brim, thus cutting off placental circulation.

The elevated Sims position is often effective. Or, a straight chair may be upturned and pushed under the mattress, from the foot toward the head, in such a way that the patient will be lying on an incline which slopes upward from the head of the bed toward the foot. Or the chair may be placed in the same position on top of the mattress, with the top of the chair-back under the patient’s shoulders. The chair should be padded with pillows in order to minimize the patient’s discomfort as she lies in this trying position.

Post-partum Hemorrhage. Should a post-partum hemorrhage occur, in the absence of the doctor, the nurse should massage the fundus, unless she has been instructed not to, and have some one elevate the foot of the bed on blocks or the seat of a firm, straight chair. The use of ice bags or cold compresses on the abdomen is sometimes helpful and some physicians advise placing the baby at the mother’s breast immediately, since the suckling stimulates the uterine muscles to contract.

In anticipation of a post-partum hemorrhage, the nurse must have a clear understanding of the doctor’s wishes, particularly in regard to the administration of pituitrin and ergot which are so widely and efficaciously used to check post-partum bleeding.

ANESTHETICS

Those of us who are accustomed to seeing anesthetics used to relieve patients of the worst of their pain, during labor, find it hard to realize that until comparatively recent years women went through this suffering without mitigation.

The use of anesthesia was introduced into obstetrical practice, in 1847, by Sir James Y. Simpson of Scotland, who first used ether but later adopted chloroform when he learned that it also had anesthetic properties. Its use in America was subsequently introduced by Dr. Channing of Boston.

In the early days, the idea of using anesthesia during labor was greeted with a storm of protest, both from the clergy and the laity, because of their belief that the relief of women in childbirth was contrary to the teachings of the Bible, as set forth in God’s curse on Eve, when He said, “In sorrow thou shalt bring forth children.”

There is to-day practical unanimity of opinion concerning the advantages which are derived from the use of anesthesia when any operative procedures are employed; but there is still some objection to its use in spontaneous deliveries. This is partly on medical grounds because of the possible ill effects of anesthetics and is partly a persistence of the early religious protest. However, in the vast majority of cases, some kind of an anesthetic, or analgesic, is administered to the woman in labor because the advantages of its use are generally conceded.

Fig. 103.—Method of giving chloroform for obstetrical anÆsthesia.

The agents used are chloroform, ether and nitrous oxid gas, while what is popularly called “twilight sleep” is produced, completely or in a modified degree, by the hypodermic administration of scopolamin and morphine.

Chloroform. Of these various drugs chloroform is apparently the anesthetic most widely used in normal obstetrics. Its advantages are that it is easy to give; quick in its action and is followed by little or no nausea or other ill effects. For some reason, as yet not explained, the woman in labor enjoys a certain amount of immunity against chloroform poisoning, but this tolerance exists only during labor as the puerperal woman is subject to the same dangers as any other individual.

Chloroform is not usually administered until the patient is well along in the second stage, or until the head may be felt through the perineum, or is in sight. The patient’s face should be oiled and protected with a towel or gauze folded across her brow, mouth and chin to prevent burns that might follow the inadvertent dropping of chloroform on her face. With the beginning of a pain, a few drops are poured on the inhaler which is held about an inch from the face to give a free admixture of air, and the patient is told to breathe in deeply. (Fig. 103.) The inhaler is removed as soon as the pain subsides, but reapplied as soon as another pain begins. The patient retains consciousness and is able to talk under this degree of anesthesia, but her suffering is greatly relieved. It has the advantage, also, of lessening the danger of perineal tears, as the accoucheur has better control of the delivery when the patient lies quietly than when she tosses violently about the bed, and a tear resulting from the sudden delivery of the head at the height of a pain may in this way be averted.

This light, intermittent anesthesia, now so widely used, is called obstetrical anesthesia or anesthesia À la reine, after Queen Victoria, upon whom it was first employed at the birth of her seventh child, in 1853.

When the perineum is distended to its maximum, obstetrical anesthesia is not always sufficient, and complete anesthesia may be employed; but even this requires very little chloroform. Under ordinary conditions, the anesthesia is discontinued as soon as the child is born, for unless there is an extensive tear, the patient is sufficiently anesthetized to permit of a perineal repair and the delivery of the placenta.

Chloroform is not often given early in labor because of the general belief that its free or prolonged use lessens the force and frequency of uterine contractions, thus prolonging labor, and also may unfavorably affect the child. But small doses seem to stimulate rather than retard contractions, and by having her pain relieved, the patient is prompted to make greater effort to use her abdominal muscles, an end greatly to be desired.

If complete anesthesia is needed for more than a few moments, after the child is born, ether usually replaces the chloroform, being considered more satisfactory for prolonged anesthesia, but many obstetricians prefer not to give it until after delivery because of its possible effect upon the child.

Fig. 104.—Giving ether for obstetrical anÆsthesia. Ether is poured into cone which is covered with nurse’s hand to prevent evaporation. When the beginning of a contraction is felt by hand on abdomen, the cone is placed about an inch from the patient’s face. (From photograph taken at the Maternity Hospital, Cleveland.)

As chloroform poisoning is likely to produce degenerative changes in the liver, and eclampsia also causes a liver necrosis, chloroform is not used for an eclamptic patient.

Fig. 105.—As pain increases and patient becomes accustomed to ether, the cone is lowered and held close to her face until pain subsides. Sufficient ether to control the next pain is then poured into cone. (From photograph taken at the Maternity Hospital, Cleveland.)

Ether, also, is used widely in normal obstetrics and is almost always preferred for continuous anesthesia, because of its being safer than chloroform. Unlike chloroform, ether is sometimes given in the first stage after the pains have become severe and frequent. About a dram of ether is poured into the cone which is held just off the patient’s face (Fig. 104.) until the beginning of a contraction, at which time it is lowered and held close to her face (Fig. 105.) As the action of ether is slower than chloroform, it should be poured into the cone in advance of a pain, which the nurse anticipates by feeling the uterus begin to grow hard under the hand which she keeps upon the patient’s abdomen. If the ether is not poured into the cone until a pain begins, its anesthetic effect may be lost because of the delay in its administration.

At the Cleveland Maternity Hospital, where ether is used during normal labor, the nurses are taught to give it as has just been described, with further instructions from Miss MacDonald, as follows: “A patient will vaporize about one dram of ether per pain during the early first stage, gradually vaporizing a greater amount until she will vaporize two or three drams per pain near the end of the second stage. Should the patient reach the excitement stage of ether before she is in the second stage of labor, discontinue the ether for from five to fifteen minutes, then give a lessened amount.

“Should it be necessary to control the descent of the presenting part, light anesthesia may be given. This may be managed by putting about two drams of ether in the cone at intervals frequent enough to sufficiently retard the descent of the presenting part. This procedure almost obliterates contractions. Lift the cone from the face for a few moments at frequent intervals to admit air. Keep the ether vapor of such concentration as avoids choking, coughing or vomiting. This may be done by administering a small amount frequently, rather than a large amount at longer intervals. When the desired stage is reached, try to keep the patient at this degree of anesthesia by giving a few drams of anesthetic at regular intervals.”

Nitrous Oxid Gas Analgesia. The effect of this drug is termed analgesia rather than anesthesia, because the patient does not lose consciousness but is unconscious of pain. From a medical standpoint it is considered practically ideal for use in obstetrics. If given skillfully it seems to have no bad effects upon the child; it tends to stimulate, rather than diminish uterine contractions; it may be started, with safety; as soon as the patient begins to suffer severely, and continued for several hours if necessary.

Its disadvantages are that it is very expensive; it can be given safely only by a skillful, trained person; the apparatus necessary for its administration is expensive, heavy and difficult to transport. But when these difficulties can be overcome, its use is attended with very satisfactory results.

“Twilight Sleep,” so called, or DÄmmerschlaf, as it is termed in Germany, has been and still is discussed so widely, that the nurse should know something of it, whether or not she aids in its administration. It may be described as a state of amnesia, or forgetfulness, produced by the hypodermic injection of morphin and scopolamin. The patient, therefore, is conscious of pain at the time but speedily forgets it.

This treatment was first used widely in Freiburg. Following an enthusiastic report from there upon a large number of cases in which it had been used, there was such a clamor for it by American women, that its temporary use was practically forced upon obstetricians in this country. It was given what appears to have been a fair trial, but its continued use in this country has not been widespread. Those obstetricians who object to its use describe its disadvantages as follows: It cannot be used outside of a well-conducted hospital; it requires the constant attendance of a well-trained obstetrician or obstetrical nurse throughout the entire course of labor; it is suitable for use in certain selected normal cases only; it prolongs the second stage and increases the percentage of cases in which operative interference is necessary; it has an asphyxiating effect upon the child and increases the percentage of fetal deaths.

On the other hand, the use of scopolamin and morphin is a routine in certain excellent maternity hospitals, and by many obstetricians of the first rank, who maintain that with a nurse in attendance and the observance of ordinary precautionary measures, the advantages far outweigh the disadvantages of a modified “twilight sleep.” An anesthetic is usually administered during the second stage, after the use of the scopolamin-morphin treatment.

Complete Anesthesia. If an emergency should arise and the nurse be required to change from the light anesthesia À la reine, and to give complete anesthesia, her responsibilities increase, for she must watch carefully the patient’s pulse, respirations, color and pupils. The flat pillow which is ordinarily left under the patient’s head during normal labor, should be removed and the inhaler should be held closely over her face with the nurse’s fingers so placed as to hold it in position and also to hold the patient’s jaw forward and up. (Fig. 106.)

The ether should be dropped in clean drops, not poured, upon the inhaler. The dripping should be steady, but slow at first, gradually increased as the patient becomes accustomed to the fumes.

Fig. 106.—Method of holding inhaler and supporting patient’s jaw in giving ether for complete anesthesia. (From photograph taken at Johns Hopkins Hospital.)

With the average, normal patient who is taking ether well the respirations become somewhat stertorous and more rapid, increasing to possibly 36 or 40 per minute; the pulse starts at a little above the normal rate and increases to 116 or 120 and then drops to normal, which is slightly below the rate at which it started; the color is normal at first and then may become crimson, or it may change very little; the pupils first dilate, and then contract almost to a pin point.

Unfavorable signs are: respirations that are rapid and shallow, then possibly slow, but still shallow; increasing pulse rate, this being so serious that the ether is usually stopped if the pulse approaches 140, and stimulation is promptly given; cyanosis which is slight at first and then extreme, and dilated pupils.

It is obviously not wise nor possible to attempt, by means of a few paragraphs and illustrations to teach a nurse so technical and important a procedure as the administration of an anesthetic, but it is hoped that these general suggestions may be helpful, particularly to the nurse who is unexpectedly confronted by an emergency.

Under all conditions the nurse must remember that no matter what anesthetic is given, nor by whom it is administered, she must guard against the very prevalent tendency to talk freely while the patient is going under, in the belief that she is unaware of what is going on about her. Many patients suffer great mental distress because of hearing, or partly hearing conversation not intended for their ears, which takes place in their hearing while they are incompletely anesthetized.

CHAPTER XIII
OBSTETRICAL OPERATIONS AND COMPLICATED LABORS

Unhappily, not all labors run the smooth and uncomplicated course which was described in the last chapter. Certain abnormalities sometimes arise to complicate delivery, occasionally necessitating operative interference or relief.

There is little that a nurse can do alone, in the presence of complicated labor, but her preparations and assistance will be more effective if she understands the purpose of the operations, and she will better appreciate the gravity of certain symptoms, which she is required to watch for and report, if she realizes the extreme seriousness of their import.

The principal conditions which give rise to, or follow complications, prevent spontaneous delivery or necessitate operations at the time of labor are perineal lacerations; contracted or malformed pelves; marked disproportion between the diameters of the child’s head and mother’s pelvis; ruptured uterus; exhaustion of the mother; poor muscle tone or certain chronic and acute diseases of the mother; death of the fetus; prolapsed cord; certain presentations of the fetus in which spontaneous delivery is doubtful or impossible.

The preparations for operations in hospitals are all so carefully planned and systematized that in the presence of such emergencies the nurse will merely have to carry out the customary routine, but in a patient’s home she may have to exercise a good deal of originality in attempting to meet the needs of the occasion and imitate hospital provisions.

A satisfactory operating table may be fashioned in any one of a number of ways. If the bed is high enough, it may sometimes be made fairly satisfactory by slipping a board, such as a table leaf, under the mattress to make it firm. The use of a kitchen table is time-honored, but it is an unsafe practice unless the available table is very secure and firm, which is usually not the case with present-day kitchen tables. A flat-topped chest of drawers, with the casters removed, makes an excellent operating table, for it is firm, a good height and about the right size. Or an ordinary bureau may be pressed into service after taking out the casters and removing the mirror by unscrewing its supports. The front and sides of a bureau, or chest of drawers so used should be protected from the damaging effects of fluids and solutions by being covered with a bed-rubber or newspapers. A pad for the top of the improvised operating table may be arranged by folding a blanket or quilt to the proper size and folding over that the rubber draw-sheet and a clean muslin sheet.

If the operation requires that the patient be held in the lithotomy position (on her back with thighs and knees flexed and knees well separated), and the doctor’s equipment does not include a strap to hold the legs, one may be improvised from a sheet. It should be folded diagonally, over and over, into a strip possibly a foot wide, passed over one shoulder and the tapering ends used to tie around the legs, above the knees, to hold them in the desired position. Bandages or tapes are not always satisfactory, for the support is subject to a good deal of strain, and narrow strips sometimes cut painfully into the legs and shoulders. Certainly if tapes or bandages are used, cotton pads or folded towels should be interposed between them and the patient’s skin.

In general, the nurse will prepare as for a normal delivery, in each instance adding such details of equipment, or preparation as the contemplated operation requires. Rigid asepsis must be observed throughout the preparations and the operations. When large instruments or appliances are to be used, a wash boiler is probably the safest thing in which to boil them, for it is scarcely possible entirely to cover them with water in a smaller receptacle; and they must be well covered while boiling, or they will not be sterile.

Perineal Lacerations. A large proportion of women during the birth of the first baby sustain some degree of perineal laceration, which may amount to nothing more than a nick in the mucous membrane, or it may extend entirely across the perineal body and tear through the rectal sphincter. The causes of these tears are generally conceded to be rigidity of the perineal muscles; disproportion between the size of the child’s head and the vulval opening; a sudden expulsion of the child’s head, before the perineum is fully distended, and certain abnormalities in the mechanism of labor. Lacerations may, therefore, be prevented, or limited, in many cases by holding back the baby’s head and allowing it to dilate the perineum slowly. But in spite of the most skillful and careful efforts, tears of some degree occur in most primiparÆ, and probably in half of all multiparÆ. These injuries are usually described as being of the first, second or third degree, according to their extent.

A first degree tear is one that extends only through the mucous membrane, usually at the margin of the perineum, without involving any of the muscles.

A second degree tear is one that extends down into the perineal body and may involve the levator ani, or even extend down to, but not through the rectal sphincter. Such a tear usually extends upward on one or both sides of the vagina making a triangular injury.

A third degree tear extends entirely across the perineal body and through the rectal sphincter and sometimes up the anterior wall of the rectum. This variety is often called a complete tear, in contradistinction to those of first and second degree, which are incomplete.

It is a fairly general custom to repair these lacerations at the time of labor, no matter what their extent, the sutures being introduced but not tied, during the third stage. The patient is usually sufficiently anesthetized to permit of this, without further anesthesia, in all but complete tears, and as there is usually but very slight bleeding before the expulsion of the placenta, the field is comparatively clear and the stitches are easily put into place. They are not tied, as a rule, until after delivery of the placenta because of the strain which its expulsion would put upon the fresh stitches. In all but very slight tears, the doctor will usually want the patient turned across the bed, with her hips brought to the edge, and her legs supported in the lithotomy position. As the few instruments necessary for perineal repairs should be boiled and placed in readiness before labor, there is usually no further preparation for the nurse to make, and the perineal dressing, after the stitches have been taken, is ordinarily the same as that following a normal delivery. (See Fig. 80 for necessary instruments.)

Some physicians prefer not to repair perineal tears until some days after labor, contending that the congestion of the soft parts immediately after delivery is not favorable to a satisfactory union. When the repair is made subsequently, therefore, the nurse prepares as she would for any perineal operation, performed independently of labor. Repairs are not often postponed for more than a few days, since long delayed or neglected attention frequently gives rise to gynecological disorders, such as descensus or prolapse of the uterus.

Episiotomy. Some obstetricians prefer to anticipate a perineal tear by making an oblique incision, usually on one or both sides, extending downward and outward from the margin of the vaginal outlet down into the perineum. This operation is termed episiotomy, and the incision is sutured after labor just as a tear would be. It is the belief of those who perform this operation that the clean-cut incision heals more satisfactorily than an irregular tear, and that by directing the incision to the side, away from the median line, the integrity of the rectal sphincter is preserved, even though the perineum tears beyond the end of the incision, when distended during the birth of the head.

Breech Extraction. In some cases of breech presentation, particularly among primiparÆ, it is necessary to assist nature in the delivery of the child in order to save its life. Complete anesthesia is usually necessary at such times and the patient is preferably on a table or at the edge of the bed in a lithotomy position.

In the majority of cases, no effort is made toward assistance until the body is born as far as the umbilicus, partly because of the difficulty of taking hold of the child securely before that time, and partly because the perineum is not likely to be fully distended, in which case a serious tear would probably result. But after the body has been extruded as far as the umbilicus, it is usually considered imperative to complete the delivery within eight minutes to save the child from asphyxiation, due either to pressure on the cord between the head and pelvic brim, or to premature separation of the placenta. The baby’s feet or legs are grasped by a towel to prevent slipping, and downward traction is made on the body until the tips of the scapulÆ appear at the outlet. During this procedure the nurse may be called upon to make pressure on the uterus with the idea of keeping the baby’s head flexed forward; preventing the arms from becoming extended upward above the head and also to help in expelling the child.

After the scapulÆ appear, the arm lying posteriorly is brought down over the chest and delivered. The body is then rotated until the other arm lies posteriorly and that is delivered. After delivery of the arms and shoulders the head is usually delivered by what is known as Mauriceau’s maneuver as follows: The accoucheur slips the index finger of one hand into the vaginal outlet and into the child’s mouth, and supports the body of the child upon his hand and forearm; two fingers of the other hand are slipped around the back of the neck and curved forward like hooks over the shoulders and strong downward traction is made by these fingers; not by the one in the baby’s mouth. The occiput emerges from beneath the symphysis, after which the body is lifted upward and the chin, nose, forehead and entire head are born.

Version. By version is meant the turning of the child within the uterus so that the part which was presenting at the superior strait is replaced by another part, in order to hasten or facilitate delivery. It is usually performed as the patient lies flat on her back, completely anesthetized, and with great gentleness, for fear of rupturing the uterus.

Common indications for a version are a transverse presentation; a prolapsed cord, when the head has just begun to enter the superior strait; and in some cases of placenta prÆvia. When the fetus is so turned that the head becomes the presenting part, the procedure is termed a cephalic version; if so turned that the breech presents, it is termed a podalic version. The methods of accomplishing these ends are described as external version, if the turning is done entirely with the hands working through the abdominal wall; internal version if one entire hand is introduced into the uterine cavity, and combined version when one hand is outside on the abdomen and two fingers of the other are introduced through the cervix into the uterus.

External cephalic version is often performed late in pregnancy, or early in labor, in transverse and also in breech presentations, to secure a vertex presentation because of the high fetal death rate in breech extractions. Podalic version, or making the breech the presenting part, is often performed in transverse presentations, in placenta prÆvia and when the cord or extremities are prolapsed. Having converted the presentation into a breech, the usual breech extraction is performed.

Forceps are instruments which are used to extract the child when presenting by the head in certain conditions which endanger the life of mother or child. The value of forceps in obstetrics can scarcely be overestimated, as before their invention the only operative method of delivering a live baby was by means of version and extraction, and in these the fetal death rate was high. The obstetrical instruments in use up to that time, therefore, were all for the destruction of the child in utero.

Forceps were devised, and first used, in great secrecy, early in the 17th century, by a Dr. Chamberlen, in England, who jealously guarded all information relating to his invention from every one but members of his own family.

There were several doctors in the Chamberlen family who practiced obstetrics and who used these forceps, but knowledge concerning the nature of the instruments and methods of using them was not shared with members of the medical profession outside of that family, until the beginning of the 18th century. Since that time the use of forceps has been widely extended and the original Chamberlen instruments have been so modified and altered and improved by different obstetricians, that there is now a bewildering number and variety in existence and in use. Probably the most widely used are those which were devised by Dr. Tarnier of France and Dr. Simpson of England, respectively. (Fig. 107.) The Tarnier instrument is known as an axis traction forceps, and can be used in all kinds of forceps operations, while Dr. Simpson’s are suitable for use only in low forceps cases.

There are two groups of indications for the use of forceps; those relating to the condition of the child and those relating to the mother.

Fig. 107.—Two widely used forceps. A, Tarnier axis-traction forceps. B, Simpson forceps.

Indications for their use in the interests of the child are symptoms of asphyxia, and these are the passage of meconium, in head presentations, and a change in the rate or rhythm of the fetal heartbeat. As pressure on the abdomen of the fetus during labor, in breech presentations, is very likely to express meconium, this is not of special significance in these cases. But in head presentations, the escape of meconium suggests paralysis of the rectal sphincter muscles, due to imperfect oxygenation, which, in turn, is caused by interference with the placental circulation by pressure on the cord or premature separation of the placenta.

Conditions which menace the life of the mother, and indicate the use of forceps, are inadequate contractions of the uterine and abdominal muscles; exhaustion, as indicated by an increase in the maternal pulse rate or elevation of temperature, and in certain chronic and infectious diseases, when the patient may be unable to stand the strain of the second stage.

Forceps are usually employed when the head fails to make satisfactory advancement after two hours of good, second-stage pains, or when it remains in one place on the perineum for an hour, in spite of good, second-stage pains.

Fig. 108.—Patient in position and draped for forceps operation. (From photograph taken at Johns Hopkins Hospital.)

Otherwise, there is danger of necrosis or sloughing of the soft parts as a result of pressure, with a subsequent recto-vaginal or vesico-vaginal fistula.

Among the acute conditions in which forceps are indicated are typhoid fever; pneumonia; acute edema of the lungs, hemorrhage from premature separation of the placenta; intra-partum infection and eclampsia, while they are sometimes used in such chronic conditions as pulmonary tuberculosis; various heart lesions, particularly when there is broken compensation.

Before applying forceps the operator will usually wish to satisfy himself that the following conditions exist: Complete dilatation of the cervix, otherwise severe lacerations with hemorrhage may result; the head must have entered the pelvis, otherwise an imperfect application of the forceps may result in death of the fetus and serious injury to the mother; the position of the child’s head must be known in order that the forceps may be properly applied over the ears; the membranes must have ruptured or the forceps may slip.

Forceps operations are usually designated as being high, mid or low, depending upon the level to which the head has descended into the pelvis. If the head is at the superior strait, a high forceps operation is necessary; mid forceps if the head is half way down and on a level with the ischial spines and low forceps when the head is on or just above the perineum.

Fig. 109.—Forceps sheet used in Fig. 108.

The application of low forceps is a simple operation and attended by little danger to mother or child; mid forceps is more serious and high forceps is very serious for the child and sometimes for the mother.

When forceps are applied, the patient must be at the edge of the bed or preferably on a table, in the lithotomy position (Fig. 108), and completely anesthetized. She should be shaved and scrubbed as for a normal delivery, after which a sterile towel soaked in bichlorid 1–1,000 or lysol 2 per cent., is placed over the vulva and allowed to remain until the operation is performed. She should be draped with sterile leggings and towels, one of which is folded over the centre of a wide strip of adhesive about twenty inches long, and hung curtain-like over the rectum by strapping the free ends to the buttocks on each side, while over all is placed a sheet with three openings; two slits for the legs to pass through and one rectangle which exposes the field of operation. (Figs. 109, 110.)

Fig. 110.—Two types of easily made leggings suitable for use during delivery or obstetrical operations.

Pubiotomy, or hebotomy, consists in sawing through the pubic bone on one side of the symphysis with a string or Gigli saw. This operation is performed in some cases of moderately contracted and funnel pelves, through which the normal expulsive forces of labor are unable to force the child. The separation of the bone allows it to gape, because of the hingelike movement of the sacro-iliac joint, and thus the superior strait is appreciably widened and the child may be delivered by high forceps or version. As the bone heals by fibrous union, there is sometimes permanent enlargement of the pelvis and there are seldom any unsatisfactory after-effects, such as impairment of locomotion. Pubiotomy is sometimes the operation decided upon when a patient is seen for the first time after labor is well advanced, and a conservative CÆsarean section is thought inadvisable because of the risk of infection. But the operation is becoming more and more rare, for the general practice of measuring the pelvis and supervising patients during pregnancy discloses serious disproportions early enough to make a CÆsarean section the elective operation.

Symphysiotomy. This operation is a cutting through the cartilage of the symphysis pubis, instead of through the pubic bone, as in pubiotomy. It was formerly performed for much the same reasons that pubiotomy is now used, but has been practically abandoned since the development of the latter operation. The reasons for giving it up were that the close proximity of the bladder to the symphysis resulted in frequent injuries to that organ, and as the cartilage of the symphysis does not heal as well as the pubic bone, the patients frequently experienced difficulty in walking and showed a tendency to tire more easily after the operation than before it was performed.

Vaginal Hysterotomy, or vaginal CÆsarean section, as it is sometimes called, consists of incising the cervix anteriorly and posteriorly, delivering the child and placenta and suturing the wounds. It is sometimes performed in cases which for some reason require immediate delivery, as in severe cases of eclampsia. It is only possible when the relation between the pelvis and the child’s head is such as to permit the child to pass through the inlet. It is rarely done in primiparÆ, because rigidity of the outlet prevents proper exposure; or in multiparÆ at term as the incisions have to be extended so high to deliver a term baby, that there is danger of tearing the lower uterine segment.

CÆsarean Section is the operation by means of which the child is delivered through an incision in the abdominal and uterine walls. It is believed by some that the operation was named for Julius CÆsar, who was presumably delivered by this method, but this seems scarcely probable. The operation was frequently fatal in those days and, moreover, as the uterine wall was not sutured after the child was extracted, a woman was not likely to have other children afterward even if she did live, and CÆsar’s mother had several children after he was born. Another explanation for the name is that during CÆsar’s reign a law was passed which required that the abdomen be opened and the child extracted in every case in which a woman died late in pregnancy, as one means of increasing the population.

Thus it will be seen that the operation itself is very ancient, but as performed to-day it embodies the most modern and scientific knowledge and methods. The usual indications for it are cases of contracted or deformed pelves; cases of tumors which block the birth canal or when very speedy delivery is imperative as in some cases of eclampsia.

The anatomical indications for CÆsarean section are dependent upon the degree and character of the pelvic contractions and upon the size and mouldability of the child’s head in relation to the pelvis. This explains why in two women with pelves of the same size and shape, one will have a spontaneous delivery and one will require a section. The former has a relatively small child which can pass through her pelvis; while the second woman’s baby is too large, or the head not sufficiently mouldable, to pass through hers.

This is one exemplification of the great importance of pelvimetry and of constant watching during pregnancy, for the best results from CÆsarean section are obtained when it is recognized that spontaneous delivery is unlikely or impossible; the operation accordingly is performed at a time which is deliberately selected by the obstetrician. The elected time is often about two weeks before the expected date of confinement in order that the baby may have the longest possible intra-uterine life and that the operation may be performed before the patient goes into labor. In these cases in which it is known that a section is to be performed vaginal examinations are omitted after the pelvic measurements are taken, in order to minimize the possibilities of infection, this being one of the great risks of the operation.

Until recent years the operation was usually delayed until after the patient had been vaginally examined, had been in labor long enough to be exhausted and the only other courses open were high forceps or a destructive operation upon the child. The results of the operation undertaken under such circumstances were not good, and the maternal deaths from infection were so frequent that the operation on the whole was very hazardous. But improved surgical technique and extended knowledge of the pelvis have so revolutionized CÆsarean section that it is now successful in the majority of cases.

There are three main types of CÆsarean section: conservative, radical and extraperitoneal.

The conservative operation consists of opening the abdomen in the mid-line; incising the uterus; extracting the child and placenta, and suturing both uterine and abdominal walls. This is the usual operation when there is a choice, but because of the danger of infection, it is ordinarily performed only before the onset of labor or in the early part of the first stage, and many obstetricians are loath to undertake it then if the patient has been examined vaginally, particularly if the technique of the examination was open to question.

In the radical operation the abdomen and uterus are incised; the child and placenta extracted and the uterus is amputated just above the cervix. This operation is usually performed when labor is well advanced and there is fear of infection.

In the extraperitoneal operation the incision in the abdomen is made low down on one side, the peritoneum is not incised but is peeled back from the bladder and lower part of the uterus. The uterus may thus be opened and the child and placenta extracted, without entering the peritoneal cavity, thereby greatly reducing the risk of infection, and also without necessitating the removal of the uterus as a safeguard against infection. This operation, also, is performed late in labor when infection is feared, but is considered very difficult and therefore is not common.

The nurse’s duties in connection with a CÆsarean section are the same as those in any abdominal operation plus preparations for receiving and reviving the baby.

A Ruptured Uterus is a splitting of the uterine wall at some point, usually in the lower uterine segment, that has become thinned or weakened and unable to stand the strain of further stretching incident to uterine contractions, and is accompanied by an extrusion of all or a part of the uterine contents into the abdominal cavity. The rupture of a uterus during labor is a very rare accident, occurring but once in from 500 to 1,000 cases and usually only in prolonged labors, obstructed labors or certain faulty presentations. It is also a very grave accident, since the baby nearly always dies and sometimes the mother as well.

The cause of a ruptured uterus may be found in scar tissue, following a CÆsarean section or an injury; inherent defects in the tissues comprising the uterine wall; contracted pelves; neglected transverse presentations and the accident may occur during a version. It is usually preceded by extreme tenderness in the lower uterine segment, the part that is being abnormally stretched. The common symptoms, after the rupture has occurred, are sudden and acute abdominal pain during a contraction, which the patient describes as being unlike anything she has ever felt and as though “something had given way” inside of her. There is immediate and complete cessation of labor pains because the torn uterus no longer contracts. Sooner or later the patient has symptoms of shock because of the hemorrhage, which is usually internal, though there may be vaginal bleeding as well. Her face becomes pale and drawn and covered with perspiration; her pulse is weak and rapid; she appears exhausted and collapsed and may complain of chilly sensations and air hunger.

Abdominal palpation shows that the lower uterine segment is even more sensitive than formerly and that the presenting part has slipped away from the superior strait while at the side of the fetus the contracted uterus, partly or entirely empty, may be felt as a hard mass. The symptoms of shock may be delayed for some time when they will be accompanied, as a rule, by abdominal distension, due to hemorrhage, and a slight elevation of temperature.

The prevention of this disaster lies in performing version and prompt extraction in transverse presentations, as soon as the cervix is dilated, and in interference if the presenting part does not engage after an hour of strong, second-stage pains.

The treatment of a ruptured uterus is influenced by many factors. Possibly the most frequent course followed is to open the abdominal cavity and repair or remove the uterus, after extracting the fetus and placenta, according to existing conditions and the judgment of the operator. Sometimes the fetus is removed through the vagina and the uterus repaired through that channel.

Destructive Operations have as their purpose the crushing or dismembering of the child in utero so that it may pass through the pelvis. In the early days such operations were resorted to fairly often in the presence of conditions that threatened the mother’s life and which apparently could not be met in any other way. They are performed less and less frequently to-day because of the success attending the performance of CÆsarean section, version, pubiotomy and forceps operations. They are never sanctioned by the Catholic Church in cases where the child is alive.

Induced Abortions and Premature Labors. As was explained in the chapter on complications and accidents of pregnancy, it is sometimes deemed advisable, or necessary to terminate pregnancy by artificial means, in the interests of the mother or child or both.

The procedures are termed induced abortion, induced premature labor and accouchement forcÉ. The effects of these operations, per se, when skillfully performed, for therapeutic purposes, are not usually considered more serious for the mother than a normal delivery, since they can be performed with deliberate care and cleanliness and can be followed by adequate aftercare. When the reverse conditions prevail, as in criminal abortions, the patient’s subsequent suffering or ill health are more likely to be due to the poor obstetrics and unclean work which is characteristic of practitioners who are willing to do illegal operations, than to the termination of pregnancy itself. It is important that the nurse fully appreciate this and be as scrupulously careful in her preparations for, and assistance with these operations as for a major operation or a normal delivery.

Induced abortion applies to the termination of pregnancy before the child is viable, or before the end of the twenty-eighth week, and is performed solely in the interests of the mother, as the fetus is always lost. It is resorted to in those cases where the mother is suffering from some condition, which may or may not be inherent to pregnancy, which threatens her life or health but which it is believed may be cured or arrested if uncomplicated by pregnancy. Such conditions may be toxemic vomiting; nephritis, particularly with evidences of increasing renal insufficiency; bleeding, due to an incomplete abortion; a dead fetus; infection following an attempt at criminal abortion. Contracted pelves and pulmonary tuberculosis are sometimes taken as indications for inducing abortions, but with the development and improvement of obstetrical operations, more and more women are able to go nearly, or quite, to term and be delivered of live babies; while increasing medical knowledge concerning the care of patients with tuberculosis, and also with some heart lesions, is applied so successfully during the prenatal period that some pregnancies which formerly would have been terminated, are now allowed to continue, and with happy results.

The methods of induction depend upon the stage to which pregnancy has advanced and also upon the importance of haste. In the very early stages, one method is for the operator to dilate the cervix with a dilator; insert one finger into the cervix and up into the uterus and separate the placenta from its uterine attachment, while making pressure on the uterus from above with the other hand on the abdomen. Another method is to introduce a gauze pack into the cervix, packing it and the vagina firmly and leaving the packing for twenty-four hours. When it is removed the ovum frequently follows. Sometimes the membranes are ruptured, after which the amniotic fluid drains off and the ovum is expelled; or vaginal hysterotomy is sometimes performed when the patient’s condition is such that haste is imperative. The termination of pregnancy before viability is never sanctioned by the Catholic Church, because of the almost certain loss of the child.

Induction of premature labor. This procedure is the termination of pregnancy after the twenty-eighth week, or after the child is viable, and may be performed to save either the mother or the child or both, from conditions which would evidently work destruction if allowed to persist. The indications for inducing labor prematurely may be a seriously overtaxed heart or kidneys; pulmonary tuberculosis; preËclamptic toxemia or nephritic toxemia; chorea, neuritis; pyelitis; placenta prÆvia; a fetus that has been dead for two weeks, with no signs of labor; in some cases of nephritis when the fetus during previous pregnancies has died, and it is believed that the child may be saved by inducing labor before the stage in pregnancy at which the others perished.

Labor is sometimes induced when the mother’s pelvis is normal, but the child has grown as large as is safe in anticipation of a spontaneous labor, and particularly if the expected date of confinement has passed.

Fig. 111.—Rubber bougie used in inducing labor.

A common method of inducing labor when haste is not important, is to introduce one or more bougies (Fig. 111) through the cervix into the uterine cavity between the membranes and the uterine wall. The presence of the bougies will often stimulate the uterine contractions and bring on labor, with expulsion of the fetus, in from six to twenty-four hours.

Fig. 112.—Champetier de Ribes’ bag.

More speedy results are obtained by the use of rubber bags, which may be collapsed before introduction and expanded afterward by filling them with sterile salt solution. There is a great variety of bags for this purpose, two of which that are frequently used are the Champetier de Ribes (Fig. 112) and the Voorhees bags. (Fig. 113.) They come in graduated sizes, the largest holding about 500 cubic centimetres.

Fig. 113.—Voorhees’ bag, collapsed.

Fig. 114.—Rubber bag rolled and held in forceps for introduction into uterus.

Fig. 115.—Syringe for introducing sterile water into bag after its insertion into the uterus.

The operation is performed with the patient in the dorsal position. The cervix is drawn down into sight, with forceps, and if intact, is slightly dilated. The bag is rolled tightly, held in suitable forceps (Fig. 114), and after being well lubricated is introduced through the slightly dilated cervix into the lower uterine segment, and pumped full of sterile salt solution. The solution is first measured in order to be sure that the bag is filled to its desired capacity, and is then introduced by means of a syringe, (Fig. 115), through the rubber tubing which is attached to the lower end of the bag, and which is then closed off by the stop cock, to prevent escape of the fluid. It is very important that the solution be sterile in view of the possibility of any rubber bag rupturing, particularly when pressed upon by the contracting uterus. (See Fig. 47 for position of bag after introduction into uterus.)

The presence of this bag stimulates uterine contractions, the cervix dilates, the bag is expelled and in some instances the child is delivered spontaneously and in others by means of forceps. The effect of this bag in producing labor may be hastened by tying a weight to the end of the tubing and allowing it to hang over the side of the bed. This traction and pressure help to dilate the cervix and seem to increase the irritation of the uterine muscles, thus increasing the force of their contractions.

Accouchement forcÉ is a speedy, forced delivery requiring the forcible widening of an intact, or partly dilated cervix, manually, or instrumentally. It is sometimes performed when existing conditions require extreme haste, as in certain heart lesions; eclampsia; concealed or accidental hemorrhage or in any condition which suddenly arises to threaten the life of the patient or her expected baby. But as the shock of this operation is great and the condition which threatens the patient can usually be better relieved by means of some one of the operations already described, it is less and less frequently performed.

THE MIRACLE^[7]

Elizabeth Newport Hepburn

The wind blows down the street,
A shutter bangs somewhere,
While twilight falls as softly as
A woman’s flowing hair.

Within a quiet room,
Adventurers at rest,
A mother holds her newborn son,
Safe, now, upon her breast!

For out of Night and Pain,
The womb of mystery,
Is sprung this miracle of Life
That she can touch and see.

No seer’s prophetic dream,
No star in all the skies
Burns with a lustre half so bright
As happy mother eyes.

No quester for the Grail,
No searcher for the Truth,
Counts more than those who bear and rear
And love and nurture Youth!

Within her curving arm,
All safe and warm he lies,
The heir of all that Man has won
Down countless centuries!

Clyx.com

CHAPTER X PRESENTATION AND POSITION OF THE FETUS

CHAPTER XI SYMPTOMS, COURSE AND MECHANISM OF NORMAL LABOR

CHAPTER XII THE NURSE’S DUTIES DURING LABOR