■•••' : v*>iw �39999999999999999999999999999999999995 V* SURGEON GENERAL'S OFFICE LIBRARY. Section No. 113, W.D.S.G.O. No: > .19210* , 3—513 A ^ / MANUAL OF RULES CHILD-BED NURSING CHARLES JEWETT, A.M. M.D., PROFESSOR OF OBSTETRICS, ETC., AT THE LONG ISLAND COLLEGE HOSPITAL. wy J59>n Copyright, 1889, by Charles Jewett, M. D. PRESS OP BROOKLYN EAGLE BOOK PRINTING DEPARTMENT, BROOKLYN, N. Y PREFACE. This brief Manual of Rules for Child-bed Nursing- was prepared for the use of the Training School for Nurses at the Long Island College Hospital. It is not intended to take the place of a text-book on the subject, but rather to aid the pupil in remembering the more important practical teachings of the lectures and the ward training. It may be found useful to graduates as well and to others interested in obstetric nursing. 307 Gates Avenue, Brooklyn, N. Y. November, 1889. RULES FOR CHILD-BED NURSING. THE LABOR. To Predict the Date of Labor.—Add seven days to the date when the last menstruation began and count forward nine months. Usually accurate within a week. Preparation for Labor.—For the lying-in cham- ber, select, if possible, a large, well ventilated room with a southern exposure, remote from the water-closet, and having no defective waste pipes nor other exposure to house drainage. Cleanliness of the room and its contents, entire free- dom from decomposing animal or vegetable matter and the poisons of contagious disease are imperative. Especially dangerous is the contagion of child-bed fever, suppurating wounds, erysipelas, diphtheria or scarlet fever. Much drapery is insanitary; it catches dust and dis- ease germs. 6 CHILD-BED NURSING. Have Ready: A dozen clean sheets. A dozen towels recently laundered. A dozen pieces of fresh boiled cheese cloth, or butter cloth, about 18 inches square, for wash cloths. Two or three clean hand basins of agate ironware or porcelain. Two new hand brushes. Two surgically clean rubber sheets, large enough to reach across the bed. Two or three pieces of straight unbleached muslin for binders, a yard and a quarter long by half a yard wide. Two dozen shield pins of medium size. A yard of strong, narrow linen bobbin for tying the navel cord. Scissors. Four ounces of glycerine as a lubricant for the doc- tor's hands. Add a half grain each of the biniodide of mercury and the iodide of potassium. Vaseline or sweet oil for anointing the child. A Davidson or a fountain syringe. A clean-vessel to receive the placenta. A rug to protect the carpet beside the bed. A bedpan (agate ironware No. 2 preferred). Plenty of hot and of cold water. A half pint of brandy or whiskey. A woolen blanket for wrapping the child. A child's bath-tub and a bath thermometer. Castile soap. A package of salicylated cotton. The child's clothing. child-bed nursing. 7 Preparation of the Bed.—Cover the mattress with a muslin sheet and that with a rubber sheet. Spread a clean muslin sheet over the rubber and pin fast to the mattress. Spread over that a second rubber covered with a muslin sheet. Place two or three fresh laundered sheets, twice folded, in position to receive and absorb the dis- charges. A separate cot dressed as above described may be used for the confinement instead of the bed, the patient being transferred to the bed after delivery. Hygiene of the Lying-in Room.— The most scrupulous cleanliness is imperative. Pure air is at all times indispensable. Ventilation to be effective must be constant. An open fire is a good ventilator. Sunlight is an important sanitary agent. The temperature of the room may be from 68° to 700 F., five or six degrees lower at night. Signs of Beginning Labor.—Pains in the lower abdomen and back, recurring at regular intervals, at first about once a half hour. (As the labor advances the pains strengthen and the intervals shorten to one or two minutes, or even the fraction of a minute toward the close of the labor). The uterus hardens during the pains. The " show," a discharge of bloody mucus from the vagina. Evacuation of the bladder and bowels more fre- quently than usual. 8 child-bed nursing. Stages of Labor.—First Stage or Stage of Dilatation.—Ends with the full dilatation of the neck of the womb. Second Stage or Stage of Expulsion.—Ends with the birth of the child. Third Stage or Placental Stage.—Ends with the expulsion of the placenta and the persistent con- traction of the uterus. Duties of the Nurse during the Labor.—First Stage.—Notify the doctor when the labor begins or be guided by instructions previously obtained. Messages to the doctor are best put in writing and should give stage of progress and full particulars. Give the patient the liberty of the room. Tell her not to " bear down" during the pains of this stage. The bladder should be frequeutly evacuated. Empty the lower bowel by an enema of warm water in every case. A hot rectal injection stimulates the pains and there- fore may or may not be proper in a given case. Moving about the room or even the bed has a like effect. Give such simple food and drink as the patient may require. For the Doctor's Examination. — Place the patient on her back in bed, at the right side, with the clothing adjusted for the abdominal and the pelvic examination. Before the first vaginal examination prepare your hands as directed on p. 22 and carefully cleanse the child-bed nursing. 9 external genitals and surrounding surfaces with soap and water, remove the soapy water and bathe with the biniodide or bichloride of mercury solution [p. 22]. Second Stage.—The patient should keep the bed from the time the labor approaches the second stage, generally after the escape of the waters or after the pains become severe. She should be dressed for the bed with her clothing tucked under the arms and pinned, and with a folded sheet fastened about the waist in the manner of a skirt. Firm pressure against the lower part of the back during the pains usually gives relief. The patient may be allowed to pull upon the hand of a bystander during the pains, or upon a sheet tied to the foot of the bed. This, however, increases the expel- ling power and should be omitted in over-rapid labor. Giving Chloroform. — Have the head low and clothing loose. Smear the skin about the mouth and nose with vase- line or glycerine, to prevent " burning " by the chloro- form. Spread a thin towel over the patient's face; lift it by the middle so as to form a large air chamber about the face. Sprinkle the chloroform upon the upper surface of the towel opposite the mouth and nose. Five to ten drops are usually enough for an ordinary pain. Give it only during the pain, the inhalation beginning promptly with the pain. It may usually be pushed to uncon- sciousness during the passage of the head over the perineum. IO child-bed nursing. For Version or Forceps Operation.—Place the patient directly across the bed, upon her back, with the hips close to the edge of the bed, and the knees drawn far up and well apart. Each lower extremity may be covered with a sepa- rate sheet or blanket. One assistant is usually required at each of the knees to hold them in the position described. Third Stage.—The nurse may be required to "hold the fundus" while the doctor is otherwise engaged. This consists in " watching " the uterus by laying the hand lightly upon the abdominal wall over the upper surface of the uterus to know whether it remains properly contracted. Moving the abdominal walls in a circular direction over the surface of the uterus, or even grasping the womb, may be needed to promote contraction. Keep the placenta for the doctor's examination; afterwards destroy by burning in the range or furnace fire. At the close of the third stage the patient's body should be cleansed of blood and discharges by bathing with an antiseptic lotion—one of the mercurial solutions preferred, [p. 22.] Sponges should never be used for bathing the genitals, but a fresh boiled cloth instead, which has lain for several minutes in the antiseptic solution immediately before use. All soiled bedding, including the upper rubber sheet, and soiled clothing, should be replaced with clean. Cover the external genitals, after cleansing, with a folded napkin (the lochial guard) which has been pre- CHILD-BED NURSING. II viously wrung out of one of the mercurial solutions and dried. Hold in place with a T bandage. Replace the lochial guard with a fresh one as often as much soiled during the first few days, and at all times often enough to prevent the slightest fetor. The binder should reach from the breast bone to a point just below the hips. Pin with shield pins and moderately tight for the first twelve hours, thereafter less firmly. THE PUERPERAL PERIOD. Points to be Noted by the Nurse Twice or More Daily. Pulse—Normal pulse of the puerperal woman is lower than her ordinary pulse. Temperature—Physiological upper limit, first four days 99I0 ; thereafter 990 F. General condition of the patient. Appetite. Color and expression of the face. Appearance of the tongue. Pains. Chills. Evacuations of the bladder and bowels. Condition of the breast, whether distended, hard, painful, nipples tender or cracked. Condition of the abdomen, bloated, tender on press- ure. Condition and size of uterus. Should contract firmly, after the first hour persistently. Tenderness on pressure over the uterus should diminish daily and 12 CHILD-BED NURSING. disappear after three or four days. Fundus at close of labor nearly midway between navel and pubes; a few hours later at the navel; tenth day at pubes. Uterus may be pushed up bodily by a full bladder or rectum. Character and amount of lochia. The normal flow is more or less bloody for about four days, paler and thinner for three or four, then creamy; gradually diminishes in quantity from the close of labor. Total amount in the first two weeks about 3^ lbs. Duration two to four weeks. Should not have any fetid odor. CHILD-BED 'NURSING. 13 FORM OF RECORD. Name of Patient Confined...........................................18 Month Day Hour Pulse Temp. Remarks 14 CHILD-BED NURSING. CARE OF THE PATIENT. Posture.—The patient should lie on the back for the first few hours after labor. Later the posture should be frequently changed. Sleep relieves the exhaustion following labor. Rest and quiet are indispensable. During the first week or more exclude visitors. Absolute cleanliness of the person, the clothing and the bedding of the patient is imperative. The external genitals should be thoroughly bathed with one of the antiseptic solutions when the vulvar dressing is changed—several times daily. Permit no fetor. Allow nothing to touch the genitals that has not first been sterilized or made germ-free by one of the antiseptic agents mentioned below. Vaginal douches should not be used unless ordered. Soiled lochial guards and all soiled linen should be immediately placed in an antiseptic solution and removed from the room. Diet may be liquid or light solid food for the first day, especially if the patient be much exhausted or has taken an anaesthetic, e. g. milk, gruels, clam broth, oyster broth, dry toast, and weak tea or chocolate. Thereafter, in the absence of exhaustion, fever or bad digestion, a moderately full diet as a rule. In simple engorgement of the breasts gentle mas- sage with oiled hands, rubbing from the base toward the nipple, is permissible if it relieves pain. An inflamed breast must not be rubbed. Support CHILD-BED NURSING. 15 by means of a bandage is useful in case of overdisten- sion. The nipples should be daily cleansed with a solution of borax during the month before labor, and if necessary gently drawn with the fingers. During the nursing period they should be bathed after each nursing, best with a weak antiseptic solution, (e. g. a saturated solution of salicylic acid in water.) The bladder should empty itself within eight hours after delivery and every eight hours thereafter. Retention of urine may sometimes be relieved by suprapubic pressure, hot fomentations to the pubic region, the sound of running water or rectal injec- tions of warm water. Do not use the catheter without consent of the attending physician. The bowels should be opened on the third day and once daily thereafter. This may be accomplished by a rectal injection of two teaspoonf uls of clear glycerine, previously warmed, or an enema of a quart of warm water repeated as required. The patient should not sit up in bed for the first week, except by order of the physician. Should as a rule maintain a reclining posture for about two weeks ; may occupy her chair a portion of the day during the third week, and may have the liberty of her room dur- ing the fourth. May leave her room at the end of a month. The nurse should sle^p on a separate cot in the same room with the patient. i6 CHILD-BED NURSING. Give no medicine without instructions. Advise the doctor at once of any important abnormal occurrence in child-bed. Use of the Catheter.—If required should con- form to the following rules.—Instrument, a soft rubber catheter in good order. Cleanse with soap and water and allow it to lie in a solution of the biniodide of mercury [p. 22], for ten minutes before using and at all times when not in use. Rinse off the antiseptic with plain boiled water immediately before using. Boiling the catheter each time for ten minutes immediately before using is a better method of cleans- ing than by the use of chemical antiseptics. Cleanse the hands as directed on pp. 22-23 before handling the sterilized catheter. The patient should lie on the back with the knees drawn apart. Let the patient or an assistant retract the labia so as to fully expose the orifice of the urethra. Cleanse the orifice and the surrounding surfaces with one of the mercurial solutions. Pass the catheter, by the aid of the eye, about one and a half inches, or until the urine begins to flow. Collect the urine in a cup or small bowl. Prevent entrance of urine into the vagina and its contact with genital wounds. Repeat the evacuation of the bladder once in eight hours. CHILD-BED NURSING. 17 CARE OF THE CHILD. Cleanse the face at birth and especially the eyes, pre- ferably with the biniodide or bichloride of mercury solution [p. 22], and dry the eyes thoroughly. Rub the skin with sweet oil or vaseline. Wrap the child in flannel and keep warm. Care- fully avoid chilling. Feeble children should not be bathed for several hours, and in some cases days, after birth. Rub daily with sweet oil instead. Inject a tablespoonful of warm water into the rectum to provoke movement of the bowels, if necessary in order to make sure that the rectum is pervious. For the bath use an infant's bath tub. Temperature of the water 950 F. Keep the child's body immersed during the bath, supporting the head above the water with the hand. Use a soft fresh-boiled wash rag instead of a sponge. Use Castile soap and little of that. Dry by enveloping in the towel with but little fric- tion. Infant powder is unnecessary. Wrap the stump of the navel cord with dry salicy- lated cotton and lay to the left side. Hold in place by a loose flannel belly-binder. Dry and re-dress the cord in the same manner after each bath. If the cord develops a fetid odor notify the doctor. After the first bath, rubbing the child with sweet oil may be substituted for further bathing till the cord falls off. i8 CHILD-BED NURSING. The temperature of the bath may be gradually reduced to 900 F. by the age of six months if the child is robust. Repeat the bath daily in warm weather, twice weekly in cold. A teaspoonful of warm water unsweetened may be given now and then, but no artificial food unless ordered. Put the child to the breast after the mother has rested. Let it nurse once in four hours until the milk comes, then once in two hours. Double the interval in the night. Gradually increase the intervals to about three hours by the age of six months. All clothing should be loose enough to easily admit several fingers underneath it. The diaper should be removed immediately when wet or soiled and replaced with a clean one fresh laun- dered. Bathe the soiled portions of the body with each change. Do not permit the use of strongly alkaline soaps or washing powders for washing diapers. Castile soap may be used instead. Bowels should move twice daily. A small soap or glycerine suppository or the injection of a teaspoonful of warm glycerine into the rectum may be used as required in case of constipation. Warmth and gentle pressure to the abdomen are harmless and useful remedies for colic. Premature and feeble children require more warmth, CHILD-BED NURSING. IQ- more frequent feeding and in smaller quantities than others. If the child's breasts become swollen let them alone. The temperature of the child taken in the rectum may afford important information. The child's habits will be in great part what the nurse makes them.* ARTIFICIAL FEEDING. PROPORTIONS OF MILK AND WATER. At birth. 3 weeks. 6 weeks. 3 mon's. 6 mon's. Fresh cow's milk, ounces. Water, ounces. i 3 i 2 2 3 i I 3 I Add bicarbonate of sodium (baking soda), one-half grain to each ounce of the food ; f salt to taste (one-half grain to each ounce of the food); J sugar to barely per- ceptible sweetness. § * For further information concerning the management of the child, see " Hygiene of the Nursery," by Louis Starr, M. D., a book which will be found useful to both mothers and monthly nurses. f The half-grain of soda may be replaced with a half-teaspoon- ful of lime water, which, however, must be added just before feeding. X Have your druggist make up powders, each containing the number of grains of soda and of salt required for the quantity of food prepared at one time, § Milk-sugar twenty-five grains to each ounce of the food. 20 CHILD-BED NURSING. Sterilize as follows: Mix the milk ready for feeding soon after it is delivered. Fill ten bottles to the shoulders, each holding enough for one feeding. Use a funnel for filling to keep the necks of the bottles dry. Plug the mouths tightly with clean cotton wool. Keep the plugs dry. Stand the bottles in a kettle and cover to the shoul- ders with cold water. Boil twenty minutes.* Feeding. Warm the bottle to ioo° F. before feeding, then remove the cotton plug and slip a clean rubber nipple over the neck of the bottle. Let the child nurse directly from the sterilizing bottle. Cleanse the nipple inside and out after each feeding, and the bottle in like manner. Boil the nipple for ten minutes before using. Amount. Average amount for a single feeding at birth, one to one and a half ounces by measuring glass. Average daily amount at birth, ten to fifteen ounces. Should be increased weekly to about twenty-four ounces at three months, thirty-six ounces at six months. * Or steam the bottles for twenty minutes, still better, for two hours, in a steam sterilizing apparatus to be had at the drug stores. CHILD-BED NURSING. 21 Frequency. At birth once in two hours, as a rule. Ten feedings daily. Gradually increase the intervals. At three months and later, once in three hours. Six feedings daily. Double one interval in the night. Peptonized Milk. Sometimes useful when simple sterilizing fails. Prepare the milk by above formula and sterilize. Peptonize the contents of each bottle immediately before feeding, as follows: For each ounce of milk in the mixture add extract of pancreas (Fairchild's) one-third grain, bicarbonate of sodium to make one grain, and shake till dissolved. Stand the bottle in water at the temperature of 1050 F. for fifteen minutes. If the milk becomes too bitter, reduce the time to ten or even six minutes. The child's average gain in weight should be at least one-quarter pound per week during the first five months of its life. PREVENTION OF CHILD-BED FEVER. Child-bed fever is caused by the invasion of the geni- tal wounds by living micro-organisms or germs. The carriers of the disease germs are in nearly all cases the hands of the doctor or nurse, instruments, utensils or other appliances brought in contact with the genitals. The disease germs are destructible by certain anti- septic agents. 22 CHILD-BED NURSING. Child-bed fever is, therefore, a preventible disease. Prevention depends upon keeping everything that comes in contact with the birth canal germ-free or asep- tic by the faithful use of antiseptic agents, especially during the labor and for a week at least after delivery. The following are the best germ-destroying or Antiseptic Agents : Boiling or steaming for half an hour. Dry heat at 2300 F. for one or two hours (baking in an oven). Bichloride of mercury eight grains, common salt eight grains, water one quart (a deadly poison). Biniodide of mercury four grains, iodide of potas- sium four grains, water one quart (also poisonous). Chlorinated soda (Labarraque's Solution), of good quality, one ounce in ten ounces of water. Carbolic acid one ounce and glycerine one ounce in eighteen ounces of water (not so good as the preceding) For cloths, linen, utensils, etc., any of these agents is suitable, except the chlorinated soda, which is destruc- tive of the fabrics. For the hands, either the bichloride or the binionide of mercury or the chlorinated soda solution should be used ; for metallic instruments, boiling or steaming for an hour. The nurse should make an entire change of clothing immediately before taking charge of an obstetric case. Should wear dresses of washable material. Should keep her hands scrupulously clean and the nails cut short. Cleanse the hands as follows before contact with the genitals of the obstetric patient: 1. Clean the nails dry. CHILD-BED NURSING. 23 2. Scrub the hands and forearms for several minutes with hot water, soap and a hand brush, paying special attention to the nails and finger tips. 3. Rinse in clean water. 4. Scrub in like manner with the biniodide or bichlor- ide solution and another hand brush free from soap. Hold the hands for a moment again in the antisep- tic solution each time before touching the genitals. To keep the hands soft after the use of antiseptics, wash in plain hot water and rub well with glycerine and water or with lanoline and wipe dry.