OBSTETRICAL NURSING 
A MANUAL FOR NURSES AND STUDENTS AND 
PRACTITIONERS OF MEDICINE 
BY 
CHARLES SUMNER Ph.B., M.D. 
PROFESSOR OF OBSTETRICS IN THE UNIVERSITY OF ILLINOIS AND THE CHICAGO 
POLYCLINIC; MEDICAL DIRECTOR, IN THE CHICAGO LYING-IN HOSPITAL 
AND DISPENSARY; ATTENDING OBSTETRICIAN TO THE UNIVERSITY, 
CHICAGO POLYCLINIC, HENROTIN, GRANT AND EVANGELICAL 
DEACONESS HOSPITALS, CHICAGO, ILL. 
SECOND EDITION, THOROUGHLY REVISED 
ILLUSTRATED WITH 126 ENGRAVINGS 
LEA & FEB I GEE 
PHILADELPHIA AND NEW YORK 
1924 Copyright 
LEA & FEBIGER 
1924 
PRINTED IN U. S. A, TO 
MY BEST COUNSELLOR AND FRIEND 
MARIE ROSTHORN BACON 
THIS LITTLE BOOK 
IS GRATEFULLY DEDICATED PREFACE TO THE SECOND EDITION. 
The chief changes in this edition consist in additions to 
the chapter on Embryology, where figures have also been 
added to aid in giving a better idea of the early development 
of the embryo and fetal adnexa, in the addition of suitable 
descriptions of certain obstetrical operations and procedures 
that have come into use in recent years and in the elimination 
of material that was considered of less value to nurses or that 
they could obtain from other sources. 
Obstetrics as a science considers the physiological and 
pathological changes in woman during pregnancy, labor 
and the puerperium, and as an art it has to do with the super- 
vision and care of the reproductive functions in woman and 
especially with assistance during labor. The obstetrical art 
includes the supervision and assistance usually given by the 
physician and the more detailed duties performed by the 
obstetrical nurse. 
The obstetrical nurse should know as much of the science 
of obstetrics as is necessary for the intelligent comprehension 
of the rules of her art. It is believed that the incorporation 
of the scientific basis for the rules will increase instead of 
detract from the practical character of the book. 
In choosing subjects, particularly in dystocia and other 
pathological conditions, it has not been forgotten that the 
nurse is the physician’s assistant and should take responsi- 
bilities only when necessary. Certain responsibilities, how- 
ever, she must assume. She may be alone with the patient 
at delivery, and she might have to contend with a postpartum 
hemorrhage. Hence such subjects are discussed more exten- 
sively than would be the case could we strictly limit the func- 
tions of the nurse to assistance. 
V vi 
PREFACE TO THE SECOND EDITION 
The lack of a sufficient supply of nurses has led to a demand 
in some quarters for a lower qualification standard for 
entrance to the training schools and a shorter course of train- 
ing to supply a larger number of nurses. On the other hand 
the movement has increased in force for a higher standard for 
entrance and a better and more scientific training to supply 
a higher grade of nurses. To adapt a text-book or manual 
to both classes is not impossible. For the nurse who has 
had only a two years’ training it is necessary that the manual 
be very practical and go into details but this does not harm 
the student or nurse of greater attainments. The latter, 
however, demands that a manual on obstetrical nursing must 
present the subject in a scientific manner and with sufficient 
completeness to satisfy her intellectual cravings. A book 
that present the science of obstetrics satisfactorily is also 
none too good for the less trained nurse. At first, indeed 
there will be some things too difficult for her understanding 
but as she progresses in her work she will be glad to find 
answers to questions that will arise that she would not find 
in a primer. 
This manual is also designed for medical students and 
practitioners who desire to know the details of the work of 
their assistants. Anything less than an accurate presenta- 
tion of the scientific part of the subject would be to them 
unacceptable. 
Any fear that a nurse might “know too much” and become 
dangerous because of a discussion with her of embryology, 
toxemia of pregnancy, mechanism of labor or pathology of 
the puerperium is obviated, by a constant insistence on the 
fact that her function is that of responsible assistance. 
C. S. B. 
Chicago, 1924. CONTENTS. 
Introductory 
Nurse’s Duties to Self 18 
Nurse’s Duties to Doctor 22 
Nurse’s Duties to Patient 26 
Engagements and Arrangements for a Case 29 
CHAPTER I. 
Anatomy, Physiology, and Embryology 
Pelvis 31 
External Genitals 35 
Mons Veneris. Labia Majora and Minora 35 
Clitoris. Vestibule 35 
Hymen 36 
Vulvo-vaginal Glands. Perineum 37 
Internal Genitals 37 
Vagina 37 
Uterus 38 
Menstruation 44 
Fallopian Tubes 45 
Ovaries 46 
Urinary Organs 47 
Intestines 49 
Peritoneum 49 
Breasts 50 
Embryology 51 
Ovum 51 
Spermatozoon 52 
Fertilization 52 
Segmentation, beginning of Yolk, Amnion and Embryo . . 56 
Body Stalk 58 
Embryo and Fetus 58 
Chorion 60 
Amnion. Yolk. Allantois 61 
Umbilical Cord 62 
Migration and Nidation of Egg. Decidua 62 
Placenta 63 
Relation of Mother to Fetus 64 
CHAPTER II. 
(vii ) viii 
CONTENTS 
CHAPTER III. 
Pregnancy 
Physiological Changes 66 
Changes in Uterus 66 
Changes in Genital Organs and Breasts 69 
Pathological Changes 70 
Nausea and Vomiting 70 
Constipation 75 
Dental Caries. Nephritis 76 
Toxemia 77 
Frequent Micturition. Edema. Varicosities 83 
Signs of Pregnancy 83 
Abortion 84 
Extra-uterine Pregnancy 86 
Placenta Previa 88 
Separation of Normally Seated Placenta 93 
Cancer of the Cervix 94 
Hydatid Mole 95 
Management of Pregnancy 95 
Diet 95 
Bathing 96 
Dress 97 
Exercise 99 
Care of the Breasts 101 
CHAPTER XV. 
Labor 
Eutocia and Dystocia 102 
Causes of Labor 102 
Forces of Labor 103 
Labor Pains 103 
Stages of Labor 104 
First Stage 104 
Effacement of Cervix 106 
Formation of Bag of Waters 106 
Rupture of Membranes 106 
Second Stage 108 
Third Stage 109 
After-pains 109 
Mechanism of Labor 110 
Posture, Position 110 
Presentation Ill 
Station. Descent 112 
Rotation 117 
Exit of Head 118 
Exit of Body 120 
Expulsion of Placenta 121 
Management of Labor 123 
Nurse’s Outfit. Patient’s Outfit 124 
Preparation of Nurse 127 
Method of Cleaning Hands 128 CONTENTS 
IX 
Preparation of Patient 130 
Enema 130 
Closet. Bath 131 
Dress. Bed 132 
Disinfection of Genitalia 135 
Solutions 138 
Room 139 
Examination of Patient 141 
Abdominal Examination 141 
Inspection 141 
Palpation 142 
Auscultation 146 
Inspection of Genital Region 149 
Palpation of Perineal Region 150 
Internal Examination 151 
Care of Bladder 155 
Nourishment 156 
Moral Support 157 
Analgesia and Anesthesia 157 
Ether and Chloroform 158 
Support of Back 159 
Pulling 160 
Supporting Perineum 161 
Position of Patient 163 
Delivery of Body 163 
Ligation of Cord 164 
Management of Third Stage 165 
Postpartum Hemorrhage 167 
Causes 167 
Atonic Hemorrhage 168 
Hemorrhage from Partial Detachment of Placenta . . 169 
Traumatic Hemorrhage 170 
Hemorrhage from Deficient Coagulability of Blood . 170- 
Inversion of Uterus 171 
Prevention of 172 
Removal of Partly Adherent Placenta 172 
Expression of Placenta 173 
Manual Removal 174 
Management of Atonic Hemorrhage 174 
Massage. Hot Douche 175 
Oxytocics 177 
Summary 177 
Combating After-effects of Hemorrhage 178 
Hypodermoclysis 179 
Dystocia 181 
From Abnormal Forces 181 
From Abnormal Passages 182 
From Abnormalities in Passenger 182 
Twins 182 
Short Cord. Prolapse of Cord 183 
From Abnormal Mechanism 183 
From Accidents 184 
Rupture of Uterus 184 
Vulvar and Perineal Lacerations 184 X 
CONTENTS 
Obstetrical Operations . 185 
Frequency 185 
Classification 185 
Preparation 186 
Induction of Abortion 188 
Induction of Labor 189 
Dilatation of the Cervix 192 
Symphyseotomy 193 
Hebosteotomy 194 
Version 195 
Changing Face to Vertex 196 
Expression of Fetus 198 
Expressing Head from Vagina 199 
Manual Extraction 199 
Forceps 201 
Caesarean Section 203 
Porro-Csesarean Section 208 
Extraperitoneal Caesarean Section 208 
Postmortem Caesarean Section 209 
Vaginal Caesarean Section 209 
Embryotomy 211 
Decapitation 213 
Removal of Placenta 213 
Repair Operations 213 
Vaginal Douche 215 
Intra-uterine Douche. Intra-uterine Tamponade . . 216 
Hypodermoclysis 217 
CHAPTER V. 
Ptjerperitjm 
Duration 218 
Lochia 219 
Care of Bed. Cleaning of Patient 220 
Puerperal Fever 223 
Symptoms 225 
Treatment 228 
Puerperal Tetanus 230 
Puerperal Insanity 230 
Difficult Micturition 231 
Constipation 234 
Diet 237 
Breasts, Lactation 241 
Colostrum 242 
Distention 242 
Pumping 243 
Bandage 244 
Ice-bags 247 
Massage 247 
Infection 250 
Galactorrhea 257 
Hypertrophy of Axillary Sweat Glands 258 
Care of Room 258 CONTENTS 
xi 
Rest . 259 
Toilet ... 261 
Posture 261 
Massage and Passive Movements . 262 
Bed Exercise 263 
Getting Up 266 
CHAPTER VI. 
The Infant 
First Care * . 269 
Asphyxia Neonatorum 270 
Treatment 271 
Slapping 271 
Removal of Mucus 271 
Hot and Cold Baths 273 
Laborde Method 274 
Byrd Method 275 
Sylvester Method 276 
Schultze Method 277 
Insufflation 279 
Oxygen Insufflation 281 
Protecting Child Before Separation 282 
First Care of E|yes 283 
Tying Cord 284 
Condition of New-born 284 
Malformation 286 
Moulding of Head 287 
Caput Succedaneum 287 
Cephalhematoma 288 
Birth Injuries 288 
The Skin 289 
Jaundice 290 
Bath 290 
Cleaning Perineal Region 293 
Care of Navel 295 
Umbilical Hernia 296 
Care of Genitalia 297 
Menstruation in Infancy 297 
Adherent Foreskin 297 
Circumcision 298 
Undescended Testicles 299 
Breasts 299 
Care of Mouth 299 
Thrush 299 
Tongue-tie 300 
Care of Nose 300 
Vomiting 301 
Diarrhea 301 
Constipation 302 
Colic 303 
Care of Ears 303 xii 
CONTENTS 
Care of Eyes 304 
Ophthalmia Neonatorum 304 
Subconjunctival Hemorrhage 305 
Dress 305 
Sleep 309 
Feeding 310 
Premature Children 318 
Dangers ■ 319 
Home or Incubator Station 319 
Warm Room 320 
Incubator 320 
Feeding 323 
Oxygen 324 
Dressing and Bathing 324 
Subsequent History 325 
Incubation for Other Debilitated Conditions 325 OBSTETRICAL NURSING. 
CHAPTER I. 
INTRODUCTORY. 
A nurse’s success or failure depends not only upon her 
knowledge of disease and its complications and the proper 
way to manage them, but quite as much upon her common- 
sense and tact in dealing with people and her ability to 
adapt herself to circumstances. When a nurse leaves the 
hospital and enters upon private nursing she finds the con- 
ditions quite different from those in which she has been 
trained. Sometimes her patient is not tractable. When a 
patient goes to a hospital she assumes that she must adapt 
herself to the regime already instituted and acquiesces in all 
the nurse’s directions. In her own home she does not so 
easily lay aside her authority and the nurse finds it necessary 
to adopt other measures in carrying out the directions of the 
physician than those she is accustomed to use in the hospital. 
Moreover, the household arrangements must be taken into 
consideration. She has to deal with one or more servants 
and must be careful not to cause any disturbance. She 
frequently has to manage not only her patient, but also her 
patient’s relatives who may have more or less authority in 
the house. Often she has to put up with unsatisfactory 
facilities for doing her work as she has been accustomed to 
perform it. In short, she finds private nursing and hospital 
nursing so different that she is often discouraged over her 
difficulties and mistakes. 
If she has the will and tact she will soon overcome these 18 
INTRODUCTORY 
difficulties, provided she has the proper foundation of a 
good training in the work she is called upon to do. It is 
the object of this introductory chapter to call attention to 
certain obligations or duties which a nurse owes to herself, 
to her patient, and to the attending physician, which, when 
duly appreciated and regarded will smooth over many of 
the difficulties and bring her a quicker and greater measure 
of success. 
The rules of conduct based upon these duties apply more 
or less to all nursing. Obstetrical nursing (lifters from other 
nursing in the fact that the obstetrical nurse has to care for 
two patients, the mother and the child. Her patients, while 
helpless, are generally not sick. Her duty is to preserve the 
health of her patients instead of to cure them. She is gener- 
ally engaged beforehand, and is the choice of her patient or 
her physician. If she gives satisfaction she is the recipient 
of much gratitude, and her success in her calling is assured. 
It not infrequently occurs that a nurse fails to satisfy her 
patient or her physician, and yet she is quite unconscious 
of the reasons for her failure. It is not uncommon for her in 
such cases to assume that her patient or the physician, or 
both, dislike her or fail to appreciate her because of some 
whim or unjust prejudice against her. A careful study of 
some of the following suggestions may lead her to clear up 
her ideas and discover where she can improve. 
As a result of the satisfactory development of the nursing 
profession in recent years the practical and ethical rules of 
conduct have been so well formulated and inculcated that 
most or all of these suggestions have become a fundamental 
part of the nurses equipment. Since this book, however, 
may be used by some who have not had the advantage of a 
training in the best modern schools of nursing and since the 
physician’s confirmation of the teaching of the school super- 
intendent or supervisor can only emphasize its importance 
the following observations cannot be considered useless or 
obsolete. 
Duties to Self.—The nurse’s chief duty to herself is the 
care of her health. Without health she not only suffers and 
risks her future career, but she is unable properly to care for NURSE’S DUTIES TO SELF 
19 
her patient. No one who is not strong and free from all 
constitutional or local disease should attempt nursing as a 
calling. If a nurse contracts a chronic disease after she has 
begun her work the question of giving up her profession 
becomes a very important one and must be decided by careful 
study in each individual case. Certain diseases are abso- 
lutely prohibitive. No nurse who has consumption, for 
example, has a right to continue her work. Syphilis and 
epilepsy are also examples of chronic diseases which abso- 
lutely disqualify a nurse. Certain pelvic diseases may greatly 
limit a nurse’s usefulness. If a nurse has very painful men- 
struation, so that she is hardly able to be out of bed for two 
or three days, she is certainly not in a condition to care prop- 
erly for her patient. Acute infectious diseases disqualify 
a nurse, of course, until she has recovered. An obstetrical 
nurse, in particular, must avoid all infection both on account 
of the mother and the child. No nurse should think of going 
to an obstetrical case until she has entirely recovered from 
scarlet fever, measles, erysipelas, etc. The greatest difficulty 
in deciding what to do arises in such affections as sore throat, 
colds, and attacks of influenza or grip. Should a nurse 
assume charge of a case of obstetrics or remain with a case 
if she has an ordinary tonsillitis or bronchitis? Ordinarily 
there is here much too great laxness of judgment. In every 
such case the nurse should consult the attending physician 
and be guided by his advice. If she remain in attendance 
she should at least take all possible care to avoid infecting 
her patients. 
As a means toward the preservation of her health, she 
must attend to the regulation of her food and drink, care 
of her person, her clothing, sleep, and exercise. 
The kind of food and its preparation will, of course, vary 
in different houses. Generally she will have no difficulty in 
obtaining a sufficient amount of good, wholesome food. 
A nurse has no right to be whimsical in her diet, and should 
not cause any unusual disturbance in the kitchen by asking 
for uncommon dishes. If she needs, during the day or night, 
an extra lunch, it is perfectly proper that she should ask 
for it in case it is not provided. A cup of hot milk is one of 20 
INTRODUCTORY 
the best lunches that can be taken, as it is both a stimulant 
and a food. Sometimes, in emergencies, which often occur 
during the labor, meal times are very irregular. At such 
times a cup of hot milk is also very valuable. 
Intimately connected with the question of eating is the 
proper care of the mouth, stomach, and bowels. Good teeth 
and a good stomach are specially valuable when there is a 
lack of good food. A decayed tooth is not only a source of 
suffering but also a cause of improper nourishment and ill 
health. Bad teeth and a disordered stomach also cause a 
bad breath, which is a very serious failing in a nurse. It is, 
indeed, so important that it practically prevents a nurse 
from caring for a sensitive or well-bred patient. A nurse 
should always keep her teeth in good condition. Upon the 
slightest sign of trouble she should consult her dentist. Even 
if she has no toothache it is well for her to consult her dentist, 
every year at least, to be certain that no decay is developing 
insidiously. She should, of course, use her brush and powder 
morning and night, and wash out the mouth with some mild 
antiseptic wash after each meal. 
If a coated tongue, eructation of gas, or regurgitation of 
food or feeling of pressure over the stomach after eating indi- 
cate a disturbance of that organ, she should make a vigorous 
effort to improve her digestion. Care of her diet, avoidance of 
indigestible foods, fried dishes, etc., will be the first measures 
to suggest themselves. A cup of hot water taken before 
meals will often improve the digestion. A regulation of con- 
stipated bowels is often important. If this care is not suffi- 
cient she should consult her physician. 
Constipation is a frequent cause of ill health in women, 
and many nurses suffer more or less from this trouble. Very 
frequently it is due to carelessness or ignorance. If a girl 
is taught to secure a regular movement of the bowels at a 
certain time every day she will grow up with regular habits. 
If she is allowed to neglect this important function, to 
attend to the bowels sometimes at one hour and sometimes 
at another, and frequently omit caring for herself an entire 
day, she will probably be more or less constipated. Every 
nurse should learn the extreme importance of a regular NURSE’S DUTIES TO SELF 
21 
daily evacuation of the bowels, and if she has not been taught 
the proper care of herself while a child she should make 
every effort to correct this mistake. In case a regular 
routine is not sufficient she may need a laxative diet and 
medicines and perhaps injections. A glass of water taken 
fifteen to twenty minutes before meals is sometimes sufficient 
as an aid. Frequently fruit is quite a help. Coarse foods, 
including bran and agar-agar, are often necessary. Some- 
times a laxative mineral water or small amount of salts 
taken in the morning for some time will help toward a cure. 
Any nurse who has had any trouble with constipation is 
advised to cure herself before she begins private nursing. 
The circumstances which surround her in a private house 
make it very desirable that she should have no trouble of 
this kind. If she is accustomed to regular habits she will 
have no special difficulty in caring for herself properly. 
The care of the digestive tract suggests the care of the 
skin. It may be impossible to carry out the habit of daily 
bathing, i. e., in a tub. Such a habit is very useful to a 
nurse and should be practised whenever possible. A free 
use of cold water over the neck and chest is a substitute to 
be recommended. Perfect cleanliness to prevent all odors 
of perspiration or exhalation is a matter of course. It is 
hardly necessary to say that the use of perfumes about the 
person is vulgar and disagreeable to the patient. 
The care of the hands will be spoken of when we come to 
consider the subject of disinfection in the preparation for 
labor. It will then appear that clean hands, without cracks, 
hangnails, or any abrasions, unadorned by rings, are the 
most important possessions of a nurse. 
The care of the skin is closely connected with the subject 
of clothing. Loose, comfortable clothes should always be 
worn. They should be warm in winter and afford the proper 
protection at other seasons of the year. Wool of the proper 
weight or wool and cotton or wool and silk are the best mate- 
rials except in the summer. The feet especially should be 
well protected. The shoes should have reasonably thick 
soles and be of sensible shape and size with rubber heels. A 
corset which compresses the waist just below the ribs is 22 
INTRODUCTORY 
unhygienic and absurd for any woman, but especially for a 
nurse. Her skirts should be light. She should rely more for 
the protection of the skin upon the undergarments than 
upon the skirt. The waist and outside skirts are of course 
of washable material. 
A word should be said concerning the night clothing. 
Since an obstetrical nurse is almost certainly called upon 
during the night, when the temperature of the room is lower 
than in the daytime, she must be prepared with the proper 
night clothes. Not only should she have a long, warm night- 
gown with the proper robe, but the feet and lower extremities 
must be protected. For this purpose pajamas with feet are 
well adapted. Warm slippers are absolutely necessary. A 
little extra care or expense will pay for itself many times 
over if it preserves to the nurse her chief capital, her health. 
An obstetrical nurse is often disturbed very much in her 
sleep, especially during the first week. Unless she is able 
to get along twenty-four hours without sleep she should 
not undertake this branch of nursing. The possibility that 
such a demand will be made upon her at the beginning of her 
engagement makes it important that she should always go 
to a case quite fresh and thoroughly rested. In the subse- 
quent weeks she generally will be able to make up her lost 
sleep. 
In order to be in the best possible condition she should 
take a brisk walk of an hour or half an hour in the open air 
every day. It may often happen that in the beginning of a 
case this is impossible, but, as a rule, it can be carried out. 
The shorter the time that can be devoted to the walk the 
more wisely should it be employed. Breathing deeply with 
the shoulders thrown back with an energetic walk of even 
fifteen minutes will be of value for the entire day. 
Duties to Doctor.—In a broad sense of the term the nurse 
is the doctor’s assistant. The doctor alone is responsible to 
the patient for the management and outcome of a case. It 
is not possible or desirable to have a divided responsibility. 
Being responsible it is necessary that the doctor should have 
complete authority. He is responsible for the nurse and she 
is responsible to him. From this it follows that it is the duty NURSE’S DUTIES TO DOCTOR 
23 
of the nurse to work entirely under the doctor’s directions. 
She should assume no responsibility on her own account 
further than may be necessary to meet emergencies during 
the absence of the physician. She should under no circum- 
stances institute treatment in opposition to that laid down 
by him. If it should be necessary to do something not 
ordered by the physician, she should report to him fully as 
soon as possible her action and the reasons for it. Only in 
this way can she secure and retain his confidence and properly 
perform her duty as his assistant. 
It is never her duty to make, unasked, suggestions to the 
doctor. As a rule only ignorant or superficial nurses think 
to increase their importance and impress the physician with 
their knowledge by making suggestions concerning the 
treatment of the case. 
If a nurse should make any mistakes, as anyone may do, 
she should report these mistakes to the physician at their 
next meeting. She will find that he will appreciate her situa- 
tion and think more of her for her frankness and honesty. 
Nothing is more calculated to shake the confidence of a 
physician in a nurse than to find out later, from other sources, 
mistakes which she has not reported. 
As the physician’s assistant the nurse has to assist or wait 
on him during his attendance at the confinement, and his 
subsequent visits and to carry out his orders in his absence. 
She must also watch her patient and report symptoms. In 
order to carry out the physician’s orders it follows, as a 
matter of course, that the nurse must understand him. If 
she has any doubts as to the meaning of any direction she 
should ask that it be thoroughly explained to her. The 
excuse that she did not understand what the doctor meant is 
no excuse at all. 
In order to report properly on the progress of a case it is 
necessary for the nurse to keep a record. The report or 
record of the nurse is of great importance to the physician, 
the patient, and to herself. The patient’s welfare and some- 
times her life depend upon the care with which her symp- 
toms are watched and recorded. A mistake in the tempera- 
ture or pulse will often deceive the physician and cause him 24 
INTRODUCTORY 
to overlook an important feature of the patient’s condition. 
Failure of the nurse to observe some unusual temporary 
symptom may have the same result. Of course a false record 
is the worst of all. If a nurse should forget to take the tem- 
perature or pulse, and in order to cover up her mistake make 
a record which she thinks is about right, she is guilty of a 
crime against the patient which, at times, might have the 
most serious consequences. 
The nurse’s record is of great importance to the physician, 
for it enables him to see in a moment the events of the day. 
If a nurse could know what satisfaction a physician takes in 
a properly kept record, complete yet not diffuse, neat and 
easily read, she would feel herself repaid for a little extra 
care. 
For the nurse herself the record is of importance because 
by it her education, ability, and character are often judged. 
Poor spelling and poor writing stamp a nurse as ignorant 
and careless. A diffuse, mixed-up report shows her to be 
illogical and poorly trained. A neatly written report that 
contains only essential matters marks her as one possessed 
of good mental qualities and proper training. 
It is always desirable that she should form the habit of 
recording each item as soon as observed. Unless this habit 
of making a prompt record is formed she will become accus- 
tomed to delaying writing for several hours, when some things 
will be forgotten and the record will lose its accuracy. If 
possible the records should be kept in ink, being thus perma- 
nent and neater. 
Of course the record should be preserved until the case 
is terminated. It is often necessary to refer back to it for 
the history of the beginning of the case. When the nurse 
leaves to whom does the record belong? If the physician 
does not care for it the nurse may preserve it if she chooses. 
It is not good policy, however, for her to preserve a number 
of records in one book. When she carries such a case-book 
from one patient to another she exposes the history of a 
former case to the eyes of strangers. The nurse cannot 
know but what the patient or the patient’s friends or the 
physician may take up her case-book to look at the record of NURSE'S DUTIES TO DOCTOR 
25 
the patient and almost involuntarily notice reports of former 
cases. A great majority of patients would object to this 
publication of the history of their sickness; therefore, if a 
nurse preserves her reports she should keep each case sepa- 
rately. 
Sometimes a physician furnishes the blanks for the records, 
as he wishes to preserve them for future reference. The 
accompanying charts show a form which will perhaps serve 
as a model for childbed and infant records. They are kept 
on cards 10 x 15 centimeters in size, to file away with preg- 
nancy and labor cards. 
Baby Record. 
Name. 
When born. 
Birth weight. Page 
Hour. 
P. 
T. 
Bowels. 
Urine. 
Navel. 
Eyes. 
Puerperal Record. 
Name of patient 
Date of confinement. 
Name of nurse. 
Page 
Hour. 
P. T. 
Bowels. 
Urine. 
Lochia. 
Breasts. 
Medicine. 
In a system like this as much space can be used as is needed. 
One or two pages or more may be used in a day or one page 
may serve as a record for two or three days. A heavy line 
drawn across the card separates the report of one day from 
another. The date is placed in heavy figures in the hour 26 
INTRODUCTORY 
column. The ordinary method of indicating the time in the 
hour column for each separate entry is, of course, known to 
all. Any necessary remark concerning the bowel movement 
is placed in the proper column. The quantity of urine as 
well as its character is to be recorded if possible. During 
the first two or three days the amount and character of the 
lochia is reported in some detail. Later a general observa- 
tion of the entire day may suffice. The condition of the 
breasts should also be noted with some detail. In the last 
column the facts concerning sleep, food, and bathing can 
be entered. General observations that might be assumed 
may be omitted. For example, patient washed, patient 
rubbed, or dressing changed are unnecessary items. More 
explanations for the use of the puerperal and baby records 
will be given in subsequent chapters. 
It is often necessary to advise a young nurse upon leaving 
the hospital to engage in private nursing that she should 
be loyal to the doctor in charge of the case. She finds that 
his practice differs, perhaps in important details, from that 
which she has been taught in her training course. She should 
never comment on this fact to the patient or to the patient’s 
friends and compare a physician in attendance with some 
other physician with whom she has been associated. Such 
a course is very unwise and will generally react against her. 
If she, by this course, should create a lack of confidence in 
the physician on the part of the patient she may be doing 
a great deal of harm to both parties. She should carry 
out directions which seem to her useless. It is not her 
business to judge. Loyalty to her physician should be her 
constant motto. If a case should ever rise where she is 
unjustly accused by the physician, she would better suffer 
quietly than to bring the matter before the patient. In 
extreme cases where she feels that great injustice has been 
done her, she would better ask the advice of the superin- 
tendent of her training-school. 
Duties to Patient.—As assistant to the doctor it is the duty 
of the nurse to her patient to carry out his orders. This 
subject has been sufficiently discussed. There are, however, 
duties devolved upon the nurse which are not directly com- NURSE’S DUTIES TO PATIENT 
27 
prised in the explicit directions given by the physician. 
These assumed duties may be comprehended in the state- 
ment that a nurse should secure for her patient the best 
possible physical and mental condition. Both are promoted 
by the proper and skilful care of the patient’s toilet, care of 
her room and surroundings, and the general conduct of the 
case so as to prevent worry, anxiety, or annoyance. 
In brushing the hair, giving a sponge bath, a douche, or 
an enema a nurse displays not only her training but also 
her habits of attentive tidiness. It is impossible to give 
explicit directions to a nurse who is careless in these respects. 
Tidiness and cleanliness should be part of a nurse’s nature. 
A nurse who makes such mistakes after a hospital training 
of three years is hopeless. A first-class nurse will attend to 
the personal wants properly because she herself knows what 
good breeding desires and demands. Knowing what she 
herself desires she will have no difficulty in satisfying any 
patient. 
The same golden rule that applies to the toilet applies 
also the the room and the surroundings. A refined nurse will 
imagine herself the patient and picture her satisfaction with 
a tidy and well-ventilated room. She would appreciate the 
nurse who knows how to dust the room, not by brushing into 
the air a cloud of dust to settle back on the furniture or floor. 
The sensitive patient regards these things often much more 
than a knowledge of anatomy or medicines. 
A nurse cares for the mental condition of her patient by 
what she does and by what she does not do. A cheerful 
and quiet manner is appreciated by everyone. Some ability 
to entertain is not to be despised. A gossipy nurse is, how- 
ever, somewhat dangerous. Above all things a nurse must 
avoid speaking of other patients or of the affairs of families 
in which she has lived. Whatever she learns of a patient or 
a patient’s family should be held strictly confidential. 
Should a patient be so indiscreet as to ask about such matters 
the nurse is in duty bound to avoid giving answers to such 
questions. 
A nurse should also avoid the introduction of disagreeable 
subjects. Conversation about diseases in general is undesir- 28 
INTRODUCTORY 
able. A nurse will soon learn the temperament of her patient 
and subjects that should be introduced. 
A nurse should not ask unnecessary questions. What- 
ever pertains to her work let her find out for herself or from 
servants or other members of the family if possible. In an 
obstetrical case it is always well for a nurse to go to the 
house before the time of the expected confinement to learn 
the arrangements of the house in order that she may not 
need to annoy the patient after the labor begins. 
A nurse should also leave her patient alone at times. 
Often a patient wishes rest of which she is deprived by the 
presence and perhaps the conversation of the nurse. Let 
the nurse occasionally withdraw from the room, remaining 
within call. 
It is a nurse’s duty to protect her patient from visitors and 
also from members of her own family. In the performance 
of this duty considerable tact and skill must be employed. A 
nurse who would brusquely order from the room a husband, a 
mother, or a sister of the patient may be very conscientious, 
but would never be a favorite. Rules must vary according 
to the case. In general, visitors are kept out of the sick- 
room for the first week or two and perhaps longer by the 
doctor’s directions. If the members of the family tire or 
annoy the patient, they also must be excluded. This can 
alwrays be done, however, in a quiet way that will give no 
offence. 
One' of the chief causes of anxiety to the mother is the 
baby, and the nurse by proper management of the baby 
can do more to make the mother easy and happy than in 
almost any other way. The idea has become quite wide- 
spread that it is the duty of the nurse to begin the training 
of the baby at its birth. Following out this idea she con- 
cludes that the baby should lie in its bed two or three hours 
at a time, when it is to be fed and replaced. If the baby 
cries it is because it is bad and needs strict training. Mothers 
do not fully appreciate the importance of this early training 
and often worry considerably over the crying of the baby. 
This training of a new-born infant is overdone. If a baby 
cries it is because it has pain. If a baby is comfortable, ARRANGEMENTS FOR AN OBSTETRICAL CASE 
29 
warm, clean, and properly fed it will sleep quietly most of 
the time. Walking with the baby is generally undesirable. 
It is the duty of the nurse to find out if possible the cause of 
the baby’s discomfort and relieve it. If she cannot discover 
the trouble she must, of course, get the assistance of the 
physician. If both the nurse and the physician fail the nurse 
must make the best of a bad situation and keep the child as 
quiet as she can. Under no circumstances should she distress 
the mother by complaining of the child and call it naughty 
or ugly. A week-old infant is never naughty. It is uncom- 
fortable or sick, not because of any fault of its own but 
because of lack of adaptation to its surroundings. A sym- 
pathetic nurse who says this to the mother will do her duty 
much better than one who is constantly grumbling about 
the baby or coldly trying to train it. 
Another duty of a nurse to her patient is to serve as an 
example. Through the example of the nurse the patient 
learns the essential ideas of cleanliness. She learns how to 
wash herself and how to care for the breasts. If the breast 
shield must be used she learns from the nurse how to clean 
the shield and the nipple. If artificial feeding is necessary 
the patient learns how to prepare the food and how to care 
for the nursing bottle. The nurse should always wash the 
baby in the proper way in order that the patient may learn 
only the best methods. As an example and as a teacher the 
nurse has a field of great usefulness. Her teaching function 
is by no means one of the least of her duties. 
Engagements and Arrangements for an Obstetrical Case.— 
An obstetrical engagement is generally made some time 
before the expected confinement. On account of the diffi- 
culty of determining in advance the exact day of the con- 
finement it is necessary that the nurse should have some 
kind of an understanding with the patient concerning the 
date of beginning and the terms of the engagement. While 
wealthy patients frequently make an engagement with a 
nurse to begin a few days before the expected confinement 
at a full salary, a great majority of patients dislike to pay a 
nurse before her work begins. It is, however, not just for 
the nurse to wait several days or perhaps two or three weeks 30 
INTRODUCTORY 
losing her time. A very reasonable compromise is that the 
nurse should receive half-pay or part-pay while waiting 
after a specified date, to be determined by the physician. 
During this time she may remain at her home or at the 
patient’s home, as would be agreed upon. This plan is espe- 
cially recommended to nurses during the first two or three 
years of their private work. Later their own business ideas 
will be a sufficient guide. 
A nurse should not make any engagements that possibly 
overlap. If, for example, she be engaged for a case for four 
weeks beginning February 1 she should not take a case 
beginning March 1 unless with a distinct understanding 
with both parties. She should always allow one week for the 
postponement of the first confinement. 
A nurse should always be prepared to go to a case without 
a moment’s delay. Her satchel and clothes should always 
be in readiness. She should never go to a case of contagious 
disease for two or three weeks before an expected obstetrical 
case. She ought to arrange for permission to leave on a 
moment’s notice any case she is attending a fortnight before 
a confinement case is expected. CHAPTER II. 
ANATOMY, PHYSIOLOGY AND EMBRYOLOGY. 
Certain elementary facts concerning the anatomical 
structure and functions of the pelvis and genital organs of 
woman are necessary to an intelligent study of pregnancy 
and labor. A short description of the chief stages in the 
development of the fetus is also desirable to furnish an 
intelligent idea of the growth of the child from the egg, its 
relations to the mother, and the meaning and importance 
of the fetal appendages during pregnancy. The most essen- 
tial facts in elementary form will be given in this chapter. 
Pelvis.—The bony pelvis is the lower part of the trunk 
skeleton. It is an irregularly shaped, somewhat curved, 
hollow cylinder, formed of four bones: the two hip bones, 
the sacrum, and the coccyx. The sacrum is formed by the 
uniting together of the five vertebrae below the lumbar 
vertebrae or those of the small of the back. The rudimentary 
last four vertebrae of the spinal column form the coccyx. 
Each hip bone, also called innominate bone or os innomi- 
natum, is formed by three bones: the ilium behind and above, 
the ischium below, and the pubic bone in front, which merge 
early in life into one bone. The junction of the pubic bones 
in front is called the symphysis pubis (Fig. 1, Frontispiece). 
The sacrum and coccyx behind with the lower main parts 
of the hip bones at the sides are bound together by strong 
ligaments and form the walls of the small or true pelvis. 
The upper wings of the hip bones at the sides and the lumbar 
vertebrae behind form the so-called large pelvis, which partly 
encloses the lower segment of the abdominal cavity. The 
true pelvis encloses the pelvic cavity, which contains, besides 
the muscles and fasciae that line its walls, also the organs of 
generation as well as the bladder and rectum (Fig. 2). The 32 
ANATOMY, PHYSIOLOGY AND EMBRYOLOGY 
soft pelvis is the name applied to the skeletal pelvis lined 
with muscles and other soft parts to distinguish it from the 
hard or bony pelvis. It is the obstetrical canal through 
which the child must pass in its birth. 
The opening into the pelvic cavity from above is called 
the inlet or brim of the pelvis. This plane is somewhat 
Fig. 2. Female pelvis, with thigh bones articulated, showing also the sacro- 
spinous ligaments which help to close the pelvis below. 
heart-shaped, the indentation from behind being formed 
by the upper part of the sacrum, which is called the pro- 
montory of the sacrum. The exit from the pelvic cavity, 
or the bony obstetrical canal, is called the outlet. We shall 
learn during the study of labor that the pelvic outlet is not 
the same as the true obstetrical exit, namely, the vaginal PELVIS 
33 
outlet. The space between the inlet and the outlet is the 
cavity or excavation of the pelvis. 
The size of the pelvis of a woman is very important, for 
if it is smaller than the child at birth, natural labor is impos- 
sible. A pelvis which is too small to admit of the passage 
into and through it of a child of normal size is called a 
contracted pelvis. It may be contracted in any part of the 
canal, but it is most frequently contracted at the inlet. 
When it is contracted from before back, i. e., when the 
Fig. 3.—Median sagittal section of pelvis. (Gray.) 
anteroposterior diameter of the inlet is shortened, the pelvis 
is called a flattened pelvis. When the inlet is equally con- 
tracted in all directions, i. e., when all the diameters are 
shortened, the pelvis is called a generally contracted pelvis. 
A funnel pelvis is one in which the inlet is normal in size 
or larger than normal, while the outlet is contracted. There 
are many other forms of contracted or deformed pelves, 
such as the obliquely contracted or Naegele pelvis and the 
many varieties of irregularly contracted pelves. A pelvis 34 
ANATOMY. PHYSIOLOGY AND EMBRYOLOGY 
may be contracted irregularly at the brim, at the outlet, or 
in the excavation (Fig. 4). 
It is interesting to know the differences between the pelves 
of the child, the woman and the man. In a child the pelvis 
is comparatively small, narrow, and straight. In a girl at 
the age of puberty, that is about twelve or thirteen years, 
it becomes larger, more curved, and assumes the adult form. 
The male pelvis is longer and narrower. 
Fig. 4.—Three types of contracted pelves: A, irregularly contracted 
(beak) pelvis; B, flattened rachitic pelvis; C, funnel pelvis; D, funnel pelvis, 
sagittal section. 
Most of the deformities of the pelvis begin in the young 
child when the bones are soft or forming, and are due to 
rickets, a disease which disturbs the growth of the bone. 
Figures representing a sagittal section through a normal 
child’s pelvis and a similar section through a rachitic pelvis 
show how the pelvic bones are deformed as a result of rickets. 
It is important to know that this preventable children’s 
disease, which is due largely to disturbed nutrition, is the 
cause of a large number of difficult labors. EXTERNAL GENITALS 
35 
EXTERNAL GENITALS. 
The genital organs in the woman consist of the internal 
organs contained within the pelvic cavity and the external 
organs which form the vulva. The external genitals include 
the mons veneris, labia majora and minora, the clitoris, the 
vestibule, the hymen, and the vulvo-vaginal glands. These, 
together with the exterior orifices of the urethra and the peri- 
neum, require a short description. 
Mons Veneris.—The mons Veneris or mons pubis is the 
region over and above the symphysis pubis, i. e., the junc- 
tion of the anterior portions of the hip bones. The skin 
is elevated with a fatty deposit and covered with hair. 
Labia Majora.—The labia majora, or large lips of the vulva, 
are broad, ellipitical folds of skin containing elastic, vascular, 
and fatty tissues, which pass backward from the mons 
Veneris, uniting behind in the fourchette, the anterior fold 
of the perineum, to enclose the vaginal outlet. They are 
more or less covered with hair. The lips lie normally in appo- 
sition and enclose the other genitals. 
Labia Minora.—The labia minora, or small vulvar lips, 
also called the nymphse, are the folds of very delicate skin 
which lie inside the labia majora. Starting from the sides 
of the latter they converge to the front, where each fold 
divides into two, the lower from each side uniting under the 
clitoris, and the upper uniting above to form its prepuce. 
The inner surfaces of the labia minora are in contact. Unless 
elongated they are not seen until the labia majora are sepa- 
rated. 
Clitoris.—The clitoris is the small sensitive body which 
lies in the middle line and is protected by the upper folds 
of the nymphse which form its prepuce, as just described. 
The end of the clitoris body is the glans of the clitoris. It is 
generally free from the prepuce, but covered by it. 
Vestibule.—The vestibule is the sensitive triangular space 
lying back of the clitoris, bounded by the labia minora on 
the sides and the anterior border of the vaginal orifice behind. 
Nearly in its center is seen the opening of the urethra, the 
canal which leads from the bladder, 36 
ANATOMY, PHYSIOLOGY AND EMBRYOLOGY 
Hymen.—The hymen is a fold of vaginal mucous mem- 
brane, frequently crescentic in shape, arising from the pos- 
terior border of the vaginal outlet, partly closing it. It is 
Clitoris 
Vestibule 
External urethral 
orifice 
Vaginal orifice 
Hymen 
Fig. 5.—External genital organs of female. The labia minora have been 
drawn apart. (Gray.) 
generally torn after marriage, and if not, always after child- 
birth. The torn edges form an irregular border to the 
vaginal outlet, and these irregularities are called the carun- 
culse mvrtiformes. INTERNAL GENITALS 
37 
Vulvo-vaginal Glands.—The vulvo-vaginal or Bartholin 
glands lie one on each side at the sides of the vagina behind 
the labia majora and empty by relatively long ducts about 
at the junction of the middle and posterior third of the 
vaginal opening just inside the nymphse. They are.important 
in obstetrics, for they are often the seat of a chronic gonor- 
rheal infection, which may be the source of a contamination 
of the child’s eyes at birth. 
Perineum.—The perineum is the name given to the body 
of muscle and fascia lying between the vaginal mouth and 
the anus. It is about two inches long from before back, and 
extends outward on each side toward the diverging anterior 
branches of the hip bones. The perineum is of some impor- 
tance to the support of the vagina. When it is torn, as often 
happens in labor, the proper closing of the vaginal outlet is 
interfered with, and gaping of the vagina results. 
The internal genital organs lie partly or wholly in the 
pelvic cavity, and consists of the vagina, uterus, Fallopian 
tubes, and ovaries (Fig. G). 
Vagina.—The vagina is a muscular fibrous tube lined 
with mucous membrane, which is the entrance canal to the 
uterus and the exit for the fruit as well as for other uterine 
discharges. It lies in the pelvis between the urethra and 
bladder in front and the rectum behind. The uterus projects 
into it and carries down the upper portion of the tube, which 
thus forms a kind of collar around this projecting vaginal 
portion of the uterus. The upper portion of the vagina 
which is reflected from the cervix and forms the upper dome- 
like end is called the fornix of the vagina. This part as well 
as the middle portion or body of the vagina is much larger 
and more distensible than the lower end or mouth. Hence 
during the passage of the child the lower end is much more 
frequently torn. The muscular and fibrous tissues which 
surround, close, and support the vagina are attached directly 
or indirectly to the walls of the bony pelvis, and with similar 
structures of the rectum form the pelvic floor. This is a very 
INTERNAL GENITALS. 38 
ANATOMY, PHYSIOLOGY AND EMBRYOLOGY 
important structure, for it helps to support the genital organs. 
It is also often torn or injured during labor, when more or 
less displacement of the genital organs results. 
Uterus.—The uterus or womb is a pear-shaped, hollow, 
muscular organ, lined on the inside with mucous membrane, 
Fig. 6.—Internal genital organs, with bladder, urethra, and rectum all 
distended, seen from the side. 
covered in part on the outside with peritoneum, the serous 
membrane that lines the whole abdominal cavity. The 
uterus is divided into two parts, the cervix or neck, and the 
corpus or body. That portion of the neck of the uterus that 
projects into the vagina is called the vaginal portion. Into 
the upper part of the body on the sides are inserted the INTERNAL GENITALS 
39 
Fallopian tubes and also the round ligaments. The base of 
the uterus or that portion beyond the insertion of the tubes 
and ligaments is called the fundus. The uterus varies in 
size, being generally somewhat larger after a woman has 
Sacrum 
Coccyx 
Vcsico-u/er in e 
excavation 
External uterine 
orifice 
Recto-uterine 
excavation 
Urethra 
Anal canal 
Fig. 7.—Median sagittal section of female pelvis. (Gray.) 
born children. In the virgin it is two and three-fourths to 
three inches long, about one and one-fourth inches belonging 
to the neck. The hollow interior of the uterus is likewise 
divided into two parts: the cavity of the body and the cer- 
vical canal. The cavity of the body is triangular, the upper 40 
ANATOMY, PHYSIOLOGY AND EMBRYOLOGY 
angles of this triangle corresponding to the openings of the 
Fallopian tubes, and the lower angle or apex corresponding 
to the beginning of the cervical canal. This opening, which 
of course is at the junction of the neck and body, is called 
the internal os. The opening of the cervical canal into the 
vagina is called the external mouth or os. 
Ureter 
Sacrogenital fold 
Ligament of ovary 
Uterine tube 
Pararectal fossa 
Round l igament of uterus 
Fig. 8.—Female pelvis and its contents, seen from above and in front. 
(Gray.) 
When a woman is standing the normal position of the 
uterus is nearly horizontal, the cervix pointing backward 
toward the hollow of the sacrum, while the base of the uterus 
lies just below the inlet to the pelvis, pointing forward. The 
uterus, which is slightly concave on its anterior or lower 
surface, lies upon the bladder, while the bowels rest upon 
its upper or posterior surface. It is supported at the sides INTERNAL GENITALS 
41 
by the broad ligaments that attach it to the walls of the 
pelvis. These are folds of peritoneum which enclose the 
same muscular and elastic tissues and the vessels that pass 
to the uterus. They, however, allow considerable motion to 
the uterus so that it straightens and rotates backward as the 
bladder fills, and forward again as it empties. Normally it 
should rise easily into the abdomen as it enlarges. 
Epoophoron 
Ligament of ovary 
Ostium 
abdominale 
Ovarian fimbria 
Ovarian 
vessels 
External uterine orifice 
Fig. 9.—Uterus and right broad ligament, seen from behind. The broad 
ligament has been spread out and the ovary drawn downward. (Gray.) 
Ligaments of the Uterus.— The round ligaments arise 
from the fundus in front of the uterine insertion of the tubes 
and pass under the peritoneum outward and forward in a 
curved line to the inguinal canals, through which they pass 
to be inserted into the abdominal walls (Fig. 8). When they 
functionate properly they help to hold the uterus in contact 
with the bladder and prevent too great a backward displace- 
ment of the uterus when the bladder is distended. The 
utero-sacral or posterior ligaments of the uterus are folds of 42 ANATOMY, PHYSIOLOGY AND EMBRYOLOGY 
peritoneum containing some fibrous and muscular tissue, 
which arise from the sides of the posterior wall of the uterus 
Uterine 
tube 
Internal 
orifice 
External 
orifice 
Fig. 10.—Posterior half of uterus and upper part of vagina. (Gray.) 
Fig. 11.—Retroversion of the uterus, with coils of intestines between bladder 
and uterus. INTERNAL GENITALS 
43 
at the junction of the cervix and body, pass around the 
rectum, and are attached to the body of the second sacral 
vertebra. They hold the lower part of the body of the 
uterus backward while the round ligaments hold the fundus 
forward. They thus help to keep the uterus in its normal 
condition in contact with the bladder. If they are weakened 
or elongated, and if at the same time the round ligaments 
are similarly injured, the uterus may change its position so 
that the fundus falls back into the hollow of the sacrum. 
Fig. 12.—Retroflexion of the uterus. 
Coils of intestine get between the bladder and uterus, which 
becomes retroverted (Fig. 11). If the junction of the cervix 
or body is thin or soft the uterus may bend backward and 
we have a retroflexion (Fig. 12). When these displacements 
occur during pregnancy they may cause troublesome or 
serious disturbances. 
Functions of the Uterus.— The functions of the womb are 
to receive a newly fertilized egg, nourish the developing 
child from its earliest beginning until it is able to live inde- 44 
ANATOMY, PHYSIOLOGY AND EMBRYOLOGY 
pendently, and then expel it. To fulfil these varied functions 
it must be liberally supplied with blood, and be lined with a 
membrane specially adapted to receive and support the egg. 
It must also be muscular to expel the ripened egg. This 
muscle is an involuntary muscle, i. e., it is not under the 
control of the will. In this respect it is similar to the muscle 
of the intestine or the heart, which organs must also work 
quite independently of the will. 
Menstruation.— In this connection one other function of 
the uterus may be mentioned here, namely, menstruation. 
This is a bloody discharge from the uterus, occurring every 
twenty-eight days, that lasts from two to six flays. Some- 
times it occurs as often as every three weeks and also as 
rarely as every six weeks. Greater variations are abnormal. 
When the flow lasts more than six or seven days or less than 
two days and when it is excessive in amount it is pathological. 
Normally there may be a feeling of fulness in the pelvis and 
a slight general malaise. Backache, cramps, headache, etc., 
are symptoms of abnormal condition and constitute a dys- 
menorrhea. The discharge consists of blood cells which 
pass out of the bloodvessels through the walls, or perhaps 
sometimes from ruptured vessels, and cast off cells from 
the lining membrane of the uterus, mixed with a serous fluid 
and mucus. The beginning of menstruation is coincident 
with the changes in a girl which makes her a woman. Among 
these changes are the development of the breasts, the growth 
and change in the shape of the pelvis, the growth of the 
uterus, etc. This period in a girl’s life we call puberty. It 
generally commences at about the age of twelve to fifteen 
years. Menstruation generally stops at the age of forty-five 
to fifty years, when certain retrograde changes occur in the 
genital organs. This period we call menopause or climacteric, 
or popularly the change of life. 
Various theories have been advanced to account for men- 
struation: one is that it prepares the uterus to receive the 
egg, another is that it results because impregnation has not 
occurred. In favor of the latter theory it may be said that a 
girl may become pregnant before she has menstruated, and 
many women become pregnant while nursing before men- INTERNAL GENITALS 
45 
struation has reappeared. It is quite possible that a woman 
may be carrying or nursing a child during all of the child- 
bearing period and never menstruate at all. Menstruation 
is dependent upon ovulation and the changes which occur 
in the ovary after the rupture of the follicle and escape of 
the ovum, i. e., in the formation of the corpus luteum. The 
menstrual discharge, or periodical escape of blood from the 
uterus, is not the only phenomenon resulting from the men- 
strual changes of the uterus. There is really a cycle of 
changes in the uterus, all probably dependent upon the same 
cause and all important. For a few days before the escape 
of blood the uterus is congested, its mucous membrane 
thickened, there is frequently some fulness of the breast 
and other symptoms. This first stage is the premenstrual 
stage. Then comes the second stage or menstruation proper. 
Then follows a stage of regeneration of the mucous mem- 
brane of about five days. Finally there is a period of rest 
lasting eight to ten days. 
All of these menstrual changes are of much importance 
not only because of their effect on the life and health of the 
woman, but also because of their obstetrical relations. Abnor- 
mal conditions may be the cause of sterility or of abortion 
or of diseased condition during pregnancy. 
Fallopian Tubes.—The Fallopian tubes are the canals for 
the passage of the egg from the ovaries to the uterus. The 
sperm cells also pass from the vagina through the uterus 
into the tubes, where they meet the egg and fertilize it. The 
tubes are therefore normally only canals, but sometimes an 
egg lodges in a tube and grows there. These cases are called 
tubal or extra-uterine pregnancies. The tube is not adapted 
to the function of nourishing the egg, however, and generally 
ruptures in a few weeks, producing one of the most dangerous 
conditions. In structure the tube is a muscular wall lined 
with mucous membrane. It is about four inches long and 
lies in the top of the fold of peritoneum, which helps to form 
the broad ligaments of the uterus. Each tube opens into the 
uterus on the corresponding side near the base by a small 
mouth. Its outer end is trumpet-shaped and opens into the 
peritoneal cavity. It is movable and has been supposed to 
grasp the ovary when an egg breaks free. 46 
ANATOMY, PHYSIOLOGY AND EMBRYOLOGY 
Ovaries.—The ovaries are small bodies, two in number, 
supported by ligaments at the sides of the uterus near the 
walls of the pelvis. They have a fibro-vascular tissue and 
contain the unfertilized ova or eggs. The ova are very 
numerous and irregularly scattered through the ovaries, 
each ovum being surrounded by small cells. In a young girl 
all of the ova are quite small, but during the child-bearing 
period some of them grow and develop from time to time into 
ripe or mature eggs. As a rule one egg ripens each month 
and breaks away from the ovary. As the ovum develops 
Fig. 13.—Section of the ovary. (After Schron.) 1. Outer covering. 
1'. Attached border. 2. Central stroma. 3. Peripheral stroma. 4. Blood- 
vessels. 5. Vesicular follicles in their earliest stage. 6,7,8. More advanced 
follicles. 9. An almost mature follicle. 9'. Follicle from which the ovum 
has escaped. 10. Corpus luteum. 
it not only grows in size itself, but the surrounding cells 
increase in number and form a cavity which becomes partly 
filled with fluid. During this change the ovum cavity, or 
Graafian follicle as it is called, moves from the interior of the 
ovary toward the surface, where it protrudes, and at last 
bursts, allowing the escape of the ovum. This process is 
called ovulation. 
Corpus Luteum.—The emptied Graafian follicle develops 
into a very interesting organ, the corpus luteum. There 
is a great proliferation of the cells which line the follicle, URINARY ORGANS OF WOMAN 
47 
and these penetrate into the blood clot which fills its interior. 
These cells are called the luteum cells because of their yellow 
color. The yellow body takes on the structure and functions 
of a ductless gland. A secretion is formed which, acting on 
the uterus, causes its mucous membrane to become con- 
gested and prepared to receive a fertilized egg. If fertiliza- 
tion does not occur menstruation takes place and then the 
“corpus luteum of menstruation” degenerates and partly 
disappears. If fertilization and nidation occur, the corpus 
luteum grows larger, and continues to functionate during 
pregnancy to gradually disappear after labor. 
Before taking up the fertilization and development of the 
egg we must consider for a moment the non-genital pelvic 
organs that may have obstetrical relations with the genitalia. 
Also we must study the breasts, which are very important 
organs in the reproductive system. 
The urinary organs consist of the kidneys, the ureters, the 
bladder, and the urethra. The kidneys are excretory organs 
whose function is increased during pregnancy. They lie 
high up in the back above the false pelvis on each side of 
the spinal column and behind the peritoneum. Unless dis- 
placed they come in spatial relation with the uterus only in 
the latter part of pregnancy. 
Ureters.—The ureters are tubes that convey the urine 
from the kidneys to the bladder, into which they open on 
its under surface. They lie under the peritoneum, and in 
their course bend over the bones that form the posterior 
wall of the pelvis at its brim. Here they are liable to com- 
pression by the heavy, gravid uterus, and there may occur a 
dilatation of the upper portion of the tube, with consequent 
disturbance of the kidney secretion. 
Bladder.—The urinary bladder is a hollow muscular organ 
that acts as the reservoir of the urine, which it receives con- 
tinually from the kidneys and evacuates from time to time. 
It is lined with mucous membrane and partly covered with 
peritoneum. It lies in the pelvis between the symphysis 
URINARY ORGANS OF WOMAN. 48 
ANATOMY, PHYSIOLOGY AND EMBRYOLOGY 
pubis in front and the uterus and vagina behind. It is held 
in position by ligaments which allow a considerable amount 
of movement. When it is empty it lies entirely in the pelvis, 
and its upper surface is flat and in contact with the under 
surface of the uterus. When distended the upper surface 
becomes rounded, and it rises out of the pelvis and the uterus 
Fig. 14.—Diagram showing relation of the urinary organs to the genital 
organs and the pelvis. 
is pushed back. The bladder may be injured during labor 
and disturbances are apt to occur during pregnancy and 
the puerperium. 
Urethra.—The outlet of the bladder, the urethra, is, in 
the female, a short tube less than two inches long, that 
passes backward from its opening or meatus in the vestibule PERITONEUM 
49 
to the lowest point of the bladder. It is closely connected 
with the anterior wall of the vagina, which it pushes out in 
a kind of rounded ridge. 
INTESTINES. 
Some loops of the small intestine lie in the upper part of 
the pelvic cavity, resting upon the upper part of the uterus 
and bladder. These are pushed up out of the pelvis as the 
uterus enlarges in pregnancy. When the uterus is displaced 
backward, coils of intestines lie between the uterus and 
bladder. (See page 43.) 
The lower portion of the colon and the rectum lie in the 
pelvis behind the uterus and vagina and in front of the 
sacrum and coccyx. The rectum may be divided into two 
parts, the upper or pelvic portion and the lower or perineal 
portion. The pelvic portion is a continuation of the sigmoid 
colon and begins at the second or third sacral vertebrae and 
ends at the outlet of the bony pelvis. Here the muscle which 
forms the pelvic floor surrounds the bowel and begins to be 
inserted into the lower or perineal rectum. The pelvic 
rectum is called the ampulla, and is the fecal receptacle. 
When empty it corresponds to the curve of the sacrum, being 
concave forward. When filled with feces it is cylindrical or 
spheroid and may displace the uterus, vagina, and bladder. 
The lower or perineal rectum is bent backward, forming 
with the upper portion an S. It is surrounded by a strong 
circular muscle, the sphincter, and except during defecation 
is empty. Its opening at its insertion into the skin is called 
the anus. It is quite vascular, and its veins frequently 
become greatly distended during pregnancy or labor and 
form piles or hemorrhoids. 
PERITONEUM. 
The peritoneum is a serous membrane that lines the ab- 
dominal and pelvic cavities, covering the walls and being 
reflected over the organs. The pelvic peritoneum may be 
pictured as a membrane that lines the soft pelvis pushed 50 
ANATOMY, PHYSIOLOGY AND EMBRYOLOGY 
inward by the rectum from behind and the bladder from the 
front. Then the uterus and its adnexa push up a fold which 
stretches across from one side of the pelvis to the other. 
Between the layers of peritoneum which form these folds 
are the vessels that supply the uterus and tubes. These 
folds are the so-called broad ligaments. Another pair of 
folds of the pelvic peritoneum pass from the sides of the 
second sacral vertebra around the rectum to the junction of 
the cervix and body of the uterus and form the utero-sacral 
ligaments of the uterus. 
BREASTS. 
The breasts or mammary glands (see page 51) are situated 
on the anterior wall of the chest, but are to be considered 
as a part of the reproductive system. Each breast is com- 
posed of fifteen to twenty lobes, each lobe having a duct 
that empties in the nipple. Shortly before entering the 
nipple it is dilated into an ampulla or a sinus lactiferous, 
that is, a small reservoir for the breast secretion. Following 
the duct into the lobe we find that it divides into many 
branches, each of which goes between the subdivisions of 
the lobe called lobules. Further branches of the interlobular 
ducts enter the lobules, subdivide and finally end in dilata- 
tions called acini. These are lined with the secreting cells 
and surrounded with a network of blood and lymphatic 
vessels and abundantly supplied with veins. 
The breasts are but slightly developed in the fetus. Some 
growth occurs shortly after birth and then the glands remain 
quiescent until puberty, when a considerable development 
occurs. 
During pregnancy the glands take on further growth and 
function, and finally after labor they are ready for their 
function, lactation. 
The size and shape of the breast differ much in different 
individuals and also in the same person at different times of 
life. In general we may say that they are conical or hemi- 
spherical, resting on the front of the chest. At the most 
prominent point is the nipple, surrounded by a pigmented EMBRYOLOGY 
51 
area called the areola. In the areola are a number of seba- 
ceous glands which increase in size during pregnancy, and 
are then called Montgomery’s glands. 
Fat 
Lobule un- 
ravelled 
Lactiferous 
tubule 
A mpulla 
Lcbides 
Loculi in connective 
tissue 
Fig. 15.—Dissection of the lower half of the mamma during the period of 
lactation. (Luschka.) 
EMBRYOLOGY. 
Development of the Egg.—Ovum.—The egg or ovum is a 
cell like all other elements of the body. But unlike all other 
cells it has the wonderful power to unite with a similar cell 
from another individual and then develop into an independent 
body. Like other cells the ovum consists of a mass of cyto- 
plasm and a nucleus. The nucleus, although much smaller 
than the cytoplasm, is the most important part of the cell, 
for it is the chief agent in the division of the cell, and it con- 
tains the fundaments of the characteristics of the parent 52 
AN ATOMY, PHYSIOLOGY AND EMBRYOLOGY 
which make the child resemble the mother. The ovum has 
also a membrane surrounding it. 
Spermatozoon.—The sperm cell, or spermatozoon, looks 
very different from the ovum, as will be seen by the figure. 
It consists almost entirely of nucleus. It has the power of 
independent motion, a power that is necessary to enable it 
to come in contact with the ovum. Sperm cells are very 
numerous in the semen, and a large number find their way 
Head-* 
Body * 
trail ■* 
Fig. 17.— Sper- 
matozoa: A, front 
view; B, profile view. 
Fig. 16.—Ovum in Graafian follicle. 
into the tubes, where they meet the ovum. Only one sperm 
cell penetrates into the egg. 
Fertilization.—The first step in the development of the 
new being is fertilization or impregnation, i. e., the fusion 
of the sperm cell with the nucleus of the unfertilized ovum. 
After the sperm cell has penetrated the membrane of the 
ovum it moves toward the nucleus until it meets it and 
merges with it to form the nucleus of the now fertilized egg 
(Fig. 18). Spermatozoon 
Female 
' promt c/eus 
n*/e 
pronucleus 
rjale 
pronudeus,- 
, Temclle 
/pronucleus 
Segmentation 
nucleus 
Fig. 18.—Fertilization, four steps. The first shows the penetration by 
the spermatozoon, the second the formation of the male pronucleus from 
the head and body of the spermatozoon, the third the approach of the pro- 
nuclei, the fourth the merging of the pronuclei. 
oo 
z 
c 
P$1' 
KZ.jy. 
e 
<£ 
Fig. 19.-—First stages of segmentation of a mammalian ovum. Semi- 
diagrammatic. (From a drawing by Allen Thomson.) z.p., zona striata; 
V-gl., polar bodies; a, two-cell stage; b, four-cell stage; c, eight-cell stage; 
d, e, morula stage. 54 
ANATOMY, PHYSIOLOGY AND EMBRYOLOGY 
Fertilization and the next stages in development have 
never been observed in the human body, but they can be 
A 
B 
yolk 
amnion 
amnion 
yolk 
C 
D 
yolk 
amnion 
yolk 
amnion 
yolk 
■vacuole 
vacuole 
E 
F 
Fig. 20.—Sections through fertilized eggs showing A, the mulberry stage, 
B, the beginning of the yolk; C and D, the presence of the yolk and amnion; 
E and F, the vacuolization of the rest of the contents of the egg. EMBRYOLOGY 
55 
Fig. 21.—Sections showing the development of the embryo and umbili- 
cal cord. A, allantois; A.c., amniotic cavity; Am., amnion; B.st., body 
stalk; Ch., chorion; C.v., chorionic villi in the region of the placenta; E, 
embryo; XJmb.c., umbilical cord; Y, yolk cavity. 56 
ANATOMY, PHYSIOLOGY AND EMBRYOLOGY 
carefully studied under the microscope in some animals: 
for example, the fish. Unfertilized fish eggs may be obtained 
by pressing them out of the female, and sperm cells are 
obtained from the male in the same way. The eggs and the 
sperm are brought together in a suitable medium and the 
changes studied under the microscope. We have no reason 
to doubt that the first stages in the development of the egg 
are essentially alike in all animals, and hence the description 
of the development of the human egg is completed by supply- 
ing the missing stages from the study of other animals. 
Fig. 22.—Kroemer-Pfannenstiel Zygote. (From Keibel and Elize’s 
Normaltafeln.) The embryonic region is folded into the form of an embryo, 
which is 1.9 mm. long, and it is possibly about three weeks old. At the lower 
end of the figure (the caudal end of the embryo) are seen portions of the 
chorion and body stalk. The cerebral portion of the neural rudiment is 
defined. Six pairs of mesodermal somites are present, but there are no 
signs of limbs. 
Segmentation and Beginning of Yolk, Amnion and Embryo. 
—After fertilization there is a resting stage which lasts for a 
few minutes and then comes the next step, segmentation, or 
division of the cell into two. In this process the nucleus 
always divides first, and then the protoplasm collects around 
each of the new nuclei so that two independent cells are EMBRYOLOGY 
57 
formed, both contained within the original cell membrane. 
We have now the egg in the two-celled stage. 
After another short rest each of the two cells divides in 
the same way as the original cell, and we have the four- 
celled stage. In the same manner the division continues, 
some of the cells perhaps dividing faster than others until 
we have a mass of cells some larger than others, but quite 
small compared with the original cell. This solid mass of 
cells is called the morula or mulberry stage. 
Heart 
Amnion 
Body-stalk 
Fig. 23.—Human embryo about fifteen days old. (His.) 
Chorion 
At this stage the development of the egg in viviparse like 
the human species begins to differ from that in oviparse like 
the fish and birds. Fluid begins to collect in two or more 
cavities within this cell mass. One of these cavities first to 
appear is the yolk cavity, whose contents are eventually 
absorbed by the embryo, and corresponds to the important 
yolk of oviparse. Adjoining the yolk cavity appears the 
amniotic cavity, which subsequently develops so as to sur- 
round the embryo and practically comprises the main part 
of the fruit sac. Between the yolk and the amnion a mass of 58 
ANATOMY, PHYSIOLOGY AND EMBRYOLOGY 
cells appears in the second or third week, which is the begin- 
ning of the embryo. 
Body Stalk.—Meantime by a process of vacuolization the 
cell mass, comprising the chief part of the contents of the 
egg, is more or less broken up outside of the embryonic mass 
and its adjacent structures. This mass is, however, firmly 
attached to the periphery of the egg by a mass of cells, which 
is known as the body stalk. Eventually it forms the path for 
the vessels, which connect the embryo and the fetus with the 
blood of the mother in the vessels of the mucous membrane 
of the uterus. 
Heart 
Fore-limb 
Hyoid arch 
Mandibular arch 
Maxillary process 
Eye - 
Olfactory pit 
Chorion ~ 
Hind-limb 
Fig. 24.—Human embryo, twenty-seven to thirty days old. (His.) 
Embryo and Fetus.—As the mass of cells between the yolk 
and the amnion develops the embryo begins to assume 
definite form. The end farthest removed from the body 
stalk is enlarged and becomes the rudiment of the head. 
Two longitudinal folds appear on the convex amniotic side 
that are the rudiments of the nervous system. They event- 
ually coalesce in the midline forming the spinal cord. The 
beginnings of the muscles appear as a series of blocks on 
each side. The body is now partly separated from the yolk, EMBRYOLOGY 
59 
Heart 
Mandibular arch 
Hyoid arch\ 
Fore-limb 
Maxillary process 
Eye 
Hind-limb 
Fig. 25.—Human embryo, thirty-one to thirty-four days old. (His.) 
, Auricula 
Eye 
Nose - 
Fore-limb 
Digits - 
_ Mind-limb 
Umbilical cord 
Fig. 26.—Human embryo of about six weeks. (His.) 60 
ANATOMY, PHYSIOLOGY AND EMBRYOLOGY 
by the folding in of the outer layer which forms the surface 
of the body. As the body is thus given its shape the various 
organs develop. The bloodvessels and heart with the blood 
appear very early. The primitive bowel is formed as a simple 
cavity on the under surface by the folding in of the outer 
surface and the separation of cells in the interior. Projec- 
tions appear on the sides of the body which form the extremi- 
ties. As soon as the embryo can be recognized as human it is 
called the fetus. This is about the middle of the second 
month of pregnancy. 
We shall not attempt to describe further the growth of 
the fetus and the development of its parts and organs. It 
will be desirable, however, to show how the egg is fastened 
to the uterus from which it obtains its nourishment, and in 
so doing describe the fetal appendages, in labor called “after- 
birth.” We must briefly study the chorion, amnion, yolk 
sac, allantois, decidua, and the placenta. 
Fig. 27.—A young ovum magnified, showing chorionic villi. Seen from the 
side and from the edge. (Biimm.) 
Chorion.—The chorion is the membrane formed by the 
outer layer of cells of the original mass of the mulberry stage 
and is continuous with the body stalk. It lies immediately 
in contact with the original cell membrane of the ovum. As 
the egg grows the original membrane disappears and the 
chorion becomes the outer coating of the egg. Its outer 
surface is covered with many short, stubby, branching pro- 
jections called villi, which give the egg a shaggy look. Mean- 
time the egg has been carried along the oviduct until it has 
reached the interior of the uterus. Here it burrows its way EMBRYOLOGY 
61 
into the mucous membrane of the uterus. The villi hell) to 
attach the egg to the uterus. After its attachment to one 
side of the uterus the villi next to the surface of the uterus, 
which also cover the area of the body stalk, enlarge greatly 
and help to form the placenta, while the villi covering the rest 
of the egg become rudimentary. Hence it happens that in 
examining the after-birth after labor the outer membrane, 
i. e., the chorion, seems to be attached to the edge of the 
placenta. In reality the chorion is a continuous membrane 
and the placenta is developed in and upon it. 
Amnion.—The beginning of the amniotic sac as an early 
cavity in the mulberry segmentation mass has been described 
above (p. 57). This cavity develops as the embryo grows 
until it finally encloses the embryo and fetus. At first it is 
separated from the chorion by a fluid, but eventually they 
come to lie in contact. At the attachment of the cord to the 
placenta the amnion is reflected over it and encircles it as 
far as the body of the child. The way the cord comes to lie 
outside of the amnion will be explained directly when we 
come to study the development of the allantois. The 
amniotic sac contains a liquid which is called the amniotic 
fluid or liquor amnii or fruit water. Its chief function is to 
furnish protection and opportunity for movement to the 
child. 
Yolk.—The yolk is at first continuous with the primitive 
bowel cavity of the child. As the constricting fold of the 
surface of the body and amnion gradually forms the abdom- 
inal wall and encloses the bowel cavity it constricts that 
portion of the yolk sac next to the body into a thin stalk. 
This stalk becomes long and thin as the contents of the yolk 
sac gradually are absorbed, until it is a mere thread forming 
a part of the umbilical cord. The yolk serves as food for the 
embryo, but in the human it is of comparatively little impor- 
tance. In fishes and birds it is very important, for it is the 
chief source of food for the growing embryo. At birth the 
yolk sac has entirely disappeared or is seen only as a small 
vesicle somewhere in the navel cord. 
Allantois.—The allantois is an important appendage of 
the embryo, for it is the organ which carries blood from it to 62 
ANATOMY, PHYSIOLOGY AND EMBRYOLOGY 
the mother. It is formed as a projection from the hind end 
of the primitive bowel. This projection passes to the chorion 
through the body stalk. Its outer end spreads over that 
portion of the chorion which is attached to the uterus. The 
fluid at first contained in the sac of the allantois disappears 
and there remains only the base of the sac attached to the 
chorion and the stalk connecting it with the body of the 
embryo. In this stalk are the bloodvessels which carry the 
blood from the body to the extended surface lining the 
chorion. These vessels penetrate the villi and thus come 
into intimate relation with the bloodvessels of the uterus. 
Umbilical Cord.—From this description it will be seen that 
the cord consists of the elongated stalk of the allantois 
combined with the rudimentary stalk of the yolk sac, sur- 
rounded by the amnion which, continuous with the skin at 
the small opening in the abdominal wall that allows the 
exit of the allantois stalk is reflected, at the outer end, over 
the internal surface of the placenta and chorion. (See p. 61.) 
Migration and Nidation of the Egg.—Decidua.—Before 
describing the placenta it will be necessary to consider the 
changes that have been going on in the uterus during the 
growth of the egg. As soon as impregnation occurs the 
mucous membrane of the uterus begins to thicken, and when 
the fertilized egg reaches its cavity it finds the inner surface 
prepared for its reception. This change in the uterus is 
thought to be due to a secretion derived from the corpus 
luteum of pregnancy. (See page 47). The egg reaches the 
uterus probably about the end of the first week. It has been 
carried along the tube by the movements of the cilia which 
belong to the cells that line the tubal mucous membrane. 
Muscular contractions of the tube may also assist in carrying 
on its contents. The chorion has already become shaggy 
and the embryo is just noticeable. The egg penetrates the 
epithelial coating of the mucous membrane and is soon com- 
pletely surrounded by it. Since this mucous membrane is 
cast off with the eggs at birth it is called the decidua. That 
portion of it which is reflected over the egg is called the 
decidua reflexa. EMBRYOLOGY 
63 
Placenta.—The chorionic villi are received into the decidua. 
Those next to the uterus develop and form the fetal part of 
the placenta. Those covering the rest of the surface of the 
egg become rudimentary, as has been said, and with their 
Fig. 28.—Semidiagrammatic outline of an antero-posterior section of a 
gravid uterus and ovum of five weeks. (Modified from Allen Thomson.) 
a, anterior uterine wall; b, posterior uterine wall; c, decidua vera; d, decidua 
reflexa; e, decidua serotina; ch, chorion with its villi. 
disappearance the decidua reflexa also undergoes retrograde 
changes. The decidua corresponding to the attached surface 
of the egg forms the maternal part of the placenta. It 
becomes thickened and very vascular. The vessels sur- 
rounding the villi dilate greatly and become practically 64 
ANATOMY, PHYSIOLOGY AND EMBRYOLOGY 
blood channels, into which dip the placental vessels. Some 
hold that the uterine vessels rupture and that the escaping 
blood flows into spaces around the villi. In either case the 
blood of the fetus is separated from the mother’s blood only 
by thin membranous walls. Through this membrane pass 
the food and oxygen from mother to fetus, while in the oppo- 
site direction pass the waste products, including carbonic 
dioxide. Thus the mother supplies the child with food and 
oxygen by means of the placenta. The placenta is therefore 
the lungs and stomach of the fetus. It is composed of two 
parts: the decidua, maternal, the chorion and allantois, 
fetal. These parts are separated as to their origin, but they 
cannot of course be pulled apart mechanically. 
Relation of Mother to Fetus.—From the study of the rela- 
tion of the mother to the fetus it appears that there is no 
nervous connection between them. The human embryo is a 
very sensitive being in the earlier stages of its existence; its 
attachment to the uterus is arranged for the purpose of 
affording it protection and food until it is sufficiently devel- 
oped to live outside of the body. It is, however, an inde- 
pendent being from the first, as truly as is an embryo chicken. 
It is evidently impossible for the mother to influence the 
child by any mental impressions. 
This subject is of some importance, for so many mothers 
have a firm belief in maternal impressions, or the possibility 
of influencing the child through mental impulses that much 
anxiety is caused through this belief. Most women expect 
to find their first child marked because of something they 
have seen during pregnancy. The first question which the 
young mother asks the physician or nurse is this: “Is my 
baby all right; is it marked?” On account of the widespread 
belief in maternal impressions and the unnecessary anxiety 
and unhappiness caused by this belief it is desirable that 
nurses should do their utmost to dispel this old notion. 
Marks or deformities in new-born children are due to 
explainable and unexplainable causes. The red “mother 
marks” that are so often found on the skin are a kind of 
blood tumor. We do not know why they come any more 
than we know why other kinds of tumors appear in later EMBRYOLOGY 
65 
life. Some deformities of the fetus are due to conditions 
in the uterus. The fetus may be subject to pressure because 
of an insufficient amount of amniotic fluid. Such pressure 
may result in producing a misshaped head or body. Some- 
times bands are formed by the fetal membranes which may 
constrict a growing limb and perhaps even amputate it. 
Such deformities are explainable, but are of course quite 
independent of the mother. A mother should be told that 
it is her duty to keep herself in good condition, to eat proper 
food, and to dress well for her own sake and for the good of 
her unborn child. If she is well the child will be well supplied 
with nourishment and develop properly. She should, how- 
ever, be told that she need not fear maternal impressions. CHAPTER III. 
PREGNANCY. 
A woman is said to be pregnant while she is carrying the 
developing embryo. The average duration of pregnancy 
reckoned from the date of the beginning of the last menstrua- 
tion is two hundred and eighty days, forty weeks, or ten 
periods of four weeks each, which are often but not correctly 
called lunar months. However there are considerable indi- 
vidual variations. Some women have a normal pregnancy 
period of ten to twenty days longer and some of a few days 
less than the average. It is probable that impregnation 
occurs in the majority of cases a few days after the end of 
menstruation. If the menstrual period lasts five days and 
conception occurs five days later, the average length of time 
from impregnation to the birth of the child would be two 
hundred and seventy days. When conception takes place 
two or three weeks after the end of menstruation, the method 
of finding the date of labor by adding two hundred and 
eighty days to the beginning of the last menstruation does 
not give us very exact results. In general, however, the 
mode of reckoning just given furnishes the best results. 
We should naturally expect that pregnancy would cause 
a change in the entire body, and such we find to be the case. 
Some of these changes do not affect the health of the woman, 
and hence they may be termed physiological changes. Some, 
however, may cause disturbances more or less serious, and 
these we would call pathological changes, i. e., changes pro- 
ducing disease. 
PHYSIOLOGICAL CHANGES OF PREGNANCY. 
Changes in the Uterus.—Very shortly after impregnation 
changes occur in the uterus. It becomes congested, i. e., a PHYSIOLOGICAL CHANGES OF PREGNANCY 
67 
larger quantity of blood is sent to it, and the mucous mem- 
brane begins to thicken and grow. A brief description has 
already been given of the way in which the mucous membrane 
of the non-pregnant uterus is changed into the decidua of 
pregnancy. As the embryo develops the entire uterus en- 
larges. At the end of the sixteenth week it is so large that 
it lies chiefly in the abdominal cavity, i. e., it has risen out 
of the pelvis. About this time, or a little later, the fetus has 
so far developed that it makes rather vigorous independent 
movements. These movements felt by the mother the first 
time are sometimes called quickening. It was formerly 
supposed that the child became endowed with life at this 
time. 
Long before the uterus has escaped from the pelvis, and 
causes an enlargement of the abdomen, the pregnant woman 
has felt that her clothes are too tight, and noticed that she 
is larger than formerly. This enlargement is mostly due to 
distention of the bowels. The congestion of the uterus and 
other genital organs often lead to some constipation, and 
with it fermentation in the bowels occurs, causing the abdom- 
inal distention. This is not a necessary result of pregnancy, 
but it is so common and frequently confounded with enlarge- 
ment of the uterus that it is worthy of mention. 
As the uterus enlarges from week to week its base rises 
higher and higher, reaching the navel by the end of the 
twenty-fourth week, until toward the end of pregnancy it 
has reached nearly to the breast bone, the organ lying in 
contact with the stomach and liver (Fig. 29). It is a curious 
fact that as the base of the uterus ascends the white line which 
runs along the center of the abdomen, called the linea alba, 
becomes darkened, and is then named the linea nigra. Fre- 
quently the skin becomes stretched, and tears which have the 
appearance of scars occur in the tissue that is underneath 
the outer layers. They are called striae. 
About two weeks before labor the head of the child may 
descend into the lower segment of the uterus and sometimes 
into the pelvis. This allows the base of the uterus to descend 
from its highest position, and is called the falling or settling 
or sinking of the uterus. 68 
PREGNANCY 
Fig. 29.—Diagram showing size and height of uterus at different periods of 
pregnancy. PHYSIOLOGICAL CHANGES OF PREGNANCY 
Changes in all the Genital Organs.—Not only the uterus 
but also the vagina and the other genital organs become 
congested when impregnation occurs. This congestion of 
the vagina deepens its color to a deep blue or purple. The 
uterine ligaments, especially the round ligaments are in- 
creased in length and size. 
Fig. 30.—Breast of pregnancy or lactation showing Montgomery’s glands 
and areola. 
Changes in the Breasts.—In the first pregnancy there is 
generally a marked development of the breasts. The enlarge- 
ment sometimes leads to such a stretching of the skin that 
striae appear similar to those in the skin of the abdominal 
wall. The breasts not only become permanently filled with 
blood, but new glandular tissue forms. A secretion, the colos- 
trum appears, which may be expressed from the nipple or 
sometimes shows spontaneously. The areola outside of the 
nipple darkens, the little circle of glands, surrounding the 
nipple, called the glands of Montgomery also become promi- 
nent (Fig. 30). In the latter pregnancies similar changes 70 
PREGNANCY 
occur except that there is no development of new glandular 
substance. 
Coincident with these changes in the genital organs, occur 
certain changes in the entire body that need not be described 
in detail. It is, however, well to mention that an increased 
sensitiveness of the central nervous system generally exists. 
It becomes more sensitive to external stimulation; particu- 
larly is it more sensitive to stomach irritations. The bearing 
of this change in the nerve centers on the diseases of preg- 
nancy will shortly appear. 
One of the noticeable changes of pregnancy, and to the 
woman frequently, the first sign of her pregnancy is the cessa- 
tion of menstruation. There is no true menstruation after 
pregnancy occurs. Any discharge of blood during pregnancy 
is always suspicious. It usually indicates either a threatened 
abortion or an improper location of the placenta. 
PATHOLOGICAL CHANGES OF PREGNANCY. 
Nausea and Vomiting.—Nausea and vomiting are so com- 
mon that they are often considered necessary accompani- 
ments of pregnancy. That, however, is not true. About 
one-third of all pregnant women escape this trouble and 
no doubt proper management of pregnancy would reduce 
the amount of nausea considerably. It is proper then to 
call this symptom pathological and not physiological. 
In mild cases there is only a feeling of nausea on getting 
out of bed in the morning. Hence arises the common term 
“morning sickness.” When the trouble is a little more 
severe, vomiting also occurs at the same time. Later in the 
day nausea disappears and the patient is able to eat and retain 
lunch and dinner. In still more severe cases the nausea lasts 
all day, and sometimes the patient is unable to retain any 
food. In these latter cases we have what is called excessive or 
pernicious vomiting. Sometimes the technical terms, emesis 
and hyperemesis, corresponding to vomiting and excessive 
vomiting, are used. 
Nausea and vomiting occur generally in the first three or 
four months of pregnancy and disappear completely in the PATHOLOGICAL CHANGES OF PREGNANCY 
71 
later months. Nausea sometimes begins during the first 
month before the patient by the failure of menstruation has 
become aware of her pregnancy. Generally it is noticed in 
the early part of the second month. Occasionally the nausea 
continues throughout the entire pregnancy. Nausea begin- 
ning in the later months of pregnancy is generally of a differ- 
ent kind from that occurring in the beginning of pregnancy, 
and due to other causes. 
While it would be impossible to enter into a satisfactory 
discussion of the causes of the vomiting of pregnancy, it is 
desirable to mention that a poor circulation of blood is an 
important factor. The congestion of the pelvic and abdom- 
inal organs means that an unusual amount of blood is accu- 
mulated in them. It follows that less blood is in other parts 
of the body. The extremities are apt to be cold. Less blood 
is sent to the brain. There is a condition resembling chronic 
shock. The brain centers become particularly sensitive to 
outside irritation. The vomiting center is easily excited. 
The heavy, congested, perhaps misplaced uterus, or the con- 
stipated bowel or the stomach or intestine distended by fer- 
mentation gases, are sources of irritation. 
Management of Emesis.—The responsibility for the manage- 
ment of severe cases of nausea and vomiting must be of course 
with the physician. It would be well if every woman would 
consult her physician at the beginning of pregnancy. Much 
of the discomfort which so many think a necessary accom- 
paniment of pregnancy could be prevented by proper hygienic 
management. It often happens, however, that the physician 
is never consulted in mild cases, while a nurse often has 
opportunity to give good and valuable advice. Hence it is 
desirable that she should know what should be done in simple 
cases. The line of management is easily discovered from a 
consideration of the cause of the trouble. A good circulation 
is most important. The overfilled pelvic and abdominal 
organs should be relieved by the stimulation of the circula- 
tion in the surface of the body. In the morning the patient 
should remain in bed in the horizontal position until a good 
circulation is secured. One of the best means is for the 
patient to take a hot drink, a cup of hot milk, for example, 72 
PREGNANCY 
while in bed. In half an hour she may be able to get up 
without much trouble. She should spend but little time with 
her toilet. Let her get out of her room into the fresh air as 
soon as possible. Then let her take a light breakfast. Some- 
times it is best for her to take breakfast in bed. In addition, 
she must care for the excretions. She must under no cir- 
cumstances allow herself to become constipated. The man- 
agement of constipation if it is at all obstinate must be left 
for the physician. She must dress warm in order that the 
skin circulation may be kept in good condition. By attention 
to these rules the ordinary cases of nausea anil vomiting can 
be satisfactorily managed. 
Management of Hyperemesis Gravidarum.—Although in 
pernicious vomiting the physician is in charge the outcome 
will depend very much upon the nurse. Hardly any other 
kind of a case tests as does this the nurse’s skill, tact, courage, 
and endurance. The neurotic element is predominant in 
the causation of this disease. The majority of patients are 
hysterical, and those who have never had well-marked hys- 
terical attacks have inherited a sensitive nervous organiza- 
tion that makes it difficult for them to withstand the strain 
of pregnancy. Frequently the patient did not want to become 
pregnant and would like to have an abortion produced. She 
has been accustomed to have her own way and rebels against 
all measures of restraint. She easily becomes panicky, fears 
death, and requires constant moral support to keep her from 
despair. At the same time the husband, other relatives and 
friends, who are all accustomed to gratifying every whim of 
the patient, give no help in the management, but on the 
contrary seek to interfere through sympathy for her or 
through fear for a fatal outcome. 
It is preferable to have such a patient in a hospital. There 
she expects to find a certain routine and is prepared before- 
hand to submit. The interference of friends is mostly absent. 
The nurse can get more help and relief from constant attend- 
ance, and she can also get moral support from the superin- 
tendent of nurses. 
If the patient remains at home the first thing for the nurse 
to do is to get control of the situation. If she has had experi- PATHOLOGICAL CHANGES OF PREGNANCY 
73 
enee in the care of nervous eases she has a great advantage. 
She must be very kind and very patient. Often she must 
regard her patient as an irresponsible, spoiled child and pay 
no attention to her moods. She must be always cheerful and 
radiate encouragement and hope and confidence. 
The treatment of the physician will probably consist in 
absolute rest in bed, withdrawal of all foods and liquids by 
the mouth, cleansing and nutrient enemata, perhaps stomach 
lavage and medicine to produce sleep. The patient is kept 
in the horizontal position without a pillow, or with only a 
very small pillow because this position favors the flow of 
blood to the brain. Sometimes it is desirable to lower the 
head by raising the foot of the bed. All attempts at vomiting 
must be avoided as much as possible. They do only harm. 
Frequently a little ammonia water, smelling salts, alcohol, 
or vinegar held before the nose will prevent a vomiting 
attack. If the vomiting attack cannot be stopped, the patient 
must not be allowed to sit up and retch violently. Instead, 
the nurse must turn her gently to the side and support her 
head just over the edge of the bed. The patient should be 
encouraged to control the retching and resume the dorsal 
position as soon as possible. Some volatile stimulant like 
ordinary smelling salts will often aid in such control. 
Taking nothing into the stomach is frequently the quickest 
and best way to success. Should this order be given the 
nurse should carry it out strictly, of course. Sometimes the 
physician allows the patient 5 to 10 drops of water in the 
mouth every ten minutes. This amount is absorbed before 
reaching the stomach. The great thirst from which the 
patient suffers is relieved by enemata. Normal salt solution 
or better hypotonic salt solution enemata are given for this 
purpose. Each day one large enema of 2 to 4 quarts can be 
given to clean out the bowel and two or three small enemas 
of 6 to 8 ounces to be retained. Salt solution may also be 
given by the drop method. Of course all of these must be given 
with proper technic in order to avoid disturbing the patient 
as much as possible and to be efficient. The temperature of 
the solution and the rate of injection must be considered. A 
large injection should be given with a rectal tube and the 74 
PREGNANCY 
patient should lie with the hips elevated. When cramps 
occur the flow should be stopped, the irrigator tube discon- 
nected from the rectal tube and some of the injection or 
eventually gas should be allowed to escape from the latter 
until the patient is comfortable, then the injection should 
be resumed. 
Sodium bromide is sometimes used in proper doses to 
replace the sodium chloride or common salt in the salt solu- 
tion when the quieting effect of the bromide is necessary. 
Other sedatives or hypnotics may also be given in solution. 
Some physicians add small doses of alcohol to the enema 
for its stimulating effects and also as a food. Nutritive 
enemata containing milk, eggs,' digested meat, etc., are 
undesirable in this condition. They have no food value for 
they are not digested in or absorbed from the rectum or 
colon, and render these passages irritable after a short time. 
Alcohol has a considerable food value, 2 ounces being equal 
to about 20 ounces of milk, and it has the great advantage 
that it is readily absorbed and does not in proper dilution 
disturb the bowel. 
The only other food that needs no digestion and can be 
absorbed from the colon and rectum is glucose or grape 
sugar. This may be given in a 4 to 10 per cent solution 
together with alcohol either by the drop method or in small 
frequently repeated enemata. 
Under no circumstances should the nurse try to carry 
the tube into the colon unless she is expressly directed to 
do so by the physician. The so-called colonic flushings are 
almost always delusions. It is very difficult to carry the 
tube through the sigmoid above the brim of the pelvis. It 
generally coils around in the ampulla of the rectum and 
may injure the mucous membrane of the bowel or irritate 
the uterus. 
The stomach frequently contains large quantities of mucus 
and sometimes the contents of the intestine have been carried 
back into the stomach by reverse peristalsis induced by 
vomiting. This mass is foul and irritating, made worse by 
fermentation set up by numerous yeast germs. It is not 
completely emptied by vomiting. Therefore it is often a PATHOLOGICAL CHANGES OF PREGNANCY 
75 
good plan to wash out the stomach. This procedure may 
have also a very good moral effect on the patient. Frequently 
the lavage is followed by the introduction of milk. It is 
somewhat remarkable that a patient can retain and digest 
1| pints of milk introduced into her stomach without her 
knowledge, while she could not retain a \ ounce taken by the 
mouth. 
The induction of abortion for the pernicious vomiting 
of pregnancy is almost never necessary when the patient 
can be properly managed. Patients and their friends are 
only too ready to demand this extreme measure. The 
nurse should under no circumstances suggest it. On the 
contrary, she should always encourage her patient, for the 
most extreme cases, if uncomplicated, have very good 
chances. The treatment may last some weeks, generally, 
however, not more than two or three, and then recovery is 
apt to be very rapid. 
Constipation.—Constipation is a condition so common in 
pregnancy, and at the same time so important as a source 
of disturbance during pregnancy, and during childbed, that 
it is well for a woman to know its importance in order that 
she may be alert to avoid it and its consequences as far as 
possible. Pelvic congestion, lack of the usual exercise, 
changes in diet, and in the later months, pressure of the 
large uterus on the colon, are the chief causes of constipation. 
Distention of the bowel by fermentation gases is one result. 
Chronic poisoning of the body by absorption of poisons from 
the sluggish bowel is another. In the later months of preg- 
nancy, the gases may cause considerable disturbance by in- 
terfering with breathing. In childbed vigorous efforts to 
remove the accumulation of feces sometimes causes consider- 
able poisoning, leading to fever. Constipation may be pre- 
vented by attention to diet, daily habits, exercises, etc. 
Drinking freely of water, eating laxative foods and as much 
fresh fruit as possible are often sufficient. A cup of hot water 
with a little salt taken fifteen to twenty minutes before 
meals is beneficial. The further management of constipation 
should generally be left to the physician. Taking of strong 
cathartics should under all circumstances be avoided, for 
they may lead to abortion. PREGNANCY 
Dental Caries.—Occasionally a pregnant woman is troubled 
with a rapid decay of the teeth. It is a common idea that 
the substance of the teeth is absorbed for the purpose of 
furnishing matter for the bones of the child. This is a mere 
fable with no scientific foundation. The ordinary causes 
of tooth decay, that is, poor circulation in the gums, lowered 
resistance of the tissues and the presence of bacteria are par- 
ticularly active during pregnancy. To prevent decay, a 
woman should be particularly careful to keep the mouth in 
good condition, using a mild antiseptic tooth wash and a 
brush freely. She should also consult a dentist at the begin- 
ning of pregnancy and have all cavities filled. She should 
inform the dentist of her condition, and he will of course 
avoid giving her long sittings, or causing her much pain. 
For large or painful cavities, temporary fillings should be 
used. A hopelessly bad tooth should be extracted. 
Nephritis of Pregnancy.—Changes in the kidneys are 
perhaps the most important pathological changes that occur 
during pregnancy. These take place chiefly in the latter 
part of pregnancy. The kidneys become temporarily inflamed 
and fail to excrete properly. Sometimes the amount of urine 
passed is very much decreased. Again the quantity of urine 
may be normal but the amount of solids is greatly lessened. 
The kidneys may also allow the passage of albumin from the 
blood into the urine. This is called albuminuria. 
As a result of this deficient action of the kidneys, the 
waste products of the body begin to accumulate and to pro- 
duce symptoms of poisoning. As a result of changes in the 
blood and in the circulation, fluid collects in the tissues 
outside of the bloodvessels and we have general edema or 
dropsy. This is most marked in the lower extremities, espe- 
cially during the day when the patient is on her feet. In the 
morning there is swelling of the face, which is especially 
noticed under the eyes. If the trouble becomes serious, the 
skin swells and pits on pressure. The internal organs also 
becomes edematous; for example, the breathing becomes 
difficult, on account of the edema of the lungs. 
Other results of this self-poisoning or auto-intoxication 
by the waste not excreted by the kidneys are headache, PATHOLOGICAL CHANGES OF PREGNANCY 
77 
dizziness, disturbance of vision, and sometimes nausea, 
vomiting, and diarrhea. This nausea and vomiting occurring 
late in pregnancy resulting from kidney disease is quite 
different in its nature and importance from the so-called 
“nausea and vomiting of pregnancy” that have already been 
described. 
With the appearance of headache and disturbance of vision 
the condition becomes very threatening. The patient is in 
great danger of that most dreaded of all complications, 
eclampsia, or convulsions. These convulsions are quite 
similar to uremic convulsions occurring outside of preg- 
nancy due to disease of the kidneys. 
Disease of the kidneys is not the only factor, however, in 
the causation of eclampsia. One of the functions of the liver 
is the breaking up of poisons so that they may be excreted 
by the kidneys. This function is often interfered with in 
pregnancy because of changes in the liver caused by the 
same poisons that injure the kidneys. 
Toxemia of Pregnancy.—According to the theory now most 
generally accepted, these poisons of pregnancy are pro- 
duced by the egg or the fetus. As you have learned in the 
study of physiology, all living cells give off waste products 
which are poisonous. These are the so-called metabolic 
poisons. They enter the blood of the mother and must be 
eliminated promptly, else they accumulate so as to poison 
her tissues, especially the delicate nerve elements. Some- 
times by reason of the rapid production of ovular poisons, 
for example, in twin pregnancy, or because of deficient 
activity in the liver and the excretory organs, the metabolic 
products accumulate and the condition of toxemia or blood- 
poisoning results. As these poisons tend to produce convul- 
sions or eclampsia we call this disease the eclamptogenic 
toxemia of pregnancy. 
This toxemia is really the cause of the liver and kidney 
disease. There are also changes in the blood and blood- 
vessels and in other organs and tissues of the body. The 
most marked symptoms of this disease are, besides the 
albuminuria already noted, edema, increased blood-pressure, 
disturbance of vision, headache, dizziness, nausea and 78 
PREGNANCY 
vomiting, and finally eclamptic convulsions. The latter 
should be regarded as a symptom denoting that the disease 
has reached its climax rather than as a disease itself. 
Eclamptic convulsions occur sometimes during pregnancy 
when they may or may not bring on premature labor, or they 
may come on during labor, or lastly they may appear during 
the puerperium. The name puerperal convulsions, commonly 
used, would only apply to the latter. Whenever they occur 
they are of the same nature, and may be regarded as the 
outbreak of the nervous system, showing that it has been 
poisoned, so that it is beyond the control of the ordinary 
restraining influences. An eclamptic convulsion is a spasm 
of all muscles of the body. The patient is quite unconscious. 
The extremities, head and body, are in violent motion, while 
the face twitches horribly. If the tongue gets between the 
teeth, as often happens, it will be badly bitten by the move- 
ments of the jaw. The convulsion comes on suddenly. It 
lasts from one to two minutes, and ceases with the patient 
purple from the obstructed respiration and apparently very 
much exhausted. She generally remains in a comatose state 
for fifteen to thirty minutes, when she gradually regains 
consciousness and goes into another convulsion. The fre- 
quency and severity of the convulsions is an index of the 
seriousness of the case. Death may occur during a convul- 
sion from failure of respiration or it may follow after several 
hours from exhaustion resulting from the poisoning. 
The prevention of eclampsia requires the early recognition 
of the eclamptogenic toxemia. All of the symptoms above 
given are important, but albuminuria has always been con- 
sidered most serious. Hence the study of the condition of 
the urine becomes one of the most important duties of the 
physician. The obstetrical nurse should be sufficiently 
informed on this subject to be able to advise the patient of 
the importance of a timely consultation with the physician, 
and particularly as to the serious meaning of the chief symp- 
toms of headache, dizziness, and general dropsy in pregnancy. 
She may also be called to care for a patient threatened with 
convulsions, and may be asked to make elementary exami- 
nations of urine. PATHOLOGICAL CHANGES OF PREGNANCY 
79 
An accurate collection of urine is of first importance. It 
is necessary to know the quantity of urine excreted in twenty- 
four hours. Then a sample from the whole amount will give 
its average composition and tell the activity of the kidneys. 
The urine should be free from foreign substances, including 
the bacteria, that cause its decomposition outside of the body. 
Urine is generally collected in an ordinary chamber-vessel. 
This will answer if the vessel is scalded well and kept covered 
the whole day or during the period of collection. Then the 
urine is shaken up, well measured, and a sample of at least 
3 ounces put into a perfectly clean bottle. In case there is 
no measure in the house a drinking glass may be used, 
measuring it by filling it with a bottle of known size, for 
example, a 2-, 3- or 4-ounce bottle. The ordinary larger 
drinking glasses hold about 8 ounces while the smaller ones 
hold 6 ounces. 
Experience shows the necessity of explaining what is 
meant by collecting urine for twenty-four hours. It is not 
meant to collect the urine passed from the bladder, but the 
urine passed from the kidneys. Hence if we begin the col- 
lection at 8 a.m., for example, the bladder must be emptied 
at that hour, but the specimen not saved for it has been 
accumulating perhaps all night. Then all the urine passed 
until 8 a.m., the following day is saved. This represents the 
kidney excretion for twenty-four hours. 
If the physician does not require the urine for twenty- 
four hours the nurse should always note on the history sheet 
the amount passed each time. A specimen of the urine 
passed at any time may be used for examination if the length 
of time of its excretion is known. 
The examination that the nurse is sometimes required 
to make consists in the determination of the specific gravity, 
the reaction, and the presence or absence of albumin. To 
determine the specific gravity of urine or its weight com- 
pared with water the urinometer is used. This is a weighted 
glass bulb with a graduated stem reading from 1000 to 1040. 
The bulb put into urine, generally contained in a long, 
small, cylindrical vessel, sinks more or less according to the 
density of the urine. In average normal urine it sinks to 80 
PREGNANCY 
the 20 mark, which denotes that the urine is 20-thousandths 
heavier than distilled water, i. e., its specific gravity is 1020. 
In taking this specific gravity the urine should be at the tem- 
perature of a living room, i. e., about 70° F. 
The chemical reaction of the urine is determined by litmus 
paper. Red litmus paper remains red in urine that is acid 
and turns blue in alkaline urine, while blue paper remains 
blue in alkaline urine and reddens in acid urine. Urine that 
is neutral, i. e., neither acid nor alkaline, does not affect 
either kind of paper. 
The heat test is used in examining for albumin. Albumin 
in urine, like the white of egg or most other kinds of albumin, 
coagulates when heated. To apply the test, a test-tube, 
an alcohol lamp or gas burner, a small funnel, acetic acid, 
and filter paper are necessary. The test-tube is filled one- 
half or two-thirds full of filtered urine and held slanting 
over the flame so that the upper part of the column of urine 
is heated. If albumin is present it shows as a more or less 
dense cloud in the heated urine, well contrasted with the 
clear cold urine in the lower part of the tube. If the urine 
is not acid a few drops of acetic acid must be added to it 
before applying the heat test. 
In caring for a case of toxemia the nurse may be also 
required to take the blood-pressure daily or more frequently. 
Either a mercury or a spring instrument is used. The 
technic of applying the cuff or armband and reading the 
pressure when the pulse disappears is simple and should 
be mastered by every nurse. 
In the milder cases of eclamptogenic toxemia of pregnancy 
the duties of the nurse consist in a careful observation of 
the patient, and teaching her how to carry out exactly the 
physician’s directions. These include care of the diet, the 
excretions, and the regulation of the exercise. The diet is 
a more or less strict milk diet. Fruit in considerable 
quantities may generally be allowed. Starch foods like 
rice, etc., are also permitted if well cooked. Meats, includ- 
ing meat soups, are forbidden. In emergency cases it is 
best to withhold all foods for two or three days. The bowels 
should be moved two or three times a day. The skin is PATHOLOGICAL CHANGES OF PREGNANCY 
81 
kept in good condition by frequent baths and warm woolen 
clothing. The patient should never become tired. If she 
must remain much in bed she should have massage and 
passive movements to keep her in good condition. 
Fig. 31.—Sphygmomanometer in use. 
In most severe cases when, for example, there may be 
considerable disturbance of the respiration from dropsy of 
the lung it may be necessary to increase the excretion from 
the skin by giving the patient a sweat every day. For this 
purpose a hot wet pack or a hot-air or vapor bath may be 
employed. The hot-air and the vapor baths may be given 
in bed or with the patient sitting. In the latter case the 
tent is very cheap and convenient. The patient sits on a 
wooden-seated stool or chair, under which is the alcohol or 
gas burner. Over the flame may be placed a pan with 
plain or medicated water. If the vapor bath is given the 
patient should be carefully watched during the bath. If 
she becomes exhausted or dizzy the bath must be stopped. 
A cold compress on the head is generally agreeable. When 
the bath is finished the patient should be wrapped in a 
woolen robe or blanket and put to bed while rolled in blankets. 
There she should lie for half an hour, when she is to be well 
rubbed and dressed in warm dry flannels, 82 
PREGNANCY 
When a hot-air or vapor bath is to be given in bed the 
patient should lie upon or be wrapped in a flannel blanket. 
Over her is placed a frame extending from her shoulders to 
her feet. Covering this frame is a rubber cloth, or an oil- 
cloth, over which are blankets that are carefully tucked 
around the patient’s neck. The hot air or vapor is intro- 
duced into the space surrounding the body by means of 
a small tube or pipe, like the pipe of a gas stove. A double 
pipe or one covered with asbestos, which does not get so 
hot on the outside, is better than a single pipe. At the 
foot of the bed a burner is placed, on which stands a vessel 
with liquid, in case vapor is to be used. The pipe is bent 
at right angles by means of an elbow, and supported by 
wire at the foot of the bed, conducts the hot air or steam 
under the frame. The patient must be watched as in the 
tent, and the after-care is of course the same. 
Sometimes the ordinary wet pack is employed. This 
is generally used in emergencies, but when a number of 
sweats are given the tent or bed-frame is generally pre- 
ferred. The technic of the wet pack is so well-known as 
to require no description. 
If convulsions have already occurred, in the absence of 
the physician, the nurse should get the patient into bed, 
remove the clothing, wrap her in woolen blankets, and 
keep her from all external disturbance. No noise should 
be allowed, and no one except those needed for help should 
be permitted to remain in the room. During a convul- 
sion the nurse must protect the mouth and tongue from 
injury by at once introducing a fair-sized wooden mouth 
gag. If the convulsion is very severe, and respiration 
stops, it may be necessary to employ artificial respiration. 
Under no circumstances should she give chloroform or 
other anesthetic unless ordered to do so by the physician. 
If the patient comes out of the stupor following a convulsion 
and wishes a drink of water that may be given, although 
the irritation of swallowing may bring on a convulsion. 
Nothing should be forced on the patient. While waiting 
for the doctor the nurse should never let the patient out of 
her sight. She may prepare what she thinks may be needed. PATHOLOGICAL CHANGES OF PREGNANCY 
83 
Some physicians manage eclampsia in the so-called con- 
servative method, with elimination and sedatives. Others 
empty the uterus at once.' For the former there will be 
required a frame and burner for a hot-air bath, hot irons 
or bricks for a hot pack, the necessary oil-cloths and blankets, 
etc. If an operation is made the nurse must prepare for 
it in some other room unless the patient be sent to a hospital. 
If labor has begun she will, of course, prepare for it as 
directed in the next chapter. 
Frequent Micturition.—Frequent micturition or passing 
of water is a common disturbance of pregnancy. It may 
be due to congestion of the bladder or to pressure upon the 
bladder by the growing uterus. Frequent urination during 
early pregnancy, due to pelvic congestion, can sometimes 
be relieved by the frequent use of the knee-chest position. 
If a woman is troubled at night she may get relief by sleep- 
ing in the Sims’ position or on her face. Later in pregnancy 
frequent micturition, due to the pressure of the large uterus, 
may during the day be helped by wearing an abdominal 
bandage. 
Edema of the Legs.—Pressure of the enlarged uterus upon 
the return vessels from the lower extremities may cause 
edema of the legs. This should not be mistaken for general 
edema due to kidney disease. This is not serious, and may 
be relieved by wearing an abdominal bandage. If the 
swelling of the legs is considerable and troublesome they 
may be bandaged. 
Varicosities.—Sometimes the pressure of the uterus also 
causes varicose veins of the legs and vulva. These dis- 
tended veins may become so large and tender as to cause 
much suffering, and they may even burst, causing serious 
hemorrhage. Bandaging is here also the proper treatment; 
sometimes collodion is better for small areas or in locations 
where a bandage is hard to apply. 
Signs of Pregnancy.—All of the physiological and path- 
ological changes of pregnancy are signs of pregnancy. They 
are, however, only probable and not positive or certain 
signs. Cessation of menstruation, for example, which is 
one of the earliest and most important signs, may be due 84 
PREGNANCY 
to other causes than pregnancy. Its value as a diagnostic 
sign depends much upon the fact whether menstruation 
has been previously regular. Enlargement of the uterus 
may be due to a tumor. Nausea and vomiting are, of 
course, not necessarily due to pregnancy. 
The physician or nurse is 
absolutely certain of the ex- 
istence of pregnancy only 
when the head, body, or ex- 
tremities of the fetus are felt, 
when movements are noticed, 
or when the fetal heart is 
heard. Even the mother 
cannot be trusted in all cases 
when she says she feels the 
child. Sometimes a woman 
ceases to menstruate, her 
abdomen gradually enlarges, 
she feels the movements of 
the fetus, and has in fact 
all the probable signs of 
pregnancy and so deceives 
herself and perhaps her 
physician that she makes 
all preparation for the con- 
finement. At the expected 
time pains may begin and 
the physician be called only 
to find that the uterus is of 
normal size and that the 
supposed tumor of pregnancy 
is only a gaseous distention 
in an hysterical woman. 
Such cases, called pseudo- 
cyesis, show the necessity of a careful examination before 
assuming a condition on the diagnosis of the patient. 
Abortion.—The termination of pregnancy before the child 
is viable, i. e., before it can live outside of the uterus, is 
called abortion or miscarriage. Premature labor is the 
Fig. 32.—Varicose veins of the leg in 
pregnancy. PATHOLOGICAL CHANGES OF PREGNANCY 
85 
interruption of pregnancy after the child is viable. It is 
possible that a fetus of twenty-eight weeks may survive. 
Hence this is the date generally taken to distinguish abortion 
from premature labor. The term abortion is sometimes 
restricted to denote the expulsion of the egg before quicken- 
ing or before the fetal movements are felt, i. e., before the 
sixteenth to the twentieth week, while miscarriage applies 
to the expulsion between the date of quickening and the 
twenty-eighth week. 
The causes of abortion are diseases of the mother or 
diseases of or injuries to the egg. Severe acute diseases, 
like pneumonia, typhoid fever, scarlet fever, etc., very 
frequently cause abortions. Among the chronic diseases 
that result in abortion or premature labor may be men- 
tioned serious heart diseases, kidney diseases, and syphilis. 
Women differ greatly in their liability to abortion. Some 
women can work hard in the house or field, take long drives 
or make journeys, dance or swim, suffer from falls or blows 
without danger, while a slight strain or a little unusual 
exertion will bring on an abortion in others. A woman in 
her first pregnancy does not know her own susceptibility, 
and hence she should be careful to avoid all those things 
that tend to cause trouble. If a woman has had one or 
more abortions she undoubtedly has a sensitive uterus which 
is easily irritated or excited to contractions. 
The injuries to which the egg may be subjected are either 
accidental or intentional. Accidental injuries are such as 
may result from falls or severe jars to which the mother 
is subjected. These accidents may cause more or less 
separation of the egg from the uterus, or they may even 
rupture the membranes and thus allow the escape of the 
fruit water. When the egg is intentionally injured we have 
criminal abortion. 
An abortion is said to be complete when the entire egg 
has been expelled from the uterus. It is incomplete if part 
of the egg is retained. The fetus may be expelled, but 
some of the placenta or the membranes may still remain 
in the uterus. In an incomplete abortion there is generally 
hemorrhage and discharge. A threatened abortion is a 86 
PREGNANCY 
condition where there is danger of expulsion of the egg, but 
where such an expulsion is not inevitable. There is present 
pain, due to uterine contractions, and hemorrhage due to 
some separation of the egg. Both symptoms may disappear 
and the pregnancy continue. 
The treatment of either threatened or incomplete abortion 
is, of course, the function of the physician. He should be 
called immediately. Women are very often ignorant of 
the significance of the signs of threatened abortion. Pains 
are often attributed to disturbances of the bowels. It 
should always be impressed upon a patient that any pain 
of an intermittent character is very dangerous and demands 
instant attention. Any hemorrhage during pregnancy is 
also of serious import. If the nurse is called to a case of 
threatened abortion before the advent of the physician she 
should keep the patient absolutely quiet in bed in the 
horizontal position. Any discharge which occurs should be 
carefully saved for examination by the physician. 
Physicians sometimes treat abortion by packing the 
uterus and vagina with gauze or cotton and subsequently 
removing the packing with the adherent placenta. The pack- 
ing is generally made without anesthesia, but sometimes 
this is required. In other cases the contents of the uterus 
are removed with the finger or with a curette after prelim- 
inary dilatation of the uterus. Ilere anesthesia is nearly 
always required. The nurse may prepare for the operation 
so far as possible before the coming of the physician. 
Extra-uterine Pregnancy.—Pregnancy outside of the uterus 
is one of the most serious pathological conditions. It occurs 
where there is some obstacle in the tube that prevents the 
passage of the fertilized egg into the uterus, but which is 
not sufficiently great to obstruct the passage of the sper- 
matozoa outward from the uterus into the tube. The 
fertilized ovum begins to grow and becomes attached to 
the inside of the Fallopian tube. The thin tube wall dis- 
tends to accommodate the ovum until it ruptures or the 
ovum eats its way through the tube wall. A rent is made 
in the tube which causes a rupture of the distended vessels 
and a very serious hemorrhage occurs. The patient may PATHOLOGICAL CHANGES OF PREGNANCY 
87 
die suddenly of the shock and hemorrhage from the rupture 
of the tube, or the hemorrhage may be checked temporarily 
by the formation of a strong clot. In a few hours or days 
the hemorrhage reappears and generally the patient dies 
unless she receives the help of the surgeon, who operates 
and removes the tube. In many cases of tubal pregnancy 
the egg becomes separated from the tube and is expelled 
from its outer end. This is called tubal abortion. 
Fig. 33.—Double tubal pregnancy, showing rupture of the tube on the right 
side and tubal abortion on the left. 
It is a peculiar fact that when pregnancy occurs in a 
tube the mucous membrane of the uterus undergoes some- 
what the same changes as when pregnancy occurs in the 
uterus itself. If contractions in the tube occur or rupture 
takes place the uterus also contracts and tends to expel 
this lining membrane, which comes away in pieces or some- 
times entire in the shape of a cast of the uterus. This fact 
often leads to a mistake in the diagnosis. A woman has 
thought herself pregnant and now has pain and some dis- 
charge from the uterus. She thinks she is having an abortion 
and the treatment, so far as the nurse or the patient is con- 
cerned, is the same as in cases of abortion. It consists in 
absolute quiet in bed. If there is much shock from the 88 
PREGNANCY 
hemorrhage the head must be lowered and warm applica- 
tions applied. The necessity for immediate attention is very 
evident. The nurse should never forget the possibility of 
extra-uterine pregnancy in a case that is apparently an abor- 
tion attended with symptoms of shock. 
The discharge of blood from the vagina during pregnancy 
is always a symptom of some serious trouble. Besides the 
two pathological conditions already mentioned, abortion 
and extra-uterine pregnancy, in which this occurs, there are 
also others equally dangerous. These are placenta previa, 
separation of the normally seated placenta, cancer of the 
cervix, and hydatid mole pregnancy. 
Placenta Previa.—The placenta is normally seated in the 
upper part of the cavity of the uterus and does not reach to 
the internal os. Sometimes, however, it lies in the lower 
segment of the uterus and in front of the child, and this 
condition is called placenta previa. If it lies directly over 
the internal os so that it covers the cervix when that is well 
dilated it is called total or complete placenta previa. If it 
only partially covers the opening of the dilated cervix it is 
called partial placenta previa. When the placenta does not 
cover any of the opening of the cervix, but extends only to 
its margin or border, it is called marginal placenta previa. 
The danger of this condition is due to the fact that when 
the cervix begins to dilate in labor under the action of the 
uterine contractions the attachment of the placenta to the 
uterus is more or less broken, and from the dilated region 
bleeding is likely to occur. The detachment and con- 
sequently the hemorrhage is greater when the placental 
implantation is complete. 
It frequently happens that the preparatory pains cause 
sufficient detachment of the placenta to bring on a hemor- 
rhage, so that the bleeding may occur before labor begins. 
It may occur any time during the last six months of preg- 
nancy. When this is not the case it is often one of the first 
signs of beginning labor. If a nurse should, therefore, 
notice a hemorrhage at the beginning it ought to arouse her 
suspicion of placenta previa and she should instantly com- 
municate the fact of the hemorrhage to the physician. PATHOLOGICAL CHANGES OF PREGNANCY 
89 
The management of placenta previa is, of course, the 
function of the physician. The only thing the nurse can 
do before his arrival is to keep the patient absolutely quiet. 
Anything that might excite or increase the uterine con- 
tractions should be avoided. The patient should, there- 
Fig. 34.—Complete placenta previa. (Bumm.) 
fore, remain absolutely quiet in a horizontal position. She 
must use the bed-pan and under no circumstances get out of 
bed or even sit up in bed. 
In the meantime the nurse may prepare for the physician. 
He may conclude to tampon the vagina or perform some 90 
PREGNANCY 
operation. She should have everything in readiness for 
him so far as possible. She must have, of course, the 
necessary solutions for disinfection, and it would be well 
for her to have on hand gauze or sterile cotton for tampons. 
She should prepare the operating table and the douche. 
Fig. 35.—Partial placenta previa. (Biunm.) 
It may happen that a nurse may be left with a patient 
who has had one or more slight hemorrhages from placenta 
previa. Ordinarily this complication is a reason for the 
induction of labor. If, however, the child is not yet viable 
and the urgency seems not great and the patient is able to PATHOLOGICAL CHANGES OF PREGNANCY 
91 
keel) a competent nurse by her constantly it may be decided 
to allow the pregnancy to go on for some weeks. When 
in charge of such a case a nurse must fully appreciate her 
responsibility and be ready to act if necessity requires. 
The directions will be given, of course, by the physician 
Fig. 36.—Marginal placenta previa. (Bumm.) 
in charge. The patient, if allowed to be around the house, 
will be told to avoid everything that may bring on uterine 
contractions. She will avoid jar and blows as well as all 
accidents. 
In case of hemorrhage, however slight, she will go to 92 
PREGNANCY 
bed and remain there. When the hemorrhage is severe the 
nurse may be required to introduce the tampons herself. 
The technic is as follows: 
The nurse should disinfect her hands as directed in the 
chapter on Labor. The patient should be shaved and the 
genital region thoroughly disinfected. For the introduction 
of the tampons the nurse will require a good-sized retractor 
or a Sims’ speculum and dressing forceps. These, of course, 
should be boiled. In a sterile bowl a 0.5 per cent carbolic 
solution should be prepared. For the tampons, sterile 
Fig. 37.—Tamponing vagina in placenta previa. Insertion of retractor. 
Cotton tampons and forceps at hand. 
absorbent cotton is needed, which should have been pre- 
pared in a sterilizer. In emergency they may be torn oft' 
from a sterile roll in pieces, each the size of the hand, dipped 
into the solution, the superfluous fluid squeezed out, and 
then placed on a sterile plate. A dozen to twenty of these 
tampons should be prepared. The plate should be placed 
on a table convenient to the bed. With the patient lying 
in the Sims’ position the nurse inserts the speculum or 
retractor and pulls back well the posterior vaginal wall. 
Then taking a tampon in the dressing forceps she wipes 
out the blood from the vagina and then proceeds to pack PATHOLOGICAL CHANGES OF PREGNANCY 
93 
in the remaining tampons. In this position the uterus falls 
forward and allows the distention of the vagina to its fullest 
capacity. Two or three of the tampons are placed behind 
the vaginal portion of the cervix, another is placed in front, 
and then the remaining tampons are placed over the cervix 
and the entire vaginal canal is filled. When the outlet of 
Bleeding between 
placenta and 
uterine wall. 
Fig. 38.—Premature separation of normally seated placenta. (Bumm.) 
the vagina is reached the packing should stop. No tampons 
should be placed in the vulva, for they will irritate and cause 
unbearable pressure. 
Separation of Normally Seated Placenta.—This condition 
is due to injury or disease. It is generally attended with a 
discharge of blood. The diagnosis between this condition 94 
PREGNANCY 
and placenta previa is not easily made. So far as the nurse 
is concerned the treatment consists only in keeping the 
patient cpiiet in bed and sending for the physician, who 
must assume all responsibility for the management of the 
case. 
Fig. 39.—Hydatid mole. 
Cancer of the Cervix.—A woman is not likely to become 
pregnant if she has cancer of the cervix in an advanced 
stage. A beginning cancer will develop with great rapidity 
during pregnancy, so that a bloody discharge is apt to 
occur before the end. The diagnosis is easily made by 
the physician, but the nurse, without an internal examina- 
tion, can only bear in mind the possibility of this com- 
plication when she has to do with a case of hemorrhage 
during pregnancy. MANAGEMENT OF PREGNANCY 
95 
Hydatid Mole.—This rare disease is due to a degeneration 
of the placental villi. The mole looks somewhat like a 
bunch of bleached-out grapes of various sizes. The embryo 
or fetus dies and the mole enlarges rapidly. It generally 
begins during the second or third month of pregnancy, and 
before the end of the fifth month the uterus is nearly as 
large as at term. Contractions are set up and the uterus 
begins to expel the mole. Some bleeding occurs. With 
the bloody discharge, pieces of the mole are sometimes 
found and their discovery confirms the diagnosis. The 
history of the rapid growth of the uterus, the absence of 
fetal movements and heart sounds, as well as the softness 
of the uterine contents, also help in the diagnosis, which 
is established by the physician by an internal examination. 
While the management of pregnancy is not the function 
of the nurse, still her opportunities for giving good advice 
are so numerous that it is very desirable that she be prepared 
with the elementary principles upon which are based the 
proper hygiene of this condition. 
Diet.—There is a common notion prevalent that a woman 
needs to eat twice as much when she is pregnant as when 
she is not pregnant. The saying is: “She must eat for 
two, herself and her child.” This, however, is not true. 
Very little extra food is required to supply the needs of the 
fetus. Moreover a pregnant woman, as a rule, takes less 
exercise and is less exposed to cold, and therefore needs 
less food for herself. The amount of food taken before 
pregnancy is quite sufficient during pregnancy. 
The attempt has frequently been made to modify the 
growth of the fetus by varying the character of the food. 
It has been thought that the development of the fetus may 
be retarded by modifying the mother’s diet and thus make 
labor easier. The attempt to keep the fetus small by 
restricting the mother to a starvation diet was at one time 
given a trial, but abandoned on account of the suffering thus 
inflicted on the mother and the poor results obtained. Later 
MANAGEMENT OF PREGNANCY. 96 
PREGNANCY 
the attempt was made to withdraw the bony matter from 
the child by keeping the mother on a fruit diet. It may be 
true that the labor is easier after such a diet strictly carried 
out. The child is less developed, but the explanation 
based on the theory of the bone salts is absurd. Fruit is 
not deficient in the bone salts, and the considerable quantity 
of fruit given in this diet contains probably quite as much 
of the bone salts as does an ordinary diet. The true expla- 
nation of the action of the fruit diet is that is it practically 
a starvation diet. The amount of nutriment contained in 
the fruit is slight in spite of the considerable quantity eaten. 
The proper diet for a healthy woman during pregnancy 
is the ordinary mixed diet. It is best for the mother and 
for the unborn child. In case digestion is interfered with 
attention must be paid to the choice of food, so as to exclude 
all articles difficult of digestion. Since there is generally 
a slight diminution in digestive capacity it is well for the 
woman to avoid such things as are known to remain long 
in the stomach. For this reason great care should be 
observed in the use of salads, nuts, pork, smoked meats, 
fried meats and vegetables, as well as pickles, etc. Fruits 
are, as a rule, desirable. Many patients, however, find fruit 
acids harmful to the stomach and have to discard nearly all 
kinds of fruits. 
Special care must be taken with the diet in cases of nausea 
and vomiting of pregnancy. Also in kidney disease a strict 
diet is often prescribed. These are pathological conditions 
and must be treated by the physician. 
A pregnant woman often finds it necessary to eat more 
than three times a day. Frequently a light lunch must 
be taken in the forenoon and also in the afternoon, and 
occasionally it is desirable that something should be taken 
at night. In these cases hot milk is often prescribed. 
Bathing.—The functions of the kidney, bowels, and skin 
are intimately related. To a certain extent one can take 
the place of either of the others. We all know that in 
warm weather when perspiration is free the urine is less 
free, and in cold weather when the skin excretion is checked 
the urine is more abundant. In pregnancy the care of the MANAGEMENT OF PREGNANCY 
97 
skill is of much greater importance than most women think. 
Protection from cold by the wearing of warm and loose 
clothing and the use of frequent baths with friction are the 
measures needed to keep the skin in good condition. 
The frequency, duration, and temperature of a bath 
depend somewhat upon the previous habits of the patient. 
If a woman is accustomed to taking a cold plunge every 
morning it is not necessary for her to change this habit, 
provided it does her no harm. If she is warm after the 
bath, if rubbing brings a glow to the skin, the bath is prob- 
ably beneficial. If the previous history indicates that the 
patient has a tendency to abort, cold baths should be avoided. 
It is safer to prohibit all swimming and surf bathing, although 
some women who are accustomed to water can continue to 
swim for several months without danger. Frequent cleans- 
ing baths in tepid or warm water are needed under any 
circumstances. In the latter part of pregnancy it is some- 
times difficult for a woman to get into a bath tub. In this 
case, or when she has no facilities for taking a tub bath, 
she must be satisfied with a sponge unless she can procure 
a shower bath. 
Dress.—The dress of a pregnant woman should be warm, 
loose and light. Underwear of wool, silk and wool, or cotton 
and wool should be worn if the weather is at all cool or 
changeable. A light weight should, of course, be chosen 
in warm weather. The feet should be well dressed; fortu- 
nately thick-soled, sensible shoes are now in style. The 
chest and abdomen should not be constricted by corsets 
or tight waists. To support the skirts, a “corset waist” 
or any soft waist like a corset cover may be worn. For the 
breasts some find a special bust supporter satisfactory. 
Whatever is worn there must be absolutely no constriction 
about the waist. A corset so made that it constricts the 
waist must be laid aside as soon as the diagnosis of preg- 
nancy is established. A proper corset, however, may 
often be worn with advantage through the whole pregnancy. 
Sometimes it must be made to order. Some corset makers 
now understand the principles which should determine a 
maternity corset. It should be as light and soft as possible, 98 
PREGNANCY 
with no more stays than are necessary to hold it in shape. 
It should be rather long and fit snugly around the hips. 
It should increase in size from below up so that the waist 
is bigger than the hip segment. The chest segment that 
supports the breast must also be perfectly loose. Provision 
must be made for enlarging the middle and upper segments 
Fig. 40.—Side view of a good maternity corset at about the eighth month 
of pregnancy. 
as pregnancy progresses. A proper corset thus becomes 
not only a support for the skirts and for the breasts, but 
also serves as an abdominal bandage to assist the abdominal 
walls in withstanding the pressure of the enlarged uterus. 
The skirts should be as light as possible. With warm, 
tight-fitting underwear heavy skirts are unnecessary. The 
underskirt as well as the dress skirt must be made with MANAGEMENT OF PREGNANCY 
99 
folds so that it, from time to time, can be made larger about 
the waist. The outer garment or both garments may, 
with advantage, be made in one piece. 
Attention should also be given to the night-dress. A 
woman often disturbs the circulation of the skin by careless 
dressing at night. If she is obliged to get up and pass 
through a cold hall to a bath-room or water-closet she should 
be provided not only with a warm wrapper, but also with 
warm stockings and slippers. 
If a maternity corset is not worn an abdominal bandage 
will be found of value during the last half of pregnancy. 
It also prevents the overstretching of the abdominal walls. 
Fig. 41.—A good abdominal bandage for use during the latter part of 
pregnancy. 
A number of good bandages are on the market, or a suitable 
bandage may be made out of strong cotton cloth or linen. 
As a rule no straps under the thighs are needed at this 
time to hold the bandage in place. 
The abdominal bandage is specially useful in cases of 
women who have born several children and have pen- 
dulous abdomens. It also gives relief from the pressure 
symptoms of edema of the lower extremities, frequent 
micturition, etc. Sometimes violent movements of the 
child cause the woman much distress. Here also the bandage 
gives relief. 
Exercise.—It is impossible to lay down a universal rule 
regarding the amount and kind of exercise that a pregnant 100 
PREGNANCY 
woman should take. Moderate exercise is almost always 
beneficial in that it improves the circulation of the blood 
and stimulates the activities of all tissues and organs of 
the body. It improves the appetite, helps digestion, and 
favors the regular movements of the bowels. The chief 
danger of exercise during pregnancy is that if excessive in 
amount or too violent it may bring on contractions of the 
uterus, resulting in abortion or premature labor. Abortion 
is much more easily induced in some patients than in others. 
Until a woman knows whether she aborts easily or not it is 
well for her to be rather careful in regard to exercise and 
watchful for the symptoms of trouble. Hhe should not 
become tired and she must watch especially for the symp- 
toms of backache and a bearing-down feeling in the pelvis. 
When she notices these symptoms she must at once lie down. 
If she finds that she is able to walk and ride without getting 
tired she will find such exercise beneficial. The danger is 
not generally in moderate daily exercise indoors or outdoors. 
It is rather the unusual exertion that a woman makes in 
an occasional shopping trip or visit, particularly as on such 
a trip she is apt to wear corsets that she has discarded at 
home for some weeks. She would better avoid dancing at 
parties or balls. Horseback- or bicycle-riding in the early 
stages of pregnancy is not unusually harmful for a good 
rider if she has studied her own case carefully as just de- 
scribed. Such exercise must, however, be undertaken only 
by a person who appreciates its dangers and watches its 
effects carefully. The same may be said of the use of the 
sewing machine. A careful woman may use the machine 
for half an hour at a time without danger; but if she should 
sew for half a day or a whole day at a time and become very 
tired she would be in danger. The lifting of heavy weights 
or straining the body in any way may be harmful. It may 
result in a partial detachment of the egg. That excessive 
caution that makes a woman afraid to lift her arms above 
her head is, however, unnecessary. 
Toward the end of pregnancy some women find it 
impossible to walk or take other exercise without becom- 
ing very much exhausted. Encouraged by their friends to MANAGEMENT OF PREGNANCY 
101 
continue they are brought to the verge of despair. This 
is not good. When exercise leads to exhaustion it should 
be given up. As a substitute, massage combined with 
passive movements is valuable. It relieves the edema which 
in these cases generally exists and improves the circulation 
better than exercise. 
Care of the Breasts.—The breasts should be let alone 
until the last month or two of pregnancy. Manipulations 
are unnecessary and may bring on uterine contractions. 
Support should be given with a proper corset or waist. 
During the last six to eight weeks the nipples should be 
well washed with soap and warm water to remove secre- 
tions and then dried thoroughly with a clean towel. The 
secretion sometimes makes a crust which covers the nipple. 
If this is not removed until the nursing begins the nipple 
is found to be very tender and is easily infected. The daily 
cleaning and rubbing of the nipple puts it in good condition 
for nursing. 
Some physicians advise washing the nipple with alcohol 
or some astringent solution to toughen it. Others advise 
the use of lanolin or some other lubricant to soften the skin 
of the nipple. The simple rule given above will be found 
satisfactory. 
Sometimes it is advised to employ methods to develop 
a nipple when it is retracted or deformed. These measures 
are generally unsuccessful. The subject will be further 
discussed when treating of lactation. CHAPTER IV. 
LABOR. 
Labor is the expulsion or delivery or birth of the child 
and the fetal appendages or after-birth. Confinement is a 
term that has about the same significance, but refers espe- 
cially to the disability of the mother. Likewise, the French 
term accouchement, i. e., bringing to bed, and the English 
lying-in apply to the mother’s condition rather than to her 
active efforts. 
Labor at term is labor occurring about forty weeks or 
two hundred and eighty days from the beginning of the last 
menstruation or when the child has reached the normal size 
and development to begin life outside of the uterus. Pre- 
mature labor is that occurring between the twenty-eighth 
week of pregnancy and term. Retarded or delayed labor 
occurs when pregnancy has lasted more than forty weeks. 
Sometimes labor has occurred three hundred and twenty days 
after the last menstruation. Very rarely labor does not 
come on at all; eventually the child dies and remains in the 
uterus. This is called missed labor. 
Labor in its duration may be normal, slow, rapid, or 
precipitate. It is spontaneous when it terminates without 
assistance or artificial when some interference is required. 
Eutocia and Dystocia.—In the study of labor we must 
consider the forces, the child or passenger, the passages 
and the mechanism. When all of these are normal we have 
normal labor or eutocia. When any of these are path- 
ological we have dystocia. Dystocia may terminate spon- 
taneously. Artificial labor is, of course, always dystocia. 
Causes of Labor.—Much has been written about the factors 
which set up labor, but nothing is certainly known. Some 
have thought that the nerve centers that control the uterine LABOR PAINS 
103 
contractions are directly stimulated by toxins or poisons 
of some kind in the blood, while others hold that there is 
reflex action, the peripheral irritation being distention of 
the uterus, changes in the placenta, etc. 
Forces of Labor.—The forces of labor are muscular con- 
tractions. They are of two kinds, involuntary and volun- 
tary. The contractions of the uterine muscle belong to 
the first class and those of the abdominal muscles to the 
second class. The strength of the uterine contractions has 
been measured in various ways. It varies, of course, greatly. 
Normal contractions exert a pressure of from about 10 
pounds to 25 pounds per square inch. Contractions of 
less intensity are abnormally weak and those of greater 
intensity are excessive. Practically we estimate approxi- 
mately the strength of the uterine contractions by noting 
the degree of hardening of the uterus with the hand applied 
on the abdomen. 
Labor Pains.—The uterine contractions generally cause 
suffering, and hence they are termed pains. The use of 
the word pain often leads to an apparently paradoxical 
expression. A strong or good contraction we call a good 
pain. It does not always happen that the contraction 
causes suffering any more than the contraction of the heart 
or stomach. Some women feel only the pain caused by 
the stretching or tearing of the vulva when the child is 
expelled. They have been almost or entirely unconscious 
of the contractions which opened the uterus and forced 
the child into the pelvis. Suffering is, however, such a 
usual accompaniment of the uterine contractions that we 
commonly speak of them as pains. Uterine contractions 
or pains occur at more or less regular intervals, separated 
by periods of rest. The contraction begins slowdy and is 
perhaps not felt by the patient. The hand placed on the 
abdomen over the uterus notices a hardening of that body. 
It becomes shorter and thicker. If the woman is lying on 
her back the uterus rests against the backbone and projects 
more prominently toward the front. As the contraction 
increases in intensity it becomes more painful. The uterus 
is felt through the abdominal wall almost as hard as a stone. 104 
LABOR 
After reaching the climax the contraction gradually dis- 
appears. By keeping the hand over the uterus and noting 
exactly the time of the beginning and the end of the con- 
traction we notice that it lasts longer than the pain which 
the woman feels. A good contraction lasts from a minute 
and a half to two minutes. The pain is felt by the mother 
perhaps a minute. 
Pregnancy Pains.—We may often observe uterine con- 
tractions during pregnancy. A cold hand placed on the 
abdomen over the uterus will often cause it to harden. 
During the last three or four weeks of pregnancy, spon- 
taneous contractions at irregular intervals are the rule. 
They may occur every hour or two or they may occur 
several times in one day and not at all the next. They 
are sometimes noticed by the patient, but frequently cause 
her no suffering and are entirely unobserved by her. These 
pains occurring during pregnancy are often called prepara- 
tory or false pains. They partly obliterate the cervix and 
probably sometimes force the head of the child into the pelvis. 
Stages of Labor.—Labor begins when the contractions 
occur with considerable regularity and continue until, 
in normal cases, the child is born. Labor is generally 
divided into three stages. In the first or opening stage 
the mouth of the uterus is dilated until there is almost no 
separation between the uterus and the vagina; they form 
one canal (Fig. 42). In the second stage the child is expelled 
from the body. In the third stage the after-birth is expelled. 
First Stage of Labor.—In the first stage the pains are 
called opening or dilating pains. Only the contractions 
of the uterine muscles are here of value. The mother has 
little or no tendency to help with the abdominal muscles, 
i. e., to bear down. Sometimes an ignorant nurse will 
encourage her to bear down. Such advice is unwise. The 
abdominal muscles can help but little, and the mother 
unnecessarily exhausts her strength. 
As has been said, the contractions are not always felt. 
With the first child there is considerable suffering, and 
there need never be fear of the lack of warning. In sub- 
sequent labors, however, it is often important that the FIRST STAGE OF LABOR 
105 
patient should be informed that she may not feel the first 
pains much. Without this warning she may be too late 
in calling the nurse and physician. A woman who has 
easy labors should be instructed to watch closely for the 
uterine contractions when the time of her expected confine- 
ment arrives. She must report if she feels uncomfortable. 
The nurse, if she be present, can determine whether the 
discomfort is due to the beginning of labor or not by watch- 
Interna/ os 
InTerna! os 
Cery/ca/ 
Cana/ 
- Externa/ os 
-Externa/ os 
{Interna/ os 
■•Jfjfema/ os 
-Externa/ os 
■/ixTerna/ os 
Fig. 42.—Effacement and dilatation of the cervix. 
ing for the uterine contractions by placing her hand on the 
abdomen. 
At the beginning of labor, pains occur every ten to thirty 
minutes. As labor progresses they generally increase in 
frequency and in intensity. The contractions may or may 
not cause pain in the back. 
The first stage of labor may last from two or three hours 
to several days. In women who have never born children 
it is generally longer than in those who have had children. 106 
LABOR 
With the first labor this stage lasts on an average fourteen 
to sixteen hours. In women who have had children it lasts 
from six to eight hours. Its apparent shortness in some 
eases is due, as just said, to the impossibility of ascertaining 
exactly when it begins. 
Effacement of the Cervix.—The system of muscle fibers 
of the uterus is so constructed that when they contract 
they tend to pull open the internal os. The fibers of this 
region are, so to say, gradually pulled up into the lower 
segment of the body. The cervix becomes more and more 
funnel-shaped as the internal os is gradually opened. 
Eventually the projecting cervix disappears as the cervical 
canal becomes a part of the cavity of the uterus, forming 
a part at least of its lower segment. We say that the cervix 
is effaced or obliterated. Sometimes this effacement is 
effected by the preparatory contractions of pregnancy. 
When it is completed the dilatation of the external os begins 
(Fig. 42). 
Formation of the Bag of Waters. —During the effacement 
of the cervix the wall of the lower segment of the uterus 
is more or less separated from the membranes which enclose 
the fruit and its waters. This causes a slight “first show” 
which is one of the first signs of the beginning of labor. 
It also results in the formation of the bag of waters. This 
consists of the free or separated portion of the membrane 
which projects into the funnel-like canal and later into or 
through the dilating os when distended by the uterine con- 
tractions. The distention disappears during the interval. 
The water which fills the bag is called the forewater, and 
is that portion that lies in front of the head. During a 
contraction the head is pressed against the side wall and 
like a valve cuts off the forewater from the rest of the 
fruit water. The bag during a pain may be hemispherical, 
glove-shaped, or pyriform. The contained fluid transmits 
the pressure equally in all directions and hence the bag is 
very valuable in the dilatation of the cervix. 
Rupture of the Membranes.—The rupture of the membranes, 
or the bag of waters, may occur at any time during labor. 
It sometimes happens hours or even days before labor begins. RUPTURE OF THE MEMBRANES 
107 
When it occurs before the beginning of labor the fruit water 
may drain away and we may have what is called a dry 
labor. In such a case the woman should remain in bed to 
Fig. 43.—Formation of the bag of waters with the forewater. During 
effacement and dilatation of the cervix the head or presenting part separates 
the overlying membranes from the lower membranes which project into the 
cervical opening as a pouch or bag and contain the forewater. 
prevent unnecessary loss of the liquor amnii. If the bag 
of waters breaks before the end of the first stage of labor 
there is said to be a premature rupture of the membranes. 108 
LABOR 
If the membranes are very tough they may not rupture 
when the uterus is opened. Sometimes the head reaches 
the vaginal outlet before the membranes rupture, and it 
may be necessary for the physician artificially to tear open 
the bag in order to allow the escape of the child’s head. 
A tardy rupture of the membranes delays labor. In abso- 
lutely typical cases the membranes should rupture at the 
end of the first stage of labor. 
Second Stage of Labor.—The pains during the second 
stage of labor are called expelling or bearing-down pains. 
Here both the contractions of the uterus and of all of the 
abdominal muscles are brought into play. It is not neces- 
sary that the mother be instructed to bear down; she does 
it unconsciously. As the head is forced through the pelvis 
and approaches the outlet the vulva begins to open. The 
dilatation of the vaginal outlet causes a peculiar tearing 
pain. The cry of the woman is quite different from that 
in the early stage of labor. An experienced nurse or physi- 
cian can often tell the stage of labor by the nature of the 
patient’s cry. 
The second stage of labor lasts from a few minutes to 
several hours. It is two or three hours long on the average 
in women who have never born children, and in subsequent 
pregnancies the average is perhaps one to two hours. 
One can determine the exact moment of the complete 
dilatation of the uterus only by making an internal exami- 
nation. For the physician this is often undesirable, and 
for the nurse such an examination is very seldom allowed. 
While it is not necessary to determine this moment with so 
great accuracy, it is, however, desirable to know approxi- 
mately the stage or progress of labor. If a nurse is alone 
with the patient she wishes to be able to inform the physician 
concerning its progress. This she can do by observing the 
character of the pain and noticing when the bearing-down 
pains begin. The rupture of the bag of waters is also noted 
and reported. As the head passes through the cervical 
ring that is not completely dilated a tear, generally slight, 
frequently occurs which is attended with a show of blood. 
This may be called the “second show” and should also be AFTER-PAINS 
109 
recorded. By external examination the nurse can find 
out whether the head has entirely entered the pelvis, and 
by pressing with the fingers behind the anus on each side 
of the coccyx she can tell whether the head is approaching 
the outlet. 
Third Stage of Labor.—The third stage of labor may last 
from a few minutes to many hours. The greater part of 
the after-birth is often expelled from the body of the uterus 
into the cervix and vagina, where it remains held by the 
membranes which are not wholly detached. This partial 
retention of the placenta accounts for many cases of pro- 
longed third stage of labor. Sometimes, however, the 
placenta is quite firmly attached to the uterus or the uterine 
contractions are too weak, and the third stage would be 
much prolonged if the spontaneous expulsion of the after- 
birth were waited for. In these cases labor is often com- 
pleted by expressing or squeezing out the placenta with the 
hand so that the third stage is rarely allowed to last longer 
than two hours. The pains of the third stage are called 
after-birth pains. The uterine contractions differ con- 
siderably from those that occur in the earlier stages of labor. 
They are much longer and the resting intervals are shorter. 
A change is gradually taking place in the muscles of the 
uterus by which it becomes a hard, firmly contracted body. 
After-pains.—After the completion of labor by the ex- 
pulsion of the placenta the uterine muscle passes into a 
state of permanent contraction. This contraction causes 
no suffering. It occasionally happens, however, on account 
of the presence of blood clots or pieces of retained decidua 
which act as foreign bodies that the uterus is excited to 
renewed contractions. These are painful and have received 
the name of after-pains. They may occur at regular inter- 
vals and may last for three or four days. Anything which 
stimulates the contraction of the uterus may cause these 
pains: for example, kneading the surface of the abdomen 
with the hand or the application of the child to the breast. 
They may occur after the birth of the first child, but are 
more likely to be present after subsequent labors. 
It will be seen that we have five kinds of uterine pains. 110 
LABOR 
There are the preparatory or false pains which occur during 
pregnancy. Then during labor there are the opening pains 
in the first stage and expelling or bearing-down pains in the 
second stage and the after-birth pains in the third stage. 
Then finally in child-bed there are the after-pains. 
MECHANISM OF LABOR. 
By this term we understand the results of the action of 
the forces of labor applied in expelling the fruit from the 
uterus. Very briefly we describe the progress of the child 
through the obstetrical canal. 
Posture.—Introductory to this description, however, we 
must define a few terms in common use. By the posture 
or attitude of the fetus we understand the relation of the 
various parts of its body to each other, i. e., how the fingers 
are held, how the hand lies in relation to the forearm, how 
the forearm lies in relation to the arm, the arm to the body, 
etc. The normal posture or attitude of the fetus in the 
uterus is that of flexion. The head is somewhat flexed on 
the neck and the neck on the body. The body is bent on 
itself. The thighs are flexed against the body, the legs on 
the thighs, the feet on the legs. The arms are applied to 
the body. The forearm is flexed on the arm and the hand 
flexed on the forearm. In this attitude the child occupies 
the smallest possible space. It is the natural posture for 
a child to lie in when enclosed in a cavity of limited size. 
Sometimes, however, a deviation from this flexion attitude 
is found. It may be called a partial extension attitude. 
The head is extended on the body and the back bent back- 
ward instead of forward. This is the posture of the child 
in cases where the face presents instead of the top or back 
of the head. The posture of the child varies during its 
passage through the obstetrical canal. 
Position.—By position of the child we denote its relation 
to the uterus. The position of the child is expressed by saying 
that it lies with its back to the left or to the right, to the left 
anterior or to the right posterior, etc. If the head presents 
we may denote position by using the back of the head or MECHANISM OF LABOR 
Ill 
occiput as the determining point. Thus we say the position 
is occiput left anterior (o. 1. a.) or occiput left posterior 
(o. 1. p.), etc. The position varies also during the passage 
of the child. 
Fig. 44.—Sagittal section through the pelvis and uterus near the end of 
the first stage of labor, showing the posture of the child and also the bag of 
waters intact (A). (Bumm.) 
Presentation.—By the presentation we mean that part of 
the child that precedes in its progress through the obstet- 
rical canal or the part that is first felt when a vaginal ex- 
amination is made. Thus we may have a head, a breech, 
a foot, an arm, a shoulder presentation, etc. Usually the 
head presents. Under head presentation we may also have 
the face or the brow presentation when the child lies in an 112 
LABOR 
attitude of extension. In a typical labor some part of the 
skull presents. We distinguish here the vertex, the occiput, 
the fontanelle, etc. The presentation depends upon the 
attitude of the child. If the presenting head is well flexed 
the presentation is occiput. If the head is well extended the 
presentation is face. The position is independent of the 
posture or presentation. For example, the position may be 
o. 1. a. whether the attitude be one of flexion or extension. 
Station.—The head may be located in the inlet of the 
pelvis or above the inlet, in its excavation or in its outlet. 
The term station is used to denote the location or situation 
of the head or presenting part. 
In our description of the mechanism of labor we shall 
describe first in some detail the progress of the typical 
head presentations. These comprise over nine-tenths of 
all cases of labor, and it is desirable that the nurse should 
understand them, for she is liable to be alone with the 
patient during a normal labor. In cases of abnormal 
presentation labor is usually very much delayed and the 
physician will be present and assume responsibility for the 
management. The nurse should be able to determine by 
external examination the presentation, position, and posture 
of the child, but she is not expected to conduct the labor in 
abnormal cases, and hence needs to understand its mechanism 
only so far as may be necessary to recognize deviation from 
normal. 
Three kinds of movements of the fetus occur, namely, 
translation or movement of the fetus along the canal, flexion 
or movement on a transverse axis, and rotation or move- 
ment about a longitudinal axis. The progress may be 
described in four steps: 
Descent.—The first step is the descent of the head into 
the pelvis. As has been said, this may begin during the 
last weeks of pregnancy if the opening into the pelvis is 
large as compared with the child’s head and if the lower 
segment of the uterus becomes relaxed. By observing the 
shape of the inlet it will be seen that its cross diameter is 
longer than its antero-posterior diameter. It will also be 
observed that the antero-posterior diameter of the child’s MECHANISM OF LABOR 
113 
Fig. 45.—Diagram showing the status of fetus and pelvis at the beginning 
of labor. The presentation is vertex (flexion has not begun); position, 
occiput left (o. 1.); station, above inlet. 
Fig. 46.—Status during first step in the mechanism of labor. Descent 
has begun, accompanied by flexion. Presentation, posterior vertex; posi- 
tion, occiput left (o. 1.); station, in inlet. 114 
LABOR 
head, i. e., the occipito-frontal diameter, is larger than the 
transverse diameter. It is therefore evident that when the 
Fig. 47.—Sagittal section showing same progress in the mechanism of labor 
as Fig. 46. 
Fig. 48.—Status during second step in the mechanism of labor, i. e., 
rotation in progress. The presentation is posterior vertex; position, occiput 
left anterior (o. 1. a.); station, head in excavation. 
head descends into the pelvis its long diameter, which must 
coincide with the long diameter of the pelvis, must lie more MECHANISM OF LABOR 
115 
or less transverse, i. e., the occiput must point to one side 
or the other of the pelvis. When the head has passed into 
the pelvis so far that its greatest circumference has passed 
Fig. 49.—Status at the end of descent and rotation. Presentation is vertex; 
position, occiput anterior (o. a.); station, head in outlet. 
Fig. 50.—Fetal skull, showing displacement of bones in moulding as in 
Fig. 52. The right parietal bone projects over the left and both over the 
occipital. (Bumm.) 116 
LABOR 
Fig. 51.—Fetal skull, showing displacement of bone in moulding as in 
Fig. 53. The parietal bones project over both the frontal and occipital. 
(Bumm.) 
Fig. 52.—Moulding of fetal head during labor. Bone displacements shown in 
Fig. 50. Caput succedaneum also shown. (Bumm.) MECHANISM OF LABOR 
117 
through the inlet it is said to have descended or entered the 
pelvis (Fig. 48). Its station is in the excavation. During 
this step some flexion of the head may take place (Fig. 46). 
Some moulding of the head begins so that it fits the passage 
(Figs. 52 and 53). Likewise a swelling of the presenting 
part of the head may occur. This is called the caput suc- 
cedaneum (Fig. 52). 
Rotation. —The next step in labor is the rotation of the 
head. While the transverse diameter of the inlet is longest, 
Fig. 53.—Moulding of fetal head during labor. Displacements of bone 
shown in Fig. 51. (Bumm.) 
at the outlet the antero-posterior diameter is longest. Hence 
it is evident that the head which descends with its long 
diameter crosswise must now rotate so as to bring that 
diameter into the antero-posterior diameter of the pelvis in 
order that its expulsion may take place most advantageously. 
If the rotation occurs normally the back of the head or occiput 
is brought to the front; sometimes an abnormal rotation 
occurs by which the forehead is brought to the front or the 
occiput posterior. This is a great disadvantage, for it 
makes the expulsion of the head much more difficult. The 118 
LABOR 
rotation occurs within the cavity of the pelvis and usually 
in the early part of the second stage of labor. 
Fig. 54.—Sagittal section showing the beginning of the third step in the 
mechanism of labor or the exit of the head. (Compare Figs. 49 and 56.) 
Fig. 55.—End of the third step in the mechanism of labor, i. e., the exit of 
the head. (Compare Fig. 57.) 
Exit of Head.—The third step in the mechanism of labor 
is the exit or expulsion of the head, which occurs with its 
extension. After the rotation of the head in the pelvis the MECHANISM OF LABOR 
119 
presenting part, i. e., the occiput, is gradually forced through 
the vulva and appears close under the symphysis. When 
the pain stops the head recedes into the pelvis to appear 
again at the next contraction. Even before the head is 
visible in the vulva it can be felt by pressing with the fingers 
each side the end of the sacrum. By observing the perineum 
during the pain it is seen to distend. As soon as the vulva 
Fig. 56.—Beginning of the third step in the mechanism of labor, i. e., 
exit of the head. The perineum is distended and the head visible. (Bumm.) 
begins to open and a trace of the head can be seen we say 
the head is visible. Often about this time the lower end 
of the vagina becomes stretched so much that a slight tear 
occurs attended with a show of blood. This may be called 
the “third show.” When the head advances so far during 
a pain that it does not recede into the pelvis in the interval 
we say that it has escaped from the bony pelvis. The vulva 
dilates more and more with each pain. The occiput pro- 120 
LABOR 
jects more and more out of the pelvis. If the patient is 
lying on her back the presenting part which first pointed 
in the horizontal direction is now directed more and more 
upward. When the presenting part has passed from under 
the symphysis, so that the region below the occiput, i. e., 
the subocciput, is applied to the symphysis, the condition 
is favorable for the birth of the head. More and more of 
Fig. 57.—The head is about to pass through the vulvar ring in the sub- 
occipito-frontal circumference. (Bumm.) 
the head appears, the vulvar ring stretches, and finally 
slips over the forehead and over the face when the head is 
born. You will observe from this description and from the 
accompanying figures that this expulsion of the head is 
accompanied by an extension. Hence this process is also 
called extension. 
Exit of the Body.—The final stage in the mechanism of 
labor is that of expulsion of the body. While the shoulders MECHANISM OF LABOR 
121 
descend into the pelvis lying more or less in the transverse 
diameter of the inlet, i. e., generally with the back of the 
child toward the front of the mother, in the pelvis they 
rotate back again and are delivered with the back to one 
side. Sometimes the anterior shoulder comes out first 
under the symphysis, when the posterior shoulder follows 
over the perineum, while at other times the posterior shoulder 
is delivered first. After the birth of the shoulders the rest 
of the body slips out without any further trouble. 
Fig. 58.—Exit of the body. The anterior shoulder is escaping first. Notice 
that the head is only supported by the hand; no traction is made. 
Expulsion of the Placenta.—The methods of the separa- 
tion and expulsion of the after-birth, i. e., the placenta and 
membranes, are illustrated by the two accompanying fig- 
ures. One is called the Schultze method, because it was 
well described by Prof. Schultze, the celebrated obstetrician 
and teacher of Jena, Germany. The other method was 
described by Duncan, a famous obstetrician of England, and 
so is called the Duncan method. According to Schultze the 
placenta begins to separate from the uterus in the middle. 
Blood collects in the space between the placenta and the 
uterine walls. This grows larger and larger as the separation 122 
LABOR 
continues until the placenta is fastened only by a rim at the 
attached border, or perhaps only by the attached membranes. 
Fig. 59.—Separation of the placenta by the Schultze method. 
Fig. 60.—Separation of the placenta by the Duncan method. MANAGEMENT OF LABOR 
123 
At this stage the placenta is lying in the lower segment of 
the uterus. Finally the last adhesions to the uterus are 
severed and the mass is expelled from the body with the 
membranes and fetal side of the placenta on the outside, 
and the blood that was behind the placenta contained on 
the inside of the bag as it is now turned inside out. Accord- 
ing to the Duncan mechanism the placenta begins to separate 
from the uterus at its lower edge. As the separation con- 
tinues it is gradually expelled from the uterus with its 
uterine surface foremost, in which way it appears at 
the vulvar outlet. Both methods of expulsion are normal 
and occur with about equal frequency. By the Schultze 
mechanism there is generally no hemorrhage until after 
the placenta is expelled, when a large clot or quantity of 
blood comes in or with the after-birth. By the Duncan 
mechanism there is apt to be some hemorrhage during the 
process of expulsion. 
MANAGEMENT OF LABOR. 
In Hospitals.—Lately, in many cities and large towns, 
maternity or lying-in hospitals or maternity departments 
in general hospitals have been provided for the care of 
women in labor. When well equipped and well managed 
these are very desirable. Not only can normal labor be 
conducted with a minimum risk to the patient, but in case 
complications develop and artificial interference becomes 
necessary it can be made much more efficiently. Such 
hospitals are provided with a separate preparation room and 
delivery or accouchement rooms and with a technic that 
differs somewhat in the different institutions, just as the 
operating room technic may differ, but which conforms in 
general to the principles of asepsis and antisepsis. We 
shall not attempt to describe in detail hospital equipment 
and technic which must differ in accordance with the capacity 
of the hospital or department. Nurses during their training 
will become familiar with the technic in their own training 
schools. Since many labors still must be conducted in 
homes we shall here give special attention to the manage- 124 
LABOR 
ment of labor in private houses, where all kinds of con- 
ditions will be met. The following directions, while con- 
templating the special needs of home cases, also comprise 
the essentials of hospital technic. 
In Private Houses.—It is the duty of the nurse who is 
assisting in a case of labor to avoid infecting the patient 
herself, to prepare the patient and her bed so that she may 
not become accidentally infected, to prepare for all possible 
emergencies and to assist the patient as far as possible dur- 
ing labor. Certain general directions concerning the nurse’s 
duties have been given already in Chapter I. If the nurse 
is not in the house when labor begins she has, as a matter of 
course, visited her patient and made herself familiar with 
the management of the house, and knows where to find the 
bedding and the patient’s outfit. She has with her those 
things that are absolutely necessary for disinfection and for 
use about the patient in case of need in an emergency. 
Nurse’s Outfit.—The following articles make a fair outfit 
for the nurse: 
Nail brush. 
Tube or bottle of clean or antiseptic soap. 
Nail file. 
Scissors. 
Glass and soft rubber catheter. 
Glass douche point. 
Bottle of sublimate tablets (7 + grains each) 
Tape or ligature. 
Aspirating catheter. 
Hypodermic syringe. 
Two fever thermometers. 
Phonendoscope or stethoscope. 
Rubber gloves. 
Large gown. 
Patient’s Outfit.—Sometimes the patient purchases the 
supplies for dressings in bulk and the nurse prepares them. 
If sterile gauze and cotton are used and the nurse prepares 
the dressings antiseptically, subsecpient sterilization is unnec- 
essary. In most towns as well as cities there are, however, 
large hospital sterilizers where dressings, sheets, towels, and MANAGEMENT OF LABOR 
125 
gowns can be sterilized, and it is in general more satisfactory 
to have the patient send her sheets to be sterilized with the 
dressings and then have them kept untouched ready for use. 
Under any circumstances the patient needs bowls, pitchers, 
etc., with certain druggist’s supplies. Such a list should 
include the following articles: 
One rubber or enamel 3-quart fountain syringe. 
One enamel combination douche-pan and bed-pan. 
Two or 3 enamel or china bowls. 
Two or 3 enamel or china pitchers. 
One slop pail or jar. 
One bath thermometer. 
Two large nail or hand brushes. 
One nail file. 
One bottle (25) sublimate tablets (7+ grains each). 
Three ounces of lysol or compound solution of cresol. 
One pint of alcohol. 
Two hundred and fifty grams of ether. 
One tube or bottle of antiseptic soap. 
One ounce of fluidextraet of ergot (or some other pre- 
paration for hypodermic use). 
Three ounces of olive oil for baby. 
One sac containing a sterile blanket, 1 yard square, with 
a sterile napkin and 4 large safety pins for receiving baby. 
(See page 282.) 
Safety pins, large and small. 
Rubber sheeting, 3 yards (If yards wide). This is cut 
so as to make two pieces, one, If x If yards, to cover the 
mattress, and one, If x If yards, to serve as a rubber draw- 
sheet or drainage sheet. 
If the nurse makes the dressings she will need the follow- 
ing additional supplies: 
Twenty-five yards of sterile gauze. 
Four pounds of absorbent cotton. 
Four yards of strong cotton cloth for bandages. 
In addition the patient should have laundered and put 
away for use during and following the confinement: 
One dozen sheets. 
One and a half dozen towels. 126 
LABOR 
Three pillow-cases. 
Three night-gowns. 
Three pairs long stockings. 
One dressing gown or bath robe. 
When the dressings are prepared and sterilized in the 
hospital the following list makes a satisfactory outfit: 
Three packages of vulvar dressings, 1 dozen in each pack- 
age (each dressing 18 x 8, taking gauze 12 x 36 and cotton 
filling 12 x 7, full thickness). (Twelve yards of gauze and 3 
pounds of cotton.) 
One package of perineal gauze sponges, each 9x9, four 
thicknesses (6 yards of gauze). 
Two packages cotton sponges, 25 in each (1 pound of 
cotton). 
One pound of sterilized cotton. 
Five yards of sterile gauze in 1-yard lengths. 
Two packages of bed-pads, 1 in each, 24 x 24, 2 thick- 
nesses of cotton. 
One pair of leggings. 
Six breast bandages, 12 x 48. 
Four abdominal bandages, 18 x 48. 
Ligature of No. 8 silk, 28 inches long, in envelope. 
Two 4-ounce bottles of sterile soap. 
One nail file, 1 bath thermometer, 1 douche point, all 
sterile. 
Two sterile nail brushes. 
The outfits described cost from $15 to $30. A poor 
patient can save considerable in various ways. Newspapers 
are often used to protect the bedding and when they are 
clean and covered with a clean sheet they help in the clean 
management of the case. A piece of new white oil-cloth 
for additional protection and to use as a drainage sheet 
if required may substitute the rubber sheeting. The patient 
may get along with 2 pounds of cotton, and she may dis- 
pense with lysol and ether. She may use a syringe and 
bowls, pitchers and douche-pan that are already in the 
house, or she can borrow, for these can be sterilized by 
boiling before using. MANAGEMENT OF LABOR 
127 
Preparation of Self.—In order to avoid any danger of 
infecting the patient, the nurse should be as nearly clean 
as possible. She must be free from suspicion of any con- 
tagious disease. If she herself has had measles, scarlet 
fever, whooping-cough, mumps, erysipelas, or any other 
contagious disease she must not go to a case of obstetrics 
for at least a month after recovery, during which convales- 
cence she must have taken numerous cleansing baths. Colds 
and la grippe are also contagious; it is certainly not desirable 
that an obstetrical nurse should be suffering from a severe 
cold. There is always danger that she will be the means of 
conveying it to the mother or child. If she has unfortunately 
contracted such a cold a few days before the expected con- 
finement she should use all measures to cure herself, including 
gargles and spraying of the throat and nose. 
If she has been in attendance on a case of contagious 
disease she should not go to an obstetrical case for a week 
during which time she should bathe frequently, and partic- 
ularly wash the hair. If a quicker preparation is absolutely 
necessary, she should take a Turkish bath and wash the 
hair with utmost thoroughness. If she is very conscientious 
it may be possible for her to disinfect herself in a day. 
When labor begins the nurse should put on clean wash 
clothes. It is well known that of all sources of danger the 
hands are much the greatest. It is not possible for a nurse 
to keep her hands sterile. During the labor she is obliged 
to handle so many things about the room that she is con- 
stantly contaminating her hands. Unless she is conducting 
a labor herself, and needs to touch the genitals of the patient, 
it is not necessary that she be absolutely sterile. When she 
is preparing the dressings or touching the patient she should 
be so clean that there is no danger of contamination. For 
this purpose it is better that she put on gloves. At all 
times, however, she must be sure that her hands are not 
contaminated with dangerous germs, i. e., pus germs or 
those of erysipelas. For this reason it is proper that she 
should clean her hands as well as she can with soap and 
water before giving the patient her enema and bath, and 
then sterilize them before preparing the patient for her 128 
LABOR 
examination. If she has thoroughly disinfected her hands 
at the beginning of labor and washes them frequently during 
the labor, especially when they become contaminated, she 
is doing her duty. If in the absence of the physician it is 
necessary that she should deliver the patient herself, she 
must, of course, see to it that her hands remain sterile and 
also wear gloves. 
It is well known that the skin, even when ordinarily clean, 
is contaminated with innumerable bacteria. If an abrasion 
or other wound is made these bacteria cause an infection 
which results in an inflammation of greater or less extent, 
and perhaps in the formation of pus. While these germs 
are all over the surface of the body they are found in much 
greater numbers in some places than in others. About the 
hand they are found especially between the fingers and 
around the nails. If a person wears rings, they are found 
also in numerous quantities under the rings. A nurse should 
never wear rings. 
The germs we especially fear are the ordinary pus germs, 
the germs of erysipelas and bacteria that are found in the 
feces, and the ordinary germs of decomposition. 
While nine-tenths or more of the germs can be removed 
by the proper use of soap and hot water, yet some remain, 
and they must be destroyed or gotten rid of by certain 
chemical substances which we call antiseptics. The method 
of cleaning the hands is as follows: 
Method of Cleaning the Hands.—First scrub the hands and 
arms with clean soap and hot water, using a clean brush, 
for ten minutes. The water should be as hot as can be 
borne. The soap must be clean. A cake of dirty soap, 
perhaps with numerous cracks, which is lying around the 
common house sink and has been used by everyone for 
weeks, is dangerous. The hands could even become con- 
taminated by the use of such soap. A clean cake of any 
good soap will do. The soft or green soap which contains 
a small amount of antiseptics, put up in collapsible tubes, 
is a very convenient and safe form to use. It may also be 
kept in small bottles. The brush must also be clean. A 
brush that has been used to clean an infected hand is posh MANAGEMENT OF LABOR 
129 
tively dangerous. Pus germs may live for days or weeks 
in its fibers. It is easily seen how these may be rubbed 
into the fingers and cause a serious contamination. Unless 
the brush is known to be clean it should be boiled before 
using. In scrubbing the hands it is important to separate 
and wash carefully between the fingers. The region of the 
nails is much the most dangerous, and about nine-tenths of 
the whole time consumed in cleaning the hands should be 
spent in cleaning around the nails. During the washing 
the water should be frequently changed. It is better to 
use running water. If a bowl of water is used the water 
should be renewed at least three or four times. The dirt 
removed at the first washing remains in the water, and 
would easily cause a renewed contamination of a clean hand. 
Next comes the cleaning of the nails with a clean nail file. 
A nail file that has been contaminated by use on a con- 
taminated hand would be one of the most dangerous things 
to use. A suspected file can always be cleaned by boiling 
thoroughly. From three to five minutes at least are required 
to clean the nails. The best way to determine whether the 
nails are clean or not is to look at them in a good light with 
a conscientious eye. If any particles of dirt, no matter 
how minute, are seen around the nail, or on the ridge at 
the side of the nail, one may be certain that the cleaning is 
not complete. If particles of dirt large enough to be seen 
are present, we may be sure that bacteria which are micro- 
scopical are not removed. 
After the use of the nail file the hands should be scrubbed 
again with soap and hot water for from two to five minutes, 
to remove all matter loosened by the file. These steps in 
the disinfection have consumed from fifteen to twenty 
minutes. 
The hands and arms should now be dried with a clean 
towel and then scrubbed with 70 per cent to 80 per cent 
alcohol for from three to five minutes. The alcohol can 
be used in a small clean bowl like an eating bowl or a finger 
bowl. As said before, the nails are, of course, the parts of 
the hand that receive the most attention. 
Now comes the chemical disinfection. We may use a 130 
LABOR 
sublimate solution of a strength of 1 to 500 to 1 to 2000, 
or carbolic acid 2 to 3 per cent, or lysol 2 per cent. Such 
a solution is contained in an earthenware or enamelware 
bowl. The hands and arms are thoroughly scrubbed in this 
solution for from three to five minutes. 
The entire disinfection by this process requires from twenty 
to thirty minutes. After the hands are once thoroughly 
cleaned the later sterilization requires much less time. If 
the hands have been badly contaminated, for example, in 
dressing a case of erysipelas or caring for a person with puer- 
peral fever the disinfection will take much longer. It is 
impossible to disinfect the hands at one time in such a case. 
Here it is necessary to repeat the process three or four times 
at intervals of two or three hours. 
If there are on the hands or arms inflamed sores, no matter 
how small, they must after the disinfection be covered with 
iodine. Any pustules, no matter how small, must be 
evacuated, cleaned thoroughly with alcohol or iodine, and 
then sealed with collodion. If such a collodion dressing 
cannot be kept on the hand, or if there is any doubt as to 
its furnishing a sufficient protection, the hand should be 
protected by rubber gloves. If a nurse has any such sores 
on the hands she should call the attention of the physician 
to them and ask his advice as to their proper care. In 
this way only can she feel that she is doing her duty and 
also protect herself against the possible serious charge of 
infecting the patient. 
Preparation of Patient.— Begin during Pregnancy.—The 
preparation of the patient may well begin a week or more 
before her expected confinement. A thorough, daily bath 
to keep the skin in good condition, laxatives and injections, 
if necessary, to empty out the large bowel, make not only 
the labor itself safer but also the child-bed more normal. 
The patient’s hair should also be washed. If the nurse is 
in attendance before the confinement she will supervise 
this preparatory treatment. 
Enema.—When real labor first begins the nurse should 
give the patient an enema and then a bath. The enema 
should under no circumstances be omitted unless the labor MANAGEMENT OF LABOR 
131 
is too far advanced. Often the patient will assure the 
nurse that her bowel is empty, that she lias had three or 
four passages. The enema must be given to wash out the 
rectum, which still retains some fecal matter in spite of the 
bowel movements. If the head is down on the perineum 
of course it will be impossible to introduce much water into 
the rectum, and there will be no time for the enema, which 
must therefore be omitted. 
Use of Closet.—Shall the patient use the water-closet 
after taking the injection and during the progress of labor? 
There are two or three objections to the use of the water- 
closet. The closet seat is not clean and the patient’s skin 
becomes contaminated; after the cleaning of the patient, 
therefore, she should not sit on the closet. If she should 
by chance use the closet she should be thoroughly washed 
before getting back into her prepared, sterile bed. Foul 
gases frequently come from the closet basin. These may 
result from poor plumbing, which allow the sewer gases to 
ascend. They may also be due to the fact that the basin 
is not thoroughly clean. It is indeed a very difficult matter 
to thoroughly clean both the basin and its outlet down to 
the trap. When a woman sits on a closet these gases ascend 
and contaminate not only the external genitals but also 
perhaps the vagina itself. Later in the labor there is also 
the danger of the expulsion of the child during the act of 
defecation. A woman frequently mistakes the straining 
caused by the descending child for a call to stool. If she 
goes to the closet it is possible that the child may be expelled 
and even fall into the closet basin. Such accidents have 
more than once occurred. For these reasons it is safer for 
a patient to use the chamber-pot. If a patient uses the 
closet after the first enema the nurse should see that the 
seat is thoroughly cleaned. Later in the labor she would 
better always make use of the pot or the bed-pan. 
Bath.—After the enema a thorough cleansing bath should 
be given. If time permits and the facilities are at hand a 
tub bath or a shower bath should be used. Otherwise a 
sponge bath is given. The objection to the tub bath is 
that the water becomes contaminated with the dirt from 132 
LABOR 
the body. The water comes in contact with the vulva or 
may enter the vagina. The danger, especially with clean 
patients, is slight. Nevertheless, a shower bath or a spray 
is equally cleansing and does not subject the patient to that 
risk. 
After the bath the patient is dressed in clean clothes, 
lies on her bed protected by a clean sheet, or sits in a chair 
while her hair is cared for. It is to be combed, braided, 
and securely tied so that it cannot come undone during the 
labor. 
Dress. — The dressing of the patient during her labor 
must now receive our attention. If she is to remain in bed 
all of the time a short gown or shirt is sufficient. A clean 
undershirt with sleeves answers every purpose and is per- 
haps better than a cotton or linen garment. A long night- 
dress may also be used, but it is more in the way and becomes 
soiled by discharges, and needs to be changed several times 
during a labor of ten to fifteen hours. A long night-gown 
may be worn if an obstetric gown has not been prepared. 
Glean stockings may be worn if the feet are cold or if for 
any other reason they are desired. If it is not necessary for 
the patient to remain in bed during the whole labor a long 
night-gown should be put on over the short obstetrical 
gown and over this the ordinary dressing-gown. When the 
patient returns to her bed both the dressing-gown and the 
long night-gown should be removed. It is hardly proper 
for the patient to be around the room in the gown which 
she wears to bed. She contaminates her gown and then 
her bed. Unless her dressing-gown is freshly washed it is 
hardly proper for her to wear it over the dress she wears in 
bed. A very good plan is for a woman to have a perfectly 
clean bath robe to wear during labor when she gets out of 
bed. Before she steps on the floor the nurse should put on 
her stockings, which are to be removed when she returns to 
her bed. By this way the contamination of the bed by the 
clothing, which so often occurs, will not happen. 
Bed.—The bed itself next requires the nurse’s attention. 
A single or three-quarter bed is more convenient than a 
wide double bed. If possible it should always stand so MANAGEMENT OF LABOR 
133 
that it may be approached from both sides. If the mattress 
of the bed is lower than the side pieces, which happens 
especially in folding beds, it must be raised to the level of 
or above the sides by putting under it blankets or boards. 
Feather beds, which are once in a while found, must be 
removed. The mattress should be covered with a rubber 
sheet. In the outfit already given you will notice that a 
rubber sheet 3 yards x If yards is provided. This is cut 
in two so as to make two pieces, one, If x If yards and the 
other If by If yards. The larger sheet is placed over the 
Fig. 61.—Labor-bed, with first rubber sheet and draw-sheet. After labor 
this becomes the puerperal bed. 
mattress on the side on which we expect to work, generally 
the right side of the bed. It will cover the mattress except 
about 1 foot at the upper and 1 foot at the lower end, and 
is drawn over so as to cover the edge. Over this protecting 
rubber cloth is a draw-sheet folded so as to be about 4 feet 
wide and then another sheet covering the bed. Over this 
is laid the smaller rubber sheet, which becomes the rubber 
draw-sheet. This sheet extends 8 to 10 inches over the 
edge of the bed. Over this rubber draw-sheet is placed 
another sheet folded so as to be about 3f feet wide. On 134 
LABOR 
this last sheet the patient lies, unless pads have been espe- 
cially prepared. The patient is covered with a clean sheet 
and with one or more clean blankets if necessary. The 
pillows are of course provided with clean pillow slips. 
Rubber Draw-sheet.—The second rubber sheet, that is, 
the rubber draw-sheet, enables us to protect the bed so that 
a change after labor is ordinarily unnecessary. By removing 
it with the pads and sheets over it a dry bed is left for the 
patient without further manipulation. The rubber draw- 
sheet is also of great value if we have to give the patient a 
Fig. 62.—Labor bed complete, with rubber and cotton draw-sheets. 
douche. To give a douche, for example in a case of post- 
partum hemorrhage, the patient is pulled to the very edge 
of the bed (Fig. 76), so far that the outer hip is partly over 
the edge, the pads and draw-sheets covering the rubber 
draw-sheet are removed, the rubber draw-sheet is pulled 
over far enough so that its lower end leads into a pail or 
slop jar placed at the edge of the bed, and its edges are 
turned in so as to form a trough which will conduct the 
water into the pail. In this way a large douche of gallons 
if necessary may be used without wearying or even disturb- 
ing the patient. In case of any operation where it is neces- MANAGEMENT OF LABOR 
135 
sary to turn the patient across the bed the draw-sheet is 
arranged in the same way. This use of the draw-sheet for 
the giving of douches is preferable to the use of a drainage 
pad like the Kelly pad. The latter cannot be cleaned 
easily and it is certainly risky to carry it from one patient 
to another. The rubber sheet is so cheap that a patient 
always has a new one for use in each case. If a patient is 
too poor to get a rubber sheet, a piece of white oil-cloth as 
recommended in the cheap outfit will answer very well the 
same purpose. 
Bedsheets.—Ordinarily clean sheets for the bed and for 
pads answer all requirements. Old cotton sheets will do 
quite as well as expensive linen sheets. They should be 
carefully washed in clean water, dried, ironed, and put 
away together not to be disturbed until they are used. 
While such sheets are not absolutely sterile they are per- 
fectly safe. Even if sterile sheets are used they will remain 
sterile on the bed but a moment. The important thing 
is that the sheets shall be well washed and boiled in clean 
water, ironed by one who has clean hands, and then put 
away where they will not be handled by anyone who has 
dirty hands. There is no objection to sterilizing the sheets 
if the patient or nurse have access to a sterilizer. 
Pads.— If obstetrical pads are desired they should be 
made of sterilized cotton and sterilized or antiseptic gauze. 
The cotton is enclosed between a double layer of gauze and 
quilted so as to hold it in position, using clean or sterilized 
thread for this purpose. They should be about 1 yard 
square and may be sterilized after they are made. Pads 
made of common cotton and cloth are not as good or as 
safe as plain sheets unless thoroughly sterilized. 
Disinfection of the Genitalia. —After the nurse has given 
her patient an enema and bath and prepared the obstetrical 
bed she proceeds to disinfect the genital region. The dif- 
ficulties in the way of a thorough disinfection of the skin 
which have been described in speaking of the disinfection 
of the hands are considerably greater here. The creases 
and folds in the skin about the vaginal and anal openings 
and in the thigh and groin flexures together with the growth 136 
LABOR 
of hair make the region very hard to clean. At the same 
time it is badly contaminated because of the glandular and 
vaginal secretions and the fecal contaminations. The 
sensitiveness of the skin and vulvar structures prevents the 
thorough mechanical cleaning that is possible with the 
hands. On account of these difficulties it is impossible to 
completely disinfect or sterilize the genital region at one 
attempt. Repeated efforts during the course of the labor 
will perhaps succeed. The best that the nurse can hope to 
do at first is to remove the greater number of the contami- 
nating germs and render the remainder innocuous by the 
use of disinfectants. In this way the patient may be pre- 
pared so that it will be possible for an internal or a vaginal 
examination to be made without serious risk of carrying 
infectious matter into the interior of the obstetric canal. 
Shaving.—Considerable of the difficulty in the disinfection 
will be avoided if the patient be shaved. In the preparation 
for a gynecological operation this is always done. Many 
patients, however, object to the shaving, and as some 
physicians consider it not absolutely necessary they omit 
it in simple cases. Whenever any kind of an obstetrical 
operation has to be performed, or when the labor is unusually 
prolonged and the chances for infection thereby increased, 
the hair should always be removed. 
To clean the genital region a large amount of soap and 
water, as well as a disinfecting solution, must be used. To 
do this without soiling the bed, the patient must lie upon 
her back, having under her a suitable receptacle for receiving 
the water. The proper way to proceed will now be described. 
Method of Cleaning the External Genitals. — Gather up a 
sheet in the middle so that it makes a V; with this cover 
the patient’s legs and thighs with the middle of the sheet 
over the lower abdomen, leaving the genitals exposed. 
If more convenient two sheets may be used, one for each 
limb, or the sheet which covers the patient may be left 
over the left limb and a large towel may be used to cover 
the right. Slip under the patient, lying on her back, the 
thighs flexed, a douche or a bed-pan. Take a basin of warm 
water with a fewT pieces of absorbent cotton or sterilized MANAGEMENT OF LABOR 
137 
gauze for sponges and a cake or tube of soap. Wash the 
perinea] region thoroughly with soap and water, including 
the inside of the thighs. Wash separately the anal region, 
being careful not to rub from the anus toward the vulva. 
Use plenty of water and do not separate the labia majora 
to wash their inner surfaces and the outlet of the vagina 
until after the outer region has been thoroughly cleansed. 
Always get a fresh basin of water before washing inside. 
It is best to use plenty of sponges and not dip the sponge 
that has been used in rubbing the skin into the basin. When 
the patient is not shaved the hair, particularly if long and 
thick, should be cut with the scissors. A satisfactory washing 
of the vulva with soap and water will take at least ten 
minutes. Then a basin of disinfecting solution containing 
sponges is substituted for the basin of soap and water. A 
strong sublimate solution of 1 to 500 to 1 to 1000 is perhaps 
the most efficient and best to use. A 2 per cent solution 
of carbolic acid or a 1 per cent lysol solution may also be 
used. With this solution the cleaning is done in the same 
order as before, that is, the anal region, the inner surface of 
the thighs, the outer surface of the labia majora are first 
washed, then the large lips are separated and their inner 
surfaces with the opening of the vagina are thoroughly 
covered with the disinfecting fluid. The inner structures 
are not rubbed so much as the outer but plenty of the solution 
is allowed to flow over them, being squeezed out of the 
saturated sponges. 
The irrigator or douche may be employed in the wash- 
ing. The water from the tube is allowed to flow over the 
genital region, which is in the meantime scrubbed with 
the cotton sponges. 
Vaginal Douches.— The vaginal douche should not be 
given unless it is specially ordered by the physician. While 
some obstetricians use the preparatory douche in all cases 
of labor, its use is generally confined to those cases where 
there is some vaginal infection. If the douche is given it fol- 
lows a thorough disinfection of the external genitals as just 
described. The physician will direct what solution is to be 
used. 138 
LABOR 
Vulvar Pad.— After the disinfection of the genitals an 
antiseptic pad is sometimes placed against the vulva, espe- 
cially after the rupture of the membranes, to absorb the 
escaping liquor amnii. If such a napkin is used it should 
be changed frequently. Under no circumstances should 
a napkin be allowed to remain too long, for it is likely to 
become saturated and dam back into the vagina the dis- 
charge, producing a condition that is favorable for its con- 
tamination. 
Douche-pan.— The douche-pan and bed-pan should be 
handled with some care. A nurse who had prepared a bed 
with sterile sheets has been known to take a douche-pan 
from the floor under the bed and put it on the sterilized bed 
under the patient. A floor, especially a carpeted floor, is, 
of course, thoroughly contaminated, and a douche-pan thus 
used will contaminate the bed. Before it is used it should 
be thoroughly cleaned either by boiling it or washing it well 
with soap and water or some disinfecting solution. After 
use it should be emptied and then placed on a table or stand 
that is covered with a clean sheet or towel. 
Solutions.—The nurse may now prepare the solutions 
and sponges that will be needed in the further conduct of 
the labor. A stand large enough to hold two or three bowls 
and pitchers should be placed near the foot of the bed, 
covered with a clean sheet. On this stand or table is placed 
a basin with a disinfecting solution, sublimate 1 to 1000 
or lysol 2 per cent for washing the hands and another bowl 
for the solution with the sponges. If there is not a station- 
ary washstand convenient another bowl with hot water and 
brush and soap for the preliminary washing of the hands 
is necessary. The sponges consist of pieces of absorbent 
cotton the size of the hand or similar pieces of sterile gauze. 
A small bowl like a finger bowl or eating bowl for alcohol 
is also needed. A pitcher for hot water and one for cold 
water is provided. Unless the hydrant water is known to 
be bad it will answer very well for washing the hands and 
external genitals. The nurse should have provided, however, 
a gallon or two of cold, boiled water for eventual use in the 
giving of salt solution injections under the skin or in giving MANAGEMENT OF LABOR 
139 
of douches. The nurse must always see that there is an 
unlimited amount of water at hand. It may happen that 
after labor a severe hemorrhage occurs. To control this 
a continual douche of hot water may be required for half 
an hour. Any delay in securing this douche may be fatal; 
hence provision must be made for a continual supply. 
Fig. 63.—Arrangement of bed, tables, etc., for a labor-room in a private 
house. 
Protection of the Floor.—The nurse should next take a 
large piece of oil-cloth, 2 to 3 yards square, that has been 
provided for the floor, and place it under and at the side 
of the bed. This is especially necessary if there is a carpet 
on the floor. A slop jar or pail for the soiled sponges, etc., 
should not be forgotten. 
Douche Bag. —The nurse may next prepare the douche bag. 
If a new bag has been provided it will only be necessary 140 
LABOR 
to boil it for two or three minutes. If we have to use an old 
bag that has perhaps become black from use and age it must 
be first thoroughly scrubbed in soap and water. The tube 
in particular must be thoroughly washed. Then the bag is 
placed in a kettle to boil for ten minutes. A cord or hook 
is also provided so that the bag can be fastened either on 
the head of the bed or in some convenient place. It is then 
wrapped in a clean towel and laid away until needed. 
Fig. 64.—Arrangement of bed, instrument table, solutions, and douches in 
labor-room. 
The douche tube, scissors, the tape, or other ligature for 
the infant’s navel are next boiled and laid away in sterile 
gauze or towel. In the outfit previously recommended 
(page 126) sterile ligature is provided. The catheter that 
may be needed for drawing mucus from the baby’s mouth is 
also cleaned and laid at hand. 
The nurse may next utilize the time that she does not 
need to devote to the patient in preparing napkins for future 
use. They are made in the following way: A piece of gauze 
about 30 inches long is cut from the roll and spread out 
on a clean towel. On this is placed a strip of cotton about MANAGEMENT OF LABOR 
141 
15 inches long and 5 inches wide and of the thickness of a 
cotton layer. This is enclosed in the gauze and is ready for 
use. Eight or 10 of these napkins may be made and folded 
up in a sterile towel ready for use. 
After the nurse has prepared the blankets and the bed for 
the reception of the baby she is now able to give her entire 
attention to the patient. 
Examination of Patient.—In the absence of the physician, 
when the nurse is alone with her patient, she must keep 
track of the condition of the patient and the fetus and the 
progress of labor. The general rules for examining a patient 
that apply in all other cases hold here. The rate and char- 
acter of the pulse should be taken frequently and recorded. 
The temperature also is important. The amount of food 
and drink taken should be noted. If the patient vomits, 
which is not infrequently the case, this fact should also be 
recorded, as well as the action of the bowels and the bladder. 
Any headache or dizziness should be inquired into. The 
frequency and duration of the pains should be accurately 
studied and reported. 
The position and presentation of the child and its location 
or, in other words, the progress of labor are determined by 
both external and internal examinations. Internal, including 
rectal and vaginal examinations, are rarely necessary and 
should never be made unless ordered by the attending physi- 
cian. The external examination comprises both the abdom- 
inal examination and the external examination of the genital 
region. 
Abdominal Examination.— Inspection.—The abdominal ex- 
amination is made by inspection or sight, by palpation or 
touch, and by auscultation or hearing. On uncovering the 
skin we see the general size and shape of the abdomen as 
well as the movements due to the child. The uterine tumor 
fills a considerable part of the abdominal cavity extending 
from the pelvis to the chest. When the child lies in the nor- 
mal position and posture the long axis of the tumor is length- 
wise with the body. As a rule the uterus does not lie directly 
upon the spinal column but is more to one side. In the 
majority of cases it lies more to the right side. In a cross 142 
LABOR 
presentation the shape of the uterine tumor is different. It 
is broader and not so long; hence a cross presentation can be 
determined generally by inspection. When looking at the 
uterus we frequently see the movements caused by the 
motions of the fetus. These, of course, show that the fetus is 
alive. 
Palpation.—By palpation we determine the presentation 
and location of the child as well as the question of the fulness 
of the bladder and the condition of the uterus. All these 
questions can be determined much better by the external 
examination than by the vaginal examination. It is rarely 
absolutely necessary that an internal examination be made 
in labor especially if the attendant can remain with the 
patient. 
In making the abdominal palpation a routine should 
be followed so that the fewest possible manipulations need 
be made. With a little practice a nurse may determine with 
two or three manipulations within half a minute and with 
almost absolute certainty how and where the baby lies. 
First Manipulation.—In the first manipulation the nurse, 
standing on the right side of the patient and facing her head, 
places the hands, one on each side of the upper part of the 
abdomen so as to grasp the fundus of the uterus through 
the abdominal walls. The fingers are extended and the whole 
hand lies firmly but lightly on the body. Now by moving the 
hands back and forth, changing their position but little on 
the skin, the part of the fetus that lies in the fundus will be 
moved from side to side and be thus felt. We have to deter- 
mine whether this part be the head or the breech. It is 
generally possible to distinguish the head by its size, hard- 
ness, and shape. If the uterus contracts during this manipula- 
tion the findings are indefinite and we must wait, keeping 
the hands on the abdomen, until the contraction passes away. 
Sometimes, however, even when the uterus is relaxed, the 
breech of the child feels so large and hard that we are in doubt 
and must wait for the second manipulation to clear up the 
question. 
While making the examination of the fundus we often feel 
the small parts of the child. A foot, or leg, or knee, or some- MANAGEMENT OF LABOR 
143 
times a hand, is often violently forced against the abdoininal 
wall and the examining hand. Sometimes we may grasp 
this small part of the child and make out quite clearly what 
it is. 
Second Manipulation.—In making the second manipulation 
the nurse turns around, facing the patient’s feet and grasps 
the lower segment of the uterus through the fundus. The 
hands are kept well to the sides of the lower abdomen, the 
little finger and ring finger being pressed well down into 
the groin. Firm pressure must be made, but very gently, 
so that the patient does not feel pain and resist. The chief 
Fig. 65.—Palpation of the abdomen to locate the presenting part. Second 
manipulation. 
work is done with the outer border of the hand and the ring 
and middle finger. The head, if presenting, is felt as a hard 
mass, which by patience can be outlined, and if it be not 
engaged in the pelvis can be moved from side to side. If the 
examination causes any contraction of the uterus we must 
again wait until the contraction passes away. 
By this manipulation we determine not only the location 
of the head in the lower segment of the uterus but also the 
position of the head. In the normal flexed posture of the 
child the line of the back is almost continuous with the back 
of the head, while the forehead forms a prominence or pro- 144 
LABOR 
jection. In other words, the forehead projects a great deal 
more than the back of the head. Remembering this fact 
we have a means of determining the position of the child. 
While making the second manipulation we feel a much greater 
prominence with one hand than the other. This prominence 
denotes the child’s forehead, consequently the back of the 
head lies to the other side. By this second manipulation 
we also locate the head or determine the extent of its progress 
through the obstetrical canal. If we feel the entire head 
movable above the pelvis it of course has not begun to enter 
the pelvis. When the head has nearly engaged in the pelvis, 
Fig. 66.— Palpation of the abdomen to locate the back. Third manipulation. 
we feel the back of the head not at all or with some difficulty, 
while the forehead is still easily made out. When the head 
has entirely entered the pelvis and we cannot reach it by the 
external manipulation, the hands then feel only the shoulders 
and the trunk. 
Third Manipulation.—By the third manipulation we com- 
plete our examination of the position of the child by deter- 
mining the position of the back. Turning so as to face the 
patient the nurse places one hand on the fundus over the 
breech of the child and presses down somewhat firmly in the 
direction of the axis of the uterus. In this way by pressing 
the breech toward the head she increases the curve or con- MANAGEMENT OF LABOR 
145 
vexity of the back and makes it more prominent. Then 
she places the right hand first on one side of the abdomen 
and then on the other and outlines with it the position of 
the back. Often she can feel quite distinctly the curve of the 
back against the abdominal wall. When this is not possible, 
she at least experiences greater resistance on one side than 
on the other. This greater resistance denotes the back. 
It is evident that the child may lie exactly on its side, 
when the back will be directly to the side of the mother, or 
its back may be directed more toward the front or abdominal 
wall or toward the back of the mother. When the back of 
the child lies against the front wall it is more easily made out 
by this third manipulation than when it is turned toward 
the back of the mother. In the latter case the small parts 
of the child, that is, the hands, elbows, arms, and lower 
extremities, are more easily felt. 
Importance of Determining Fetal Heart Tones.—The fetal 
heart sounds are generally best transmitted through the back 
of the child and the corresponding portion of the uterine and 
abdominal walls. Consequently when the back of the fetus 
is turned toward the front of the mother’s abdomen the heart 
tones are heard at their best. Their distinctness also depends 
upon the amount of liquor amnii and the amount of fat in 
the abdominal wall. In a head presentation they are gener- 
ally heard best below the level of the umbilicus, while in a 
breech presentation they are best heard above this level. 
When the back of the child is turned to the left side they are 
heard to the left of the middle line, and when the back is to 
the right they are heard on the right side. Consequently 
the location of the area of the fetal heart tones helps us in 
determining the position of the fetus. In rare cases when 
we are unable to feel the back with certainty the finding 
of the heart tones on one side or the other will help us to a 
decision. 
The counting and the observation of the fetal heart tones 
is the duty of the nurse. Almost our only way to study the 
condition of the child is through the study of the rapidity 
and character of the fetal heart beats; hence it is necessary 
for a nurse who is often responsible for a patient for hours 146 
LABOR 
at a time in the absence of the physician to be perfectly able 
to examine the fetal heart. She has two patients under her 
care and she is just as responsible for the unborn child as 
for the mother. If during the absence of the physician 
the mother should die and upon the physician’s return the 
nurse should be ignorant of the fact, she could hardly excuse 
herself to the physician or to the family. She should keep 
just as close watch upon the unborn child as upon the mother. 
Frequent examinations of the fetal heart, especially in a long 
and severe labor, must be made, and if she finds any change 
Fig. 67.—Auscultation. Counting fetal heart tones with phonendoscope. 
she must report this to the physician just as she would anv 
unfavorable change in her other patient, the mother. 
Auscultation.—The fetal heart tones may be heard by lis- 
tening with a stethoscope or phonendoscope or by applying 
the ear directly to the skin. The best way is with the phon- 
endoscope. This instrument should be a part of the nurse’s 
outfit and she should thoroughly understand its use. It 
should lie securely on the abdomen by its own weight and 
not be held or pressed against the skin. The way of finding 
the exact location of the heart tones is the same as in direct MANAGEMENT OF LABOR 
147 
auscultation which, as it involves a more difficult technic, 
will be described in some detail. 
After palpation, as described above, the nurse covers the 
patient with a sheet and kneeling by the side of the bed, 
corresponding to the supposed location of the back of the 
child, she applies her ear to the skin protected by the sheet. 
She should first listen at a point half-way between the navel 
and the symphysis pubis. Then if the heart tones are not 
distinctly heard at this point she should carry the listening 
gradually to the side and then up and down until the whole 
Fig. 68.—Auscultation. Counting fetal heart tones with ear applied to 
abdomen. 
lower quarter of the abdomen has been examined. In case 
she does not hear the heart at all she should then pass to the 
other side of the patient and examine the other section of the 
lower quarter the same way, suspecting she has made a 
mistake in the examination with her hands. If she still fails 
to find the heart tones she may examine the upper half of the 
abdomen in the same way. Still failing, she may apply her 
ear directly to the skin, for the sheet sometimes disturbs the 
hearing. If she is still unsuccessful she should place her hand 
over the fundus of the uterus as in the third manipulation 148 
LABOR 
in palpation and press upon the breech of the child so as to 
increase the curve of its back and bring it nearer the abdom- 
inal wall. Then she may be able to hear the sounds which 
were before obscured by the fruit water that separated the 
child from the wall of the uterus. Sometimes the sounds are 
brought out more prominently by having the mother turn 
on one side or another, generally turning so that the back 
of the child is uppermost. These examinations during labor 
should be made in the intervals between the pains, for the 
contractions of the uterus very frequently obscure the fetal 
heart tones so that they cannot be heard. Examining this 
way a nurse who is accustomed to listening to the fetal heart 
will almost always find it if the child be living. Its absence, 
therefore, together with all absence of fetal motion as felt 
by the nurse or mother, would create a strong suspicion that 
the child was dead. 
Counting Fetal Heart Tones.—In counting the fetal 
heart beats it is well for the nurse to count for fifteen seconds, 
then begin again and count for fifteen seconds more, repeat- 
ing the counting this way for the minute and make a record 
of her findings by quarter minutes instead of by minutes. 
For example, she counts for the first quarter 33, for the 
second 35, for the third 34, and for the fourth 37, this would 
be recorded, 33, 35, 34, and 37. From this record one not 
only sees the total for one minute 139, but also the irregu- 
larity in the fetal heart. 
At the beginning of labor the nurse will be informed by 
the physician where the fetal heart may be found or she 
will discover this for herself. Then she shoidd count the 
sounds several times at intervals of about every half-hour 
in order to discover what is the normal heart beat of this 
child. Then she is in possession of the facts that enable her 
to judge of the irregularity and changes in rate at a later 
stage of a severe labor. 
Rapid and Slotv Fetal Heart Beats.— Very rapid and 
very slow heart beats show that the child is in danger. If 
the normal heart beat of the fetus is 130, a rate of 180 shows 
considerable disturbance in the child’s circulation. For a 
child whose normal rate was 155 or 160 a rate of 180 would MANAGEMENT OF LABOR 
149 
not be so important. A rate of 100 or less is also generally 
a sign of danger. 
Irregularity in the Fetal Heart Beats. — A great variation in 
the heart beat is also to be observed with care. If the count 
should be 33, 36, 40 or 30, 35, 25, 22 we would feel some 
anxiety for the child and realize that it must be watched 
with great care. Uterine contractions frequently cause 
some irregularity in the fetal heart even in the early stages 
of labor. At a later stage these irregularities are more 
pronounced and if not too great may not be of so much 
importance. Irregularities that are noticed in the interval 
between the pains are probably of greater moment. Under 
any circumstances they call for unusually careful observation 
and, of course, record. 
Much less importance is to be attributed to the clearness 
with which the fetal sounds are heard. As has been stated 
this depends very much upon the position of the child. Since 
the position may change during the labor the sounds will 
vary in distinctness. After the membranes break and the 
fruit water escapes the sounds are generally heard more 
distinctly. If, however, the nurse has kept a careful watch 
of the sounds in the latter part of labor after the waters have 
escaped, and has a good basis for judgment as to the clear- 
ness of the sounds, then a marked change in their character, 
consisting of great diminution in clearness and distinctness, 
will be a good reason for thinking the child is in danger. 
Inspection of the Genital Region.—The external examina- 
tion of the genital region consists of inspection and palpa- 
tion. By inspection we recognize the distention or pro- 
trusion of the perineum during a pain which indicates 
that the head begins to escape from the bony pelvis and 
press upon the perineum. As the head advances farther 
the vulvar lips begin to separate. Shortly after this the 
advancing part of the head is seen. All of these stages 
can be observed by the nurse and of course necessitate the 
more or less urgent call for the physician if he be absent. 
By inspection one also notices the character of the dis- 
charge from the vagina. When the membranes rupture 
the liquor amnii begins to escape and it continues to flow, 150 
LABOR 
as a rule, during the rest of the labor. It occasionally 
happens in a protracted labor that the fruit water becomes 
discolored. It has a dirty blackish color, due to the presence 
of meconium. This generally indicates that the brain centers 
have been injured by pressure or asphyxia resulting in par- 
alysis of the sphincter ani. The presence of the meconium 
in the liquor amnii in a head presentation is therefore an 
important symptom, and should be noted and reported to 
the physician at once. 
Blood may be found in the vaginal discharge at almost 
any time during the course of labor. In the latter part of 
the first stage of labor it generally denotes a spontaneous 
tear in the cervix. This we have called the “second show,” 
page 108, just as the slight bleeding which accompanies the 
beginning of the separation of the membranes from the 
internal os and the expulsion of the mucous plug from the 
cervix constitutes the “first show,” page 106. In rare 
instances bleeding is due to an abnormal location of the 
placenta or to other serious complications which have 
already been discussed (see pages 88 and 93). In the 
second stage of labor the blood may come from a tear in 
the vagina. Rarely a severe hemorrhage occurs from 
rupture of varicose veins in the vagina. The hemorrhage 
should always be noted by the nurse when she is in charge 
of a case. 
Palpation of the Perineal Region.—Besides inspection, how- 
ever, the nurse has another means of determining the progress 
of labor and one that may be employed before the bulging 
of the perineum begins. This is palpation of the advancing 
part of the head through the skin just below the anus. It 
may be practised with the patient on her side or on her 
back. Protecting herself with a gauze sponge, with the tips 
of the fingers resting on the skin between the sacrum and 
the anus, the nurse presses inward during the pain and thus 
can easily determine if the head be approaching the outlet 
of the bony pelvis. This manipulation is quite valuable, 
for it enables one to judge concerning the progress of labor 
after the head has completely disappeared from the abdomen 
and can no longer be felt from above. During this stage MANAGEMENT OF LABOR 
151 
ot‘ labor the nurse, who is forbidden to make an internal 
examination, is often uneasy in regard to the advance of 
the head. 
Internal Examinations.—While the presentation, position 
and station of the child can be determined generally by 
external examination alone, it sometimes happens, especially 
in cases of dystocia, that the results of the external examina- 
tion are unsatisfactory. Moreover, the causes of the lack of 
progress of labor are occasionally obscure and can be deter- 
Fig. 69.-—Palpation through the perineum. 
mined only by internal examination. For example, the 
progress of dilatation of the cervix can be known surely only 
by such examination. In hospitals with resident physicians 
or interns in attendance, nurses are rarely or never called 
on to make any kind of internal examinations. In out- 
side practice however, and sometimes in smaller hospitals 
that have no resident physicians, nurses may be asked to 
make such examinations, especially supervising nurses and 
those who make a specialty of obstetric nursing and who 152 
LABOR 
sometimes take a state examination in midwifery. Hence 
it is necessary that the subject be discussed in this place. 
Rectal Examination. — Internal examinations may be 
made through the rectum or through the vagina. The 
former is less dangerous to the patient and fairly satis- 
factory and therefore much more likely to be asked of the 
nurse. The things to be determined by such an examination 
are the kind of presentation, head or breach, the amount 
of descent of the presenting part, the presence or absence of 
any obstruction in the pelvis and the amount of dilatation 
of the cervix. 
The technic is comparatively simple. The bowels and 
the bladder should be empty. The patient may lie either 
on her left side or on her back. The nurse, standing behind 
the patient or on her right side, with a rubber glove on her 
right hand, introduces the gloved forefinger, lubricated with 
petrolatum, into the rectum and explores the pelvic cavity. 
She can determine easily whether the presenting part is above 
or entering the pelvic inlet, or whether it is already in the 
pelvic cavity. It is more difficult to determine the condition 
of the cervix uteri but generally after feeling through the 
anterior rectal wall she can make out the cervix, the amount 
of opening of its external os and the presence or absence of 
the bag of waters. A prolapse of the cord she would be 
likely to detect and likewise any marked abnormalities in 
the pelvis. 
Vaginal Examination.—The value of vaginal examinations 
in labor has been much over-rated both by physicians and 
midwives. Fortunately trained nurses generally have been 
taught that the making of internal examinations, especially 
vaginal examinations, is not one of their duties. Needless 
to say such examinations may be much more dangerous 
than rectal examinations by carrying infecting germs into 
the obstetric canal. During an examination the membranes 
might be ruptured prematurely, causing, perhaps, a serious 
disturbance to the progress of labor. They are, moreover, 
as a rule, quite unnecessary. A nurse in general practice 
might never be called upon during her whole life to make 
such an examination. Occasionally, however, a physician MANAGEMENT OF LABOR 
153 
expects this of a nurse, and it is for this reason, at least, 
that she should know the proper mode of proceeding and 
have in mind what she should find. The examining hand 
should be protected with a rubber glove. A thorough dis- 
infection of both hands should, nevertheless, be made. 
The front and middle finger of the right hand are generally 
employed. After the patient has been thoroughly washed 
Fig. 70.—Method of making an internal examination. The nurse separates 
the labia and is about to introduce the examining fingers. 
and disinfected as well as possible, as has been previously 
described, the nurse, holding apart the labia so that the 
examining fingers may not come in contact with any out- 
side contamination introduces the fingers into the vagina. 
If lysol is used as a disinfectant there is no need of a lubricant. 
If the vagina seems somewhat dry or the vaginal outlet is 
rather small, a lubricant may be desired. Great care must 
be used in selecting something which is not in itself con- 154 
LABOR 
taminating. Ordinary vaseline, for example, in a half- 
filled box, which perhaps has been lying around the house 
for some time and into which many dirty fingers have been 
dipped, will doubtless be a source of danger. A boiled oil 
would answer the purpose. The tube of antiseptic soap 
or liquid soap which is recommended in the outfit is very 
well adapted for this purpose, as it is clean and convenient 
to use. Glycerin may also be employed. 
The object of the internal examination is to determine the 
condition of the vagina, the possible presence of any growths 
in or deformities of the pelvis, the condition of the cervix, 
including its thickness and the amount of its dilatation and 
the location, position, and condition of the presenting part 
of the fetus. These objects should be kept in mind and the 
examination conducted with a certain routine so that as 
much as possible may be learned in as short a time as possi- 
ble. The element of time is of great importance in making 
a vaginal examination because there is more danger from 
abrasions and dislodged germs in an examination of five 
to ten minutes than from one of a half a minute. 
The nurse will, therefore, proceed with her examination, 
sweeping the fingers around the vagina and noting its 
smoothness or roughness, the amount of secretion, and the 
presence of any abnormality. During this process she 
will also notice the presence of any growths obstructing the 
pelvis as well as the shape of its walls. In particular she 
should notice the shape of the sacrum, whether it has the 
proper curve or not and the forward projecting coccyx. 
She should next feel for the cervix. You will remember 
that the uterine contractions first cause the obliteration of 
the vaginal portion of the cervix and then gradually open 
the cervix until the uterus and the vagina form a continuous 
canal. Sometimes the obliteration of the cervix has taken 
place before the real labor begins, having been produced 
by the preparatory pains. By the examining fingers we 
first find whether this vaginal portion still exists or not. 
If it is obliterated we next determine whether the cervix is 
open, and if so how much. The degree of opening of the 
cervix is expressed by estimating how many fingers it will MANAGEMENT OF LABOR 
155 
admit, or after it is half dilated by indicating the width of 
the rim that remains. We say, for example, that the cervix 
will admit one finger or two fingers, or that a rim of one or 
two fingers’ breadth still remains. Sometimes the cervix 
is thin, its border feeling not much thicker than a sheet of 
paper; at other times it is thick and feels, perhaps, some- 
what like a swollen lip. 
In making the examination of the cervix, we also deter- 
mine whether the membranes are ruptured or not. If they 
are intact and the cervix is open one will feel the bag pro- 
jecting into the cervix more or less, especially during a pain. 
If it has been ruptured, the finger will come into contact 
with the head or presenting part without any intervening 
membrane or tissue. If the membranes are intact the 
examination must be made very carefully so as not to rupture 
them. About all the nurse will be expected to do will be 
to recognize the presenting part, whether it be a head or 
face, the breech, the hand or foot, and determine whether 
it is in the inlet, excavation, or the outlet. If the cord be 
prolapsed the condition should be recognized, for it is a 
very important one and calls for immediate treatment. 
Care of the Bladder during Labor.—It occasionally happens 
that a patient cannot urinate voluntarily during labor. 
This ischuria may be due to the pressure of the child against 
the urethra. The bladder may be injured by distention. 
Moreover, such distentions often interfere with the abdominal 
contractions, which are important elements in the second 
stage of labor. It may, therefore, become necessary to 
draw urine from the bladder. The presence of any con- 
siderable amount of urine will be recognized at onde by the 
nurse when she makes the abdominal examination. A 
distended bladder will easily be felt above the pubis, per- 
haps reaching half-way up to the navel. If the head is in 
the pelvis and the bladder entirely displaced into the abdo- 
men it will be very easy for the nurse to exaggerate the 
amount of fluid it contains, as the bladder will form such a 
mass in the lower abdomen. When the head is in the pelvis 
six ounces of urine in the bladder will cause a considerable 
tumor. 156 
LABOR 
Catheterization.—Under these circumstances drawing the 
urine with the glass catheter that is used in the puerperium 
and in other conditions is not desirable and often not possible. 
The catheter might not reach the urine, and there would 
be some danger of its breaking by the pressure of the child’s 
head during the pain. For this purpose a fairly large soft 
rubber catheter is recommended. It should be used after 
a thorough washing of the patient as before described, and 
with the same precautions that are used in other cases and 
which will be more particularly considered when we come to 
speak of catheterizing in the puerperium. 
Shall the Patient Remain in Bed?—In considering further 
the conditions of labor we must allude to the question that 
is frequently asked the nurse as to whether the patient can 
sit up or walk about or whether she would better remain 
in bed. Also, if in bed, in what position should she lie? 
After the membranes break the patient should remain in 
bed. By so doing she will lose less of the fruit water. Its 
retention, as much as possible, is of advantage both to her 
and to the baby; consequently in an early or premature 
rupture of the membranes the patient must remain in bed 
during the whole labor. Even when the rupture occurs 
two or three days before labor begins the same rule applies. 
If the patient is weak she would better remain in bed. 
There is no particular advantage in having her sitting or 
walking about the room. The labor may progress a little 
faster, perhaps, but, on the other hand, she is apt to lose 
some rest that she might obtain in bed. However, if she 
feels better up, if there is no contraindication, she may be 
allowed to do as she pleases. 
In bed a patient generally wishes to change her position 
occasionally. As a rule the pains are apt to be more vigorous 
when she lies on her back. If she wishes to lie on her side 
she is generally directed to lie on the side corresponding to 
the back of the child. This position favors the normal 
mechanism of labor. 
Nourishment. —In a long labor lasting a day or more the 
question of nourishment becomes important. In a short 
labor it is often impossible for the patient to eat much MANAGEMENT OF LABOR 
157 
because of the disturbance of the stomach. Severe pains 
may act in one way or another to cause an evacuation of 
the stomach contents. In a long labor there are apt to be 
intervals where the pains are not so severe. These must 
be utilized to give the patient nourishment and stimulants. 
Sometimes milk with lime water and brandy is best borne. 
In such a case, however, the physician is always present and 
will, of course, assume the responsibility. 
Moral Support.—An extremely important part of the 
nurse’s duty is to furnish moral support to her patient, who 
suffers from both pain and fear. While the pain varies 
greatly in intensity and is no doubt often very acute and 
quite exceeds any other kind of pain to which people are 
ordinarily subjected, yet it is made much worse to bear by 
unnecessary fear. The patient fears that the pain will 
become greater and quite unbearable. She fears that she 
will become exhausted. She fears that all is not going well, 
that some operation will be necessary. Often she has vague 
and indefinite, but none the less real fears, that cannot be 
described. If these fears can be dispelled, if the patient 
could be made to believe that her pains will never be greater 
than she can bear, that she has nothing to fear, that she is 
only suffering as millions of women have suffered in the past 
and as hundreds are suffering every hour she will be relieved 
of an important element of her distress. 
Analgesia and Anesthesia.—Many efforts have been made 
to discover a means by which pain may be done away with. 
Various drugs have been used as analgesics or pain annihil- 
ators. Morphine, chloral, and other drugs that have any 
effect may interfere with the uterine contractions or they 
so endanger the fetus that they cannot be used to such an 
extent as to relieve all pain. Nevertheleless, when used in 
proper dosage and not less than four hours before the end 
of labor they are not harmful either to mother or fetus 
and are very valuable in painful and protracted labors. 
“Twilight sleep,” of which one has heard much in recent 
years is a stuporous condition secured by repeated injec- 
tions of morphine and scopolamine. It requires much care 
and the constant watchfulness of the physician. It is not 158 
LABOR 
devoid of risk, and the responsibility for its management 
should not be imposed upon nor assumed by the nurse. 
The anesthetics, chloroform and ether, have been much used 
to alleviate suffering. The discoverer of the anesthetic 
properties of chloroform, the celebrated obstetrician Sir 
James Y. Simpson, hoped that he had found a means of 
rendering child-bearing painless. Our experience shows us 
that while anesthetics are very valuable in certain stages 
of labor, and while they may be used in the last part of 
labor so as to control the most severe pain due to the expulsion 
of the child, they cannot with safety be used during the 
whole course of confinement. 
Ether or Chloroform?—To the nurse is frequently entrusted 
the duty of giving the anesthetic, and she should, therefore, 
take every opportunity to perfect herself in the technic of 
its administration. Both ether and chloroform are employed. 
While in this country, in general surgery, ether is more 
used than chloroform, in obstetrics, chloroform has been 
used almost exclusively until the last ten or fifteen years. 
Recently a good many obstetricians have begun to use 
ether in labor more extensively, and believe that it has the 
advantage over chloroform, that it does not as much inter- 
fere with the uterine contractions, that when the contractions 
are stopped by the anesthetic they begin sooner upon its 
withdrawal, and that it is safer and more pleasant to use. 
Especially at night, when there is a gas or lamp flame in the 
room, chloroform is decomposed and a very irritating gas 
is formed. Ether is inflammable if brought near the flame. 
If great care is used, however, in opening the can and keep- 
ing the ether some distance from the flame there need be 
no danger. 
Administration of Ether.—Ether is given generally with 
some kind of a cone or it may be given on a mask like chloro- 
form. About a dram is sprinkled over the cloth in the cone 
at a time. In the beginning of the administration it should 
be held an inch or two from the face so that the patient will 
not be frightened. The ether is generally given only during 
the pain. In this way the pain is diminished, but conscious- 
ness is not entirely obliterated. Since the nurse will use MANAGEMENT OF LABOR 
159 
the anesthetic only under the direction of the physician, 
she will, of course, be guided by him as to the amount 
employed and the degree of anesthesia produced. 
Administration of Chloroform.—The method of giving 
chloroform differs from that often employed with ether in 
the fact that the former must always be well diluted with 
air and that it is given in very much smaller amounts: a 
few drops only at a time sprinkled over a cloth held over the 
patient’s nose and mouth. The well-known mask may be 
used or a thin cloth, like a handkerchief, may be supported 
on the fingers. The back of the hand is laid over the face, 
the nose being between the middle and ring fingers and the 
handkerchief held by them from contact with the skin. In 
dropping chloroform from the bottle it is best to cut a groove 
in the cork through which the chloroform escapes in small 
drops. 
Nitrous Oxide Gas.—Nitrous oxide gas is now used con- 
siderably in some hospitals in the second stage of labor. 
It is rather more agreeable to take than ether and when 
properly given, combined with oxygen, it is probably as 
safe for both mother and child. The technic of its adminis- 
tration is more difficult and can be learned only by training 
under a good teacher. 
Support of the Back.—Mention has been made of the value 
of massage as a preparatory treatment during pregnancy. 
It diminishes abnormal sensibility and thus proves a great 
aid during labor. One measure by which the pain may be 
at times somewhat lightened, Arery old but none the less 
important, may be added. This is the support of the back. 
During certain stages of labor, under certain conditions, 
pain in the back is intense. Whether this pain be due to 
pressure on the large nerve trunks found in this region or 
to the stretching of the posterior joints or to some other 
causes, it is a fact that it sometimes may be relieved by 
firm pressure. This is best applied when the patient is on 
her back, by placing the hand under the sacrum with one 
finger just at the upper border of the hip bone and resting 
the arm on the bed as a support, raising up the back with 
the hand. 160 
LABOR 
Pulling.—When the patient comes to the second or ex- 
pulsive stage of labor she has an inclination to support the 
body in such a as to obtain the most power from the 
abdominal muscles. This leads her to brace her feet so as 
to fasten the lower part of the trunk and also to immobilize 
her chest so as to make the best possible use not only of the 
muscles of the abdominal wall but also of the diaphragm.- 
Pulling with the arms further than this is probably of little 
value, yet this action seems an unconscious accompaniment 
of the abdominal work. The patient may be encouraged 
Fig. 71.—Support of the back during labor. 
to immobilize herself by taking hold of the rounds at the 
head of the bed if her bed be of such construction; otherwise 
she may grasp the hands of her nurse, or perhaps it is just 
as well to grasp her hands together. It is quite unnecessary 
for the patient to pull herself all over the bed in her frantic 
efforts. Not only is the cleanliness of the bed thus destroyed, 
but the attendant is very much handicapped in his efforts 
to manage the labor. 
Prevent Contamination of Genital Region.—As the head 
approaches the outlet its pressure behind forces out any MANAGEMENT OF LABOR 
161 
contents of the rectum. These will, of course, contaminate 
the bed and also probably the vulva and vagina. The 
nurse must at once collect upon the sponges that have been 
prepared for that purpose any particles that may be dis- 
charged from the anus. 
Supporting the Perineum.—As the head is expelled from 
the vulva it becomes the nurse’s duty to prevent the tear- 
ing of this opening. Since the tear is generally through 
the perineum this manipulation is called protecting or 
supporting the perineum. A mistaken idea concerning 
this manipulation is quite common. Many think it con- 
sists of pressing back the perineum by holding the hand 
against it. The importance of the subject is great, for 
tears lead often to subsequent disturbances which seriously 
affect the health and comfort of the patient. To under- 
stand properly the method of preventing tears we must for 
a moment study the way in which tears are produced. 
Many tears are unavoidable. When the circumference 
of the child’s head is greater than any opening that is per- 
mitted by the elasticity of the outlet a tear must result. 
Under the most favorable conditions, where labor is managed 
in the best possible manner, tears occur in about one-third 
of all primiparse. In these cases all the attendant can do 
is to prevent the extension of the tear as much as possible. 
Unnecessary tears are avoided by preventing a too hasty 
exit of the head, thus securing a gradual dilatation and by 
causing the head to make its exit in the most favorable 
position so that it passes through the vulva in its smallest 
circumference. 
Prevent Rapid Expulsion.—When the uterine and abdominal 
forces are very powerful the head may be forced along so 
fast that the outlet has not time to enlarge normally and 
is torn. In such cases the head shoidd be held back. In 
general the head should never be allowed to make its exit 
during a pain. With each pain the vulva is distended more 
and more until at the last, in the interval between the pains, 
the head is pressed out by the hand placed behind the anus, 
resting over the face against the perineum. 162 
LABOR 
Keep the Head Flexed.—The head is in the most favor- 
able position to pass through the vulva without lacerating 
Fig. 72.—Head passing through vulva in the attitude of flexion. Compare 
the suboccipito-frontal diameter, which denotes the stretching of the vulva 
with the occipito-frontal diameter in Fig. 73. 
Fig. 73.—Head extended in exit. Note that the occipito-frontal diameter 
here denotes the distention of the vulva instead of the shorter suboccipito- 
frontal diameter in Fig. 72. MANAGEMENT OF LABOR 
163 
it when it is flexed as much as possible. When in this 
position the largest circumference that passes through the 
vulva is the suboccipito-frontal. Unless the occiput is well 
through the vulva when the extension occurs a larger cir- 
cumference, the occipito-frontal, will have to be accom- 
modated. From this it follows that the nurse should strive 
to keep the head well flexed and be sure that the occiput 
has passed out of the vulva and the nape of the neck appears 
before extension is allowed to occur. With these two 
principles clearly in mind she will be able, after she has had 
some experience, to secure the best results. 
Position of Patient during Delivery.—The patient may 
be delivered lying on the back or on the side. If she lie 
on the back the hips should be somewhat elevated by one 
or two extra pads. Under no circumstances should she be 
allowed to assume a posture where the hips are sunk into 
the bed. In such a position the attendant would have 
absolutely no control of the perineum. 1 he best control 
at least with beginners is probably obtained with the patient 
lying upon the left side. With the patient in this position, 
her hips flexed, the attendant behind her, with the left arm 
between the thighs, is in a position to control the movements 
of the head; with the right hand she is able to press against 
the forehead of the child, thus securing proper flexion and 
at the same time, with a sponge, protecting against possible 
contamination from the anus. 
When the patient lies on her back the attendant sits at 
the side of the bed facing her and places the right hand, 
protected by a sponge, over the anus so as to keep the head 
flexed and prevent its too rapid expulsion. With the left 
hand the back of the head is pulled forward, if necessary, 
until the occiput is well through the vulva. 
Delivery of the Body.—As soon as the head is born the 
attendant examines to find if the cord be around the neck, 
removes it by pulling it over the head if that be the case, 
wipes the face of the child, supports the head without pulling 
on it (see Fig. 58), and waits for the expulsion of the body. 
This follows, in some instances, almost immediately, and 
generally with the next pain, within two or three minutes 164 
LABOR 
after.the birth of the head. Only rarely is any assistance 
required. When the nurse believes that the child is in 
danger on account of finding irregular heart tones, and there 
is several minutes’ delay after the birth of the head, she 
may assist the delivery of the body by pressing on the 
uterus through the abdomen. During the birth of the 
shoulders and trunk there is renewed danger to the integrity 
of the vulvar outlet or perineum. Quite often a perineum 
that has remained intact during the careful passage of the 
head is torn because of a sudden exit of the shoulders. Some- 
times also the elbow escapes shortly after the shoulder and 
makes a tear in the perineum. The circumference of the 
body and shoulders is almost always a little less than that 
of the head, and they should not produce a laceration. It 
is only necessary to observe the same rule that has been given 
for the delivery of the head. They must be brought through 
slowly, and if necessary in an interval between the pains. 
The same rule holds in the delivery of the elbow. 
After the body is born the child is covered with a warm 
sterile blanket and allowed to lie between the thighs of the 
mother until the pulsation of the cord ceases, when the 
cord is tied and the child removed. The method of caring 
for the child and tying the cord will be described when we 
come to speak of the care of the infant. 
Ligation of the Cord.—The cord is tied in two places, 
about 2 and 4 inches from the child, and cut between the 
ligatures. The ligature next to the child must be tied 
tightly to prevent hemorrhage. The chief object of the 
ligature on the placental side is to prevent the soiling of the 
bed with the blood which fills the vessels of the cord and the 
placenta. In case of a twin pregnancy there may be a con- 
nection between the circulation of the children, when the 
second ligature would be necessary to prevent the second 
child from bleeding to death. 
It is convenient to place another ligature around the 
cord near the vulva and remove the outer piece of cord. 
Very slight traction is made in order to pull out any loops 
in the cord which may remain in the vagina. Then a tape 
js tied around the cord just at the vaginal outlet and the MANAGEMENT OF LABOR 
165 
outer portion cut off. The placental end will then retract 
within the vagina. The patient may now "be cleaned and 
a vulvar dressing applied. When the placenta is expelled 
from the uterus and remains in the vagina the cord will be 
pushed out from the vulva and will thus indicate the location 
of the placenta. 
Management of the Third Stage.—After the birth of the 
child begins the third stage of labor, the birth of the placenta, 
and to this we next give our undivided attention. The 
nurse, if she happens to be alone with her patient, should 
not leave her side. When the baby is separated it is quickly 
placed in its previously prepared bed and needs no further 
care. The mother should have constant attention on account 
of the possible danger of hemorrhage. 
As soon as the child’s body is born the nurse should lay 
her hand upon the abdomen and watch the uterine con- 
tractions. As a rule it is not necessary for her to rub the 
abdomen or make any particular manipulations. The pres- 
sure of the hand will, perhaps, cause a slight stimulation to 
the uterus. The chief object, however, is careful obser- 
vation. The uterus will be felt during a contraction as a 
hard body, almost like a stone, extending perhaps two- 
thirds of the way to the navel. The hard contraction lasts 
perhaps a minute, when relaxation begins; it them becomes 
larger and softer. It should be possible, however, always 
to outline it. The period of relaxation varies also in length. 
These alternating relaxations and contractions continue 
until the placenta is expelled. 
The placenta may be expelled by the first contraction 
after the expulsion of the child or it may not be expelled for 
several hours. If there is no urgency on account of hemor- 
rhage or because of a serious condition of the patient the 
nurse need not be worried over the delay in the expulsion 
of the after-birth. She will quietly await the appearance 
of the physician, keeping, as said before, a close watch upon 
uterine contractions. 
When the placenta appears at the vulva the nurse must 
endeavor to prevent the tearing of the membranes so that 
no part of them are retained in the uterus. For this reason 166 
LABOR 
she holds the placenta in the hand or in a basin and gradually 
draws it away as the membranes peel off from the lower 
segment and pass through the cervix. Patience and avoid- 
ance of any unusual traction are all that are needed. 
After the placenta is born it should be placed in a basin 
or other receptacle and examined to determine whether it 
is intact or whether a part has been left in the uterus. First 
the uterine surface is observed and the absence of any lobes 
noted. Then the membranes are arranged as carefully 
as possible in their natural position. The location of the 
tear through which the child escaped is noted and the com- 
pleteness of the membranes determined. The placenta is 
then set to one side for the inspection of the physician. 
With the placenta come, frequently, some clots of blood 
which have accumulated behind it and sometimes fresh 
blood. A contraction of the uterus which follows after the 
expulsion of the placenta should prevent hemorrhage of 
any considerable duration. A hand placed over the abdo- 
men now feels the uterus contracted as before, but it is soon 
in a state of almost continuous contraction. There are, 
at first, periods of relaxation, but these periods are shorter 
and less pronounced. In normal cases, such as are now 
being described, the continuous, firm contraction of the 
uterus at the end of fifteen or twenty minutes convinces the 
nurse that all danger of postpartum hemorrhage is over. 
As a rule, however, she should not leave the patient in less 
than thirty minutes after the birth of the placenta, and then 
she should keep close watch of the uterine contractions for 
another half-hour. 
As soon as the child is born and wrapped in a warm 
blanket (see p. 282) the wet pads under the mother are ex- 
changed for dry ones, so that she may lie in comfort during 
the third stage of labor. After the birth of the placenta, as 
soon as it is evident that there is no serious hemorrhage to 
combat, the soiled pads and draw-sheets are removed, the 
patient is cleaned thoroughly and the napkin and bandage are 
applied, as will be directed in the next chapter. The wash- 
ing of the patient and changing her from the childbed to the 
lying-in bed is accomplished without distracting our attention 
from the condition of the uterus. POSTPARTUM HEMORRHAGE 
167 
POSTPARTUM HEMORRHAGE. 
Hemorrhage after labor or postpartum hemorrhage is one 
of the most serious complications with which the obstet- 
rician and the obstetrical nurse have to deal. Its causes 
and the methods of preventing and managing it should 
be thoroughly understood by the nurse, for it is a condi- 
tion that demands immediate action and generally per- 
mits of no delay, such as would be caused by waiting for 
a physician. If a nurse is alone with the case she should 
always keep in mind the possibility of hemorrhage and make 
every preparation beforehand to meet it. Preparation is 
of the the utmost importance. The sudden loss of a large 
quantity of blood is likely to upset the most experienced. 
The well-grounded fear that a patient may die in a few 
moments unless effectual aid is given, calls not only for a 
clear head but also for well-trained, systematic, vigorous 
action. 
Causes of Hemorrhage.—Let us consider first the causes of 
postpartum hemorrhage. A comprehension of this subject 
will necessitate a short study of the mechanism by which 
hemorrhage is prevented in ordinary cases of normal labor. 
You will remember that when the after-birth separates 
from the uterus it carries along with it a part of the decidua 
(see page 62). The line of separation of the placenta passes 
through the middle of the decidua or changed uterine mucous 
membrane. In this plane there are numbers of blood- 
vessels and blood sinuses which supply nourishment to the 
fetus. Of course, many of these vessels are torn open by 
the separation of the placenta. The question is: “Why is 
there not always an alarming hemorrhage from these torn 
vessels? What is the mechanism by which these vessels 
are closed?” 
To answer these questions we must take into consideration 
the arrangement of the fibers of the uterine walls. In the 
unimpregnated uterus the muscle fibers cross each other 
and interlace in a very complicated system. During preg- 
nancy these muscles not only enlarge and elongate, but also 
change their relation to each other so that they come to 168 
LABOR 
lie somewhat parallel with each other. As soon as the 
uterus is emptied the uterine muscle fibers not only contract 
but also immediately begin to assume the arrangement that 
existed before pregnancy. In this way, that is by a com- 
bination of prolonged contractions of the uterine muscle 
fibers and a resumption of their interlacing arrangements, 
the bloodvessels, passing in a tortuous manner through the 
uterine walls among the individual fibers, are so contracted 
that their caliber is nearly or entirely closed. This allows 
the formation of clots in the vessels which gradually organize 
and obliterate them. 
It is therefore by the action of the uterine muscles that 
postpartum hemorrhage is prevented. The continuous 
contraction and rapid rearrangement of the muscular fibers 
close the vessels so quickly and surely that ordinarily only 
a few ounces of blood, and sometimes indeed only a few 
drams, escape after the birth of the placenta. 
Atonic Hemorrhage.—We can now understand how a 
failure in the contraction of the uterus may lead to bleed- 
ing. We may here use the term contraction to denote not 
only the contraction of the individual fibers, but their re- 
arrangement. This uncontracted condition of the uterus is 
often called atony of the uterus, which means, of course, its 
lack of power; and a hemorrhage resulting from such atony is 
called atonic bleeding. The bleeding goes on continuously 
from the unclosed vessels of the uterus, and chiefly from those 
of the placental site. The blood may flow away almost 
continuously through the dilated cervix, or as usually hap- 
pens, the cervix may contract sufficiently to partly close for 
a moment the exit from the uterus. In this case the blood 
will accumulate inside the womb and distend it until it may 
become nearly as large as it was before the expulsion of the 
child. A contraction will then force out this enormous mass 
of blood from the uterus and vagina to the outside, when the 
process of filling and emptying the uterus will again be 
repeated until the patient dies from the loss of blood. As 
a rule the hemorrhage, shown by the appearance of blood 
on the outside, is more or less intermittent, corresponding 
to the contractions of the uterus which force out the blood. POSTPARTUM HEMORRHAGE 
If the hand is held over the abdomen in such a case of hemor- 
rhage it will be noticed that the uterus becomes large and 
soft and frequently indistinguishable. No blood will then 
escape from the vulva until by rubbing with the hand the 
uterus contracts and becomes hard and a gush of blood 
appears. When it again relaxes, a sign that the blood is 
filling ii]) the uterus, the external hemorrhage ceases. These 
observations show us that it is not the appearance of the 
blood on the outside that we need fear. Massaging of the 
uterus or perhaps a movement of the patient causes a uterine 
contraction and expulsion of the blood, and this frightens 
the patient and perhaps leads her to think that the rubbing 
makes her bleed and therefore is dangerous. We know 
that the blood that is collected in the uterus is already on 
the outside of the bloodvessels of the patient and is no longer 
of any value to her. It is only a source of danger in the 
uterus, for it prevents the firm uterine contractions, hence 
it is much better outside the body. As we shall learn in a 
moment, when we come to speak of the management of 
hemorrhage, we seek to control the escape of blood from the 
bloodvessels and not the retention in the body of the blood 
already lost to the patient. 
Weakness or atony of the uterus is more apt to occur 
after a long and severe labor, or in cases where the uterus 
has been unusually distended, for example in twin preg- 
nancies or hydramnion. It is at times the result of a pre- 
mature expression of the placenta. After the severe con- 
tractions required to expel the child it would seem natural 
that an interval of rest were necessary before the final stage 
of labor. Interference which deprives the uterine muscles 
of this interval of rest is often a cause of subsequent ineffi- 
cient contraction and resulting hemorrhage. 
Hemorrhage from Partial Detachment of the Placenta.— 
Another important factor in preventing efficient uterine 
contraction and producing hemorrhage, is the presence in 
it of a more or less detached placenta. Until the placenta 
begins to separate there is, of course, no hemorrhage from 
the placental site. When a part of the placenta remains 
adherent to the uterus it may prevent a thorough contraction 170 
LABOR 
of the uterine muscle and thus give rise to bleeding from the 
denuded portion of the uterine wall. This may happen 
whether the partially separated placenta remains in the 
uterus or whether the separated portion has been expelled, 
leaving a piece of the adherent placenta. 
We therefore have two classes of cases, one where there 
is a partial separation of the placenta and the other where 
there is complete separation of the placenta. When there 
is partial separation of the placenta the entire after-birth 
may remain in the obstetrical canal or the separated portion 
may be expelled. 
Traumatic Hemorrhage.—Postpartum hemorrhage may 
also be due to tears in the obstetrical canal, generally in the 
cervix or the vagina. A large tear, sufficient to cause con- 
siderable or serious hemorrhage, rarely occurs in uncompli- 
cated, spontaneous labor, but is due generally to operative 
interference. It consequently does not interest the nurse 
so much as atonic hemorrhage, since she is never alone and 
obliged to assume the responsibility of these cases. It will 
consequently be necessary to mention only the cause of the 
hemorrhage and perhaps to point out how it may be dis- 
tinguished from that due to atony of the uterus. Hemor- 
rhage due to tears or lacerations is continuous, while in 
atonic bleeding the external hemorrhage is intermittent or 
ceases, at least in part, after contractions of the uterus. 
Hemorrhage from Deficient Coagulability of the Blood.— 
Still another cause of postpartum hemorrhage is occasion- 
ally found in the altered condition of the blood. Unless 
the blood possesses a certain power to coagulate or clot the 
stoppage of hemorrhage from a ruptured vessel is impossible. 
Blood varies in its coagulative ability. There are some 
people whose blood has very little tendency to clot, and 
these individuals bleed very freely whenever the smallest 
vessels are ruptured. A slight cut, pulling of a tooth, or 
blowing of the nose may be followed by a very severe bleed- 
ing. These people are often called “bleeders.” It is evi- 
dent that a woman who has this bleeding tendency would 
be in more danger from hemorrhage after labor than a 
woman not so affected. In some kinds of disease also the POSTPARTUM HEMORRHAGE 
171 
coagulability of the blood is diminished. This is true of 
malaria for example. If the nurse has reason to think, from 
the past history of the patient, that she is liable to attacks of 
frequent and severe hemorrhage, she should, of course, take 
unusual care to prevent and control hemorrhage after labor. 
Fig. 74.—Partial or incomplete inversion of the uterus. The placenta is 
still attached and hemorrhage may not occur until its separation begins. 
Inversion of the Uterus.—One other cause of postpartum 
hemorrhage is the occurrence of a serious accident known 
as inversion of the uterus. This is a turning inside out of 
the womb, due to traction upon the placenta or sometimes 
to pressure made in the effort to expel the placenta, or some- 
times it happens spontaneously while the cervix is still open 
so as to admit of the passage through it of the base of the 
organ. It is, of course, a very serious accident not only 
on account of the hemorrhage but on account of the shock. 
It is very rare, and is only mentioned as one of the possibili- 
ties which the nurse has to bear in mind. (Fig. 74.) 172 
LABOR 
Prevention of Postpartum Hemorrhage.—The prevention 
of postpartum hemorrhage is mainly, so far as the nurse is 
concerned, its prompt and vigorous treatment at the instant 
of its appearance. As was said above, hemorrhage might be 
due to the improper expression or extraction of the placenta. 
As a nurse, however, should never attempt to extract the 
placenta, unless such a measure were indicated by hemor- 
rhage, it is not necessary to allude further to this point. 
Removal of the Partly Adherent Placenta.—In considering 
the treatment of postpartum hemorrhage we must take 
into account the question of the presence or the absence of 
the placenta in the uterus. If bleeding occurs before the 
placenta is born we have a partly adherent placenta which 
prevents an efficient contraction of the uterus; hence it is 
necessary to get rid of the after-birth in order to stop the 
bleeding. 
We must, therefore, consider the methods of extracting 
or expelling the placenta. Three may be mentioned: 
Traction on the cord, Crede expression, and manual sepa- 
ration. The first method, that of removing the after-birth 
by pulling on the cord, should never be practised. Unless 
the placenta is very tough it might tear in two and a portion 
be left behind in the uterus. If it is very tough and firmly 
adherent the uterus might be inverted by forcible pulling. 
Expression of the Placenta.—Expression is the proper 
technic to employ in removing the placenta. It is called 
the Crede method because it was described and advocated 
by the great German obstetrician who taught many years 
in Leipzig. It is also and better called the Dublin method, 
because it was practised in the Rotunda Hospital in Dublin 
even long before the time of Crede. It is performed in the 
following way: The fundus of the uterus is grasped as 
well as possible in the hand through the abdominal walls, 
the separated fingers passing behind and the thumb in front. 
If the nurse is on the right side of the patient she grasps the 
uterus with the left hand. Before beginning the manip- 
ulation the uterus has been rubbed to secure a contraction. 
As soon as it begins to harden the expression begins. Having 
grasped the uterus it is squeezed in the hand, at the same POSTPARTUM HEMORRHAGE 
173 
time pressing down in the axis of the outlet of the pelvis. 
A firm grasp and an energetic pushing movement must be 
continued for one or two minutes or until the placenta 
appears. If this measure does not succeed and the hemor- 
rhage is very great the nurse may repeat the manipulation, 
using both hands. She must remember, however, that the 
Fig. 75.—Crede’s method of expressing the placenta. (Bumm.) 
expression of the placenta is to be done only when there is 
great danger of bleeding. A slight hemorrhage or one that 
is easily controlled by a little rubbing over the uterus is not 
an indication for interference. 
Manual Removal of the Placenta. -The third method of 
removing the placenta by the introduction of the entire 174 
LABOR 
hand into the uterus and peeling it off from the surface 
is one that is required very rarely, perhaps 2 or 3 times 
in 1000 cases, and should never be done by the nurse 
except in the most extreme cases. It is a dangerous manipu- 
lation, because the patient is subjected to very great dan- 
ger of infection by the introduction of the hand into the 
raw, absorbent uterus. As there is probably not 1 case 
in 10,000 where this manipulation will be required of a 
nurse it need not be further described. In practically all 
cases where the nurse is alone with the patient, where the 
removal of the placenta is necessary, the Crede expression 
properly performed will succeed. 
When the bleeding begins before the expulsion of the 
placenta the nurse should at once tie the cord and separate 
the child if it still remains attached. She should then rub 
the uterus through the abdomen somewhat vigorously to 
stimulate the uterine contractions. If the bleeding con- 
tinues moderately the massage should be persisted in. If 
the bleeding becomes more serious she should then try to 
secure a uterine contraction by rubbing and then grasping 
the uterus and express the placenta. If she should not 
succeed at first her efforts may, however, produce sufficient 
contraction to control the hemorrhage. If not, and the 
hemorrhage becomes alarming, expression with both hands 
must be made. Afterward the steady, persistent massage 
of the uterus through the abdominal wall to keep up the 
contraction, aided by other measures about to be described, 
will be indicated. 
A question may arise concerning the measures to take 
in case a portion of the placenta remains in the uterus. 
When there is no hemorrhage this adherent placenta will 
cause no trouble and must be let alone. It will seldom 
happen if the third stage of labor is properly managed. 
Probably it will never be a source of danger so great that 
it will not permit the calling of a physician. 
Management of Atonic Hemorrhage.—When we now come 
to consider the management of hemorrhages that occur 
after the expulsion of the placenta we must mention the 
stimulation of the uterine contraction by massage of the POSTPARTUM HEMORRHAGE 
175 
uterus through the abdomen, by hot-water douche, and by 
the administration of pituitary extract or ergot, and the 
combating of the serious and dangerous symptoms by 
attending to the position of the patient, by bandaging the 
extremities, and by the hypodermic injection of salt solution. 
Massage.—Attention has been called already to the im- 
portance of keeping the hand on the abdomen after labor 
for the purpose of studying its condition, and perhaps exert- 
ing a slight stimulating effect on the uterus. In order to 
stimulate efficient uterine contractions in case of hemorrhage, 
vigorous manipulation must be made. The hand should 
move up and down and back and forth across the uterus, 
pressing the fingers behind the uterus so as to grasp it as in 
the Crede expression. Squeezing movements as well as 
rubbing with the ends of the fingers should be employed. 
These manipulations must not be discontinued as soon as 
the hemorrhage stops, but should be employed for twenty 
to thirty minutes to prevent relaxation. A supplement 
to the hand in the stimulation of the skin may be had in 
cold. A piece of ice or a cold, wet towel placed over the 
lower abdomen may help at first in starting the uterine 
contractions. 
Hot Douche.— The next measure against hemorrhage is 
the hot vaginal douche. It is immaterial whether sterile 
water or some weak antiseptic substance be employed. A 
large quantity may be needed, perhaps gallons. The main 
thing is that the douche should be hot. It should have a 
temperature of 120° F. Warm water from 100° to 110° F. has 
only a relaxing effect, while water of 120° F. is a powerful 
stimulant to the contracting fibers of the bloodvessels and 
to the involuntary uterine muscles. 
It is very essential that the douche should be given 
promptly. It should always be prepared before the com- 
pletion of labor. The bag or receptacle is filled and all 
that is needed is to pull the patient over to the edge of the 
bed, turn up the edge of the rubber draw-sheet, introduce 
the tube, and let the water run. If the bed has been pre- 
pared as before described and the douche prepared the 
irrigation should begin within twenty seconds from the 176 
LABOR 
beginning of the hemorrhage. Provision must be made 
to keep up the flow. Someone must assist in filling the 
Fig. 76.—Giving a hot vaginal douche for postpartum hemorrhage. The 
patient lies on the right side of the bed with her right leg supported on a 
stool. The nurse is separating the labia with the thumb and fingers of 
her left hand and is about to insert the douche point which she holds in her 
right hand. 
irrigator. It will then he possible for the nurse, sitting by 
the bed, to support the patient, whose right hip and thigh 
lie partially over the edge of the bed with the foot resting POSTPARTUM HEMORRHAGE 
177 
on a chair or stool, and at the same time with her left hand 
to keep up the massage over the uterus. 
It should be repeated and emphasized that the douche 
should not be stopped as soon as the water begins to come 
away clear. A return of the hemorrhage is always to be 
feared and a cessation of the bleeding fifteen minutes is 
necessary before one is justified in withdrawing the stimulus 
of the douche. It may be continued an hour or more. 
When it is given as advised the patient is not at all disturbed 
and may even go to sleep while the water is running. 
Oxytocics.—Pituitary Extract and Ergot.— The third means 
to stop uterine hemorrhage is the use of oxytocics or agents 
to excite and strengthen uterine contractions. The anterior 
lobe of the pituitary gland has this remarkable property, 
and a preparation of this substance from the gland of the 
sheep is prepared by various manufacturers for hypodermic 
use. It is put on the market in ampoules each containing 
from 0.5 to 1 cc which is the average dose for hemorrhage. 
Ergot is also a powerful oxytocic whose action is somewhat 
more permanent than pituitary extract. It is given gener- 
ally by the mouth, in the fluidextract preparation, in the 
dose of 1 to 2 drams. 
Summary of Treatment of Postpartum Hemorrhage.—As 
with the douche, so the hypodermic injections of pituitary 
extract have been prepared beforehand in order that no 
time may be lost. The order of proceeding will be as follows: 
If a sudden hemorrhage appears the patient is drawn to the 
edge of the bed and the douche begun; with the left hand the 
nurse manipulates the uterus through the abdominal walls, 
with the right hand she takes her syringe and injects the 
pituitary extract. Then she is at liberty to supervise the 
filling of the douche bag or can, and to watch the patient 
and the effect of her measures. There should be no 
confusion. The patient need not be alarmed. The nurse 
knows what is to be done and has confidence in herself 
because of this knowledge. Under no circumstances should 
she change from this routine and try a number of measures 
one after another. But three measures have been described, 
and these are all that are necessary if efficiently employed. 178 
LABOR 
If the physician be present he may pack the uterus with 
sterile gauze. This is an operation which a nurse would 
never be expected to perform, and therefore it is not neces- 
sary to describe it in detail. Many other things have been 
advised from time to time, but none are as good or as safe 
as these, and the importance of persistent action along a 
definite line is so great that it seems best not to introduce 
any complication by recommending other agents. 
Combating After-effects of Hemorrhage. — In a severe 
hemorrhage the patient becomes dizzy and faint, and per- 
haps nauseated, has difficulty in breathing, perhaps hears 
a buzzing in her ears and, of course, looks very pale. These 
symptoms are due to lack of blood in the brain, which 
suffers very promptly upon the failure of the circulation. 
The pulse is very weak. The heart requires a certain 
amount of fluid in order to contract properly. The char- 
acter of the circulating fluid is of less importance than the 
quantity. If two pounds of blood be drawn from the body 
suddenly there is greater distress than if twice that quantity 
were drawn slowly in twenty-four hours. In the latter 
case the quantity is made up by the passage into the vessels 
of the fluid outside of them. 
In order to combat the symptoms and dangers due to 
the hemorrhage it is necessary to make use of all the blood 
that remains and to inject into the body a substitute for 
the lost blood. We make use of the remaining blood by 
putting the patient in such a posture that the blood will 
flow to and remain in the center which controls the vital 
processes, namely, the head. The head is lowered and the 
body elevated. The pillow is removed and the foot of the 
bed raised. In extreme cases this may be supplemented 
by bandaging the extremities. A nurse, when she is alone, 
would, of course, never leave her position at the side of the 
patient where she is giving the douche and kneading the 
uterus. She may, however, be called upon by her physician 
to do this. For the purpose of bandaging, a sheet may be 
torn into strips 3 or 4 inches wide, quickly rolled and applied 
firmly, beginning at the toes and passing up as far as possi- 
ble on the thighs. POSTPARTUM HEMORRHAGE 
179 
Ilypodermoclysis. — The lost blood is substituted by the 
normal salt solution. This may be best administered by 
means of a fountain syringe or by the use of a reservoir 
with a tube, employing the principle of gravity. Into the 
further end of the rubber tube is placed the large stem of 
a glass Y, which is to divide the stream. To the smaller 
limbs of this Y are attached smaller pieces of rubber tubing 
| yard long, which carry large hypodermic needles. With 
this apparatus the solution may be introduced into two 
separate parts of the body at the same time and with con- 
siderable rapidity. The parts best adapted to receive the 
saline solution are the fronts of the thighs. The method of 
preparing the solution and using it is as follows: 
Unless the physician or nurse is provided with sterile 
salt tablets ordinary clean table salt will answer. There 
being no exact measure at hand, let her take a medium- 
sized teaspoon, fill it with salt lightly, not packing the salt, 
and then with a straight edge, as, for example, the edge of 
a knife-blade, strike off the extra salt. This level teaspoonful 
of salt is sufficient for 1 pint of water. The water used should 
have been boiled. Into the water the salt is placed and 
then boiled again in order that the solution may be per- 
fectly sterile. If a great quantity of the solution is needed, 
of course double the quantity of salt and water will be 
employed. If the nurse anticipates the use of the solution 
she would better prepare it of double strength beforehand. 
It may then be diluted with warm water when needed for 
use. The apparatus for the introduction of the salt solution 
should be put together and wrapped in a towel or piece of 
gauze and put into a kettle and boiled, when it is ready to 
receive the solution. 
The proper temperature of the solution is about 98° to 
99° F. A variation of 3° or 4° is, however, unimportant. 
Since the solution cools during the process of introduction 
a little hot solution should be added from time to time or 
a flame placed under the receptacle. To determine the 
temperature a sterilized thermometer should be on hand. 
The thermometer included in a glass connecting link that 
can be inserted in the tube is desirable. One may estimate 180 
LABOR 
the temperature fairly accurately by allowing the solution 
to flow from a needle over the back of the hand. Every- 
thing being ready, the skin in the region of the proposed 
puncture is disinfected and the needles introduced. They 
should not pass too close to the skin, neither should they 
Fig. 77.—Hypodermoclysis. Injecting normal salt solution into the thighs 
pass too deeply into the muscles. Before introducing them 
the receptacle is raised and the solution allowed to flow 
until the tube and needles are full of the warm solution. 
The rapidity of the flow will depend partly upon the height 
of the receptacle, partly upon the nature of the tissue into DYSTOCIA 
181 
which the solution is introduced, and partly upon the mas- 
sage manipulations which help in the absorption of the fluid. 
Ordinarily 1 to 2 pints can be injected in fifteen minutes. 
Long before the injection of this amount is completed 
its effects are apparent. The pulse improves, the patient 
breathes more easily, and the terrible feeling of thirst is 
allayed. The salt solution, moreover, has not only a tem- 
porary but also a permanent effect. Patients recover 
much more rapidly and without complications after its use. 
While the nurse will hardly ever, and perhaps never, be 
called upon to use the salt solution upon her own responsi- 
bility, she should understand the technic of its preparation 
and administration so that she may prepare it and use it 
properly when ordered by the physician. 
DYSTOCIA. 
Definition. —Dystocia, or abnormal labor, occurs when 
there is some abnormality in the forces of labor, in the 
passages, in the passenger, or in the mechanism of labor. 
Likewise any accident occurring during labor is a cause of 
dystocia. 
According to this definition, postpartum hemorrhage 
(see page 107), separation of the normally seated placenta 
(see page 93), and other conditions already discussed are 
cases of dystocia. Although its management is always the 
business of the physician, it is desirable that the nurse should 
have a brief outline of the subject. 
Dystocia from Abnormal Forces.—The contractions of 
the uterus may be excessive or weak. Excessive contrac- 
tions may be too strong, they may last too long, or they may 
be too frequent. When the contractions come so fast and 
last so long that the resting periods are no longer than 
the contracting periods the contractions are pathological. 
When the contractions are practically continuous they are 
said to be tetanic. We shall not discuss the causes of 
excessive contractions except to say that ergot or pituitary 
extract will produce them. The most important result is 
the injury or death of the child by the compression of the 182 
LABOR 
placenta and the uterine vessels. Precipitate labor may 
result and also rupture of the uterus. The treatment is 
generally the administration of sedatives or anesthetics. 
Weak contractions lead to inertia or atony of the uterus. 
The contractions may be less in intensity, shorter, or less 
frequent. This condition may be primary at the beginning 
of labor, or secondary, occurring during labor. In the 
latter case it may be due to exhaustion following excessive 
contractions. The chief danger is the exhaustion of the 
mother and in the third stage of labor, atonic hemorrhage. 
The treatment depends upon the cause of the atony and 
the condition of the patient. 
Dystocia from Abnormal Passages.—Contracted and 
other deformed pelves (see page 33) may interfere with or 
absolutely prevent the passage of the child. The treatment 
may be delivery by forceps or by enlarging the pelvis or by 
a delivery through a Caesarean section. Ovarian tumors 
and tumors of the uterus may prevent normal delivery and 
require removal of the obstruction or of the child. 
Fetal Dystocia.—Dystocia from Abnormalities in the Pas- 
senger.—Occasionally a child is too big to pass through 
even a normal pelvis. This may be due to retardation of 
the labor or to hereditary influences. The case must be 
managed like one of contracted pelvis. Sometimes deform- 
ities of the fetus, like fetal tumors, hydrocephalus, etc., make 
labor abnormal and require interference. 
Twins.—In this connection we may speak of multiple 
pregnancies in which the labors are frequently abnormal. 
Twins occur once in about 90 pregnancies and triplets 
once in about 8000 pregnancies. Heredity is a factor in 
the causation; a history of twins on either the mother’s or 
father’s side is nearly always found. They may originate 
in different ways. Two Graafian follicles may rupture 
simultaneously and both ova be fertilized, or there may 
be two ova in one follicle. Then one ovum may have two 
nuclei. Finally after the fertilization of an ordinary ovum 
the nucleus may divide completely and each half develop 
as a separate egg. When the twins are from the same egg 
both are of the same sex. When they are from different DYSTOCIA 
183 
eggs they may be of different sexes. When they are from 
one egg there is often a connection between their placental 
vessels. In this case after the birth of the first child if the 
placental end of the cord were not tied before cutting the 
second child might bleed to death. 
The great distention of the uterus may interfere with its 
normal contractions. Sometimes the fetuses become locked. 
After the birth of the first child the delivery of the second 
may be delayed. Finally postpartum hemorrhage is always 
to be feared. 
Short Cord.—Rarely the cord is so short that it does not 
allow the escape of the child from the vagina. More fre- 
quently the cord is rather long but coiled several times 
around the neck of the child, so that it also prevents the 
birth of the child. Ordinarily one or two coils around the 
neck cause no disturbance in the labor. 
Prolapse of the Cord.—One of the most serious kinds of 
fetal dystocia is prolapse of the cord, which occurs about 
once in 150 labors. It is more often found in cross-presen- 
tations of the fetus and in labors in flat pelvis. As it gener- 
ally results in death of the child unless it is properly managed 
it is important to make an early diagnosis. Unfortunately 
without an internal examination a diagnosis can hardly be 
made before the cord appears at the vulva. Any marked 
irregularities in the fetal heart tones would raise a suspicion 
of pressure on the cord. Hence this is another reason why 
the nurse should watch the heart tones carefully. Should 
the cord present at the vulva, or should there be other 
reason to suspect a prolapse of the cord while waiting for 
the physician, the patient should first take the knee-chest 
position for three or four minutes and then lie with the hips 
much elevated so as to favor the reposition of the cord by 
gravity. 
Dystocia from Abnormal Mechanism of Labor.—Here we 
have abnormalities in one or more of the steps of labor. 
We may have abnormal presentation at the inlet. Instead 
of the vertex or the occiput the brow or face or the side of 
the head may present. In some cases the breech or foot 
or shoulder may be in advance. In the excavation the head 184 
LABOR 
may not undergo proper internal rotation. If no rotation 
takes place and the occiput remains to one side the con- 
dition is called deep transverse arrest. If the occiput 
rotates backward we have the so-called occiput posterior, 
a condition that makes spontaneous labor slow and difficult. 
Sometimes there is a compound presentation such as an 
arm or leg with the head. When the progress of labor is not 
satisfactory some abnormality in the mechanism is to be 
suspected. 
Dystocia Due to Accidents.—Eclampsia, placenta previa, 
postpartum hemorrhage, separation of the normally seated 
placenta, and inversion of the uterus, which have already 
been considered, belong here. Another pathological con- 
dition during the third stage is the adherence of the placenta 
and membranes. Partial adherence with resulting hemor- 
rhage has been discussed (see page 169). Complete adher- 
ence is generally attended with no hemorrhage and need not 
disturb the nurse. She watches the patient carefully and 
waits for the physician. 
Rupture of the Uterus.—This accident is fortunately very 
rare, occurring only once in about 1000 labors. The tear 
is generally found in the lower uterine segment at the junction 
of the cervix and body. Spontaneous rupture follows exces- 
sive contractions in an obstructed labor, for example in a 
case of transverse presentation. The lower dilating seg- 
ment becomes very thin and finally gives way. Artificial 
rupture results from some operation like turning, forceps, 
etc. The immediate results of rupture are pain, shock, 
cessation of uterine contractions, hemorrhage, internal and 
external, and disappearance of the fetus. Practically all 
children die, and in spite of treatment about 50 to 70 per 
cent of the mothers. It is important to know that this 
terrible accident is possible in a very hard labor, especially 
when the contractions are very severe. 
Vulvar and Perineal Lacerations.—The way for the nurse 
to prevent laceration has been described. The physician 
will generally repair them after the expulsion of the placenta 
if the patient is in condition. Sometimes small tears are 
repaired while waiting for the placenta to come away. OBSTETRICAL OPERATIONS 
185 
The nurse will be called on to assist in the operation or in 
the anesthesia. Preparation must be made while waiting 
for the third stage unless everything was in readiness before- 
hand. 
OBSTETRICAL OPERATIONS. 
Frequency.—If all kinds of operations are considered, 
including repairs of lacerations, they probably occur in 
one-fourth t° one-third of all cases of labor. This fact 
indicates the importance of the subject. The nurse must 
prepare for them and assist at them. It is necessary, there- 
fore, that she knows their object and general character and 
the names and uses of the instruments employed. 
The following classification of obstetrical operations may 
be of value in furnishing a general oversight of the subject: 
Preparatory Operations. 
Induction of labor and abortion. 
Dilating: cervix (metreurysis). 
Vagina and vulva (colpeurysis and episiotomv). 
Pelvis (symphyseotomy and hebosteotomy). 
Improving position and attitude: turning, changing 
position and presentation, replacing parts. 
Delivery Operations. 
Expression: Kristeller or expressing body; Hofmeier, 
expressing head. 
Forceps: low, middle, and high. 
Manual extraction. 
Caesarean section: classical, Porro, extraperitoneal, cer- 
vical transperitoneal, vaginal. 
Embryotomy: perforation and cranioclasis, decapita- 
tion. 
Third Stage Operations. 
Manual extraction, Crede expression, expression from 
vagina. 
lleparatory Operations. 
Cervix, vagina, vulva, perineum. 
Accessory Operations. 
Douche; vaginal and intra-uterine. 
Hypodermoclysis. 186 
LABOR 
Preparation.—The more serious preparatory, delivery, and 
reparatory operations should be done in a hospital when 
one is accessible and the transfer of the patient is possible. 
When it is necessary to operate at home the best possible 
preparation should be made. The largest, warmest, best 
lighted, and most convenient room in the house should be 
chosen. Frequently the kitchen or dining-room possesses 
these qualifications. Hugs should be removed from the 
Fig. 78.—Kitchen table arranged for an operating table. The sheet on the 
table is to be used as a leg-holder. 
floor and a carpet should be covered with an oil-cloth or with 
sheets. In daytime light is secured from windows, which 
may be rendered translucent when necessary by a tem- 
porary sash curtain or by coating the glass with soapsuds. 
The table is placed so that the light falls most advantage- 
ously on the genitalia. At night if the house has electric 
lighting the bulb may be held or hung so as to give an ideal 
illumination. Generally an extra powerful lamp may be 
secured. If only an overhead light is available, as with a OBSTETRICAL OPERATIONS 
187 
gas jet, tlie table should be placed so that the light comes 
from behind the operator at an angle of about 60 degrees. 
Lamps can rarely be placed behind the operator in good 
position, and he sometimes uses a head mirror to reflect the 
light from the lamp placed safely at the side. 
For most operations the ordinary kitchen table makes a 
very satisfactory operating table. As the patient is gener- 
ally in the lithotomy position it is long enough. It should 
be covered with a blanket and a clean sheet. A rubber or 
oil-cloth sheet is laid on the end of the table and drawn into 
a pail or jar for drainage. 
Slight repair operations may be made with the patient in 
bed, her hips being elevated on the douche-pan, or she may 
be turned across the bed. More extensive repairs and all 
delivery operations should be done on a table. 
Behind the table is a plain chair for the operator. At his 
right hand is a large table or two small ones, covered with a 
clean sheet to hold the instruments, basins with solutions, 
pitchers, sponges, sheets, towels, etc. At one side is the 
irrigator hung up and filled ready for use before the patient 
is brought to the table. A long sheet rolled diagonally, to 
be used as a leg holder, is placed on the operating table. 
Most operations are better made under anesthesia. 
Although the services of a physician or a trained anesthetist 
should always be secured if possible, yet sometimes in an 
emergency the nurse must given the anesthetic. The 
administration of an anesthetic to produce complete anes- 
thesia is more difficult and involves greater responsibility 
than the use of a little ether during contractions to dull the 
pain of labor. As ether is always much safer than chloro- 
form, probably a physician would choose it if the nurse is 
the anesthetist. It is to be given in the way already de- 
scribed, but continuously. The patient may pass through 
stages of exhilaration before she is under the influence of 
the drug. This part of the process is, however, watched 
by the physician. Later when it is necessary to hold the 
patient unconscious she must carefully observe the pulse 
and respiration as well as the color of the face. A nurse 
should take every opportunity of watching the adminis- 188 
LABOR 
tration of anesthetics and particularly learn how to hold the 
jaw so as to keep the tongue from dropping back and imped- 
ing respiration. 
Induction of Abortion.—This operation is made only in 
those extreme cases of pregnancy complicated by serious 
heart disease, kidney disease, tuberculosis, or similar affec- 
tion, when the operation is necessary to save the life of the 
mother. When the operation is not absolutely necessary 
it ceases to be legitimate; then it is not a therapeutic 
but a criminal abortion. It is forbidden by law under 
penalty of imprisonment. If the patient should die as 
the result of a criminal abortion the operator is guilty of 
murder. Hence to avoid any suspicion every physician 
will consult with a reputable colleague before deciding upon 
making a therapeutic abortion. He will also secure the 
consent in writing of the patient and if possible of her hus- 
band or next of kin. The operation can generally be done 
in a hospital. 
Before the fourteenth week the operation can be done at 
one sitting by rapid dilatation and curettement. The instru- 
ments needed are a branched dilator or a set of Hegar’s 
dilators, a curette with a flexible shank, 2 vaginal retractors, 
2 volsellum forceps, and a dressing forceps for eventual pack- 
ing. 
Between the fourteenth and twenty-eighth week it is gen- 
erally necessary, on account of the size of the fetus, to 
make a preliminary dilatation with tents, followed after 
twelve hours with further dilatation and curettement. It 
is necessary that the tents should be sterile. They cannot 
be boiled, of course, because they swell upon being brought 
in contact with a watery fluid. They can be put into and 
kept in strong alcohol after they have been sterilized with 
dry heat. 
To introduce the tent anesthesia is not generally neces- 
sary. The patient must be shaved and otherwise thoroughly 
prepared. The instruments needed are the vaginal re- 
tractors, a volsellum forceps to grasp the cervix, a small 
dilator for preliminary dilatation, and a dressing forceps 
to hold the tents. One or more are introduced according OBSTETRICAL OPERATIONS 
189 
to the size of the tents and the amount of dilatation of the 
cervix. Frequently a small vaginal packing of sterile or 
antiseptic gauze is used to help keep the tents in place. 
After about twelve hours the patient is anesthetized and 
the tents removed, the cervix further dilated with instru- 
ments or digitally, and then the fetus and placenta are 
removed. This is accomplished with the fingers alone or 
with the fingers and curette combined. Packing for post- 
partum hemorrhage or to help the contractions of the 
uterus must be in readiness; likewise ergot and a hot douche. 
Sterile petrolatum or oil should always be on hand to 
lubricate the dilators and the tents. 
Fig. 79.—Tents, and instruments for introducing them, to induce abortion. 
Induction of Labor.—Labor may be induced because of 
some disease of the mother, like heart disease, kidney dis- 
ease, consumption, or threatened eclampsia, which threatens 
her life if pregnancy continues. Here the operation must 
be done when the mother’s condition requires it, although 
in general it is postponed as long as possible on account of 
the child. Sometimes the operation is done because the 
pelvis is too small to admit the passage of a full-term child 190 
LABOR 
while it is big enough for a child of thirty-five to thirty-seven 
weeks. Here the labor is never induced before the thirty- 
fifth week because a younger child has too poor a chance 
of living. 
Preparations for this operation include not only the 
usual preparation of the mother but provision for the child. 
It must be handled with care, and especially must it be 
protected from chilling. Possibly an incubator should be 
provided as well as a tank of oxygen, and the nurse shoidd 
be ready to care for the child as directed in the discussion 
on the management of premature infants (see page 319). 
One method of inducing labor is the introduction of 
one or more bougies into the uterus. The hollow bougies 
with the stylets are sterilized by boiling. The other instru- 
ments needed are a vaginal retractor, a volsellum forceps, 
and a dressing forceps. No anesthetic is necessary. The 
operation is done with the patient in the lithotomy position 
on a table. Solutions and sponges are, of course, in readi- 
ness as well as gauze for packing the vagina. 
Labor rarely starts very promptly after the use of the 
bougies. If regular pains do not come on in the course of 
eighteen hours the physician removes the bougies, cleans the 
vagina thoroughly, and introduces others. When labor is 
well started the bougies are permanently removed. Some- 
times when there is a large amount of liquor amnii or when 
the patient is suffering from dyspnea, labor is induced by 
simply rupturing the membranes. This may require no in- 
struments, the physician simply breaking the membrane 
with the examining finger or perhaps with a rather sharp 
pointed blade of an artery forceps. 
The most common method of inducing labor is the dila- 
tation of the cervix with a bag. Such a bag is called a metre- 
urynter, and the process is metreurysis. The best kind of a 
metreurynter is non-elastic, made of a strong tissue which 
is vulcanized. It has a tube for filling, by means of which 
traction can be made on the bag. The Voorhees bags, 
which are conical in form and come in different sizes, in sets 
of four or more, are most used in this country. 
The bags are sterilized by boiling. For introduction there OBSTETRICAL OPERATIONS 
191 
are needed 2 vaginal retractors, 2 volsellum forceps, 1 sponge 
forceps to hold the bag, 1 dressing forceps, L or more dilators, 
sponges and solutions, a bulb syringe for filling the bag, and 
a ligature for tying the tube. A nervous and sensitive patient 
may need an anesthetic. The sterile bags and syringe, con- 
tained in a basin or pitcher of sterile water, are held near 
the vulva on the right side of the operator. After grasp- 
Fig. 80.—Instruments for metreurysis. One Voorhees bag is held in the 
forceps ready for introduction. 
mg the cervix and dilating, if necessary, lie punctures the 
membranes with the end of the dressing forceps and then 
carries the folded bag with the sponge forceps through the 
cervix into the amniotic cavity. Sometimes the membranes 
are not ruptured and the bag is inserted into the lower part 
of the uterus by pushing up the membrane. The physician 
then removes the vaginal retractors and, introducing the 
left half-hand into the vagina, he holds the bag in place while 192 
LABOR 
he fills it with the bulb syringe worked with his right hand. 
When it is full he ties the tube and pushes it up into the va- 
gina, retaining it there with gauze packing. Or if traction 
on the tube is desirable the tube is left protruding from the 
vulva. 
Labor starts more promptly after the introduction of the 
bag than after the bougie. There are generally some con- 
tractions at once, which gradually cease. After a few hours 
they recommence and continue as genuine labor pains. Oc- 
casionally the first contractions continue and develop into 
regular labor. When it becomes necessary to hasten the 
labor the physician may make intermittent traction on the 
tube. The nurse is frequently entrusted with this duty. 
Should labor proceed very vigorously for some time and 
then stop or become much weakened the nurse may suspect 
that the bag has escaped from the cervix and lies in the 
vagina. She may determine the condition by gentle traction 
on the tube if that has been left protruding from the vagina. 
She should notify the physician in any case of the change 
in the character of the pains. 
Dilatation of the Cervix.—The objects of the various oper- 
ations for dilating the cervix are to induce labor, to hasten 
labor, and to prepare for delivery operations. Metreurysis, 
or bag dilatation, which has just been described, is the chief 
method used for inducing labor. It may also be used for 
hastening labor and also to prepare the cervix for delivery 
operations. Here other methods which are more rapid 
are generally employed. Especially for accouchement force, 
i. e., rapid, forcible emptying of the uterus. These are 
manual or digital dilatation, the use of metal dilators, and 
incisions. 
Digital or manual dilatation is done with the fingers of 
one hand or with two hands. The patient is thoroughly 
prepared, anesthetized, and on the table. All preparations 
for the following delivery are first made. No instruments 
are needed, but the proper solutions and sponges must be 
in readiness. The physician generally begins with one hand 
with the so-called Harris method, and after dilating to the 
size of the fist he then employs both hands in the Edgar 
method. OBSTETRICAL OPERATIONS 
193 
Metal dilators are rarely used in this country for com- 
plete dilatation, but only at the beginning, to provide for 
the introduction of a finger or a bag. The Bossi dilator, 
sometimes used in Italy and Germany, is a powerful instru- 
ment, but feared on account of the tears it makes. 
When there is very great urgency the cervix may be 
opened by incisions. This is only possible after efl'ace- 
ment. The incisions are generally anterior and posterior 
and extend 2 or 3 inches to the vaginal wall. They are 
made with a long handle angular scissors. The other in- 
struments needed are 2 vaginal retractors and 2 tenaculum 
forceps. All preparations for the subsequent operation must 
be made. 
Symphyseotomy.—Cutting through the junction of the 
pubic bones is called symphyseotomy. After the bones are 
separated the ends are pulled apart from 2 to 2\ inches by 
abducting the thighs. This increases the size of the inlet 
of the pelvis one-third to one-half. The operation may be 
done in a moderately contracted pelvis when the course 
of the labor has shown that spontaneous labor is impossible 
and forceps delivery would be dangerous to mother and 
child. 
The operation is generally followed by the immediate de- 
livery of the child either by forceps or turning and extrac- 
tion. Hence the preparation for the delivery must be made 
in advance. Repair work must also be provided for. Some- 
times the bones are reunited by wire sutures. Generally 
they are held in contact with a band of adhesive plaster, 
which must be ready. The patient can be cared for better 
after the operation if she is placed on a sling bed that can be 
raised and lowered with pulleys. This also helps to keep 
the bones in apposition. The cross-strip under the patient’s 
buttocks is made so that it can be removed for the care of 
the bowels and urine and frequent cleansing of the genitalia. 
In preparing the patient for the operation the pubic 
region must be cleaned as well as possible. The instru- 
ments needed for the symphyseotomy itself are 2 scalpels, 
1 for the soft tissues and 1 to cut through the symphysis, 
several artery forceps, scissors, small retractors, dry dis- 194 
LABOR 
sector, needles, catgut and silkworm gut, needle forceps. 
Sometimes a special symphyseotomy knife, Galbiati knife, 
is used. 
Hebosteotomy.— Instead of cutting between the pubic 
bones the pelvic girdle may be enlarged by cutting through 
one of the bones about a finger’s breadth to the side of the 
symphysis, dliis operation is called hebosteotomy or 
sometimes lateral pubiotomy. rl he operation is generally 
done subcutaneously. A small incision is made through 
Fig. 81.—Instruments for hebosteotomy, showing Doederlein’s and 
Bachelle’s needles, Gigli wire saw, collodion bottle, and cotton. 
the skin and underlying tissues down to the upper border 
of the pubic bone. Through this opening a special needle 
is carried close behind the bone nearly parallel to the sym- 
physis and emerges below the lip of the vulva. A wire 
saw, called a Gigli saw, is then attached to the end of the 
needle and pulled through the track of the needle as it is 
withdrawn. Handles are then attached to the ends of the 
saw and the bone is sawed through. As soon as the bone 
is divided the sawing is stopped in order not to injure the 
soft tissues. The pelvis is then enlarged by separating the OBSTETRICAL OPERATIONS 
195 
ends of the bone just as in symphyseotomy. After the 
delivery of the child the ends of the bone are brought in 
contact and held with an adhesive plaster bandage. A 
thread drain may be inserted into one of the openings, or 
both may be sealed up with collodion. 
The instruments needed are the same as for a symphy- 
seotomy with the addition of a hebosteotomy needle and a 
Gigli saw. 
Version. —Version or turning is changing the presentation 
of the child. Cephalic version is changing a breech or a 
cross-presentation to a head. Podalic version is changing 
a head or a cross-presentation to a foot. External version 
is done by external manipulation alone. It may be at- 
tempted before labor or in the beginning of labor, and re- 
quires no special preparation. The physician may need the 
assistance of the nurse in the manipulation. 
Combined version is turning with the fingers of one hand 
or the whole hand in the uterus in contact with the child 
and with the other hand on the abdomen. If the cervix 
is opened only so that the fingers can be introduced the 
operation may be called combined digital version. It is some- 
times called Braxton Hicks’ version, after the name of the 
English obstetrician who advocated and described the 
technic of the operation. When the whole hand can be 
introduced into the uterus through the cervix the operation 
is a combined manual version. This operation is often called 
simply internal version. 
Combined version is nearly always podalic version, and 
is done to correct a cross-presentation or to bring the leg 
into the cervix to control bleeding in placenta previa or 
to secure rapid delivery, as in prolapse of the cord or after 
symphyseotomy. It should be done on a table with the 
patient anesthetized. No special instruments are needed 
unless it be a long dressing forceps or perhaps one blade of 
a scissors for puncturing tough membranes. The obstetrician 
should be provided with long gauntlet rubber gloves to 
cover his forearms. If an arm is prolapsed in a cross-pre- 
sentation a long tape must be ready to slip over the wrist 
before it is replaced to assist in the subsequent delivery. 196 
LABOR 
If extraction is to follow immediately, preparation must 
be made for the child and for repairs, as will be described 
in discussing extraction in foot and breech presentation. 
If labor is allowed to terminate spontaneously after turn- 
ing, the patient and the unborn child must be watched very 
carefully. Generally the physician will remain with the 
patient, but if he should leave the nurse in charge for a 
short time she has a great responsibility not only to observe 
and judge the progress of labor but also to keep the patient 
clean with a limb projecting from the vulva. 
Changing Face to Vertex Presentation.—As labor is always 
more difficult in the face than in the vertex presentation 
it is generally desirable to rectify this abnormal presentation. 
If it is discovered early before the membranes rupture the 
physician generally waits until dilatation is complete, when 
he ruptures the membranes and rectifies the presentation, 
or if the membranes rupture spontaneously before the cervix 
is open he at once changes the presentation. If the mem- 
branes have been ruptured for some time and the waters 
have drained away the uterus will have contracted firmly 
around the body and the head will have passed far along 
in the pelvis, making the operation much more difficult. 
Here the head must first be pushed up out of the pelvis. 
In all cases it is necessary not only to flex the head but also 
to change the attitude of the body from that of the dorsal 
flexion to ventral flexion. Sometimes this operation is done 
wTith the patient across the bed, but usually the use of the 
table is preferable. The physician introduces one hand into 
the vagina and uses the other for external manipulation. 
The nurse, if she is not giving ether, assists by pulling the 
breech to one side while the physician with the external 
hand pushes the shoulders to the opposite side. 
After the operation, when the patient comes out of the 
anesthetic, it will be necessary to hold the head in the pelvic 
inlet during several pains in order that the contractions 
shall not bring back abnormal presentation. 
Other preparatory operations are occasionally required. 
When the hand or foot presents by the side of the head it 
must be replaced. Anesthesia may be necessary. When OBSTETRICAL OPERATIONS 
197 
the head rotates improperly after its descent into the pelvis 
so that the occiput is posterior, the physician may intro- 
duce his hand into the vagina and turn the head around 
so that the occiput comes to the front. The nurse may be 
asked to assist in rotating the body by external manipnla- 
Fig. 82.—Correction of face presentation by manipulation. Arrows 
show direction in which various parts of fetus are carried by operator. A, 
toward the pubes; B, toward the sacrum; C, breech toward mother’s anterior 
abdominal wall. (Thorn.) 
tion. Frequently this is done without ether. Sometimes 
in a breech presentation the breech descends into the pelvis 
and then becomes impacted and cannot go farther. Here 
the physician will push back the breech and bring down a 
leg. This requires complete anesthesia. It is followed by 
extraction, for which preparation must be made in advance. 198 
LABOR 
Expression of the Fetus.—Among the delivery operations 
the oldest and simplest is manual expression. From the 
earliest times of which we have record it has been the custom 
of midwives to assist in pressing out the fetus often with 
the crudest and crudest procedures. About thirty years 
ago Kristeller gave the indications for the operation and 
described in detail the method of carrying it out so that 
the operation is often called Kristeller’s expression. It is 
indicated only in the second stage of labor, and when there 
is delay and the pressing efforts of the mother are weak and 
insufficient. The physician stands at the side of the mother 
and grasps the uterus through the abdomen, with the thumbs 
in front and the fingers behind and at the sides, and presses 
the child downward. A certain degree of anesthesia, which 
may be entrusted to the nurse, is often necessary. Similar 
expression is made in breech extraction. 
Another form of expression is that applied directly to the 
head to force it into the pelvis. This was specially recom- 
mended by Hofmeier, and is sometimes called by his name. 
It is used when labor is delayed because the head cannot 
enter the moderately contracted pelvis. Anesthesia is also 
required here. 
Walcher Posture.— In the Hofmeier expression as well as 
in other operations where the head has not entered the pelvis 
because the inlet is too small the-patient is frequently put 
into the Walcher posture. In this posture, as shown in 
Fig. 83, the lower extremities are extended on the hips so 
as to pull the symphysis away from the promontory. When 
the posterior or sacro-iliac joints allow considerable motion 
the antero-posterior diameter of the inlet may be increased 
nearly an inch. This enlargement may make considerable 
difference in case of a tight-fitting head. 
In a hospital where there are a number of assistants and 
where a table can be had to lower the shoulders and raise 
the hips it is easy to secure this posture. In a private house 
it is more difficult. If the patient is on an ordinary kitchen 
table with the hips at the edge and legs hanging down she 
must be held by two or three people, especially when forceps 
are applied. Dickinson has proposed to secure elevation OBSTETRICAL OPERATIONS 
199 
of the hips, and thereby a more perfect posture, by using 
a kitchen chair firmly fastened upside down on to the bed 
or table and covering it with blankets and sheets. 
Fig. 83.—Walcher posture. 
Expressing the Head from the Vagina.—When the head is 
in the vaginal outlet, but held by a firm vulvar ring, it may 
be pushed out by pressing on the posterior wall of the birth 
canal at each side of the anus. This manipulation may 
also help to save the perineum from tearing. This measure 
is sometimes called the Ritgen expression, although that 
obstetrician proposed to introduce the fingers into the 
rectum to secure a better hold of the face or brow of the 
child. This, of course, contaminates the fingers and is no 
longer done. This manipulation is done only by the phy- 
sician, and should not be attempted by the nurse when she 
is alone with the patient and obliged to conduct the labor. 
Manual Extraction.—In foot or breech presentation, 
although labor may terminate spontaneously, the physician 
is always anxious for the life of the child. As soon as the 
body descends into the pelvis and passes through the cervix 
there is danger that the cord may be compressed between 
the shoulders or head and the sides of the pelvis or by the 
incompletely dilated cervix. This would cut off the supply 200 
LABOR 
of oxygenated blood from the mother and the fetus would 
suffer, just as a person suffers when he is deprived of air. 
The fetus might begin to make respiratory efforts and thus 
draw fluid into its lungs and down in the fruit water. 
To prevent this disaster the physician must be ready to 
interfere as soon as the hips begin to pass through the vulva. 
As a rule it is dangerous for the child to be more than three 
minutes passing out of the pelvis after the hips are born. 
Frequently the shoulders and head will be detained in the 
inlet or in the outlet, and traction on the portion of the 
body already born will be required. This is called manual 
extraction. 
All preparation for this interference should be made in 
advance. Some physicians prefer to deliver all breech 
presentations on a table. The nurse must then have the 
table in readiness in the confinement-room or in a neigh- 
boring room and assist in transferring the patient to the 
table before the hips appear in the vulva. Other physicians 
turn the patient across the bed. 
No anesthetic is given, as a rule, because all of the powers 
of the patient are needed to assist in the expulsion. If the 
patient should be very unmanageable it might be better 
to anesthetize her and rely upon traction and expression. 
The nurse must be prepared to conduct the anesthesia. 
In combination with traction, pressure on the uterus 
from above may be desirable. Here the nurse may be of 
great assistance. Pressure is applied directly to the child’s 
head in the direction of the axis of the inlet. 
In all cases of breech delivery it is necessary to have 
everything ready for resuscitating the child: Aspirating 
catheter, hot and cold water, oxygen, etc., as described on 
page 273. 
Sometimes, after turning, extraction is made immediately. 
The method of procedure does not differ materially from 
that just described for breech presentation. 
Some physicians apply the forceps to the after-coming 
head. They will, of course, require the forceps to be in readi- 
ness. OBSTETRICAL OPERATIONS 
201 
Forceps.—In a head presentation, manual extraction can- 
not be employed without turning the child. In olden times 
version and extraction was the method employed to remove 
a child when spontaneous delivery was impossible. About 
three hundred years ago the forceps was invented for the 
purpose of ending difficult labors with head presentation. 
It is designed to grasp the head and hold it safely while 
traction is employed to extract it from the obstetrical canal. 
Fig. 84.—Obstetric forceps: Milne-Murray axis-traction forceps, a 
common forceps with an English lock, a Naegele forceps with a notch lock, 
a Tarnier axis-traction forceps. 
The ordinary forceps consists of two crossed pieces or 
branches. Each piece consists of a blade, a handle, and a 
shank. The blade is the broad part, about 7 inches long, 
that is applied to the side of the head. It is generally 
fenestrated to make it lighter and hold better. It has two 
curves, a head or cephalic curve to fit the head and a pelvic 
curve to correspond to the curve of the pelvis. The handle 
is thick and corrugated and often has a hook so that it may 
be better grasped in the hand. The shank connects the 202 
LABOR 
blade and handle and elongates the branch so that it may 
be applied to the head when it is some distance above the 
vulvar outlet. The lock placed at or near the junction of 
the shank and handle is an arrangement for fastening the 
branches together. 
There are numerous varieties of forceps differing in more 
or less important details. They are generally named from 
the obstetricians who devised the modification. Some for- 
ceps are made with a short shank and used at the outlet. 
Fig. 85.—Preparation for forceps operation. 
They are called short or outlet forceps. In a well-known 
short forceps the blades are solid. The English or Simpson 
forceps have the English lock, two shoulders fitting together. 
The French forceps have a pivot lock. One other kind of 
lock very frequently employed is the notch lock. 
Forceps operations are classified as low, middle, and 
high. Low forceps is the application to the head in the 
lower half of the obstetrical canal. Middle forceps is the 
application to the head in the excavation or cavity of the OBSTETRICAL OPERATIONS 
203 
pelvis. High forceps is the application when the head is in 
the inlet or, rarely, above the inlet. 
While the ordinary forceps can be applied to the head in 
the outlet, or in the excavation it will not answer as well 
for high forceps, for with it we cannot make traction in the 
right direction. 
For use in the inlet, Tarnier devised a forceps that is 
sometimes called the inlet forceps, or more frequently the 
axis-traction forceps, because with it traction can be made 
in the line of the axis of the pelvis. The distinguishing 
feature of this forceps is the presence of traction rods and 
a handle. These rods are attached to the blades and pass 
below them out of the vulva, where they are bent back- 
ward so that the handle can be fastened low down. 
Forceps is indicated in certain cases when there is danger 
to either mother or child. Certain conditions of the pelvis 
and uterus must be present to justify an operation. The 
discussion of this important subject is not appropriate in 
this work. 
The operation would always be better made on a table. 
The physician needs 3 assistants: 1 for the ether, 1 to help 
hold the forceps and assist in expressing the child and later 
to care for the child, and 1 to bring solutions, towels, etc., 
and wait on him as may be required. Frequently, however, 
in private practice he must be content with the nurse and 
1 colleague who generally gives the anesthetic. The nnrse 
must prepare beforehand everything that may be needed, 
including solutions, sponges, douche, packing, and repair 
instruments. 
Caesarean Section.—When the pelvis is very small, for 
example, when the antero-posterior diameter of the inlet is 
less than 6 cm. or 2\ inches, the child cannot be delivered 
through the maternal passages and must be removed by 
Caesarean section; that is, through an opening made in the 
abdomen and the uterus. Such a contraction of the pelvis is 
said to furnish an absolute indication for Caesarean section. 
When the pelvis is larger but still too small for spontaneous 
labor at term we may choose between Caesarean section 
and other operations, namely, high forceps, symphyseotomy 204 
LABOR 
and hebosteotomy, induction of premature labor, and 
embryotomy. This degree of contraction, therefore, is 
said to furnish a relative indication for Csesarean section. 
The operation is also made sometimes on account of tumors 
in the pelvis which prevent normal delivery and for serious 
diseases of the mother, like eclampsia and placenta previa. 
When the absolute indication is present the operation 
must be done even if the child is dead and the mother 
already infected. In other cases Caesarean section would not 
be done for a dead child and rarely where there is infection 
of the mother. 
If the physician can select the time for the section he 
prefers to operate at the end of pregnancy, that is, a day 
or two before labor is expected. After labor has begun, 
and especially after the membranes have ruptured and 
after the patient has been examined, there is more danger 
of contamination of the patient and consequently more risk 
of infection. 
The operation should be made in a hospital if possible. 
Nowadays no laparotomy is made in a private house if the 
patient can be transferred to a hospital. In cities or large 
towns there are hospitals with fairly well-equipped oper- 
ating-rooms and attendants who understand to assist in 
major operations. In such places a patient requiring a 
Csesarean section would always be sent to the hospital. The 
preparation for any laparotomy in a private house is still 
described in text-books on surgical and gynecological nursing, 
and reference must be made to the directions there given 
for the preparation for Csesarean section should this ever be 
required in a house. 
The preparation of the patient and the preparation for 
the operation is the same as that for any laparotomy. If 
she is not in labor and there is no urgency she is given a 
laxative and enema the day before the opera ion. The 
genita' region is cleaned as has been described on page 135. 
Some obstetricians order a vaginal douche and perhaps a 
thorough scrubbing out of the vagina. If the latter is done, 
sterile cotton sponges soaked in lysol solution are used with 
the gloved fingers after the vaginal douche has been given. OBSTETRICAL OPERATIONS 
205 
The swabbing must be done very gently so as not to injure 
the vaginal mucous membrane. Ordinarily the vaginal 
cleaning, including douching, is omitted except in cases 
where labor has begun and the membranes ruptured, and es- 
pecially where numerous internal examinations and delivery 
manipulations have been made. An antiseptic dressing is 
applied to the vulvar region, which must be cleaned again 
before the operation. 
The abdomen is to be prepared as for any laparotomy 
according to the directions of the operator or the technic 
of the hospital in which the operation is made. Especial 
care must be used in cleaning the navel. 
Three nurses are needed for the operation: 1 for the 
instruments and sponges, 1 for general assistance, and 
1 for the baby. If there are enough nurses it may be 
better to have 1 nurse care for the sponges and another 
for the instruments. Both must be clean and wear gloves. 
The operator also requires 2 physicians as assistants, the first 
assistant who helps in the operation and the anesthetist. 
Five minutes before the incision the patient should receive 
a hypodermic injection of pituitary extract. Another in- 
jection should be prepared for eventual use during the oper- 
ation. Normal salt solution for hypodermoclysis should 
also be in readiness for use in case of shock or when much 
blood is lost. 
For asphyxia of the child there should be a tank of oxygen, 
hot and cold water in long basins or infant bath tubs, a proper 
tongue holder, and, of course, the usual aspirating catheter, 
as well as clamp forceps and ligature for the cord. 
The following instruments are required: 2 scalpels, 2 
scissors, 16 short and 8 long artery forceps, 4 long forceps 
for sponge holders, 4 tenaculum forceps, 4 strong curved 
needles for sewing the uterine walls, 4 tissue forceps, 4 needles 
for the serous coat, 2 needles for the fascia in the abdominal 
wall, and 2 skin needles and 2 needle forceps. This list 
contains twice as many instruments as are really needed 
and makes provision for any emergency that might arise. 
There should also be strong No. 2 or No. 3 catgut for the 
uterine wall, No. 1 or No. 2 catgut for the peritoneum and 206 
LABOR 
Fig. 86.—Instruments for Caesarean section. OBSTETRICAL OPERATIONS 
207 
fascia, silkworm gut for the skin, or horse-hair for the sub- 
cutaneous stitch if that is used. 
Laparotomy sheets and towels, pads and sponges, dress- 
ings, etc., are, of course, provided by the hospital or the 
operator. If the nurse who cares for these is in doubt 
concerning the wishes of the operator regarding the pre- 
paration or counting of sponges or any other detail of the 
technic she must inform herself in advance. 
Sometimes the uterus is eventrated before it is opened. 
This requires a long abdominal incision. After eventra- 
tion the neck of the uterus does not fill the opening and the 
intestines tend to roll out behind the uterus. This is pre- 
vented by bringing together the edges of the incision with 
two or three tenaculum forceps. If the uterus is opened 
and the child extracted before eventration its body is then 
drawn outside for suturing and the superfluous opening 
behind closed with the tenaculum forceps as in the first 
case. The uterus is protected from the forceps and line 
of incision by a large towel or laparotomy sheet. 
After the closure of the uterus the nurse must be pre- 
pared for any supplementary operation. The most com- 
mon is the sterilization of the patient by removing the tubes. 
For this the operator requires a scalpel, scissors, and suturing 
outfit. 
When the abdominal wound is closed dressings are applied 
and held in place w ith adhesive strips and a bandage. Sub- 
sequent control of the uterus is easier if the layer of dressings 
is not too thick. There will be considerable bloody dis- 
charge from the uterus and vaginal cavity if the operation 
has been done before labor begins. The vulvar region is 
to be cleaned and a large vulvar dressing applied as after 
delivery through the obstetrical canal. 
The subsequent treatment is that appropriate to a lapa- 
rotomy patient who is also a puerpera. She must be looked 
after carefully for twenty-four hours for vomiting, shock, 
hemorrhage, or pain. Thirst is relieved as soon as nausea 
permits. The bowels generally are moved on the third 
day with calomel, salines, oil, or a hypodermic injection of 
a physostigmine salt. The patient is encouraged to urinate 208 
LABOR 
and catheterization is seldom necessary. The vulva is kept 
very clean and occlusion dressings constantly employed. 
The baby can be put to the breast the third day, from which 
time the course differs but little from that in a normal labor. 
Porro-Caesarean Section.—The operation just described 
is generally called conservative Caesarean section, because 
the uterus is conserved or saved. If the uterus is already 
infected it is dangerous to try to preserve it, for the infection 
is hard to overcome and is likely to spread. Hence when 
the section of an infected uterus is necessary it generally is 
removed by amputation at the neck. Rarely uncontrollable 
hemorrhage after removal of the placenta may necessitate 
removal of the uterus in a case which was started as a con- 
servative section. The amputation of the uterus in con- 
nection with a section is called the Porro operation, after 
the name of the Italian obstetrician who first performed it. 
The list of instruments already given will suffice for this 
operation. 
Occasionally after the removal of the child the uterus is 
not amputated, but the entire organ is removed for infection 
or where there is cancer of the cervix. As the vagina must 
be opened it should be thoroughly disinfected beforehand. 
Extraperitoneal Caesarean Section.—Recently another oper- 
ation, called extraperitoneal Caesarean section, has been de- 
vised especially for unclean cases where section is indi- 
cated. The abdomen is opened low down, generally with 
a Pfannenstiel or transverse incision; the bladder is pushed 
to one side and the peritoneum pushed up so that space is 
obtained to open the cervix and lower part of the uterus 
below and outside of the peritoneum. In this way the 
possibly contaminated fruit water is prevented from enter- 
ing the abdominal cavity. After the emptying of the uterus 
it is sewed up and likewise the abdominal wound. As the 
uterus is preserved the operation is a modification of the 
conservative Caesarean section. 
The preparation for the operation differs little from 
other sections. The patient is generally placed in the 
Trendelenburg posture, that is, with the hips elevated. 
A few ounces of normal salt solution are injected into the OBSTETRICAL OPERATIONS 
209 
bladder just before the operation begins to aid in its manip- 
ulation. Retractors are necessary to hold the edges of the 
wound apart and to displace the bladder while preparing the 
uterus for incision. 
Suprasymphyseal, Cervical, Transperitoneal Caesarean Section. 
—In this operation the incision into the uterus is also through 
the cervix and lower uterine segment, but no attempt is 
made to keep outside of the peritoneum. That is incised 
as in the usual classical section, but of course low down. 
This operation is now preferred by some obstetricians to 
the incision higher up for nearly all cases where Caesarean 
section is indicated. Here as in the extraperitoneal section 
forceps are used in extracting the head. 
Postmortem Caesarean Section.—If the mother dies suddenly 
from any cause either during labor or in the last months of 
pregnancy the child may remain alive in the uterus for 
twenty minutes and can be saved if quickly removed by an 
abdominal section. This is called postmortem Caesarean 
section. No instruments are needed except a scalpel and 
no previous preparation is required. Afterward the incision 
is closed by sutures. 
Vaginal Caesarean Section.—When the pelvis is large but 
the uterus closed, delivery may be effected by opening the 
uterus from below. This vaginal Caesarean section may 
be indicated when the cervix cannot be dilated as in cancer 
of the cervix or when rapid may be necessary on 
account of eclampsia or other maternal disease. It was 
stated on page 193 that in urgent cases the cervix could be 
opened with incisions provided it was effaced. Before 
effacement the incisions in the cervix are not sufficient. 
It is here necessary to carry the incision up some distance 
into the body. The bladder is separated from the anterior 
vaginal and uterine walls, and the latter is then incised as 
far as the peritoneal covering. This is then pushed up and 
the incision extended as far as may be necessary. In vaginal 
Caesarean section the peritoneal cavity is not opened. The 
child is removed either with forceps or with turning and 
extraction. The closure of the wounds in the uterus, cervix, 
and vagina is made with catgut. Some begin repair in the 210 
LABOR 
uterus before removing the placenta, while others remove 
the placenta at once after extracting the child and pack 
the uterus to prevent hemorrhage. 
Fig. 87.—Instruments for vaginal Caesarean section. 
The operation is made like most vaginal operations with 
the patient in the lithotomy position at the end of the table. OBSTETRICAL OPERATIONS 
211 
It is very important to have a good light that can be thrown 
into the vagina. Three nurses are necessary: 1 for the in- 
struments, 1 for general assistance, and 1 for the baby. The 
operator also needs 3 physicians as assistants, 1 anesthetist, 
and 1 on each side to hold retractors and otherwise assist in 
the operation. 
The preparation of the patient is the same as for an ab- 
dominal section. The abdomen should be cleaned, because 
the turning of the child will make it necessary to manipulate 
through the abdominal wall. The vagina must be well dis- 
infected (page 204). The bladder and rectum must be 
empty. To protect the vagina from contamination from 
the anus a small towel may be fastened to the perineum and 
the buttocks by short tenaculum forceps or by sutures. 
The following instruments are needed: 2 large vaginal 
retractors, 2 large narrow retractors for holding the bladder 
away from the cervix, 4 Doyen forceps, 4 tenaculum for- 
ceps, 2 sponge forceps, 4 long artery forceps, 1 long-handled 
scissors, 4 curved needles, 2 needle holders, twenty-day No. 2 
catgut, obstetrical forceps, and also gauze for packing the 
uterus. 
Some operators also use a uterine bag or metreurynter 
as an aid in pulling down the cervix and as a guide in incising 
the uterine wall. 
Embryotomy.—Embryotomy means literally cutting up 
or cutting into the embryo. It is done for the purpose of 
making the fetus smaller so that it will pass through a con- 
tracted obstetrical canal. Sometimes both the head and 
the body are cut up. Much more frequently the head alone 
is cut open. This is called craniotomy. The perforation 
of the skull may be done with a pointed scissors-like instru- 
ment whose branches are sharp on the outside and cut 
wrhen opened. A sharp-pointed instrument that is pushed 
or screwed into the skull may also be used. After the per- 
foration a long tube or forceps is introduced into the skull 
cavity to break up the brain, which is pressed out of the 
opening as the head is compressed. After the perforation 
and consequent decrease in size of the head the delivery 
may be left to Nature. More frequently an instrument 212 
LABOR 
which grasps and compresses the head is used to extract 
it. Such an instrument is the Braun cranioclast. One 
blade is introduced into the cranial cavity to the base of 
the skull and the other one on the outside of the skull or 
face. They are then brought forcibly together by a screw. 
A cephalotribe is a modified obstetrical forceps with strong 
blades to seize the head and crush it. The instrument most 
used nowadays was devised by the French obstetrician 
Auvard, and is a combination of these two instruments. 
Fig. 88.—Embryotomy instruments: Braun hook; Auvard’s cranioclast; 
cleidotomy scissors; Braun’s cranioclast; Smellie’s perforator. 
It has three blades, the middle one of which is introduced 
into the skull cavity, a second, with which the inner blade 
forms a bone forceps like the cranioclast, and a third, which 
is applied to the opposite side of the head and forms with 
the second a cephalotribe. Generally the middle blade is 
sharpened to serve as a perforator. The operation of grasp- 
ing the head with the cranioclast, which involves more or 
less compression or breaking up, is called cranioclasis. The 
operation with the cephalotribe is cephalotripsy. A basio- OBSTETRICAL OPERATIONS 
213 
tribe is a modified cranioclast or cephalotribe designed 
especially for crushing the base of the skull. 
Craniotomy is indicated when there is a contracted pelvis 
and a dead child. The pelvis must not be too small else 
the child cannot be extracted even if the head is made smaller. 
We regard an antero-posterior diameter of the inlet of the 
pelvis of 6 cm. as the boundary line separating the indi- 
cations for craniotomy and the absolute indication for 
Caesarean section (see page 203). Formerly craniotomy 
was done even on a living child, but this operation is now 
almost entirely abandoned. 
Itarely the craniotomy is done without an anesthetic if 
the vagina is not sensitive. Usually, however, the extrac- 
tion follows the perforation, and anesthesia is desirable. 
The patient is in the lithotomy position on the end of a 
table prepared as for a forceps operation. The instruments 
required are the same as for forceps, with the exception of 
the perforator and cranioclast. 
Decapitation.—Version is a dangerous operation in a 
neglected cross-presentation after the liquor amnii has 
drained away and the uterus firmly contracted around the 
child and fitted to it. It is apt to cause that most serious 
accident, rupture of the uterus. If the child is dead, decapi- 
tation is much safer for the mother. This is done with a 
Braun hook. Anesthesia is required and the same pre- 
paration as for forceps. 
Removal of the Placenta.—The expression of the placenta 
has been described on page 172. The manual removal 
there alluded to is done only by the physician. No instru- 
ments are required, but the patient must be thoroughly 
anesthetized. The physician should wear a long gauntlet 
rubber glove to cover his forearm. The operation is gener- 
ally done with the patient across the bed, but sometimes she 
is put on a table. An intra-uterine douche must be in readi- 
ness as well as the outfit for packing the uterus. 
Repair Operations.—Tears of the cervix and the upper 
part of the vagina can be repaired satisfactorily only with 
the patient on a table and in a good light. Likewise exten- 
sive and deep tears of the perineum extending up into 214 
LABOR 
the vagina or back into the rectum can be mended much 
better with the patient on a table. Slight superficial lacer- 
Fig. 89.—Repair instruments. 
ations can be repaired with the patient in bed, her hips raised 
on a douche-pan, and frequently while waiting for the birth 
of the placenta (see page 187). OBSTETRICAL OPERATIONS 
215 
The repair instruments which should be in readiness 
after the labor in all primiparse and whenever required in 
multiparse are the following: 2, sometimes 4, vaginal re- 
tractors, 4 short and 2 long tenaculum forceps, 2 long and 
2 short artery forceps, 1 dressing forceps, 4 medium curved 
needles for the vagina, 4 larger needles for the perineum, 
1 needle forceps, No. 2 catgut 28 inches long, and several 
strands of silkworm gut. 
For good work the physician needs 4 assistants: The 
anesthetist, a clean assistant to help with the retractors 
and sponges, and another clean assistant to care for instru- 
ments and sutures, and a general assistant to care for sup- 
plies, light, etc. Generally, however, the physician must 
be satisfied with an anesthetist and 1 nurse. The patient’s 
legs are held with the sheet leg-holder, and the nurse stands 
at her right side and assists with the retractors. The 
instruments, sponges, etc., have been previously prepared 
and are placed on a table of sufficient size on the right of 
the operator. The nurse wears gloves while assisting with 
the instruments and removes them if she has to leave her 
post. 
Instead of attempting a difficult repair with too few 
assistants and with insufficient preparation many obstet- 
ricians defer the operation for a few hours or even for a day 
or two until satisfactory assistants can be secured. Some 
even refuse to make any immediate repairs and wait for 
several days, when the patients are carefully examined and 
all injuries attended to. This course often reveals obscure 
injuries that would be overlooked immediately after labor. 
Vaginal Douche.—The technic of the hot vaginal douche 
for postpartum hemorrhage has been described (see page 
175). The cleansing, antiseptic, vaginal douche, intra- 
partum and postpartum, should begin with the patient on 
her back on a douche-pan or on a drainage sheet. Whether 
water alone or normal salt solution or some antiseptic solution 
be used the water should be sterile. A fountain syringe of 
rubber or enamelware should always be provided, and this 
should be sterile as well as the tubing and glass douche- 
point. The receptacle should not be too high and give too 216 
LABOR 
great pressure. The quantity of water required depends 
upon the object of the douche, but generally 3 quarts is 
sufficient. The vulva must first be well cleaned and then 
the labia separated before introducing the tube. The nurse 
must remember that the direction of the vagina is backward 
and inward. 
Intra-uterine Douche.—This is given only by the physi- 
cian. If he employs it for postpartum hemorrhage he may 
use the usual vaginal douche-point because the cervix is 
still well dilated and there is no obstruction to the return 
of the fluid from the uterus. During the puerperium the 
douche may be employed in puerperal fever. As the cervix 
is now more or less closed he must provide for a return flow 
by using an intra-uterine douche-point, else the fluid might 
be forced out of the cavity of the uterus into or through the 
tubes. For the same reason he will not have the reservoir 
too high above the uterus. The patient must be on a table 
or possibly across the bed. ITe may get along without any 
instruments, but generally the nurse should prepare 2 
vaginal retractors, 1 tenaculum forceps for catching the 
portio, dressing forceps and sponges, and a solution for 
cleaning the vagina and cervix. 
Intra-uterine Tamponade.—The technic of the vaginal 
tamponade to prevent hemorrhage in placenta previa or 
abortion has been given (see page 92). The intra-uterine 
tamponade to control postpartum hemorrhage is used more 
freely by some physicians than by others. It is generally 
applied with the patient on her back across the bed, or better, 
on a table. As the operation is quite painful some physicians 
prefer to give an anesthetic. This reduces the shock of the 
operation, but also delays it. When the hemorrhage is 
severe and cannot be controlled with massage it may be 
necessary to pack immediately without ether in spite of the 
pain caused by the operation. 
The instruments needed are 2 vaginal retractors or 
a large Neugebauer speculum, 2 tenaculum forceps for 
holding the cervix, a dressing forceps, and a scissors. A 
strip of sterile gauze, 9 to 18 inches wide and 8 to 13 yards 
long, is needed for the packing. The physician may have OBSTETRICAL OPERATIONS 
217 
prepared this beforehand and brought it with him in a 
sealed tube or jar. If not the nurse must cut off a strip of 
proper width from the 25-yard roll of gauze of the patient’s 
outfit. 
For the packing the obstetrician should have 2 nurses 
besides the anesthetist. One is at the side of the patient 
and holds the retractors or assists in holding the uterus 
while the other holds the jar of gauze and if necessary one 
of the retractors. A packing tube enables the operator to 
dispense with one nurse and at the same time introduces the 
gauze without the danger of contamination. 
Hypodermoclysis. —The injection of a quantity of liquid 
under the skin is hypodermoclysis. The technic of the injec- 
tion for hemorrhage has been described on page 179. It is 
also used to overcome shock. Generally, normal salt solu- 
tion which is absorbed about as easily as blood-serum is 
the liquid chosen. To recapitulate here the rules for its 
administration it may be said: The needles must be large 
enough, the apparatus and solution must be sterile, the solu- 
tion must be kept warm, it must never be injected into the 
breast but some distance below the breast or into the front 
of the thighs, and not more than 10 to 12 ounces should be 
injected into one place. CHAPTER V. 
CHILDBED, LYING-IN PERIOD, PUERPERIUM. 
These terms are equivalent and are generally used to 
denote the period from the end of labor, that is, the birth 
of the placenta to the completion of the change in the genital 
organs when they resume a condition normal for a woman 
who has born children. 
Duration.—There is some difficulty in defining the dura- 
tion of childbed. If the term were used literally to denote 
the length of time that the patient remained in bed we should 
find that its duration varied greatly according to the social 
condition of the patient, the custom of the time and place, 
the ideas of the attending physician, etc. In some cases it 
would last four or five weeks, more frequently nine to twelve 
days, often only two or three days, while in the case of the 
North American Indian female there is, literally speaking, 
no childbed, for it is not her custom any more than that of 
animals to lie down after labor. If we should take the 
presence of the discharge or lochia as the measure of the 
duration of childbed we should also have some confusion. 
Although frequently the discharge ceases in about two weeks, 
still it frequently continues longer and often returns after 
the patient gets out of bed. Moreover it may run into a 
more or less permanent leucorrhea. It is therefore best to 
make the limit of the puerperium coincide with the resump- 
tion of the normal condition of the genital organs. After 
labor the uterus, its appendages, and the abdominal wall all 
begin to decrease in size. This process is called involution. 
It comes on with varying degrees of rapidity, but in ordi- 
nary normal cases it is completed in from six to twelve weeks; 
hence this may be considered the duration of the lying-in 
period. As a rule it is only during the first third or half of 
this period that the patient is under the care of the nurse and LOCHIA 
219 
physician. Yet the resumption by the patient of all of her 
household or social duties before the completion of this 
period may lead to incomplete involution with unpleasant 
and lasting complications. 
Lochia.—The discharge from the genitals during child- 
bed is called the lochia. For a day or two it is frequently 
composed mostly of blood, although it would not be proper 
to include under this term a severe bleeding or hemorrhage 
after labor. It comes chiefly from the uterus and may be 
considered a wound discharge. Besides the bleeding from 
the opened and injured vessels it is also due to desquamatory 
changes in the placental region and in the decidua, the 
transformed mucous membrane of the uterus. The dis- 
charge gradually becomes lighter in color, containing less 
and less blood until after seven to fourteen days it may be 
only a slimy or partly purulent discharge, which continues 
for a few days longer and then ceases. It may disappear 
for a few days to reappear when the patient sits up or moves 
around much or because of a displacement of the uterus or 
from some unknown cause. It may be difficult to distinguish 
such a reappearance of the lochial discharge from menstrua- 
tion. The quantity and duration of the lochia varies greatly 
in different women and also depends upon the character of 
the labor and other causes. It frequently has a peculiar 
and somewhat disagreeable odor due to decomposition caused 
by bacteria. If all bacteria in the vagina and on the vulva 
were destroyed during labor and kept away from the genital 
outlet afterward all odor would be prevented. This peculiar 
smelling lochia is not very dangerous, but as a sign of con- 
tamination it should be prevented as much as possible by 
care in the genital dressings. A more offensive lochia due to 
the colon bacteria and sometimes to other germs may indi- 
cate a more dangerous contamination. The presence and 
character of any odor as well as the color, nature, and quan- 
tity of the lochia, should always be carefully entered on the 
history sheet. The stoppage of the lochia indicates lack of 
drainage from the uterus and is not uncommon in cases of 
infection of the uterus; hence it should be watched for and 
reported. 220 
PUERPERIUM 
Care of Bed, Cleaning of Patient, and Care of Genitals.— 
As was said in the preceding chapter the contraction of the 
uterus should be carefully observed for several hours by 
examining frequently with the hand through the abdominal 
wall, and if it is found to contract poorly, sometimes becom- 
ing large and soft, while at the same time considerable blood 
escapes from the vagina, it should be stimulated to continued 
contraction by rubbing through the wall of the abdomen and 
by other measures before referred to. In cases of postpartum 
hemorrhage the change of the bed and dressing of the patient 
is deferred until the bleeding is stopped. When the vagina 
or perineum is torn the application of the dressing is also 
delayed until the lacerations are repaired. In normal cases, 
however, as soon as the after-birth is expelled the patient 
may be cleaned and the bed changed. If the draw-sheet or 
pad under the patient is much soiled it is rolled together and 
removed and a clean sheet underlaid. Then all blood-spots 
are washed off from her body, if necessary her night-dress is 
changed, and then the douche- or bed-pan is put under her 
and the external genitals thoroughly cleaned from clots with 
soap and sterile water and later bathed with sublimate or 
lysol solution. A large, thick napkin is then applied, the 
sheet with the rubber draw-sheet removed and a clean draw- 
sheet put under her, when the change from the labor-bed to 
the bed of the lying-in period is complete. 
The abdominal bandage may now be applied and the 
napkin fastened. Some physicians object to this bandage. 
If it is so applied that it can roll up and make a kind of 
cord around the middle of the body it becomes uncomfort- 
able and useless. If it remains on too long and becomes 
soiled with the discharge it becomes dangerous. But if 
properly applied it relieves the patient from the unpleasant 
feeling caused by the change in the pressure within the 
abdomen, prevents the tendency to displacement of the 
abdominal organs, especially if they have been previously 
prolapsed, and perhaps aids the patient in regaining a good 
shape. The bandage should be changed at least every day 
and as often as it becomes at all soiled. It should be made 
of strong cotton cloth, long enough to reach around the CARE OF PUERPERA 
221 
body and lap sufficiently to pin, and wide enough to reach 
from below the trochanters or upper projecting parts of the 
thighs to within 1 inch of the lower end of the sternum, 
that is, about 12 inches. The 4 yards of cotton cloth fur- 
nished in the obstetrical outfit is sufficient for 8 bandages, 
part of which may be used for breast bandages if desired. 
The abdominal bandage should be fastened in front with a 
sufficiently large number of safety pins to hold it smooth 
Fig. 90.—Abdominal and breast bandage and vulvar dressing. 
and well in place. The lower edge is drawn so tightly that 
it will not slip up over the trochanters. 
To this bandage, made and applied as described above, 
the vulvar dressing is fastened at each end so that it makes a 
fairly good occlusion bandage. The essential point is to 
make the ends of the dressing wide and fasten them firmly 
at the corners so that they fit well in the groins in front and 
against the sides of the back behind. In this way the dis- 
charge cannot run out between the thighs and abdomen 222 
PUERPERIUM 
along the groin as soon as the patient turns on her side, as 
generally happens if the dressing is fastened only in the 
middle or held in place with the ordinary T-bandage. 
The T-bandage is unsatisfactory not only because it does 
not hold the napkin well in place, but also because the piece 
which goes between the thighs is soon soiled and cannot 
be discarded without the whole bandage. 
The frequency with which the napkin should be changed 
depends upon the amount of discharge. The rule is to never 
let the napkin become saturated. When this occurs it forms 
a good soil for bacteria, which quickly penetrate to the vulva. 
As a rule the napkin must be changed every half to two 
hours for three or four times after labor, then for two days 
every three hours, and afterward every four to six hours, 
or as often as the patient passes urine or feces. Whenever 
a fresh napkin is applied the clean douche-pan should be 
put under the patient and the nurse with clean hands should 
wash off all traces of discharge from the whole genital region 
from the pubes to the anus, using plenty of warm water and 
soap. For washing she may have a basin of water and cotton 
or gauze sponges placed close to the douche-pan. Instead 
of sponging the parts for simple washing the vulvar or 
external douche may be employed. The water or solution 
in a pitcher is poured over the genital region until all dis- 
charge is washed away and then the labia are separated by 
the thumb and finger of the left hand and the vestibule 
thoroughly washed with the remainder of the liquid. Instead 
of the pitcher the irrigator may be used. If the patient has 
had a bowel movement she should be sponged. It is import- 
ant that the anal region should be thoroughly washed first, 
and care should always be taken not to rub upward, that is 
from the anus toward the vulva. Of course the sponge that 
comes in contact with the anal region should not be used 
in washing around the vulva. After the cleansing with soap 
and water the genital region is washed with a disinfectant 
solution, sublimate 1 to 2000, carbolic acid 1 to 2 per cent, 
lysol 1 per cent, according to the direction of the attending 
physician. Then the fresh napkin is applied. 
Not only must the napkin be changed as often as it becomes PUERPERAL FEVER 
223 
soiled, but the bedclothes as well. The draw-sheet or pad 
which can be easily changed should protect the lower sheet. 
The bed covering should be light and comfortable. The 
comfort of the patient depends much upon the care of the 
bed, which must be well made morning and night and con- 
stantly kept smooth and clean. 
Cared for in this way the chances are that the lochia will 
be free from odor, any repaired laceration will heal without 
any trouble, and no trace of fever be present. 
Formerly the vaginal douche was considered necessary 
in all cases to remove germs that might remain in the vagina 
after labor or to remove the lochia which was thought to be 
poisonous. Now it is pretty generally abandoned because 
of the danger that attends its routine use when by any lack 
of care healing wounds may be broken open and germs carried 
into the vagina from outside. Moreover it has been found 
to interfere with the power of cleansing itself which the 
vagina possesses. Hence it should never be given by a nurse 
unless it is ordered by the physician. It may be required 
when there is offensive lochia, for hemorrhage, or in cases of 
delayed involution of the uterus. For offensive lochia a 
cleansing douche generally of sterile water or a mild disin- 
fectant solution at a temperature of about 100° F. is given two 
to four times a day. In the third or fourth week of childbed 
a large, flabby uterus may be stimulated to contract and 
undergo the involution changes by a douche as hot as can 
be borne. 
An intra-uterine injection is sometimes used in cases of 
postpartum hemorrhage, and also occasionally in cases of 
infection of the uterus. It is a rather serious procedure and 
should always be given by the physician. Should he ever 
entrust this to a nurse he would give her special directions 
in the method of its performance. 
Puerperal Fever or Genital Wound Infection.—In all 
cases of labor in primiparae and frequently in multiparae 
some abrasions, if not tears, of greater or less extent, occur 
about the vulva and in the vagina and cervix. Moreover, 
the inside of the womb is practically a large raw or wound 
surface. These wounds, like wounds in other parts of the 224 
PUERPERIUM 
body, become infected when infectious matter, that is, 
matter containing bacteria, comes in contact with them. 
Before labor the germs may have been present in the vagina 
or on the skin about the vulva and rectum. They may have 
been brought to the wound by the hands of the patient, 
nurse, or physician before, during, or after labor. The 
wound may likewise have been infected by soiled napkins, 
clothes, or bedclothes. The bed of the patient may have 
been contaminated by a dirty bed-pan or by the soiled 
clothes of physician, nurse, or relatives of patient if they 
have sat on the bed. Impure water used to wash the wound 
may likewise be the source of infection; likewise a contami- 
nated douche. These sources of infection have been referred 
to when describing the preparation for labor. The air, which 
is so frequently accused as a source of infection, is probably 
very rarely the cause of trouble, and the elaborate precau- 
tions sometimes advised, such as stopping up the pipes of 
stationary washbowls, etc., are quite needless and superfluous. 
The severity of the infection depends upon the amount 
or extent of the infection, the nature of the infection, that 
is, the kind of infecting bacteria, and the resistance of the 
patient to the invasion of the germs. The most common 
infecting germs are the streptococci, or chain bacteria, 
similar to those which cause erysipelas; staphylococci, or 
bacteria which grow in clusters like those which commonly 
cause boils; gonococci, or those which cause gonorrhea; colon 
bacteria, that is, those which live in the colon, which cause 
disease when growing in wounds; the Klebs-Loffler bacilli, 
which cause diphtheria; and various germs which cause 
decomposition of dead matter. When only a few germs 
obtain access to a wound, or when the germs are not very 
virulent, or when the resistance of the tissues of the body 
is great, the germs may grow only a short time before they 
are killed and thrown off from the body. When the germs 
are present in great numbers, or more virulent in character, 
or the tissues less resistant, the infection may spread super- 
ficially or penetrate deeply, causing severe local and general 
disturbance. The method of extension of the infection 
differs according to the character of the bacteria; for example, PUERPERAL FEVER 
225 
streptococci penetrate deeply into the tissues, while gono- 
cocci spread over the surface, perhaps from the vulva into 
the vagina, through the uterus, into the tubes. The germs 
thus cause both local and general disturbance. 
Symptoms.—The local symptoms are heat, swelling, and 
tenderness of the region infected, together with more or 
less discharge which may or may not have an offensive odor. 
If the infection is quite circumscribed there may be so little 
trouble that the patient may remain quite unconscious of 
it. Sometimes the discharge is the chief symptom, but it 
may be confounded with the lochia and so pass unnoticed. 
Hence it is important that the nurse examine carefully and 
record on the history sheet the character of the lochia. There 
may be present one or more inflamed patches in the vulva 
or vagina which frequently become covered with a pseudo- 
or false diphtheritic membrane, and hence are called diph- 
theritic or puerperal ulcers. 
When the infection invades the uterine cavity we have an 
endometritis or metritis, generally attended with uterine 
tenderness. In these cases the infection is sometimes chiefly 
in the clots which close the vessels of the placental site. 
When these infected clots break down particles may get 
into the blood stream and be carried to different parts of 
the body. Here they may lodge in any of the organs, like 
the liver, and kidneys, and abscesses will be formed. This 
condition is called septicemia, septic matter in the blood, or 
pyemia, pus in the blood. Bacteremia is a more general 
term, that denotes bacteria in the blood and may occur with- 
out septicemia. The entrance of septic matter into the blood 
is attended with chills. 
If the infection penetrates into the tissues surrounding 
the uterus it may cause a large amount of serous or purulent 
matter to be poured out, causing tenderness and resulting in 
abscess or lasting pelvic disease. If the infection penetrates 
through the uterus and surrounding tissues to the peritoneum, 
or if it spreads through the tubes to this membrane, it causes 
either a local peritonitis limited to the membranes affected 
shown by local pain, or perhaps a general peritonitis shown 
by a general distention of the abdomen and much pain, 226 
PUERPERIUM 
with all the other serious symptoms accompanying this 
condition. 
When the infection is carried to the thigh and leg and 
deposited in the large lymphatics and veins of the inside 
of the upper part of the thigh it causes a swelling or edema 
of the limb which is in consequence very pale and is called 
“white leg” or “swelled leg.” This condition has also been 
called “milk leg,” because from its milky appearance it was 
supposed to be due to the milk that left the breast. In this 
condition the milk frequently dries up because of the fever 
and general infection. The Latin name for this condition 
is phlegmasia alba dolens. 
Besides the disturbance caused by the bacteria them- 
selves, either when they remain confined to certain localities 
or when disseminated throughout the body, there are other 
symptoms caused by the distribution through the body of 
poisons generated by the growing bacteria. We may suppose 
that as bacteria grow they produce a very deadly poison which 
readily passes into the bloodvessels and is carried to the 
brain as well as to all other tissues of the body. The amount 
of these poisons depends upon the extent of the infection, 
that is, the number of bacteria. In bacteremia, for example, 
the amount of poison produced might be very great. Their 
effects depend largely upon the kind of infection. For 
example, the poisons produced by the gonococci are much 
less serious than those produced by the streptococci. The 
circulation of these poisons gives rise to what we call the 
general symptoms of an infection, viz., chill, fever, rapid 
pulse, vomiting, loss of appetite, sometimes diarrhea, deli- 
rium, etc. It will be necessary to study these symptoms 
somewhat in detail. 
A chill may be of all degrees of severity, from a slight 
feeling of coldness to a severe shivering or shaking of the 
whole body. The temperature may be normal or subnormal 
at the time of the chill, but generally rises shortly afterward, 
or it may be high at the time. As a sign of infection it is 
important and should lead the nurse to take the temperature 
frequently after it. 
It is, however, important to know that a chill immediately PUERPERAL FEVER 
227 
following labor is a not infrequent occurrence, generally 
does not indicate any infection, and ordinarily need not 
occasion any anxiety. It is controlled by covering the 
patient warmly and giving her a hot drink. 
Fever is one of the most important symptoms of an infec- 
tion and is generally taken as an index of its severity, and, 
as we know, gives the name to the diseased condition, viz., 
puerperal fever. It is first necessary to define what is meant 
by fever. For practical purposes we have to draw an arbi- 
trary line. We say that a temperature over 100° F. is fever. 
In this way we allow for slight variations in the temperature 
of the body due to local rises in temperature, for example, 
such as result from the severe muscular exertion of labor. 
We assume what is almost always true, that a temperature 
of over 100° means an infection. Rise in temperature is 
often ascribed to worry or fright, but generally without 
reason. Also the common idea that the establishment of the 
milk secretion is attended with fever is contrary to the results 
of investigation. Hence we may confidently assume that 
fever after labor is due to some infection, either in the genital 
tract or the breasts, or in some organ not connected with the 
child-bearing process, like the throat, lungs, etc. 
Since increased temperature is an important symptom it is 
of greatest consequence that the physician may be able to 
rely absolutely upon the record made by the nurse. There- 
fore it is her duty to know that her thermometer is correct, 
that it is properly held by the patient, that the temperature 
is taken as often as necessary, and that it is correctly recorded. 
There are numerous variations in childbed fever corre- 
sponding to the differences in the infectious process, and 
temporary fever lasting from a few hours to two or three days 
is due to a limited infection which generally leaves behind 
little or no traces. The height of the fever determines the 
amount of intoxication by the bacterial poisons. If the fever 
is associated with an offensive discharge it denotes the pres- 
ence of germs of decomposition and the condition is not as 
dangerous as in the case of a similar fever where the lochia 
has no odor. A long-continued fever without peritonitis 
often denotes the presence of the infectious process around 228 
PUERPERIUM 
the uterus. All of the meanings of fever are learned only 
by much study. 
Next in importance to the study of the body temperature 
is that of the pulse. Immediately after labor the pulse is 
often uncommonly slow. A pulse rate of 55 to GO is not 
uncommon and sometimes as low as 45 to 50. The slow pulse 
rate may continue two or three days. The cause of this 
singular phenomenon is not certainly determined. Like 
the chill initiating the puerperium it has no pathological 
importance. 
Immediately after labor a rapid, weak pulse leads to the 
suspicion of hemorrhage, which should be carefully watched 
for. Later in childbed, fever is associated with a rapid pulse. 
The two symptoms, however, do not always go hand in 
hand. In the worst cases of puerperal sepsis the fever may 
be low, while the fast, soft pulse warns us of the seriousness 
of the danger. 
The other general symptoms already mentioned, head- 
ache, loss of appetite, vomiting, etc., need not be further 
considered, for they do not differ essentially from the same 
symptoms in other diseases of an infectious nature. 
Treatment.—In the treatment of puerperal fever, while 
the physician is responsible for the general management, 
the nursing is very important. Some physicians lay more 
weight upon the local treatment and some believe in a general 
symptomatic treatment, that is, they support the patient 
while Nature cures. 
Direct local treatment of a case, so far as the nurse is 
concerned, means generally vaginal douches. These are 
used especially when there is any odor to the discharge and 
when there are vaginal ulcers. The manner of giving such 
douches has been described already. In caring for a patient 
it is well for the nurse to keep constantly in mind the poison- 
ous nature of the discharge and avoid as far as possible 
contaminating with it her hands or clothing. When the 
hands become soiled they should be at once disinfected 
before the contamination has lasted long and before the 
hands have come in contact with other parts of the body 
and the clothing. Here is a place where the nurse should PUERPERAL FEVER 
229 
wear gloves, not to protect the patient but to protect herself. 
It would be well also for her to protect her clothing when she 
is caring for the patient by wearing a large apron. The vulvar 
dressing should be burned and the patient’s garments and 
bed-linen should be kept, until boiled, in a large bag separate 
from other wash. The excretions should be disposed of at 
once, the bed-pan boiled or sterilized with a strong antiseptic 
solution (1 to 500 sublimate solution). 
If a nurse is in a hospital and has care of a fever case while 
she is obliged to attend clean patients she must carry out 
these rules with the utmost thoroughness to prevent con- 
tamination. Not only must she have for the fever patient 
gloves and apron which are left in the patient’s room, but 
also she should wear gloves while waiting on other patients. 
It is much better that fever patients be separated from clean 
cases, and cared for by nurses that have nothing else to do. 
In the general or symptomatic treatment the most impor- 
tant indication is to relieve pain. For the relief of local pain 
in peritonitis, in milk-leg, etc., the warm, moist dressing is 
very valuable. This dressing consists of a wet cloth like a 
folded towel wrung out of warm water, covered with an 
impermeable material like oil-silk or rubber-cloth, and kept 
warm by placing over the whole a hot-water bag filled about 
one-quarter full with hot water. A swelled leg should be 
lifted on pillows or blankets and bandaged with cotton, with 
the moist dressings applied over the groin and inside of the 
thigh. An ice-bag or ice-water coil has much the same sooth- 
ing effect and is frequently to be preferred. 
The distention of the bowels with gas, or tympany, is a 
cause of much pain and disturbance to the heart and respira- 
tion. It can be relieved sometimes by medicine and fre- 
quently better by large enemata as described on page 73. 
High temperature in cases of puerperal fever is best con- 
trolled with a sponge-bath and with an ice-bag to the head. 
The various excretions of the body should be kept free. The 
kidney excretion is favored by the use of large quantities 
of liquid given by the mouth and by salt solution enemata. 
The bowel excretions are favored by the use of salines and 
enemata. The skin is kept in good condition by free bathing. 230 
PUERPERIUM 
The strength is kept up by attention to the feeding and 
by the careful conservation of all the body energy. The diet 
must consist of water, plain or carbonated; milk; easily 
digested food given with regularity at proper intervals. 
Often the patient is not hungry and would go for days with- 
out asking for food. Careful observation must determine 
what quantity of food the patient can take and digest and 
what is the proper interval for feeding. In the preservation 
of the strength of the patient we must not only avoid all loss 
of energy by any unnecessary exertion, but also the loss of 
heat which follows exposure. 
If the fever is high or lasts more than a day or two, lacta- 
tion must be suspended. Generally the secretion of milk 
will be lessened and its quality impaired so that it will not 
be suitable for the baby. Moreover, the strength of the 
mother, which must be conserved, is affected by nursing. 
She may be told that she will not lose her milk or that it will 
return as soon as the fever leaves. 
Puerperal Tetanus.—A special form of puerperal infection 
is puerperal lockjaw or tetanus. Like all forms of tetanus 
it is due to a special kind of bacterium that is often found 
on the ground or floor. The germ is especially found around 
horses and some other domestic animals. Cases of puerperal 
tetanus have been ascribed to the introduction of unclean 
ice or snow into the uterus to stop hemorrhage. It might 
be produced by the use of dirty cloths for napkins, or by a 
dirty douche-point. The treatment is that of tetanus from 
any other source and cannot be given here. 
Puerperal Insanity.—Another rare puerperal disturb- 
ance may be mentioned here, namely, puerperal insanity. 
It is occasionally the result of infection, but according to 
our present knowledge is also due to a variety of other causes, 
the chief of which is exhaustion following a severe labor in a 
weakened anemic person. The insanity generally takes the 
form of an acute mania, sometimes a melancholia. The 
attendants are generally forewarned of an outbreak by the 
unnatural, moody behavior of the patient. The manage- 
ment of the case consists chiefly in care and watchfulness 
to prevent the patient from injuring herself and others, and DIFFICULT MICTURITION 
231 
nourishment and attention to general health. The baby 
should be taken from the breast and removed from the pres- 
ence of the patient as soon as the condition is discovered. 
A large majority of the cases recover if managed properly, 
but the condition may last many weeks or months. 
Difficult Micturition.—After labor patients frequently 
have difficulty in micturition, that is, in passing urine. This 
difficulty is due generally to injuries to the urethra and base 
of the bladder during labor, with subsequent swelling and 
spasm of the bladder. It is likewise increased by the fact 
that the patient must urinate while lying on her back—an 
unusual position for her. Overdistention of the bladder, 
always to be avoided, is particularly harmful after labor. 
It may lead to a long-continued paralysis of the bladder 
muscle or to injury of the mucous membrane of the bladder, 
a condition which predisposes to infection. It also interferes 
with contractions of the uterus and thus favors postpartum 
hemorrhage. Hence the nurse should be on the watch for 
an overfilled bladder, especially as the patient is frequently 
unconscious of it. Sometimes a little urine overflows from 
a distended bladder deceiving both patient and nurse. With 
a little practice this condition can be determined by examin- 
ing with the hands and finding a soft mass above the pubis 
in front of the hard, contracted uterus. The uterus is fre- 
quently to one side and the bladder to the other side. Should 
there be any doubt whether a swelling in this location is 
bladder or bowel, percussion would easily show the difference 
between the dull sound of the bladder and the sound pro- 
duced by a distended intestine. Sometimes the bladder 
fills very rapidly after labor, and in the course of three or 
four hours extends nearly to the navel. Perhaps the patient 
did not pass her urine for some time before the child was 
born. In such cases the bladder should be emptied as soon 
as the condition is discovered, otherwise the patient may 
wait eight to ten hours. Rarely should the nurse delay 
longer than twelve hours after labor and then only if she be 
quite certain that the bladder is not overfull. 
It is always better for a patient to pass her urine than to 
have it drawn with a catheter. When a laceration has 232 
PUERPERIUM 
occurred, fear is sometimes expressed that urine flowing 
over the sutured wound may interfere with the healing. 
This fear is due to the not uncommon but erroneous idea 
that urine is in some way very poisonous. Urine from a 
healthy bladder is quite sterile and of course can cause no 
infection. It is not particularly irritating, and if the parts 
are washed off, as they should be immediately after urina- 
tion or even during urination not the slightest harm can be 
done. 
If the patient cannot urinate while lying on the bed-pan 
she may sometimes be helped by pressing with the hand 
over the bladder or by such well-known expedients as using 
hot fomentations over the pubes, hot water in the bed-pan, 
letting water run from a faucet and from a pitcher. Some- 
times a patient can urinate after an enema while emptying 
the bowel. All these measures, however, are often futile, 
and then it may be necessary for the patient to rise to the 
sitting posture. It will be found that the easiest position 
for the patient is when she is kneeling with the chamber-pot 
between the knees and legs. She throws one arm over the 
shoulder of the nurse, who sits partly behind her and sup- 
ports her with an arm around her body. As this is the posi- 
tion that the patient may have to take when her bowels 
move, it is desirable that the nurse know exactly how to 
bring her patient into this attitude easily and support her 
securely. 
Of course if the patient is very weak from any cause, and 
particularly if she has lost much blood, this treatment 
would not be employed. In normal cases, however, no 
harm will result. Some physicians prefer to have the patient 
get out of bed. Many might object, however, to having a 
patient sit up, and therefore it would be well in case the 
nurse does not know the ideas of the attending physician in 
this regard to ask him whether she shall catheterize the 
patient, in case micturition is impossible, in the horizontal 
position or if the sitting posture should be tried. 
When for any reason it is not desirable that the patient 
should be raised from the horizontal position or when she 
cannot urinate even sitting it becomes necessary to catheter- DIFFICULT MICTURITION 
233 
ize her. Here the nurse is obliged to assume a grave responsi- 
bility. The great majority of cases of cystitis or inflamma- 
tion of the bladder have been caused by the catheter. There 
are two dangers in catheterization: (1) Injuring the bladder 
wall, and (2) carrying infectious germs into the bladder. 
By the careful use of a smooth-glass catheter, which is the 
only kind to be employed by a nurse, there is not much 
danger of a severe injury to the bladder; yet it may often 
happen that a contraction of the neck of the bladder upon 
the introduction or the withdrawal of the instrument may 
cause some injury to this region in spite of the best technic. 
Undoubtedly the great danger is that of infection. Even 
if the catheter is made absolutely sterile by boiling, which 
should always be done, the frequent presence of large 
numbers of bacteria around the mouth of the urethra, often 
penetrating a third of an inch into the canal, makes it very 
hard to avoid carrying them into the bladder. The follow- 
ing rules should be strictly followed: (1) Disinfect the hands; 
(2) boil the catheter; (3) disinfect the genital region as 
already described, using the irrigator and having the patient 
in a good light; (4) separate the small lips with one hand 
so that the mouth of the urethra is clearly seen, and with the 
other hand thoroughly douche the vestibule with quantities 
of sterile water, directing the stream so as to wash out the 
mouth of the canal; (5) substitute for the irrigator-point the 
catheter, insert it into the urethra about a third of an inch 
and let the water run for a minute, then leaving the catheter 
in the urethra, disconnect the tube and push the catheter 
into the bladder (no lubricant is required); (6) when the 
urine ceases to flow in a stream, without waiting until the 
last drop is expelled, remove the catheter and once more 
wash off the vulva with the irrigator. Where the irrigator 
is not used the vestibule and mouth of the urethra are cleaned 
with sponges, after which the catheter is introduced without 
using it first as a douche-point to wash out the bacteria from 
the urethra. 
Frequently one catheterization is all that is required, the 
patient being able to empty the bladder afterward. If the 
catheter must be used for several days the danger of infection 234 
PUERPERIUM 
is much increased, because it is very natural for the nurse 
to relax in her efforts. Conscientious thoroughness is here 
of great importance. 
The nurse was formerly taught to catheterize “by the 
touch” or “under the sheet.” The mouth of the urethra 
was found through the sense of touch by the fingers of one 
hand and the catheter, held in the other hand, pushed into 
the bladder. It was considered a great feat and almost 
a test of a good obstetrical nurse to be able to find the right 
opening and carry the catheter into it without first pushing 
it into the vagina or perhaps the rectum. The false modesty 
that dictated this foolish practice has now been driven 
away by the general spread of the knowledge of germ dis- 
eases, and the practice is only mentioned to be condemned. 
For the first week the quantity of urine passed by the 
patient should be estimated or measured and recorded on 
the history sheet. 
Constipation.—The majority of women in childbed are 
constipated. The chief factors that bring this about are 
fecal retention during pregnancy, the causes of which are 
discussed in Chapter III, the frequent lack of coarse food 
in the diet, the absence of exercise, the horizontal position 
of the patient, and the lax abdominal walls. The degree in 
obstinacy of the constipation varies much with different 
patients. Sometimes a regulation of the diet, a dose of salts, 
an ounce of liquid petrolatum, or a simple enema are all the 
measures that are required. In other cases of long-continued 
constipation with large accumulations in the intestine, the 
management of the bowels may be the most difficult part 
of the nurse’s duty in the care of the case. The patient 
should have an evacuation of the bowels every day. For 
the guidance of the physician the nurse should always report 
fully not only the number of bowel movements but also 
their character, the amount of difficulty experienced in 
defecation, and also between the bowel movements the 
amount of gas in the bowel and the amount of discomfort 
arising from it. 
The measures employed by the nurse to relieve constipa- 
tion and its attendant discomforts are massage and enemata. CONSTIPATION 
235 
In performing massage it is necessary to remember the course 
of the large bowel. Starting in the lower part of the abdomen 
near the middle of the right groin, it passes lip to the liver 
under the ribs as the ascending colon, crosses to the left side 
as the transverse colon, and descends to the left groin as 
the descending colon, terminating in the sigmoid flexure, 
which ends within the pelvis in the rectum. In the lax con- 
dition of the abdominal walls after labor it is reached more 
readily than at any other time. Much of it is covered by the 
small bowel, especially where the latter is at all distended 
with gas. The portions of the large bowel most readily 
accessible are the beginning of the ascending colon, the 
middle of the transverse colon, and the lower part of the 
descending colon. Massage acts in two ways: (1) The con- 
tents of the bowel, liquid or solid, are moved along mechani- 
cally, and (2) the worm-like or peristaltic movements of the 
intestine are stimulated. When massage is combined with 
an enema the liquid is first carried backward to the beginning 
of the colon by the reversed movement and then forced out 
again. By keeping in mind the location of the colon and the 
object of massage an intelligent nurse with a little practice 
can do fairly well even without special training in the technic. 
The manipulations which are executed over the accessible 
portions of the colon may be made with the ball of the 
thumb or the outer side of the hand or with the fingers, the 
skin moving with the hands. Pressing over the abdomen 
with the hand during defecation may also be of value in 
forcing along the contents of the colon. 
The enemata employed in childbed are of various kinds. 
The amount may vary from 1 dram to 3 quarts. Plain 
water or glycerin or oil may be used, and also various water 
solutions of common salt, Epsom salts, soap, turpentine, 
glycerin, etc. The injection may be cold, tepid, or warm. 
Injections of 1 to 4 drams of glycerin or glycerin and water 
may be given with a small glass or hard-rubber or piston 
syringe; larger amounts are generally given with the fountain 
syringe. The rectal point, whether of glass or of hard rubber, 
should be smooth and clean. An old, cracked, hard-rubber 
point or one with a rough end might cause an abrasion of the 236 
PUERPERIUM 
mucous membrane while being pushed, perhaps roughly, 
through the sphincter ani and lead to an infection or an 
obstinate wound. For this reason some prefer to use always 
a soft-rubber tube that has two opposite, smooth side-open- 
ings or eyes about 1 inch behind the somewhat blunt, taper- 
pointed end. It should be coated with a clean lubricant. 
The amount, kind, and temperature of the injection should 
be specified by the physician. If a patient suffers with con- 
siderable gaseous distention of the bowels an injection of 
1 ounce of glycerin, 1 ounce of magnesium sulphate, and 4 to 
6 ounces of water is frequently ordered. 
Sometimes the rectum and sigmoid flexure are stopped 
up with an impacted mass of feces that cannot be washed 
out with an injection. Here it will be necessary to insert 
the finger, well lubricated and protected with a glove, and 
break up the mass little by little, using the irrigator with 
soap solution, from time to time, to wash away the loosened 
particles. 
When there is an accumulation in the colon the so-called 
colonic washing or lavage is indicated. This may be given 
in the following way: The bed being protected with rubber 
sheets and pads and the bed-pan being at hand, the pelvis 
is raised so that water may run into the bowel by lifting the 
foot of the bed. Normal salt solution 1 level teaspoonful 
to a pint of water, or a soap solution, both at a temperature 
of about 70° F., is used. The end of a large soft-rubber tube, 
about No. 30 of the French scale, connected with the irrigator, 
elevated 1 or 2 feet above the patient, is introduced 3 or 4 
inches into the rectum and the water allowed to run. No 
attempt should be made to carry the tube into that portion 
of the bowel that lies above the promontory or inlet of the 
pelvis. The tube will simply coil around in the gut. When 
the patient begins to feel uncomfortable the flow is stopped, 
the rectal tube disconnected and allowed to empty into the 
bed-pan; then this procedure is repeated four or five times. 
Not all of the water returns through the tube each time the 
rectum is emptied, but some of it remains in the colon, and 
finally a sufficient quantity has passed to stimulate thor- 
oughly the peristalsis and effect a good evacuation. If this 237 
DIET 
washing is repeated once or twice a day for several times 
the entire colon will be well emptied without the disturbance 
caused by the use of the usual large tepid enema. 
Diet.—As a rule the physician gives directions concern- 
ing the diet of the patient in childbed. As in so many other 
questions not obstetrical, there also exist here antiquated 
and unfounded notions, so that it is desirable for the nurse 
to know the principles of dietetics in order that she may be 
able to assume safely whatever responsibility is thrown 
upon her. 
There are prevalent two common erroneous ideas con- 
cerning the diet of women in childbed: One is that hearty 
food, especially meat, etc., will cause fever. There is, of 
course, absolutely no basis for this notion. The cause of 
fever is infection from some source, in the great majority 
of cases from genital wounds or from breast wounds. Indi- 
gestible food, like salads or pickles, may distress the stomach 
and make the patient uncomfortable, but only in that way 
can the food harm her. 
The other common error is that very many foods injure 
the milk secretion and harm the nursing infant. Particu- 
larly are sour substances like fruit thought to be harmful. 
About all the exact observations that have been made on 
this subject, however, tend to discredit this popular notion. 
Even pickles and salads, which may be harmful because 
they produce indigestion, have no effect on the demonstrable 
chemical composition of the milk nor on the nursing child. 
Hence the problem of feeding the mother does not differ 
from that of feeding any other individual under similar 
conditions. Food is for the purpose of replacing the outgo 
of the body, including both the waste and the secretions and 
creating heat and motion. The outgo from a woman in 
childbed includes the loss from the ordinary excretions and 
also from the hemorrhage, lochia, and the breast. During 
labor a woman loses in the child, fruit-water, blood, and 
perspiration one-tenth of her weight. Generally she cannot 
take much food and the energy consumed by severe muscular 
exertion and pain is lost. Within one week after labor she loses 
about one-half as much more in the lochia and excretions. 238 
PUERPERIUM 
Hence we see the necessity for a liberal diet. Moreover she 
must supply from 1 to 3 pints of milk a day. On the other 
hand she has no great waste of heat, for she is covered in 
bed and there is very little expenditure of energy in motion. 
The conclusion drawn from these facts as well as from clinical 
observation is that the diet for a nursing woman in childbed 
should not differ essentially from the mixed diet proper for 
a woman during pregnancy. 
The proper mixed diet for a person not engaged in much 
muscular work is one that contains about 3 ounces of solid 
proteids, 2\ ounces of pure fat, and 10 ounces of carbohy- 
drates, that is, sugar and starches, with 3 to 4 quarts of 
water. About to 2 quarts of water are contained in the 
food, including fruits, soup and milk, while 1 to 2 quarts 
are drunk as a beverage. A simple dietary for a day may 
be given as an example: 
On wakening, about 7 a.m., a cup of hot milk. 
Breakfast, 8.30 to 9 a.m. Fruit: Apples, oranges, pears, 
grapes, etc. Coffee with cream, oatmeal and cream, eggs, 
toast, and butter. 
1 p.m. Fruit, chopped beef or steak, potatoes, peas, toast, 
butter, tea with cream. 
Dinner, 6.30 p.m. Soup, chicken, rice, toast, butter, 
pudding, etc., coffee. 
Any diet is to be arranged to suit the needs, the condition, 
and the appetite of the patient. For the first day it usually 
happens that she has no appetite for much solid food, but 
craves quantities of liquid. This is because of the great loss 
of water during labor from perspiration and perhaps from 
hemorrhage. This desire should be gratified and solid food 
not forced on the patient. If, however, she is hungry and 
wishes a hearty meal immediately after labor, there is no 
reason why this wish should not be gratified. To force a 
liquid diet upon a patient who has no need for great quanti- 
ties of liquid is as unwise as to force solids upon a patient 
who needs liquids. The same remarks apply to some' extent 
to different articles of diet and especially to the use of alco- 
holic drinks. A patient who is accustomed to the use of 
beer or wine with her meals may suffer from their withdrawal, DIET 
239 
while to force such drinks upon one who has never used alco- 
holic drinks with the idea that they are specially needed is 
equally unwise. One must use common-sense, seeking only 
to give enough food to supply the needs of the individual, 
trying to combine the food elements approximately correctly 
and avoiding substances known to be difficult of digestion. 
The questions frequently arise (1) whether the quantity 
of milk may increase or diminish by diet, and (2) whether 
the quality can be so changed. The amount of milk is 
diminished by greatly lessening the quantity of food, while 
free feeding frequently increases the milk secretion. A 
decrease in the quantity of milk is very rarely desired except 
perhaps during the short period of breast congestion that 
occurs during the third to the fifth day. While there may 
be no objection to a restriction of the diet at this time, still 
such restriction is hardly necessary, for the disturbance may 
be managed without difficulty by the rules given on page 243. 
The best way for a nursing mother to increase the supply 
of milk is to eat plenty of nourishing food. The common 
idea that taking much liquid will increase the milk is largely 
erroneous. Too little water may interfere with the secretion, 
but milk is formed from the solid elements of the food, and 
they are absolutely essential. Beer, malt extracts, etc., 
which are much renowned as galactagogues or milk producers, 
probably owe their reputation to their property of stimulating 
the appetite and thus inducing a better nutrition. Of the 
solid elements of food it is probable that the protein or nitro- 
genous element is most important in producing milk. It 
has been proved that all the elements of milk, including the 
fat, may be produced by the breaking up of the protein 
particles. The fat of milk, for example, does not come from 
the fat of food, but from the proteins of food. For this 
reason pure albumens have been used as milk-producing 
agents and much advertised on this account. 
There is a limit to the quantity of food that can be taken 
with advantage. If a woman who is underfed secretes too 
little milk, increasing her food consumption will probably 
increase her milk. A well-fed woman will not be so affected. 
If she has a deficient secretion it is probably due to some 240 
PUERPERIUM 
deficiency in the structure or function of the breast not 
dependent on her eating. It is unwise to feed such a patient 
more than she needs in the attempt to increase the supply 
of milk. Even when some increase in food increases the milk 
it does not follow that the increase can be continued indefi- 
nitely. Over-feeding a patient is always worse than useless. 
The quality of the food and the method of serving it have 
an important effect on the breast secretion. Not only is 
the appetite stimulated by savory, well-prepared food and 
a greater quantity is taken without forcing, but also the 
nervous control of the secretion seems to be affected just 
as the nervous mechanism of the salivary and gastric secre- 
tions is affected. Hence the nurse should get the cooperation 
of the cook in preparing the food, and then see to it that the 
meal is served properly. 
The question whether the properties of milk can be changed 
by varying the composition of the mother’s food cannot at 
present be answered definitely, for sufficient scientific observa- 
tions have not been made to give any basis of fact. If it were 
possible to increase the fat of the mother’s milk, for example, 
or to decrease the albumen of the milk when this element is in 
excess by changing the diet, such a food would be of very 
great value. It can only be said that an average mixed diet 
is best adapted to give milk of proper composition. 
The frequency of feeding or the number of meals per day 
is a question that often arises. If the stomach be in a normal 
condition the ordinary rule of three meals a day, with perhaps 
a drink of hot milk early in the morning, is the best rule to 
adopt. If the patient wants a light lunch late at night or 
between meals it may be allowed. The case is different if 
the stomach is unhealthy—a condition not uncommon. One 
of the abnormalities most frequently met with is the dilated, 
prolapsed stomach. Such an organ does not empty itself 
properly and the partly digested remaining food ferments 
and causes a very disagreeable sensation. Putting additional 
food into such a stomach would evidently add to the trouble. 
The common-sense rule in such a case would be to give food 
only after the stomach is emptied. 
in such cases it is often of much value to assist the emptying BREASTS 
241 
of the stomach by a simple kind of massage. About two to 
three hours after meals, when the movements of the weakened 
stomach have been feeble, the nurse, standing beside the 
patient, facing the foot of the bed, grasps the abdomen with 
both hands so as to get below the stomach and raise it, 
making kneading movements to empty its contents into the 
small bowel. The patient may incline slightly toward the 
right side. This maneuver may be assisted by having the 
patient drink a small quantity of some carbonated water. 
This procedure is kept up for five minutes and may be repeated 
in half an hour if necessary. It would be unwise, however, 
to empty at one time too large an amount of the acid con- 
tents of the stomach. 
In all these cases it is important that the patient does not 
drink large quantities of liquid with her meals or shortly 
after them. The rule should be to drink what is needed 
fifteen to thirty minutes before meals. Careful management 
of the stomach is very necessary for the satisfactory progress 
of the patient and particularly for the proper milk supply 
of a nursing mother, and hence requires the most intelligent 
attention of the nurse. 
Breasts.—Nearly every woman in childbed requires that 
some attention be paid to the breasts. More than half of 
all nursing women have abrasions of the nipple of greater 
or less extent. These, if neglected or improperly managed, 
may lead to infection of the breast with abscess formation, 
much suffering, and great injury. Moreover, when the 
breasts become diseased the children lose their proper nour- 
ishment and as a result much sickness and many deaths 
occur. Hence no subject is of greater importance to nurses 
than that of the proper management of the breasts. 
How often and how long at a time an infant shall nurse 
concerns both mother and child. Considering now only the 
mother, we observe that if the infant nurses too often or 
too long the mother loses her rest, wastes her strength, and 
becomes exhausted. Moreover, if the child holds the nipple 
very long in the mouth it becomes softened and more easily 
wounded and infected. When speaking of the care of the 
child we shall give rules on this point; here we shall only 242 
PUERPERIUM 
remark that ten to twenty minutes are about the proper 
length of the nursing, and once in two to four hours is often 
enough. 
Colostrum.—For from one to three days after labor the 
secretion of the breast has not the composition of ordinary 
milk. This first secretion is called colostrum. The quantity 
of colostrum that the child can get by nursing varies from 
1 or 2 drams to an ounce. It is very important that the 
infant obtain this colostrum both because it has considerable 
value as food and because it has a certain laxative effect 
that is good for the child. Moreover, the act of nursing is 
important for the mother because it stimulates the contrac- 
tion and retraction of the uterus and thus tends to prevent 
hemorrhage and assists in the proper involution of the uterus. 
Also the stimulation of the breasts by the act of nursing 
favors the beginning of the secretion of milk, so that the 
milk “comes in” earlier and with less disturbance than when 
the child is kept from the breast. Therefore the child should 
be put to the breast as soon as it is cared for and dressed, 
unless the mother be very weak from hemorrhage or the 
exhaustion of labor. For the first two or three days the 
child may nurse every three to six hours, according to its 
condition and that of the mother. The remark frequently 
heard, that the mother has no milk, need not be regarded 
too seriously, for it is not milk that we expect the child to 
obtain. The child will generally get some breast secretion, 
that is, colostrum, even when the breast seems empty to 
the superficial observation of the patient and her relatives. 
Distention of the Breast.—Gradually this first secretion 
changes to the ordinary milk and generally the third day 
the breasts begin to fill. This condition of fulness or disten- 
tion of the breast, also called congestion or engorgement, is 
frequently attended with considerable pain. It is important 
that the nature of this condition be well understood. Many 
nurses believe that this distention of the breast is caused by 
the milk which fills the milk tubes or ducts, and there is a 
general fear that this milk may stagnate and, if not emptied, 
cause caked or inflamed breasts. This conception of the 
cause of distention is largely false and the fear entirely 
groundless. BREASTS 
243 
The distention is caused largely by the swelling of the 
gland cells that are secreting the milk and by the fulness 
of the blood and lymph vessels and the lymph spaces that 
surround the glands. If these vessels be emptied by massage, 
as will be described later, the distention of the breast dis- 
appears although not a drop of milk has been evacuated. 
Moreover, decomposition of milk in the healthy breast 
never occurs. 
Sometimes a woman cannot or should not nurse, as when 
the child is dead or when she has tuberculosis or some serious 
disease that would make the drain of nursing a menace to 
the life of the mother. Here the breasts should be supported 
by a bandage and relieved by massage or ice-bags, and in a 
short time the congestion of the vessels will disappear while 
the milk in the ducts will be absorbed, leaving no bad effect. 
These facts show that congestion of the breast, however 
painful, is not dangerous and should give rise to no anxiety. 
It should be carefully distinguished from the results of infec- 
tion of the breast. The filling of the breast is never attended 
with fever, that is, with a rise in the temperature of the body 
to 100° F. The breast may be very tender, hot, hard and 
swollen, but the thermometer in the mouth or rectum shows 
no fever. 
The management of distention of the breast has for its 
object the relief of the local pain. Four measures will be 
considered: (1) Evacuation of the breast with the hand or 
pump, (2) support by bandage, (3) application of ice-bag, and 
(4) massage. 
Pumping.—Evacuation of milk either by milking with 
the hand or by the use of the breast pump will often give 
temporary relief. It is objectionable because both the hand 
and pump cause irritation of the breast, because the stimu- 
lation of the breast by these measures is not desirable, and 
because it is not necessary. Whatever relief is given by the 
nursing of the child is of course desirable. It may be neces- 
sary to obtain milk to feed a very weak child that cannot 
nurse; otherwise, if the following directions for supporting 
and massaging the breast are carried out, no pump will be 
needed. 244 
PUERPERIUM 
Bandage of Breast.—The support of the breast is an impor- 
tant means of relief. Pain or disturbance of the full breast 
is caused chiefly by the dragging down of the healthy gland 
as the woman lies on her back. She may not be able to lie 
on her side because of the pressure on the lower breast or for 
other reasons. The glands may be supported from below 
by pillows pressed against the sides, but better by bandages 
which hold them in place. The object of the bandage is 
support and not compression. It must be applied so as to 
Fig. 91.—Breast bandages. 
give relief and not cause more pain. This will be accom- 
plished if it is applied so as to hold the breast to the front of 
the chest. 
The simplest bandage is most easily applied and quite 
satisfactory. It is a piece of strong cotton cloth long enough 
to go around the body and lap sufficiently to pin in front. 
It should be about 16 inches wide with notches 7 to 8 inches 
deep for the shoulders over which the edges of the notches 
are pinned. It is applied as follows: The patient should BANDAGE OF BREAST 
245 
lie on her back near the edge of the bed, the bandage under 
her, its notches fitting well in the axilke. The nurse now 
takes hold of one end of the bandage with one hand and with 
the other hand draws up the breast quite well to the front 
of the chest, where it is held by the bandage. Then the 
patient with a hand under the breast, fingers and thumb 
being extended, holds it in place. The other breast is drawn 
Fig. 92.—Application of breast bandage. 
up and supported in the same way. Then the bandage is 
fastened with five medium-sized safety pins, the lower edge 
of the bandage being drawn perhaps a little tighter than the 
upper edge. The flaps are then fitted well over the shoulders. 
This bandage of course must be opened every time the child 
nurses and afterward reapplied. 
Sometimes the double Y-bandage is preferred. It is made 
out of the strongest cotton cloth and consists of a back piece 246 
PUERPERIUM 
4 to 5 inches wide and 14 to 20 inches long, to each end of 
which are strongly sewed two diverging strips, each 4 to 5 
Fig. 93.—Breast and abdominal bandages applied. 
inches wide and about 12 inches long. The lower limbs of 
the Y’s, which go under the breast, are fastened together in 
front with safety pins, then the upper limbs in the same 
Fig. 94.—Double Y-bandage. 
manner. With this bandage the nipples are left free so that 
pressure upon them is prevented and the nursing of the child MASSAGE OF THE BREAST 
247 
allowed without unfastening the bandage. The upper and 
lower limbs of the Y’s in front may be fastened together with 
a safety pin better to support the inside of the breast. 
Ice-bags.—If the breasts are very sensitive and not suf- 
ficiently relieved by the bandage, ice-bags should be applied. 
The large, strong, vulcanized canvas bags are more desirable 
than the rubber bags and can be fitted better to the breast. 
The axilla and arm should be protected by cloths. If the 
tender part of the breast is on the lower or outer side, the 
Fig. 95.—Ice-bags applied to breasts. On the right breast is a large, 
strong, vulcanized, canvas cap-bag supported by a pillow, and on the other 
a pig’s bladder fastened to the breast bandage with safety pins. 
bag is applied and held in place by shoulder pillows. If the 
upper, middle, or inner part of the breast is chiefly affected, 
the bag is then applied and held to the bandage with strings 
or safety pins. The patient must be in bed, of course, and 
the breast kept supported with the bandage. 
Massage of the Breast.—Massage of the breast is a measure 
which has been so often misused that it is a question whether 
it has not caused more harm than good; yet, if it be pro- 
perly done in suitable cases it may be of great value. It 248 
PUERPERIUM 
should be used only in cases of painful distention due to 
congestion, and never in cases of infection. The proper 
method of making massage will now be considered. 
The common method of performing massage is incorrect 
and founded upon a false principle. The direction is gener- 
ally given to rub the breast from the outside toward the 
nipple, as if the intention were to evacuate the milk or per- 
haps open up some occluded milk duct. This is not the 
object of massage at all. The blood and lymph channels 
and spaces of the tender, congested breast, like those of a 
sprained joint, are overfilled with blood and lymph. Just 
as in a sprained joint the surgeon begins on the inner side 
of the swelling and empties out the excessive fluid by rubbing 
toward the heart, gradually approaching nearer and nearer 
to the joint until the swelling and tenderness are gone, so 
here, beginning outside of the breast, we empty first the 
vessels which lead from it, and then approaching the gland 
itself rub always so as to favor the carrying away into the 
circulation of the extra fluids. To understand the details 
of the operation, however, it will be necessary to study for 
a moment the anatomical arrangement of the blood and 
lymph vessels of the breast. Both glands are composed of 
fifteen to twenty separate secretory systems (see page £0), 
each of which consists of a main duct which divides and 
subdivides until we come to a last group of distended acini 
lined with a special kind of cells that secrete the milk. The 
ends of the tubes form the gland proper. Around the 
gland lobules the lymph routes form a network and empty 
into channels that run along and surround the milk ducts. 
These are joined somewhere near the outside of the areola 
by ducts coming from the nipple. From this juncture 
channels pass down under the breast along its floor outside 
and upward, joining with other lymph ducts until they 
finally pass into the axilla and empty into the chain of 
axillary glands. The blood capillaries that surround the 
gland lobules pass into venules that follow a course similar 
to the lymph ducts, passing awTay from the breast in deep 
vessels to empty into the large vessels of the axilla and the 
lower front part of the neck. MASSAGE OF THE BREAST 
249 
From this description of the structure of the breast, it is 
evident that to massage it properly it is necessary to begin 
outside and above the gland and then work under the gland 
as much as possible before touching the breast itself. The 
operator or nurse should sit on the side of the patient opposite 
to the breast to be treated—for example, upon her right 
side if the left breast is to be treated. In this case the 
patient would lie upon her right side with her left arm some- 
what raised, supported upon a pillow behind her. The 
Fig. 96.—Massage of the breast. 
nurse begins by rubbing at first superficially and then more 
deeply with the palmar surface of the thumbs or hands. 
In the deep rubbing she must remember that the skin is 
not to be rubbed, but carried along with the thumbs over 
the deep tissues. After the region surrounding the gland 
has been sufficiently treated, she rubs in the same direction 
as far as possible under the gland; then the gland itself may 
be massaged. Recalling the course of the lymph and venous 
routes and small vessels from the outside of the gland toward 
the circle outside of the areola, she rubs with very gentle 250 
PUERPERIUM 
movements in the same direction, using the ends of the 
fingers. In connection with these movements kneading 
manipulations tending to empty the channels under the 
breast are combined. 
With soft hands and well-regulated pressure, all this 
may be done without the use of any lubricant. It is better, 
however, to use a solution of soft soap. Unless the patient 
is relieved without much pain the massage is not properly 
given and should be discontinued. When rightly and suc- 
cessfully given, in the course of fifteen to twenty minutes 
the previously swollen and very sensitive breast is flaccid 
and relieved. 
Infection of the Breast.—Having now considered the 
matter of the congestion of the breast, let us turn to the 
very important subject of the infection of the breast. 
Mastitis, or inflammation of the breast, is the term gen- 
erally employed to denote the condition which results 
from infection. It should not be forgotten that stagnation 
of milk does not cause an inflamed breast. Only the pres- 
ence of bacteria growing into the gland tissue can cause 
fever and the other symptoms of infection. 
The bacteria generally found in breast infection are the 
staphylococci or those which grow in the cluster arrange- 
ment. Sometimes the chain bacteria or streptococci are 
found. 
It is now agreed that breast infection generally starts 
from the nipple. The question arises, How do the bacteria 
get to the nipple? 
All regions of the skin are covered with bacteria. The 
number is especially great around the nipple of the preg- 
nant woman because of the good soil furnished by the 
secretion which exudes to a greater or less extent. Some- 
times a kind of crust forms over the nipple that contains 
numberless germs. Hence, if the nipples are not properly 
cleaned before nursing, the germs are there already, pre- 
pared to grow upon any abraded or injured surface. 
In this connection we may speak of an infection from a 
source not very common, but yet quite important, namely, 
suppurating Montgomery glands. These small glands INFECTION OF THE BREAST 
251 
around the nipple sometimes become infected during the 
nursing period, and thus a source of danger to the nipple. 
If the germs present on the breast be removed by careful 
washing before the first nursing, the nipple may afterward 
become contaminated from several sources. Articles of 
clothing, especially the shirt, may be the source of con- 
tamination. Freshly washed clothing is practically sterile, 
but after it has been worn a few hours it contains many 
germs, and in twenty-four hours it is well saturated with 
bacteria. The fingers of the patient or nurse may be the 
carriers of infection, especially if the common practice of 
pulling out the nipple, so that the baby may better grasp 
it, is resorted to. When the nurse fails to disinfect the 
hands after handling the napkins of the baby or mother, 
this source of danger may be important. Then the child 
may be the cause of trouble. Sometimes the mouth may 
contain dangerous germs, but generally the mouth becomes 
contaminated from the breast. The baby’s face rubbing 
over the breast is more frequently the origin of the trouble. 
If the baby has sore eyes or pustules or boils on the face 
or head, we can readily see how the skin may become con- 
taminated. 
The presence of germs alone cannot cause infection of 
the breast. There must be a break in the epithelial cover- 
ing of the nipple. This fact shows the importance of the 
form, size, and structure of the nipple and the detrimental 
influence of deformed nipples. A nipple perfect in shape 
and size, so that it may be easily grasped and through which 
the milk flows freely, is much less likely to suffer abrasions 
from the suckling than one that is lacking in any of these 
characteristics. If the nipple is small or depressed the 
child must grasp it more firmly and thus injures it. A so- 
called cracked nipple results from the formation of a fissure 
or the injury of a natural fissure by the act of nursing. The 
fissure may be parallel to the nipple or at right angles to it. 
Such fissures are, of course, especially dangerous points of 
entrance for the infection. 
When the secretion is slow and scanty the suction required 
and the length of the nursing will be greater, as well as 252 
PUERPERIUM 
the risk of injury and infection. This strong suction, for 
example, produces blisters, varying in size from the head 
of a pin to that large enough to cover the end of the nipple. 
The supply of milk and the ease of its flow thus become 
important factors, determining infection. 
A further factor influencing infection and determining 
its extent is the resistance of the maternal organism. This 
is a factor in all infections, and depends upon the general 
health and the immunity to the attacks of the germs likely 
to be found in the contaminating material. 
The mode of growth of the infecting microbes does not 
differ essentially from that in genital or other wounds. 
The germs may remain confined to the abrasion or fissure 
of the nipple, causing some redness and perhaps some dis- 
charge; or they may penetrate deeply into the gland or 
they may pass under the gland, or, lastly, they may grow 
over the breast and under the skin. The last mode of 
growth is characteristic of the chain bacteria or strepto- 
cocci. When the germs penetrate the breast it is a peculiar 
fact that they generally follow one or more ducts with 
their ramifications and make a circumscribed hardness that 
may terminate in abscess. When the infection is con- 
fined to the nipple there is not much general disturbance 
as a rule. A chill with fever, headache, etc., generally 
denotes extension of the infection into the breast. It does 
not, however, mean that an abscess is unavoidable. In 
8 or 9 cases out of 10 the formation of pus may be prevented 
if proper treatment be instituted. 
Although this differential diagnosis between infection of 
the breast and simple congestion concerns the physician 
much more than the nurse, it is, however, well for her to 
know that the presence of fever due to the breast shows 
infection. Whether an abscess is formed or not is, of course, 
a question for the doctor to settle. 
From what has been said concerning the cause of infec- 
tion, it is evident that it may be prevented if we can pre- 
vent the access of the infecting microbes or if we can avoid 
the abrasions or breaks in the epithelial covering of the 
nipples. The latter is often impossible, because of some INFECTION OF THE BREAST 
253 
deformity in the nipple or because of the character of the 
skin. If there is a wound of some extent, like a deep fissure, 
a protecting shield may be used, but the danger from small, 
often unobserved abrasions remains. In preventing the 
access of germs, as long as the nurse is in attendance she 
has great responsibility. 
Before labor something can be done to get the breasts in 
a proper condition. The main thing is to keep the nipples 
clean and toughen them so that they will not become sore. 
The use of salves or of tannin solutions, as frequently advo- 
cated, is generally unnecessary and possibly harmful. Ex- 
citing the nipple in any way before labor may cause uterine 
contractions and has produced miscarriage or premature 
labor. The efforts to draw out a depressed or retracted 
nipple do not do much good. The best advice to a woman 
during pregnancy is to keep the breast as clean as other parts 
of the body by the use of soap and water, and in the last two 
or three weeks rub the nipple rather thoroughly with the 
towel after washing. 
After labor the responsibility of the nurse begins. Before 
the child is put to the breast she washes the breast and 
particularly the nipples carefully with soap and wTater, and 
then with 60 to 80 per cent alcohol. The proper way to 
wash the nipple with alcohol is not to take a piece of wet 
cotton or gauze and rub vigorously. This causes pain and 
may abrade the surface, the very accident that we want 
to avoid. With cotton held below the nipple, alcohol may 
be poured over it from a bottle, or the cotton may be satu- 
rated and then the alcohol squeezed out, so as to thoroughly 
drench the nipple. Of course no drying is necessary, as 
alcohol evaporates readily. If the child should be put to 
the breast before the alcohol has time to evaporate, the 
nipples may be washed off with sterile or boiled water. 
To protect the nipple from subsequent infection it may 
be washed in the same way with alcohol immediately after 
nursing, when the abrasions are open and before the germs 
carried by the child have had a chance to grow. We choose 
alcohol as a disinfectant because it is fairly efficient and 
entirely safe. Boric acid solution, so much used, is such 254 
PUERPERIUM 
a weak disinfectant that it is blit little better than sterile 
water. Efficient disinfectants like carbolic acid or subli- 
mate solution cannot be used because they are poisonous 
to the infant. Very rarely the nurse may be directed to 
use a sublimate solution in case of an infected or wounded 
nipple. In such case she must wash off every particle of 
the poison very conscientiously before the baby is allowed 
to touch the nipple. 
After the nipples are cleaned, they are protected from 
contact with the more or less soiled clothing by covering 
them with sterile gauze. A few layers may be fastened to 
the inside of the gown or placed inside of the supporting 
bandage and changed as often as necessary. Nipple pro- 
tectors made of metal or glass or wood are sometimes used 
for the same purpose. There is the objection to these pro- 
tecting shields that they collect the milk that frequently 
flows during the nursing interval and cause the nipples 
bathed in milk to become soft. 
The danger from dirty hands needs only be mentioned. 
If the nipple must be erected for the child to grasp, the 
nurse may press around its base or else take hold of it with 
gauze, or she may put on gloves. 
The chief danger, as before mentioned, is from the face 
of the child contaminated with pus from sore eyes or from 
boils. To protect the breast from this danger is difficult. 
If the pus comes from sore eyes, they should be washed 
before nursing and then the face thoroughly washed. If 
the baby has boils they should be carefully opened, as will 
be directed in the next chapter. 
In case the glands of Montgomery are infected, each sepa- 
rate diseased gland should be opened with a sterile needle 
after flooding the region with alcohol or swabbing it with 
tincture of iodine. A shield may be necessary. 
Nipple shields are very important in cases of depressed, 
deformed, or injured nipples, as well as when the nipples 
are very painful. In the majority of cases there is a day 
or two at least when nursing is very painful on account of 
the nipple. A proper shield will give much relief and hence 
should be a part of the patient’s outfit. The best shield TREATMENT OF BREAST INFECTION 
255 
has the bowl of glass and a rubber nipple attached to the 
bowl. A bone guard keeps the child from getting the 
whole nipple into its mouth. A shield sometimes causes 
pain because of faulty construction. The opening may be 
so small as to constrict the nipple. In a shield very com- 
monly used, the bowl has a small opening leading to the 
nipple into which the breast nipple is drawn and pinched. 
Sometimes the flange of the bowl is too narrow or attached 
to the bowl at an improper angle. The nurse should study 
the construction of the shield, and if it causes pain she should 
be able to detect the fault and find one that will fit the case, 
or, if necessary, have one made. We should make the shield 
to fit the patient and not expect the patient to fit the shield. 
The rubber nipple is an important part of the shield. 
It must fit the nipple tightly and the opening in its end 
must be large enough, but not too large. The hole can be 
easily enlarged to the required size by passing through it a 
hot needle. 
The care of the shield is a matter of importance. The 
common practice is to let the shield lie around on the bed 
or a table for a few minutes after nursing, and then put it 
into a bowl of boric acid solution that is perhaps quite thick 
with flakes of milk. This illustrates again the misplaced 
confidence in the disinfectant properties of boric acid. 
Immediately after nursing the nipple should be taken off 
from the bowl and both thoroughly washed and boiled. 
It is well, after washing the outside of the nipple, to invert 
it, when the inside can be also well cleaned. After both 
bowl and nipple are cleaned, they are wrapped in a clean 
napkin or towel ready for use. 
Occasionally the nurse has difficulty in getting the child 
to draw through the shield, but patience and perseverance, 
sometimes filling the bowl with milk to get the child started, 
will succeed unless the child is feeble. It may be necessary 
to obtain the milk by manipulation or pumping and feed 
with the dropper or spoon. 
Treatment of Breast Infection.—The treatment of a slight 
localized infection of an eroded or fissured nipple where 
there are no general symptoms consists in thoroughly clean- 256 
PUERPERIUM 
ing the wound with alcohol and using the nipple shield 
when the child nurses. If the fissure is quite deep it might 
be well to stop nursing for a day. Sometimes stick nitrate 
of silver is applied to the inflamed fissure. Balsam of Peru 
and collodion are also used to close the wound. 
In deeper infection of the breast, as known by the presence 
of a chill and fever and other symptoms of infection, responsi- 
bility for the management of the case rests with the physician. 
In order to prevent the formation of an abscess it is a good 
rule to stop nursing the child on the affected side for a few 
days, support the breast with a bandage, and apply an ice- 
bag over the infected area. Properly applied, the ice will 
give great relief. Formerly hot poultices and other hot 
applications were much used. A good fomentation is a 
cloth moistened with a weak antiseptic solution covered 
with some impermeable substance like oil silk or rubber 
cloth, over which is placed a hot-water bag. The redness 
and tenderness about the swollen, infected area will generally 
disappear after a few days unless suppuration takes place. 
This is known by fluctuation or perhaps by aspirating with 
a hypodermic syringe, using a large needle. 
If only one breast is affected the child may nurse from 
the other. If the mother has been around she must go 
back to bed in order that the breast may be kept at rest 
and ice applied. When fever and tenderness have subsided, 
nursing may be resumed with care, not giving up the ice for 
two or three days. 
When an abscess is formed, it should be opened at once, 
but it is well to continue the ice-bag and the bandage. 
Some kind of local anesthesia is generally used. The incision 
is small and radiating from the nipple, and a very small 
wick drain is used that can be removed in twenty-four to 
forty-eight hours. 
A large suction cup may be used during the dressing to 
assist the drainage. It also causes a congestion that may 
assist in the healing. It is applied intermittently five 
minutes at a time for two or three times. 
The artificial congestion, or hyperemia, is also used before 
incising to heal a deep infection. This is called the Bier GALACTORRHEA 
257 
treatment. It is more painful than the ice-bag and rest 
treatment and not much used in this country. 
When a large abscess has formed, the evacuation of the 
pus and establishment of drainage is a serious matter. 
Sometimes general anesthesia must be employed. An ir- 
rigator and a large quantity of solution may be required. 
Drainage tubes or cigarettes and gauze bandages must be 
on hand. In these cases subsequent dressings are often 
needed for many days. 
Fig .97.—Bier suction applied to an inflamed breast. 
Galactorrhea.—A deficiency in the secretion of milk 
(agalactia) and the possibility of correcting it by diet have 
been discussed on page 239. The term polygalactia, which 
means excessive secretion of milk, is applied to that con- 
dition when there is a continual distention of the breast, and 
apparently more milk is produced than is needed for the 
child. It is generally associated with galactorrhea or an 
excessive flow of milk. The milk discharges from the nipple 
in the intervals between nursing. In some cases a pint or 
more may discharge in the course of a day. This is not 
only uncomfortable to the mother, but also a drain on her. 
Unfortunately but little can be done to control the flow. 
Pads to absorb the milk and compression bandages are used. 258 
PUERPERIUM 
Hypertrophy of the Axillary Sweat Glands.—Occasion- 
ally a swelling is noticed in the region of the axilla on one 
or both sides. It may be small or it may reach the size of 
the hand. Sometimes several distinct swellings are present. 
If these are carefully examined they will be found to lie in 
the skin and not under the skin. They are enlarged sweat 
glands and not lymphatic glands. At times a secretion 
can be obtained from them which has been called a kind of 
milk, and this has led to the idea that these swellings have 
the structure of milk glands. It is true that supernumerary 
breasts exist and are found on various parts of the chest 
and sometimes in the axillary region, but these swellings 
that we are now considering have not the structure of the 
mammary gland. They may appear in the last weeks of 
pregnancy or more often in the first week of the puerperium. 
They sometimes cause a little discomfort which can be 
relieved by the application of an ice-bag or a compress. 
They disappear spontaneously in a few days. 
Care of the Room.—The temperature of the room depends 
somewhat upon the question whether the infant is con- 
stantly present in the lying-in chamber or not. Every 
lying-in room should contain a thermometer. As will be 
shown in the next chapter, for the first two or three weeks 
it is better for the infant if the temperature of the air is not 
below 75° F. If the baby is feeble or troubled much with 
colic, a temperature of 80° E. is still better; hence if the baby 
is kept in the room with the mother a temperature of 75° F. 
should be maintained. If the baby has a separate room 
and is only brought to the mother to nurse (the best arrange- 
ment where it can be carried out), the temperature of the 
lying-in room may be kept a few degrees lower if the mother 
wishes. These remarks apply of course to the colder seasons 
of the year. In the summer, when the problem is to keep 
cool, the proper shading of the room, good ventilation, and 
keeping a moist air are the things to be attended to. 
Under any circumstances, proper ventilation is very im- 
portant. This means a free supply of good air without the 
creation of a dangerous draft. Generally we have to use the 
windows for ventilation. At least every two to three hours REST 
259 
there should be a complete and rapid change in the air of 
the room. The patient should be well covered and two or 
more windows opened as far as possible for about five minutes. 
In this way there is a complete renewal of the air without 
cooling off the walls of the room. At other times windows 
may be slightly lowered from the top or raised from the 
bottom so that the air may be kept in good condition. 
The comfort of the patient depends very much upon the 
degree of moisture present. A hygrometer in the room is 
very desirable. If the air is too dry it may be easily mois- 
tened by throwing a spray of water from a hand atomizer, now 
very commonly found in most households. 
Odors caused by the bowel movements are never to be 
concealed by burning pastilles; they must be removed by 
ventilation. 
Since the nurse is responsible for the care of the room, 
she may be obliged to attend to the cleaning of it herself. 
This implies that she understands how to sweep both carpets 
and hardwood floors, and that she knows that filling the 
air of a room with dust which settles back on the furniture 
to be again dusted into the air is not cleaning. A good 
housewife will be very uncomfortable in bed if her room 
becomes untidy and neglected. The more refined she is, 
the more will she hesitate to speak to the nurse about a 
dirty corner or a disorderly dresser or neglected, wilted 
flowers. The condition of a room is, moreover, one of the 
best indices of the breeding and training of a nurse. A 
nurse who neglects her room is hardly one to inspire general 
confidence in other things; hence, both the interests of the 
nurse and the welfare of the patient make it desirable that 
more attention should be given to this subject than it 
ordinarily receives. 
Rest.—To secure the best progress of a patient and make 
of childbed what it should be, a fortnight or a month of 
quiet rest and happiness after the long months of pregnancy 
and the severe labor of delivery, careful attention must be 
given to other details of management. The patient should 
have mental as well as physical rest. She remains in bed 
and careful attention is given to her bodily needs. She 260 
PUERPERIUM 
should also be protected from mental annoyances and 
harmful excitement. 
Of chief importance is the conduct of the nurse. An 
unsympathetic nurse can so disturb the patient that she 
will always look back to her childbed with unhappiness. 
Conscientious performance of duty, unselfish patience, and 
tact are the three requisites in a nurse, and the lack of any 
one is a serious drawback to her usefulness. Many a nurse 
gives too little thought to the last two qualifications, think- 
ing more of her own comfort than of the patient’s feeling. 
She talks much of the nightly disturbance of a colicky 
baby. Lacking in tact, she fails to observe the patient’s 
disinclination to hear stories of other patients or of the 
hospital, or the gossip in which she may be a proficient 
entertainer. Some otherwise good nurses are impossible 
because of this lack of tact or because of an uncontrolled 
temper. Few, however, are incorrigible, and very many 
need only a reminder of their failings. To these the follow- 
ing suggestions are recommended: 
Be patient. The more the baby cries and the mother 
worries, the more need of patience. Never allow yourself 
to speak or think of the baby as cross or bad-tempered. 
A baby cries because something is the matter. If you can- 
not find out and correct the cause, bear with it. Never 
call the mother cranky. This word, unfortunately heard 
not infrequently in the hospital, is often used by the nurse 
as an excuse for a retaliatory spirit or one which will very 
quickly engender coolness and a mutally unsympathetic 
attitude. 
Avoid gossip about other patients, their families or 
family affairs, or about physicians. However interesting 
such gossip may be, it will not increase the patient’s respect 
for you, while it may cause you trouble in ways you little 
imagine. 
Avoid showing anxiety at any emergencies that may arise. 
Keep a sharp watch of the case and report immediately to 
the physician anything abnormal, but carry what responsi- 
bility you have to take quietly, and do not needlessly or 
uselessly shift it on to the patient. POSTURE 
261 
Protect the patient from household annoyances. Mem- 
bers of the family sometimes need to be reminded of this 
rule. If troubles arise in the housekeeping arrangements, 
help to smooth over the difficulties and keep the patient free 
from worry. 
\ ou must see that the patient has a time for sleep during 
the day, and you should protect her from disturbance from 
every source during this hour. 
In normal cases for the first three or four days of child- 
bed a few short- visits from relatives or intimate friends 
may be allowed. Exaggerated strictness in this regard is 
unnecessary. The nurse must only observe that the patient 
is not tired or exhausted by these visits and that her rest 
is in no way disturbed. 
Many patients wish to be much alone even in their wak- 
ing hours. The nurse should instinctively recognize this 
fact and gratify her patient’s unexpressed desires. 
Toilet.—The comfort and welfare of the patient depend 
very much upon the general care given to her toilet. It 
is not necessary to speak of the care of the mouth and hair. 
The care of the genitals and the breast has been described 
before. The rest of the body should receive a sponge bath 
twice a day with water or alcohol. 
Posture.—If the patient wears a proper abdominal band- 
age and a well-fastened napkin, she may with advantage 
move around the bed as freely as she likes and lie in any 
position agreeable to her. The possibility of an air embolus 
has caused some physicians to keep their patients quiet 
after labor. If there is any danger from this source it is 
over in a few hours. After the first week it is well for the 
patient to take the knee-chest position for five minutes at 
a time four or five times a day. It helps to relieve pelvic 
congestion and assists involution and tends to prevent 
backward displacement of the uterus. It may be made a 
part of the exercises about to be described. 
If any person, even a healthy man, be put to bed and 
kept at rest in a recumbent position for several days he 
becomes weak from lack of exercise and from disturbed 
circulation, so that if he suddenly attempts to sit up he 262 
PUERPERIUM 
becomes dizzy and faint. This is the condition we fre- 
quently find in women in childbed. There are reasons 
why women should remain in bed as a rule from seven to 
ten days, but the muscular weakness and faintness that 
frequently arise from such a course are evils that should 
be avoided if possible. The chief reason why a woman 
should remain in bed during her puerperium is that she 
may rest and recuperate from the exhaustion of her preg- 
nancy and her labor. The care of the child and the imme- 
diate resumption of her household and social duties would 
be too great a strain on the civilized woman. Even among 
savage or half-civilized races, with the exception of a few 
tribes of North American Indians, there is a general obser- 
vance of a certain period of exclusion from association with 
others, ostensibly perhaps on account of uncleanliness, which 
practically results in a period of rest. In spite of the most 
exact rules regarding a gradual progress, permission to get 
out of bed generally results in the resumption of household 
duties. Moreover, a perfect healing of the frequent tears 
in the uterus, vagina, and perineum is favored by the recum- 
bent posture. The lochia generally ceases earlier and the 
involution of the genitals progresses more undisturbed; 
there is less tendency to a prolapse of the vagina and uterus. 
Before involution of the abdominal walls there is more dan- 
ger of enteroptosis, the prolapse of the abdominal viscera; 
hence a physician feels it a risk to allow a patient to get 
up before involution has progressed fairly well, even at 
the end of the second week. 
Massage and Passive Movements.—To avoid the evils 
that results from the non-use of the muscles, from the 
accumulation of waste in the tissues, etc., massage and 
passive movements and bed exercises are of great value. 
A professional masseuse can be employed with advantage 
after the fourth day, for the nurse who cares well for mother 
and child has scarcely time to give massage. Yet very 
few patients can afford to have a masseuse, and the question 
arises, Is massage of sufficient importance to justify the 
nurse in slighting some other work if necessary in order to 
give it? Generally, bed exercises which the patient may BED EXERCISES 
263 
take without assistance are a good substitute for massage. 
Sometimes when massage is very desirable it cannot be given 
by the nurse because she has never been taught the manip- 
ulations. 
To those who have not been trained in this important 
art, one may say, as was stated before in speaking of mas- 
sage of the abdomen for the management of constipation 
(see page 235), that the principles are simple, and applied 
common-sense will soon help one to acquire considerable 
proficiency. 
Suppose a nurse allows thirty minutes for the massage 
and ten minutes more for movements of the lower extremi- 
ties. With the patient on her face she first rubs the back 
and hips superficially for about two or three minutes and 
then kneads and rubs deeply and taps for about six minutes, 
leaving one minute for a rapid rubbing of the skin with 
alcohol. Then ten minutes are given in the same manner 
to the thighs and legs, the patient still remaining on the 
face. Afterward she turns and lies on her back and the 
remaining ten minutes are given to the abdomen and front 
surface of the lower extremities. Then come the passive 
movements, which consist in the flexion of the legs on the 
thighs and the thighs on the body against a slight resistance 
of the nurse, followed by opposed extension of thighs and 
legs. These movements, first of one and then the other 
extremity, or of both together, varied with similar move- 
ments of the feet, combined with the massage, are at least 
sufficient to prevent stagnation of the circulation and weak- 
ness of the muscles that have made confinement in bed so 
objectionable. 
Bed Exercises.—Tor the voluntary exercises, which may 
also begin on the fourth day unless the breasts are too 
uncomfortable, the patient should be flat on the bed, with 
the breast bandage and the heavy clothing removed and 
with the windows open. In place of the resistance of the 
nurse the patient makes her own resistance. While she is 
contracting the flexors she holds the extensors tense, and 
vice versa. 
The first movement is a breathing exercise. The initial 264 
PUERPERIU M 
position is with both arms, hands, and fingers extended to 
the utmost, and forming with the body a cross and with 
the lungs full. The extended arms are then swung through 
arcs of 90 degrees and brought together above the body, 
breathing out through this part of the movement; then 
they are slowly swung back to the original position during 
inspiration. The entire movement recpiires fifteen to twenty 
seconds. This movement is repeated four to eight times. 
The second movement is combined flexion and extension 
of the parts of the upper extremities. Beginning from the 
initial position the patient flexes in order slowly, and against 
her own strong resistance, the fingers, wrists, forearms, and 
Fig. 98.—Bed exercises: First position, full inspiration. 
finally arms against the chest, breathing out all of the 
time. Then she extends the parts in the reverse order and 
inspires during the half-movement. The entire movement 
takes about twenty seconds. This she repeats four to 
eight times according to its effect. Ordinarily she would 
begin with four movements and after two or three days 
increase the number. 
The third movement is extension and flexion of the feet. 
The patient begins with the legs straight, feet extended, 
and toes flexed. Then she flexes the feet and extends the 
toes, and vice versa. About twenty of these movements are 
made in a minute without regard to the breathing. BED EXERCISES 
265 
These three movements take about four or five minutes. 
The patient then rests a minute or two and repeats them. 
Fig. 99.—Bed exercises: Second position, expiration. 
The three movements repeated constitute one exercise. 
Three to five exercises are taken each day from the third 
Fig. 100.—Bed exercises: Autoresisted flexion and extension of upper 
extremities. 
or fourth day to the eighth. Then the fourth movement 
is added. 266 
PUERPERIUM 
The fourth movement is the combined flexion and exten- 
sion of the legs, thighs, and feet. The thighs are flexed 
on the abdomen, the legs on the thighs, and the feet on the 
legs and the toes extended. Then the movement is reversed. 
Five to ten movements are made at the rate of about five 
movements per minute. 
From the tenth to the fourteenth day two more move- 
ments are added. The fifth movement is a flexion of the 
extended lower extremities on the abdomen and a return 
to the initial position. The sixth movement is a flexion 
Fig. 101.—Bed exercises: Flexion and extension of legs and thighs 
of the trunk on the thighs. The trunk is raised to a vertical 
posture by contraction of the abdominal muscles and with- 
out aid of the arms. The legs must remain on the bed. 
Both the fifth and sixth movements are made four to eight 
times at the rate of four times a minute. 
Getting Up.—Formerly most physicians kept their patients 
in bed about four weeks after confinement. Recently a 
number of obstetricians have favored letting the patient 
get up on the third or fourth day, sometimes on the second 
day. For the reasons given on page 262 we favor a longer 
rest in bed, but recognize that there are many circumstances GETTING UP 
267 
to be considered which determine the practice in individual 
cases. 
A patient who has had a healthy pregnancy and has 
been active up to the last, does not need as long a childbed, 
other things being equal, as one who comes to confinement 
weak and exhausted through chronic illness, like heart or 
lung disease, or through some trouble due to pregnancy or 
from overwork. 
A patient who has had a short and comparatively easy 
labor, and particularly one who has had no hemorrhage, 
needs a shorter time in bed than one weakened by labor. 
Lacerations of considerable extent are a contraindication 
to early rising. 
Fever in childbed from any source makes a longer child- 
bed desirable. 
Persistence of the lochia, and especially the lochia rubra, 
makes necessary a longer retention of the horizontal position. 
Rapid involution of the uterus is favorable to early rising. 
However, it is not always safe to rely upon the passing of 
the uterus from the abdomen into the pelvis as a sure sign 
of rapid involution. 
A patient who has a nurse-girl to take care of or assist in 
the care of the child, may get up and dispense with the ser- 
vices of the nurse sooner than one who must alone take full 
charge of the baby. 
Finally a doctor’s decision concerning the length of time 
in bed must depend upon whether the patient can be trusted 
to follow the directions and not use the permission to get up 
for a few minutes to remain out of bed for half a day. 
It is a common idea that a patient is likely to suffer harm 
if she walks much or walks up and down stairs when she 
gets out of bed, while it is all right for her to sit up for two 
or three hours. This is an error. In the usual sitting 
posture, enteroptosis, or falling of the abdominal organs, 
is favored by the still relaxed abdominal walls. On the 
contrary, if she holds in her abdomen when walking this 
danger is avoided. Moreover, the muscular contractions 
in walking favor the venous and lymph circulations. Hence 
it is better for the patient to walk two or three minutes at 268 
PUERPERIUM 
a time several times a day than to sit up for twenty or 
thirty minutes. The rule should be: Walking comes before 
sitting. 
In an average case the patient may get up on the seventh 
day and walk briskly one or two minutes, holding in the 
abdomen as just described. She may do this four or five 
times a day. This may be made a part of the regular exer- 
cise, being added to the bed exercise. By the tenth day 
she may walk five minutes and then sit for not more than 
five to ten minutes each time she gets up. During the 
third week she may be up half an hour each time, going to 
the table and also using the closet and perhaps the tub 
bath. During this time she may go up and down stairs 
and out of doors. She should not resume her household 
duties if she can help it. After the fourth wreek she is 
around as usual, but lies down to nurse the baby and remains 
lying about half an hour each time. It is also desirable 
for her to keep up the bed exercises until the end of the 
fourth week. 
If the labor or puerperium has been abnormal so that 
she is not in good condition and her progress is delayed, 
especially if the abdominal walls are very lax and there is 
a considerable separation of the recti muscles, she should 
make extra efforts to strengthen the abdominal wall by 
proper exercise. It may be necessary for her to wear a 
supporting band when she begins to go around. CHAPTER VI. 
THE INFANT. 
In this chapter we shall consider the study and care of 
the new-born and young infant only so far as concerns the 
obstetrical nurse. By new-born we mean the child which 
retains any vestiges of its fetal condition. This stage 
generally lasts about two weeks until the navel cord is off 
and the wound healed. For a few weeks more the infant 
is often under the care of the obstetrical nurse. We shall 
notice briefly the more important physiological processes 
and describe the care of the new-born and young infant, 
taking up only the more common affections of the first few 
weeks of life and leaving to books on pediatric nursing the 
more extended study of children’s diseases. 
First Care.—The first care of the infant begins with the 
expulsion of the head. As soon as the head is born the 
physician, or the nurse in his absence, should find out 
whether the cord is around the child’s neck by passing the 
hand over the back of the head. If a loop of the cord is 
felt around the neck it is pulled over the head, else it may 
interfere with the birth of the body, and on account of the 
stretching of the cord cause harmful traction on and pre- 
mature separation of the placenta. Rarely the cord is 
wound twice around the neck. In this case first one loop 
and then the second is pulled over the head. 
If the cord is not around the neck or as soon as it has 
been attended to, the face is at once wiped off with a piece 
of dry gauze or a clean towel or napkin. The outside of 
the eyes are wiped, but the lids are not opened, neither is 
the mouth wiped out or washed. 
Should the birth of the body be delayed on account of 
large shoulders or absence of sufficient pains the head may 270 
THE INFANT 
become quite black from congestion. Ordinarily this 
need not alarm the nurse should she happen to be alone 
with the patient, and under no circumstances should she 
attempt to hasten delivery by pulling on the head. If 
there be severe hemorrhage she may help to press out the 
child (see page 198), but generally there is no need to inter- 
fere. 
Asphyxia Neonatorum.—As soon as the body is born, 
the first care of the attendant is to see that the child 
breathes. As a rule it grasps almost as soon as the body 
is out of the vaginal canal, soon cries, and within a minute 
or two is breathing regularly. Sometimes it makes a few 
respiratory movements while the body is still unborn. If 
the baby attempts to breathe while the head is still inside 
the vagina it is because of some obstruction to the fetal cir- 
culation and asphyxia is apt to result. 
Should the child be alive and yet not breathe for two or 
three minutes after birth, it is said to be asphyxiated. 
Apnea, which means lack of breathing, is a better term 
than asphyxia, which means lack of pulse, but the latter 
term is in general use. The asphyxia or apparent death 
of the new-born is due to different causes and is of different 
degrees of severity. In any person the act of breathing is 
produced by a stimulation of the respiratory center in the 
brain by the lack of oxygen or by the presence of C02 in 
the blood which circulates in the brain. If this breathing 
center is numbed by poisonous substances in the blood it 
may not respond to stimulation and the person is asphyxiated. 
This nerve center may also be numbed by injury. The 
fetus in the womb requires no air, for the placental blood 
furnishes oxygen and removes the fetal waste. Hence the 
fetus makes no effort to breathe. If the interchange of 
blood from the placenta to the fetus be interfered with in 
any way the fetus may be excited to make breathing move- 
ments, or it may be so gradually poisoned that the respir- 
atory center is numbed without first being sufficiently 
excited to cause respiratory movements. The fetal cir- 
culation may be disturbed either by interfering with the 
cord or the placenta. The circulation in the cord may be ASPHYXIA NEONATORUM 
271 
stopped by pressing upon it, as, for example, in cases of 
prolapse of the cord, when it will be compressed between 
the head and the pelvis or by a knot in the cord. The 
placental circulation may be disturbed by a partial separation 
of the placenta from the uterus. This may happen from 
an injury, such as a blow upon the abdomen or from a wrong 
position of the placenta, as in placenta previa. The placenta 
may also be injuriously compressed by the contractions of 
the uterus during labor. If from any of these causes the 
fetus suffers it may become so asphyxiated that it makes 
no effort to breathe and is born in this condition, or it may 
try to breathe before birth, when it will aspirate into the 
mouth and air tubes the water and mucus from the genital 
tract. We may therefore have the child asphyxiated either 
with or without mucus in its throat. Still another cause 
may have produced the asphyxiated condition, namely, 
injury to the brain either during a hard labor, where there 
is much compression of the head in the obstetrical canal or 
by forceps. 
Treatment.—Two degrees of asphyxia are generally dis- 
tinguished: asphyxia livida, or congestive asphyxia, and 
asphyxia pallida, or pale asphyxia. In the first case it 
is generally possible to excite respiration by stimulating 
the surface of the body, while in the second case stimula- 
tion may not be effective, and it is necessary to force air 
mechanically into the lungs. Remembering these con- 
ditions and factors, we adopt the following procedure in 
bringing-to or resuscitating an asphyxiated child: 
Slapping,— First we lift the child from the bed with its 
head down, grasping it with the left hand by the feet, hold- 
ing one leg between the thumb and forefinger and the 
other between the fore and middle fingers. The child is 
held in this position to cause the blood to flow to the brain 
and also to empty from the lungs and air tubes any liquid 
that may have been drawn in. Then the child is slapped 
gently on the buttocks with the right hand. 
Removal of Mucus.—If this does not excite the child to 
breathe it is laid on its back on the bed and the attendant 
takes an aspirating catheter and inserts it into the throat, 272 
THE INFANT 
holding the tongue forward with the forefinger of the left 
hand. The catheter is often but wrongly called a “tracheal” 
catheter. No attempt should be made to carry it through 
the larynx into the trachea. It should be always on hand 
and ready for use. As soon as it is inserted the attendant 
Fig. 102.—Suspension and slapping of asphyxiated infant. 
applying the mouth to the outer end draws into the tube 
what mucus and liquid can be obtained and then the catheter 
is withdrawn and the contents blown out. It is then rein- 
serted and again used as before. When no more fluid is 
found in the throat the child is again raised by the feet as ASPHYXIA NEONATORUM 
273 
before and another effort made to excite respiration by gently 
slapping the buttocks. 
Ilot and Cold Bath.— If this last attempt is unsuccessful 
the cord must be at once tied and one more effort made 
to excite the brain center by another kind of superficial 
stimulation. The body is first held for a few seconds in 
a large pan or tub of warm water, temperature 100° F., 
Fig. 103.—Removal of mucus with an aspirating catheter. 
and then placed for an instant in a tub of cold water as 
it comes from the hydrant or cold water from a pitcher 
is poured over the child. Then it is changed back and 
forth from the warm to the cold water a few times until 
the child begins to breathe or there seems to be no longer 
any hope from this method. 
The nurse will see the great importance of being pre- 
pared for these efforts to revive the child. Should she be 274 
THE INFANT 
alone with the patient she ought to make all the prepa- 
rations in every case so that she be not taken unawares. 
The baby’s bath-tub and a large bowl, or perhaps a 
tub, answer very well. For the cold water the stream from 
the faucet of the bath-tub or the sink may be used. 
Laborde Method.— Another method of reflex stimulation is 
the intermittent traction on the tongue, which was origi- 
nated and described by Laborde. The tongue is grasped 
with a suitable tongue forceps or with the thumb and finger 
between layers of gauze. It is then pulled out carefully 
Fig. 104:—Laborde method of artificial respiration. Grasping the tongue 
with small, tongue forceps. 
as far as possible and held for a second, when it is released. 
These tractions should be made about fifteen times to a 
minute, and may be continued for that length of time. 
If the methods for exciting respiratory movements already 
described be unsuccessful the nurse should apply her ear 
to the baby’s chest and listen carefully to determine whether 
there is any heart pulsation. If any beating of the heart 
is heard, no matter how faint, slow or irregular, she should 
at once take means to get air into the lungs. Even when 
she is doubtful whether the heart beats at all or not, she 
would better use artificial respiration for a few minutes. ASPHYXIA NEONATORUM 
275 
Several methods of filling the lungs with air will be de- 
scribed. 
Byrd Method.— In the Byrd method the child is held so 
that the right hand supports the upper part of the trunk, 
the head resting between the thumb anti forefinger, while 
the left hand holds the lower part of the trunk and the 
breech, the left leg resting between the thumb and fore- 
Fig. 105.—Byrd method of artificial respiration. Inspiration. 
finger. If desirable the child may remain in the warm bath 
during the manipulations. By rotating the thumbs out- 
ward or the ulnar bodies of the hands upward a dorsal 
flexion of the child is made which tends to expand the 
chest cavity and draw air into the lungs. The reverse 
rotation is then made with the hands, which flexes the 
child and presses the air out of the lungs. These move- 
ments are repeated about twelve times a minute until the 276 
THE INFANT 
child begins to gasp. As soon as voluntary respiratory 
movements begin the nurse should endeavor to time the 
artificial movements to correspond with the voluntary 
movements. 
Fig. 106.—Combined Byrd method of respiration. Expiration. 
Sylvester Method.— In the Sylvester method the child 
lies on its back on a table with a small blanket under the 
shoulders. The nurse first seizes the arms and draws 
them above the head, causing inspiration. She then returns 
them to the sides of the chest and compresses it, causing 
expiration. These movements are also made about twelve 
times a minute. 
Combined Byrd and Sylvester Methods.—If there be 
two persons to care for the baby the two methods just ASPHYXIA NEONATORUM 
277 
described can be combined. The second nurse extends 
the arms of the child while the other makes the first or 
inspiratory movement with the Byrd manipulation. Then 
she brings them to the sides of the chest and helps com- 
press it during the expiratory flexion. This can be done 
with the child in the bath. 
Fig. 107.—Combined Byrd and Sylvester method of inducing respiration 
Inspiration. 
Schultze Method.— The accompanying figures illustrate 
the Schultze swingings, which are made in the following 
way: Standing with her feet apart the nurse holds the 
child with the open hand supporting the back, the index 
fingers in the axillae under the arms, the thumbs over the 
shoulders and in front of the chest. The infant tongue 
forceps, which may be used to keep the tongue forward to 
prevent closure of the throat, is caught and held by the 278 
THE INFANT 
thumb. Starting from the first position, where the nurse 
bends slightly forward and holds the body hanging down, 
she then straightens her body and swings the child so that 
legs and thighs are flexed on the chest. This movement 
contracts the chest and is the expiratory movement. It 
also favors the brain circulation. Then the child is swung 
back to its first position. This expands the chest and one 
Fig. 108.—Combined Byrd and Sylvester method of respiration. 
Expiration. 
can frequently hear air rush into the lungs. Complete 
swinging up and down should take six to eight seconds. 
The swinging should be repeated if necessary ten to twelve 
times, when the child should be immersed in a warm bath 
to prevent it from becoming chilled through. 
When the method is carried out according to the directions 
given it is very efficient, and by it air can be forced into ASPHYXIA NEONATORUM 
279 
the lungs of a dead child. Of course it is very important 
that no accident happen, for example, that the child does 
not hit a piece of furniture in swinging and that it is not 
allowed to fall. The nurse should practice with a dead 
child or, if this is impossible, with a large flexible doll until 
she feels competent. 
Fig. 109.—Schultze swinging. Inspiration. 
Insufflation.—-The breathing of air into the baby’s lungs 
is done in the following way: The child, laid upon its back 
with the air passages free from mucus, is grasped with the 
right hand around the waist below the chest, the thumb 280 
THE INFANT 
pressing firmly over the stomach. Its lower jaw is raised 
with the thumb of the left hand and the lips opened with 
the fingers. Then the nurse applies her lips to the baby’s 
mouth and blows slowly and carefully. One or two layers 
of gauze are first laid over the mouth to protect the nurse 
Fig. 110.—Schultze swinging. Expiration. 
from a possibly diseased child and to protect the child from 
possible infection by the nurse. The chest is now grasped 
with both hands and compressed to expel the air. The 
lungs are filled and emptied in this way ten to twelve times 
or until the child breathes, and then it is put back into the ASPHYXIA NEONATORUM 
281 
warm bath as described before. By this method, the filling 
of the stomach and bowels with air is generally avoided. 
Care must always be taken not to blow too hard, for there 
is danger of rupturing the air cells and forcing the air into 
the tissues around the chest and neck. 
Fig. 111.—The lungmotor. 
Oxygen Insufflation.— Many hospitals are provided with 
an apparatus by which oxygen can be insufflated through 
the air passages into the lungs. (Fig. 111.) The pump 
is connected with an oxygen tank, the gas container made 
large enough to hold the proper amount for an infant and 
the mouth piece fitted firmly around the mouth and nose. 
The pump is then worked twelve to fifteen times a minute 282 
THE INFANT 
in combination with synchronous, artificial, respiratory 
manipulations on the chest. 
The order in which these movements should be employed 
may vary. One may alternate the insufflation method or 
the Laborde method with the Byrd method, keeping the 
child in the warm bath. Generally the Schultze swinging 
is the method of last resort. 
When the child begins to breathe we may desist from 
artificial respiration, but it must be watched carefully for 
some time. Although the immediate danger from asphyxia 
is past when the child has cried vigorously and breathes with 
regularity, yet its future depends upon the amount of injury 
to the brain and upon the after-treatment. Children rescued 
from pale asphyxia frequently die within forty-eight hours 
in spite of careful watching. 
Protecting the Child Before Separation from the Mother. 
—When the child is born it still remains connected with the 
mother by means of the placenta and cord. The pulsations 
generally continue in the latter five or ten minutes. Some 
think it desirable to delay the cutting of the cord until the 
pulsations cease, because by so doing the child receives 
more blood from the placenta than when the cord is severed 
immediately after birth. 
It is therefore important that the child be properly pro- 
tected during the period when it has to lie in the mother’s 
bed between her thighs. There is always present after 
birth some fruit-water and frequently blood, so that unless 
the child is properly cared for it will become wet and cold 
even if it does not draw the fluid into its lungs. The change 
in temperature to which the tender child is exposed for the 
first time in its life is perhaps 25 to 30 degrees, and suf- 
ficient to chill it seriously. 
A blanket 1-yard square lined with a cotton sheet of the 
same size which has been enclosed in a sac with four large 
safety pins and sterilized should have been warmed ready 
to receive the baby. After the patient is delivered the 
water and blood are removed with the obstetrical pad or 
sheet, a dry one is inserted if necessary, and then the sterile 
blanket is removed from the sac and wrapped and fastened FIRST CARE OF THE EYES 
283 
about the child. If it is breathing properly and there is no 
hemorrhage or other condition on the mother’s side calling 
for immediate separation of the baby it may lie as long as 
necessary. 
First Care of the Eyes.—The eyes should be attended to 
during this period of waiting for the cessation of the cord 
pulsations. Some physicians use a boric acid eye-wash, 
but it probably has no value and would better be omitted. 
If it is certain that the mother has neither a fresh nor a 
latent gonorrhea the wiping of the face after the birth of 
Fin. 112.—Crede instillation of silver nitrate solution to prevent ophthalmia 
neonatorum. 
the head is sufficient. Ordinarily it is safer to use a silver 
nitrate solution in the eyes and this is required by law in 
many States and should be the. practice of the nurse in the 
absence of the physician or when he has given no direction. 
This method of preventing gonorrheal sore eyes of infants 
was advocated by Prof. Crede, of Leipzig, Germany, and 
therefore is called the Crede treatment, or instillation. 
The solution formerly used had a strength of 2 per cent. 
In this country we generally use a 1 per cent solution. 
One or two drops are put in each eye. The lids must be 284 
THE INFANT 
opened and the solution dropped with an eye dropper into 
the eye. The lids are then wiped off with cotton. 
Tying of the Cord.—As soon as the pulsation ceases the 
cord is tied and cut. Sterilized tape or silk ligature is 
furnished in an envelope in the outfit already prepared 
(see page 126). If not prepared a narrow tape or silk or 
linen thread can be sterilized by boiling. The ligature 
must be tied tightly and should not be too fine, else it may 
cut through the soft cord, severing the bloodvessels as with 
a knife, and causing fatal hemorrhage. 
The first ligature is tied 1 inch from the child so as to 
leave room for another ligature next the body if the first 
should slip or cut through. Then the second ligature is 
placed 1 to 2 inches nearer the mother and the cord is cut 
with a pair of clean scissors about inch from the first 
ligature. The object of the second ligature is to prevent 
the blood in the cord from soiling the bed and, in case of 
twins, prevent bleeding from the second child through a 
common placenta. Many physicians tie the cord at the 
skin junction and cut it so as to leave only a thin button 
that later retracts and gives no trouble in the dressing. 
On account of the possible danger of bleeding the nurse 
may hesitate to use this method. For the further manage- 
ment of the cord and care of the mother see page 164. 
After the cord is tied and cut the baby is taken away to 
a previously prepared warm bed, there to be left until the 
mother is attended to. It is well to lay the head some- 
what lower than the body to allow mucus or other fluid to 
gravitate from the throat and prevent choking by its aspi- 
ration. It is not necessary to place the child on either side 
because of any supposed possible influence of position in 
helping the change from fetal to extra-uterine circulation. 
The Condition of the New-born.—The most important 
facts concerning the condition of the fetus at the end of 
gestation have been given in Chapter II. Here we must 
consider the condition of the new-born, especially noting 
how it has been affected by the forces acting on it at birth 
as well as a few of the more common pathological conditions 
not due to labor. THE CONDITION OF THE NEW-BORN 
285 
Mature infants differ much in weight and length on 
account of differences in the size of the parents and other 
causes not always well understood. It may be said, how- 
ever, that a weight of 7 pounds and a length of 20 
inches are about the normal average. The body is more 
or less covered with the vernix caseosa, a creamy coating 
consisting of exfoliated epithelium from the skin and the 
secretion of the sebaceous glands. The lower part of the 
body is frequently stained with meconium which is passed 
shortly after birth and sometimes before the child is out- 
side of the genital canal. This meconium is a dark yellowish- 
green, tar-like substance that is composed of exfoliated 
epithelium of the mucous membrane of the intestines and 
bile salts and also exfoliated epidermis, hair, and other con- 
tents of the liquor amnii that have been swallowed by the 
fetus. The amount is generally about 3 ounces, and it is 
all evacuated in two to four days. It is sterile at birth, 
but in the course of twenty-four hours it contains a number 
of kinds of bacteria, among thein the colon bacillus, which 
becomes a permanent resident in the intestinal tract during 
the life of the individual. Rarely a mucous plug, called 
also the meconium plug, closes the rectum and comes away 
before the meconium can escape. 
The urine likewise may be voided soon after birth. This 
urine differs from the urine secreted later in containing a 
considerable quantity of uric acid, which not infrequently 
occurs as a reddish “brick-dust” deposit. This may cause 
pain during its passage through the ureters into the bladder 
or in the urethra when leaving the bladder. Also the urine 
for the first few days contains albumin. 
The respirations vary according to the circumstances 
of birth. The pulse is perhaps a little slower than that of 
the fetus, from 120 to 140 a minute. The temperature is 
the same as the interior of the uterus, that is, about 99° F. 
As a rule the eyes are opened within a short time after 
birth. The movements of the eyes are chiefly reflex instead 
of voluntary, and for a few days the movements of one 
eye do not necessarily correspond with those of the other; 
hence the mother need not be worried because the new-born 286 
THE INFANT 
is cross-eyed. Also the bow-legs of a child need cause no 
worry, because they result from the attitude of the fetus 
in litero. 
The first inquiry of the mother is always to learn if the 
baby is all right. The prevalent belief in maternal influence 
is the cause of anxiety on the part of the mother, for nearly 
every woman during pregnancy sees some object or has 
some impression that she fancies may mark her child (see 
page 64). The marks and deformities that we sometimes 
find are either fetal tumors or they come from an error in 
the development of the fetus because of a restricted or an 
excessive development. The effect of too little liquor 
amnii and the resulting compression of the fetus has already 
been mentioned (page 65). 
Nsevi are marks of various kinds on the skin of various 
appearances. Some are much better supplied with blood 
than others. Most commonly they are merely superficial 
or stain-like spots and are frequently seen on the eyelids or 
over the forehead and show more prominently when the 
child cries. This variety usually disappears in time without 
treatment. Others are more markedly vascular, sometimes 
strawberry-like in appearance, and may need to be removed 
by caustics or other treatment. 
Malformations.—Deformities that result from errors in 
the development of the fetus are called malformations, 
and when the individual is considerably deformed it is 
called a monster. When parts of two individuals are 
joined we have a double monster; otherwise, a single monster. 
An example of restricted development in the region of the 
back is a spina bifida, which is due to the fact that the 
spinal canal that was originally formed from a groove has 
failed to close. Failure in the closure of the skull leads 
to various brain and meningeal tumors if the skin or any 
covering persists. If the covering is lacking the rudiment- 
ary brain or the base of the skull is exposed. Another 
example of non-union of parts of the head is found in cleft 
palate and hare-lip. A failure in the closure of the anterior 
wall of the body may result in exstrophy of the bladder, 
where the inside of the bladder is exposed. A failure in the CAPUT SUCCEDANEUM 
287 
closure of the umbilical ring leads to a large umbilical hernia, 
where some or all of the intestines and other abdominal 
viscera may lie outside of the body. Sometimes this may 
be cured by operation. The imperfect development of the 
genital or anal tract may lead to an imperforate anus, vagina 
or urethra. It is therefore important that this condition 
should not be overlooked, for it demands immediate oper- 
ation to relieve the bowels or kidneys. Sometimes one or 
both limbs are absent. A not very uncommon deformity 
is the change in the position of organs, a common example 
of which is the undescended or hidden testicle, which is 
in the abdomen or groin instead of the scrotum. This 
organ originates in the region of the kidney and gradually 
descends through the inguinal canal into the scrotum, 
and stoppage in the descent leads to the abnormality. As 
a. case of excessive development we might mention poly- 
dactylism, or the occurrence of more than the usual number 
of fingers. 
Moulding the Head.—The head of the new-born is almost 
always moulded more or less as it passes through the pelvis 
of the mother (see page 117). The moulding is rendered 
possible by the way the bones of the skull are loosely joined 
together by the membranous sutures and fontanelles. These 
sutures allow the bones to overlap. One of the parietal 
bones is often pushed under the other, while the occipital 
bone and frontal bones may be pushed under the parietal. 
In the usual presentation, with the occiput anterior, the 
head as it passes through the vulva will be most compressed 
at the circumference that passes under the occiput and 
around the forehead and elongated in the direction at 
right angles to the plane that passes through this line. 
Caput Succedaneum.—In addition to the moulding of the 
head thus produced there is also a swelling of the tissues 
that cover the foremost part of the head. This swelling 
is often formed while the head is still in the uterus, and is 
called the caput succedaneum (see Fig. 52). In other 
presentations, as in face or breech presentations, the shape 
of the head is very different. The deformity of the head 
generally disappears in two or three days and requires no 
interference. 288 
THE INFANT 
Cephalhematoma.—Hemorrhage between the periosteum 
and the skull bones causes a soft tumor limited to the region 
of the bone which it covers. This is called a cephalhema- 
toma. It lasts much longer than a caput, but requires no 
interference. 
Fig. 113.—Anterior view of cephalhematoma, showing sharply defined 
border of swelling. (Peterson.) 
Birth Injuries. —Injuries at birth are the cause of death 
in over 10 per cent of the children that die during the first 
week of life. Over 10,000 children are lost every year in 
the United States from this cause. Many of these deaths 
are due to intracranial hemorrhage frequently caused by 
fracture of the skull arising in instrumental delivers. Death 
may also be due to prolonged labor and may have occurred 
before instrumental interference. A much larger number 
of children are injured but do not die. These injuries are a 
frequent cause of convulsions in the new-born. 
When forceps are used in the delivery of the child the THE SKIN 
289 
marks of the blades are frequently seen on the head. Some- 
times the blades cut through the skin making wounds that 
may require dressing and may leave permanent scars. A not 
uncommon result of forceps is a temporary paralysis of 
one side of the face; sometimes the bones are broken. Other 
injuries may be due to the extraction of the child by the 
feet. Fracture of the arms, of the collar bone, of the thighs, 
etc., have occurred. These facts show how important it 
is that the nurse should examine the baby very carefully 
and report any seeming abnormality to the physician. 
The Skin.—When the child is born there is a remarkable 
change in its environment. In the womb the skin, as also 
the whole body of the fetus, is protected from irritation 
of all kinds. Outside, every organ and tissue of the body 
is subjected to new and often harmful influences. In 
particular the skin is exposed to many traumatic and other 
irritations and to infection. No wonder that the child 
soon becomes red all over the body. Ordinarily this ery- 
thema soon disappears as the protective epithelial cover- 
ing becomes able to withstand the new influences affecting 
it. Frequently, however, more or less eruption appears, 
sometimes vesicular and sometimes pustular. This is more 
common on the neck or face or around the genitalia or 
buttocks, since these regions are the ones most exposed to 
infection. The less the skin is exposed to contact with 
dirty hands or clothes the less is the infection. The erythema 
ordinarily needs no treatment except cleanliness. A small 
vesicular eruption may be helped with a mild soda bath. 
Pustules, however, must be carefully treated to prevent 
extension of the infection to other parts of the body, and 
especially to the breast of the nursing mother (see page 
251). They should be opened under alcohol with a sterile 
needle and after evacuation of the pus touched with a very 
small amount of tincture of iodine on a swab. 
Sometimes a well-marked eczema develops in the peri- 
neal region, due to the lack of care in cleaning the child or 
to irritating stools. This is called intertrigo (see page 293 
for management). An eczema of the face may also appear 
during the first weeks of the child’s life while it is still under 290 
THE INFANT 
the care of the obstetrical nurse. This may be caused by 
improper feeding which must be corrected. Meanwhile 
a protective soothing ointment is prescribed. 
Jaundice or Icterus.—A certain amount of discoloration 
of the skin is found in a majority of the new-born during 
the first two or three weeks of extra-uterine life. Its cause 
is not known. Perhaps it is due to a number of causes, 
among which are destruction of blood cells, changes in the 
liver functions, etc. It is of no importance and requires 
no treatment. 
When the jaundice is due to infection from the navel 
wound it is a sign of a more serious trouble. Hence in all 
cases the condition of the navel should be noted and if 
signs of infection are present they should be reported. 
Catarrhal jaundice from an inflammation of the gall duct 
may occur and also jaundice from a congenital stricture 
of the duct. These cases, of course, demand the attention 
of the physician. 
The Bath.—The outfit for the baby’s bath consists of the 
tub, bath thermometer, wash cloths, soap, oil, and towels. 
The best kind of tub is that made of enamelware. Although 
the first cost is high it is very durable and will last for two 
or three generations. One great advantage is that it can 
be kept clean. A tub 28 inches long will answer for one year, 
when the child can be bathed in a larger tub. For those 
who cannot afford the enamelware tub a tin tub, sold in all 
the department stores, will answer very well if not allowed 
to rust. For anyone travelling, rubber tubs which can be 
folded up may be used. These are not durable and cannot 
be well cleaned. 
The common bath thermometer enclosed in a wooden 
frame is cheap and should be in every house. The deter- 
mination of the temperature of the water by the hand, 
which is often insensitive to hot water, is too unreliable and 
has often led to the use of the bath so hot as to seriously 
injure the tender skin of the infant. 
Squares of gauze, cheese-cloth, or soft Turkish towelling 
are best for wash cloths, and should be prepared beforehand. 
The genuine imported Castile soap or a good quality of 
unscented toilet soap should be used. THE BATH 
291 
Pure sweet or olive oil is used before the first bath to 
remove the vernix caseosa. 
A large soft Turkish towel, at least 1| yards square, should 
be provided to wrap the baby in as soon as it is removed 
from the bath. Two smaller linen towels should be provided, 
1 for the face and 1 for the better drying of the creases 
between the thighs, etc. Clean gauze may be used in place 
of the latter. 
Fig. 114.—Baby’s bath. 
It is well to give the bath in some other room than the 
lying-in chamber. The temperature of the room where the 
child is bathed should be about 85° F., and this heat 
is enervating to the mother. In most houses the bath- 
room is most convenient. If any difficulty arises in heat- 
ing it sufficiently, filling the large bath-tub with boiling 
water quickly raises the temperature as much as is needed. 
The baby is often harmed by letting it become chilled in 
the first bath. This is one of the reasons why some phy- 
sicians prefer to omit the bath for a few days, simply oiling 
the child and wiping it off. 292 
THE INFANT 
Before beginning the nurse should see that everything 
needed for the bath, as well as the clothing and navel dressing, 
are in readiness. The bath-tub should be placed on a low 
stool in the bath-room; the closet seat makes a good holder 
for the tub. The nurse sits in a chair beside the tub. Some- 
times a kind of platform is made to fit over the large bath- 
tub on which the baby’s tub can be placed. Another good 
plan when the room is large enough is to use a table for 
bathing and also for all washing of the baby. The bath-tub 
is placed on the table. The nurse stands while bathing the 
child and then lifts it out of the tub into the towel lying at 
the side of the tub. Here it is dried and dressed. Whatever 
the arrangements, it is important that the nurse adopt the 
best and easiest method of bathing and caring for the child, 
since she is an example for the mother, by whom it is very 
desirable that awkward, back-breaking methods be avoided. 
The bath-water should have a temperature of 98° to 99° F., 
that is, it should be blood-warm. After two to three weeks 
it may be two or three degrees colder. Enough water should 
be used so that the baby’s body may be completely immersed. 
The face should be washed first and wiped before the child 
is put into the tub; then the body should be well soaped, 
especially the folds in the neck, in the groin, between the 
thighs, in the axillae, etc. The soaping should be well done 
and the wet cake may be rubbed over the skin. Before the 
first bath oil is freely used, beginning with the head, to 
help in the removal of the vernix caseosa, after which soap 
is employed. After the soaping is done, the child is put into 
the water, and rubbed well with a wash cloth or the hand. 
When it is taken out of the bath it is wrapped in a towel and 
well rubbed. All the flexures, and especially the genital 
region, are particularly well dried with an extra towel; then 
it is ready for the navel dressing and its clothes. 
If washed and dried as directed there will be no need of a 
powder. As a rule powders lead only to carelessness and 
laziness. Generally the child is left wet and a large mass 
of powder is sprinkled on, when it forms a thick crust. If 
the baby should be very fat and any trace of soreness seem 
to indicate a powder, an unscented borated talcum powder CLEANING OF THE PERINEAL REGION 
293 
would do, but it should be sprinkled on very thinly and any 
excess wiped off. 
When the baby is dressed in a sensible way the bathing 
and dressing should not take over fifteen to twenty minutes. 
The best time for the daily bath is about nine or ten o’clock 
in the forenoon, just before a nursing. Since the bath and 
nursing which follows generally conduces to sleep, it may 
sometimes be well to give the bath in the evening if the baby 
does not readily go to sleep. Occasionally it is better to give 
two baths a day. Since all the clothes worn during the day 
should be changed at night, and since the child should be 
washed, between the thighs at least, at bedtime, and as it 
will add but five or ten minutes’ work to give it a bath, both 
an evening and a morning bath may be desirable. In hot 
weather especially, the evening bath is very refreshing and 
almost necessary to the comfort of the baby. 
Fig. 115.—Cleaning the baby. 
Cleaning of the Perineal Region.—The washing of the 
child after the bowels move is very important, for if it is 
neglected or done in a slovenly way, the baby is apt to 
become sore. Moreover the germs that are in the feces may 
cause an infection of the vulva and vagina which may ascend 294 
THE INFANT 
through the urethra into the bladder and even into the 
kidney. For a proper washing are required: Plenty of water, 
a piece of rubber cloth over which is laid a napkin, a bowl of 
warm water, soap, absorbent cotton or gauze sponges, a 
towel, and clean napkins. The baby can never be properly 
washed while held across the lap, and the position is back- 
breaking for the nurse or mother. It may be cleaned on the 
bed or on a table. If the bed is used the nurse should sit in a 
low chair, having at her right hand on a table the things 
needed. The child is laid on its back with its head away 
from the nurse. The napkin is removed and, holding up the 
feet with the left hand, the thighs are flexed onto the body 
and the rubber cloth is inserted under the hips. Then with a 
cotton sponge, using plenty of water, the buttocks and anal 
region are thoroughly cleansed, soap being used when neces- 
sary. The nurse should never wipe upward from the anus 
toward the vulva. After washing the baby is carefully wiped 
and the clean napkin put on. If a table is used (Fig. 115), 
the nurse places the baby in the middle and has the basin of 
water and sponges and napkins conveniently at her right 
hand. Instead of a rubber cloth to protect the bed and a 
thick napkin to absorb the water, some prefer to insert a 
bed-pan so that there need be no restriction in the amount 
of water used. 
Sometimes the baby has very numerous small passages 
that frequently are quite irritating. These may require a 
washing out of the bowel or some other treatment as ordered 
by the physician. Special attention to cleanliness is needed 
and sometimes a protecting salve. Should a baby be washed 
after each passage of urine? This is not necessary when it is 
cleaned as described after the bowel movements. If the 
nurse watch the baby carefully, she can generally tell from 
its actions when it is wet, and then she should remove the 
wet napkin and apply a dry one at once. At night the napkin 
need not be changed when the baby is asleep. 
It is a common practice to dry the napkins and use them 
the second or even the third time, because of a scarcity of 
napkins or to economize in washing. At the same time the 
mother has probably provided a large wardrobe of fancy CARE OF THE NA VEL 
295 
lace dresses, any one of which has cost more than two dozen 
napkins, and the washing and ironing of which will more 
than offset the washing of the napkins. 
Care of the Navel.—After the bath comes the dressing 
of the navel. The cord dries up in a day or two and separates 
in from four to fourteen days, leaving often a slight raw sur- 
face which covers over with epithelium in a few days more. 
The object of the dressing is to protect the navel from injury 
that might be produced by the catching and pulling of the 
clothes and to prevent its infection. Infection of the navel 
is not uncommon and frequently causes fever and other sick- 
ness. A baby eight days old has been known to die of lockjaw 
where the germs of the disease were found on the navel. This 
infection probably came from some contaminated cloths 
used in dressing the cord. When the baby is born it is 
absolutely sterile. It would be possible to put on an aseptic 
dressing that would keep out all germs until the navel wound 
healed. Such a dressing is, however, complicated and would 
involve considerable care and expense. It is not necessary, 
for it is possible to manage the navel wound antiseptically 
so that no harm will result. The following method is recom- 
mended : 
Remembering that the place where infection occurs is 
where the cord separates from the body, this region should 
be thoroughly washed with alcohol, the only efficient and 
non-poisonous disinfectant. A towel or some dry cotton is 
placed over the pubes to keep from the genitals the alcohol 
which is poured over the navel. A little cotton saturated 
with alcohol may also be wound around the piece of the 
cord and left in place for two or three minutes. Then clean 
absorbent cotton is wound around the cord so that the sore 
is well covered. The cord is turned over to the left side and 
held in place with a flannel bandage about 4 inches wide and 
24 inches long. This dressing is, of course, removed when- 
ever the baby is bathed. If it should stick it will soften and 
come away when the baby is put into the water. Some 
physicians prefer to leave the dressing on the cord until the 
latter falls off, and hence give a sponge bath until this occurs. 
If this practice be followed, it is especially necessary to clean 29G 
THE INFANT 
the junction between the cord and the body. If the cord is 
cut short (see p. 284), no dressing is needed except a little 
sterile cotton. Alcohol is poured into the depression con- 
taining the short stump of cord after the bath, and at other 
times if there is any redness or odor. 
No powder is necessary on the navel. Boric acid and 
bismuth have very little antiseptic value and generally 
form a crust or scab under which suppuration goes on undis- 
turbed. After the cord has come away the wound is cleaned 
and cared for in the same manner until all discharge has 
ceased. It is important not to allow the depressed wound 
to become covered with a scab, under which bacteria grow. 
The bandage is only for the purpose of holding on the dressing 
and is discarded as soon as the wound is healed. It is prob- 
able that it has no effect in preventing umbilical hernia and 
may possibly favor its occurrence if it constricts the abdomen. 
Fig. 116.—Application of adhesive strap for umbilical hernia. 
Umbilical Hernia.—If the navel opening in the abdominal 
wall does not contract well a protrusion of the omentum or 
bowel may occur constituting an umbilical hernia. This is 
favored by much crying or straining, but it is due to a primary 
or congenital weakness and is not the result of any mistake 
in the dressing of the cord. It will generally disappear spon- ADHERENT FORESKIN 
297 
taneously, but if it is troublesome a strip of adhesive plaster 
2 inches in width should be applied so as to bring the abdom- 
inal walls together and close the opening. No button or 
other wedge-like body should be used, for it would only tend 
to keep the ring open. The plaster strip must be left in 
place for several weeks and perhaps a fresh strip must be 
used if the first comes off. While this dressing is in use the 
body must be cleaned with a sponge bath. 
Care of Genitalia.—In the female infant the vulva and 
the vagina not infrequently become infected and there is 
vulvo-vaginitis, characterized by redness, swelling, and more 
or less purulent discharge. Generally the infecting agents 
are the common pus bacteria or the colon bacilli. Some- 
times gonorrheal germs are present, coming possibly from 
the contaminated vagina of the mother during the birth or 
more often brought to the genitals by the nurse from gonor- 
rheal contaminated lochia, or from gonorrheal ophthalmia. 
Practically all genital infection of the child is due to careless 
handling, bathing, or cleaning. The nature of the infection 
can be determined with certainty only by a bacteriological 
examination. 
The infection may not be confined to the vulva or lower 
part of the vagina. It sometimes ascends through the short 
urethra into the bladder and up the ureters even to the 
kidneys. This infection may subside after a few days or 
weeks and remain latent for months or years to reappear 
later as chronic or intermittent pyelitis or cystitis. 
The prevention is care in cleaning the perineal region of 
the child (see p. 293). If infection has already occurred it 
may be necessary to use argvrol or some other antiseptic. 
Menstruation in Infancy.—Occasionally a slight bloody 
discharge is found coming from the vagina. Sometimes a 
red uric acid deposit is mistaken for blood. When the dis- 
charge really contains blood it may be due to injury or it 
may be allied to a menstruation. It does not reappear and 
needs no treatment except cleanliness. 
Adherent Foreskin.—In the male child the foreskin or 
prepuce is more or less adherent to the glans. Sometimes the 
foreskin is long and extends considerably beyond the glans. 298 
THE INFANT 
When the opening is very small we have the condition called 
phimosis. Drops of urine may be retained in this foreskin 
canal and eventually cause irritation. Occasionally a con- 
siderable amount of smegma is collected under the prepuce 
just behind the glans, and this may also become a source of 
irritation. 
For the sake of keeping the foreskin and glans clean the 
adhesions between them may be broken down with a probe 
and the foreskin retracted until it is perfectly free from the 
glans. Then it is again pulled back to its proper place. To 
accomplish this it may be necessary to dilate the foreskin. 
The nurse should never undertake to retract the foreskin. 
This is an operation and must be performed by the physician. 
Improper interference may lead to injuries and infections. 
Sometimes when forcible but unskilled manipulations are 
made by the nurse the foreskin is retracted behind the glans 
and then contracts as a tight ring, the glans swells, and it 
becomes impossible to replace it. This condition is called 
paraphimosis. The same rule applies to the penis as to the 
breast: Let it alone. 
If the physician dilates and retracts the foreskin he may 
expect the nurse to dress the child, that is, repeat the manip- 
ulations daily. For the first two or three days there may be 
some difficulty, and it is important that the nurse very 
quickly pull back the foreskin after retracting it. An applica- 
tion of sterile vaseline on the probe or with cotton aids in the 
procedure. 
Circumcision.—Sometimes the foreskin is removed by 
circumcision. This operation is also practised as a religious 
rite by some sects and races. The operation is made in 
different ways and the physician will say what instruments 
are needed. The nurse must prepare a table in a good light 
and cover it with a clean sheet. She must also furnish a 
basin with an antiseptic solution and sponges, sterile towels, 
and sterile petrolatum or oil. The child is undressed and 
cleaned and then held by the nurse while the physician 
operates. Often the child is given a half teaspoonful of 
brandy in sugar-water as an anesthetic. CARE OF THE MOUTH 
299 
After the circumcision the nurse must watch the child 
closely for two or three hours for bleeding. 
Undescended Testicles.—The testicles, like the ovaries, 
originate in the abdomen and gradually descend during 
fetal life. They finally pass through the inguinal ring and 
before birth reach the scrotum. Sometimes this descent is 
interfered with and the testicles remain in the abdomen or 
in the inguinal ring. As a rule no immediate treatment is 
instituted, but the condition should be noted and perhaps 
extra care used to avoid hurting the testicles lying in the 
groin. 
The Breasts.—There is a certain amount of swelling, 
glandular development, and functional activity in the breasts 
in nearly all children of both sexes during the first two weeks 
of extra-uterine life. The excretion (“witches’ milk”) that 
can be expressed is similar to the colostrum found in the 
mother’s breast during pregnancy and immediately after 
labor (see p. 242). Sometimes the swelling is so considerable 
as to cause anxiety to the mother or uninformed nurse and 
lead to efforts to empty the breast by manipulation or to the 
use of compresses. These measures may result in infection 
and serious injuries, and are quite unnecessary. The breast 
should be left alone. At most a protective band might be 
applied. 
Care of the Mouth.—The common practice of swabbing 
out the mouth daily with a cloth on the end of the finger is 
objectionable. If the mouth were infected, such a washing 
could not clean it, but would probably increase the infection 
by rubbing off the epithelium from the tender mucous mem- 
brane of the mouth. It is unnecessary, for the mouth of a 
healthy child will clean itself. Of course, particles of regurgi- 
tated milk may be removed. 
Bednar’s Aphthae.—This is due to infection and ulceration 
of abrasions at the junction of the hard and soft palate which 
have been caused by “mouth washing.” It is painful, inter- 
fers with nursing and may lead to a serious condition. 
Thrush.—Thrush is an infection of the mucous membrane 
of the mouth and sometimes of the throat with a fungus that 
grows in colonies from the size of the head of a pin to \ of 300 
THE INFANT 
an inch in diameter. It comes from the introduction of 
germs into the mouth in washing it or on the nipple or 
sugar teat that is given the child to pacify it. It is more apt 
to appear in children whose mouths are washed than in those 
left alone. If the child is weakly, thrush may be difficult to 
cure and sometimes leads to bowel and intestinal disturb- 
ances. The treatment is local and general. Before each 
nursing the child is held in a good light and the mouth care- 
fully exposed. The nurse has prepared a number of sterile 
cotton swabs on toothpicks; with these wet in sterile water 
she rubs off the patches. No solutions are necessary, only 
constant attention for a few days. Meantime the child must 
be well nourished and the bowels must be kept in good con- 
dition. 
Tongue-tie.—When the frenum, the membranous band 
that attaches the under surface of the tongue to the floor 
of the mouth, is inserted well forward to the tip of the tongue 
it limits its free motion and we have the so-called tongue-tie. 
Very rarely this may interfere with nursing, and later in life 
with good articulation. The physician corrects it by cutting 
the band with scissors. 
Care of the Nose.—Sometimes a little dried mucus may 
collect in the nose. This may be removed carefully with a 
moist sterile swab. Otherwise the nose needs no routine 
attention. 
Not infrequently a mild infection of the nasal passages 
leads to a slight catarrhal discharge. The child has the 
“snuffles.” It breathes with some difficulty, especially when 
nursing. The infection may come from contamination, 
perhaps with lochial germs in washing the face or by unnec- 
essary swabbing out of the nose. The infecting agents are 
generally the pus germs sometimes pneumonia or grip germs 
and rarely gonococci. The influenza and pneumonia germs 
may come from a nurse or other person who is suffering with 
a bad “cold.” The method of prevention follows from a 
consideration of the cause. The treatment generally consists 
in keeping the passages lubricated with a drop of liquid 
petrolatum dropped into the nose as necessary. DIARRHEA 
301 
Vomiting.—Vomiting in an infant is generally the regurgi- 
tation of unchanged milk during or shortly after nursing. 
Sometimes the milk may be curdled and there are signs of 
indigestion. This is most frequent in artificial feeding. 
Rarely vomiting may be due to an obstruction in the pylorus 
or to other causes. In the first case the regurgitation is 
generally of little importance. The duration of nursing may 
be lessened and the infant should also be kept quiet after 
nursing. When there are signs of indigestion the physician 
will examine the vomit and the milk and may modify the 
feeding or give some antacid or digestant. 
Diarrhea.—As a rule, within twenty-four hours after 
feeding begins, the milk feces appear mixed with the meco- 
nium, forming the “milk stool.’’ In a short time the meco- 
nium disappears entirely and the intestinal excrement is 
henceforth the feces. It is much thinner than meconium, 
has a bright yellow color, and is fairly homogeneous. Fre- 
quently, however, small curd-like masses appear and also 
pieces of mucus. 
Besides the colon bacillus, which lives mostly in the colon 
and rectum, other important germs live in the small intestine. 
In babies fed on breast milk the most common bacteria are 
the Bacillus bifidus and the Bacillus acidophilus. In those 
fed on cows’ milk an important germ is the Bacterium lactis 
aerogenes. This germ is a gas producer and, like the colon 
bacillus, probably is a not unimportant factor in digestion. 
Ordinarily the new-born has from two to four stools a day. 
Sometimes, however, the stools are more numerous, fre- 
quently a small passage after each nursing. This is not 
generally of much significance. A small enema or a dose of 
castor oil to clean out the bowel and prevent irritation from 
its contents is sufficient to correct the slight trouble. If the 
stools become quite green on passage, contain mucus, are 
acrid and cause much pain and perhaps a little fever, we 
have a distinct pathological condition. Some fault in the 
feeding is suspected, especially if there has been any artificial 
feeding. Harmful germs may have got into the intestine 
and succeeded in overcoming the colon or lactic bacteria 
which help protect the body from the pathogenic micro- 302 
THE INFANT 
organisms. The treatment is generally to stop feeding for a 
day or two, giving only water or barley-water and cleaning 
out the bowel with castor oil or enemas or both. 
Castor oil is often given in teaspoonful doses. Some phy- 
sicians favor giving 10-drop doses frequently repeated. 
For giving an enema a 3-ounce ear syring made in one piece 
of soft rubber is satisfactory. A catheter or small rectal 
tube attached to a funnel may also be used. The ordinary 
fountain syringe and the bulb syringe are not so good. 
Fig. 117.—Giving enema to baby with funnel and tube. The soft-rubber 
bulb syringe, shown on table, may also be used. 
Constipation.—Occasionally a new-born infant will have 
only one stool a day and sometimes none without help. This 
may be due to a deficiency of fat in the food or perhaps to a 
deficiency in the amount of food. Besides correcting the 
cause, if possible, it may be necessary to assist the baby to 
secure at least one bowel movement a day. It is well to begin 
to establish a habit and secure a movement before the daily 
bath. A small salt-solution enema may be used or a soap CARE OF THE EARS 
303 
suppository. Frequently the introduction of a thermometer 
into the rectum is sufficient to start the movement. 
Colic.—Etymologically this term means an affection 
of the colon. Practically it means an acute paroxysmal 
pain of any kind. Applied to infants it means either intes- 
tinal colic or else that due to the passage of urinary calculi 
through ureters or urethra. This can sometimes be diag- 
nosed by finding that the pain occurs when the red uric acid 
deposit passes from the bladder. Intestinal colic is due to 
irregular, cramp-like contractions of the bowel. 
Very few babies escape colic entirely. Sometimes it is 
very persistent and makes the most important complication 
of a case. In intestinal colic there is generally some fault 
in digestion, but it is often impossible to determine definitely 
the causes. If the baby gains in weight in spite of its crying, 
the mother may be assured that there is no danger. 
Intestinal pain due to inflammation of the bowel can 
generally be distinguished from colic by the character of the 
pain and the difference in the tenderness on pressure. 
The treatment of colic should be to remove the cause. If 
the cause cannot be discovered it is necessary to give the 
child relief at least temporarily. The best way, as a rule, 
is to give a salt-solution enema. Sometimes a dose of castor 
oil gives relief. Both of these means probably act by pro- 
ducing a general movement of the intestines and thus reliev- 
ing the local excessive action. A mild carminative such as 
oil or essence of peppermint or wintergreen will also act in 
somewhat the same way The baby should be kept warm, 
especially its feet. Sometimes a general warm bath will be 
necessary. 
Urinary colic is frequently accompanied by symptoms 
of intoxication. There are often fever and respiratory dis- 
turbances. It is probably an important factor in many of 
the fevers of the new-born that are sometimes, without very 
good reason, called inanition fevers. It is best treated 
by giving large quantities of water by month and rectum. 
Care of the Ears.—The external ears should be kept 
clean like all parts of the skin. There is very rarely occasion 
to interfere with the auditory canal. 304 
THE INFANT 
Care of the Eyes.—Healthy eyes need no washing. There 
may be a slight irritation of the eyes for two or three days 
after birth from the Crede instillation (see p. 283). This 
will generally disappear of itself. If there is a slight watery 
discharge the eyes may be washed four or five times a day 
with a boric acid solution. The common practice of washing 
the eyes every morning is unnecessary and would better be 
omitted. There is no occasion to fear the mild light of a 
room. Probably an intense light, as the direct sunlight 
shining into the baby’s face, would be unpleasant, as such a 
light is to any person. Light is not the cause of sore eyes, 
which are the result of an infection. 
Ophthalmia Neonatorum. —Gonorrheal infection of the 
eyes of the new-born is the common cause of a serious disease 
that generally appears two or three days after birth, and 
unless well treated leads to blindness. This is the cause of 
half the blindness in the world. The germs of gonorrhea exist 
generally in a latent state in the vulva and get on to the face 
of the child during its passage out of the vagina. The germs 
get into the eyes when they are opened after birth. They 
soon set up a violent gonorrhea of the conjunctiva, with the 
formation of much pus. Frequently the lids stick together 
and pus accumulates in large quantities between them and 
the eyeballs. Soon the inflammation extends from the con- 
junctiva to the cornea, and here produces one or more 
thickened, opaque patches. When these patches are over 
the pupil the sight is lost. Sometimes there is deep ulcera- 
tion, which may lead to perforation of the eyeball. 
Every case of inflammation of the eyes must be reported 
at once to the attending physician, who will immediately 
institute treatment. A microscopical examination of a smear 
of the pus will determine the nature of the infection. If 
gonorrheal, frequently 2 or 3 drops of a 1 per cent nitrate 
of silver solution will be dropped into the eye as in the 
prophylactic Crede instillation (see p. 283). Sometimes 
a stronger solution is used with the dropper or on a swab. 
The eyes are then washed frequently, every half-hour to one 
hour, day and night, with boric acid or normal salt solution. 
This may be used with an eye dropper or, better, with an DRESS 
305 
irrigator. Between the washings ice compresses may be 
applied. Some physicians prefer hot compresses. Occa- 
sionally argyrol or protargol or some other albuminate of 
silver is used instead of nitrate of silver or in conjunction 
with it. 
Non-gonorrheal infection of the eyes may result from 
contamination with colon bacilli or pneumonia germs or 
other germs found on the hands of the nurse or on the cloths 
used to wash or wipe the face of the child. This form of 
infection is not generally serious and is easily controlled by 
washing the eyes before each nursing with boric acid or salt 
solution. 
Fig. 118.—Ophthalmia neonatorum. 
Subconjunctival Hemorrhage.—A bright-red spot covering 
one-fourth or more of the front of the eye is due to a hemor- 
rhage beneath the conjunctiva, caused perhaps by rupture 
of a minute vessel during birth. It causes no trouble and 
will disappear by absorption in two or three weeks. 
Dress.—The child should be dressed so as to protect it 
from loss of heat and the changes of temperature which occur 
even in the summer season. Decorating a baby or making 
it look pretty, unless it can be done without interfering with 306 
THE INFANT 
its health and comfort, should not enter into consideration. 
The method of dressing babies that is still not uncommon 
in this country, by which they are enclosed in three or four 
long, heavy, white skirts, while over the neck and arms is 
only a thin dress covered with lace, is directly opposed to 
the proper principles of dress. The mother often gives much 
time and labor to preparing a wardrobe that is quite unprac- 
tical because she has never had her attention called to the 
importance of warm, loose, comfortable clothing. Let her 
understand why all parts of the body should be protected, 
and why the baby should be dressed for comfort and not for 
show, and she will not only acquiesce in a common-sense 
outfit, but become enthusiastic over it. 
Every object changes its temperature, that is, loses its 
heat or cold in direct ratio to the extent of its surface and 
not to its weight. For example, two blocks of ice that weigh 
10 pounds each will melt quicker than one that weighs 20 
pounds. A baby that weighs 7 pounds will lose in a given 
time much more than one-twentieth as much heat as an 
adult that weighs twenty times as much or 140 pounds. 
Moreover, the cooling off of a living body depends also upon 
the nature of the external layer. If the skin is lined with a 
good layer of fat, the body cools slowly. New-born babies 
have but little fat, and hence lose heat very rapidly. To 
conserve the vital energy of the baby it is therefore necessary 
to protect it well, not only .the lower part of the body, but 
also the upper extremities. 
For the first months of its life the baby should sleep most 
of the time and realize practically no difference between day 
and night. Its exhibition to relatives and strangers distracts 
its sleep and exposes it to changes in temperature as well as 
to dangers of infection. Let it lie undisturbed, both day and 
night, in clean, warm, loose garments, and it will thrive best. 
As a soft, warm, absorbent material both for diapers and 
shirts, the Arnold knit goods, or garments of like pattern, 
can be recommended. The diapers, especially, have been so 
extensively advertised and sold that they hardly need any 
description. For its softness and absorbent properties it 
has perhaps advantages over any woven material. The DRESS 
307 
shaping of the diaper to fit the body by taking a gore in the 
center and folding across the gore is especially to be recom- 
mended, for it prevents the diaper from slipping and makes it 
fuller in the seat where the chief amount of material is needed. 
A peculiar soft, warm, cotton cloth now on the market, made 
especially for diapers, is cheaper than the Arnold knit goods, 
and is preferable to linen or cotton flannel. The small 
squares to be laid in the seat of the large diapers is a good 
addition for young babies. Unless the napkins are changed 
quite often the contents soak through and the skirt becomes 
wet. To prevent this at night, an extra napkin may be 
fastened around the body, but not bound around the thighs. 
There are times when the rubber diaper might be used, 
for example, at a christening; but ordinarily it is objectional 
and should not be worn. 
The short skirts are best made of cotton or cotton and 
wool, or silk and wool, so that they do not shrink too much. 
The stretcher is convenient to use in drying the garment. 
If the baby is born in the warm season, stockings are not 
necessary, but in winter, unless the house is kept at an even 
temperature, they are often valuable. They are fastened 
to the diaper by safety pins. 
In summer a long skirt of single thickness may be all the 
baby needs in the daytime, while at night the double gar- 
ment is put on. In winter it is well to use both the single 
and the double garment. In this mode of dressing, the arms 
are protected as well as the body. An additional sleeveless 
skirt is quite unnecessary. Pinning blankets which hamper 
the exercise of the legs are not only unnecessary but undesir- 
able. 
In some hospitals a much simpler outfit is in use, and there 
is no valid reason why it should not be used in private houses. 
Such an outfit consists of a diaper and a sack-like garment 
without sleeves, that ties around the neck and extends below 
the feet. It may have a shirring string in the bottom so 
that the baby may be entirely enclosed in the bag. Such a 
garment has the advantage of keeping the hands and feet 
enclosed so that they cannot become cold and the baby 
cannot get its hands into its mouth or scratch itself. Its 308 
THE INFANT 
simplicity and cheapness together with its other advantages 
makes its more general use advisable. 
The bibs, to be worn continuously if the child regurgi- 
tates much, or otherwise only at feeding time, should be 
absorbent and from 9 to 10 inches long, large enough to be 
of value. Fine Turkish towelling is a good material to make 
them of. 
Fig. 119.—Sack gown for new-born infant. 
The house jacket is a very important garment. While 
the lower part of the body is enclosed in blankets, the arms 
and chest may be free and exposed. A short house jacket 
should be adapted to the temperature of the room, If the 
room is quite cool or if the child is exposed to drafts, a thick 
knitted jacket or a sweater is greatly to be recommended. 
The outside jacket, the hood or cap, and as well SLEEP 
309 
as the shoulder blankets to wrap the child in when being 
carried about the room or from place to place, need no special 
description. 
All clothing should be changed night and morning. The 
shirts worn one day may be aired and worn again unless 
soiled. The nurse is responsible for the care of the clothes. 
If she does not wash them herself she must see that they are 
washed properly. The Arnold goods, at least the diapers, 
require no ironing. Napkins soiled with feces must be washed 
out in cold water, rinsed, and then well boiled and rinsed 
again. When soiled with urine, they should be rinsed well 
with hot water. 
Sleep.—Since the baby sleeps most of the time when 
it is not eating, its bed is an important matter. It should 
never sleep in the same bed with the mother, because the air 
is not so good, there is danger of the mother’s lying on it, 
and it is apt to disturb the mother. If it is possible it should 
sleep in another room which can be warmed and ventilated 
to suit the baby. Frequently a temporary bed, suitable for 
five or six months, is made out of a large clothes basket or a 
basket made for the purpose is procured. A hood at the 
head is unnecessary and objectionable, as it interferes with 
good ventilation. This basket-bed may be placed on a low 
table or perhaps on a large chair. If it is in the mother’s 
room it should stand in a protected part. At the bottom a 
small hair mattress is laid and covered with a piece of rubber 
cloth over which is spread a thick flannellette blanket or a 
comforter, and then a warm flannel blanket, which also lines 
the sides of the basket. The baby is then wrapped in a thick 
flannel blanket, or, in warm weather, perhaps in a shoulder 
blanket. In the warm season of the year or in a room well 
ventilated without drafts the baby gets better air and seems 
to enjoy itself more when it lies on the bed in daytime. 
Sometimes a child’s crib is provided, before the baby comes. 
A rocking crib or cradle is unnecessary and objectionable. 
The ordinary crib with low sides answers very well for the 
baby, but is objectionable as soon as the baby is large enough 
to climb up, for then it is likely to fall head first out of the 
bed. For a child’s bed, suitable also for older children, that 310 
THE INFANT 
is, those a year or two old, a crib with some kind of a safety 
device that has sides high enough to prevent a child falling 
out, when it is old enough to stand up, is to be recommended. 
The open construction of such a bed also allows perfect cir- 
culation of air. 
A baby needs no pillow. It may lie on the back, on either 
side or on its face. The latter position is often indicated 
when it has colic. 
All bed-clothing should be well aired every morning while 
the baby is bathing or nursing. 
Feeding.—In Chapter V, p. 242, it was stated that the 
baby should be given the breast secretion from the beginning, 
because the colostrum is nourishing and a proper food for 
the new-born, and because nursing is advantageous to the 
mother. Until the milk secretion is well established the 
baby may nurse, when the mother’s condition does not 
contraindicate, every three or four hours if the baby is 
awake. Since the colostrum does not generally furnish liquid 
enough it is necessary to add water. For this reason the 
nurse should give the baby as much pure water as it will 
take, generally 2 or 3 teaspoonfuls at a time every two 
hours. Occasionally when it is necessary to get a large 
quantity of water into the system, as in anuria or urinary 
colic, sugar-water, 1 or 2 teaspoonfuls to the pint, may 
be given. Managed in this way, the baby will keep in good 
condition for the first two or three days of its life before 
lactation begins, and will not lose more than 0 to 12 ounces 
in weight. 
If the breast is not very well developed and the baby does 
not take hold of the nipple well, or if the condition of the 
mother indicates a need for considerable rest, it is not good 
to annoy her at first too much with nursing the child. At 
no time should it be at the breast longer than twenty minutes. 
After the milk has come the regular routine for the feeding 
of the baby must be determined and followed out. It is 
best that the baby should be fed with some regularity, both 
for the convenience of the mother and the good of the child. 
Although little lambs or calves may run to the mother 
every few moments it does not follow that it is a good plan FEEDING 
311 
for children of civilized parents to adopt the same ride. 
Those mothers who nurse their babies every time they cry, 
thinking they are hungry, may become martyrs to the prac- 
tice. On the other hand, an unvarying insistence upon a 
two-hour or a three-hour rule may also become a tyranny, 
and may be quite unnecessary. 
It is important to study the child’s needs. While some 
children ought to be fed every two hours, others, because 
they have larger stomachs or obtain more milk, go very well 
three or four hours between nursings. To make a two-hour 
child go three or four hours without nursing will torture 
and harm it, while to wake a four-hour baby and insist upon 
its nursing every two hours will tire out the mother and 
nurse. 
The best index of the sufficient feeding of a child is its 
growth. If it gains properly from day to day or from week 
to week, that is from | ounce to 2 ounces a day, or from 4 to 
10 ounces a week, it gets enough to eat, although there may 
be some fault in the composition of its food that causes colic. 
On the other hand, although a baby may be very good and 
quiet, yet if it loses in weight or stands still it is not getting 
sufficient food. Hence it is important that the baby should 
be weighed as accurately as possible from time to time. 
A scale that will weigh to ounces at least is very desirable. 
A lever balance with separate weights or with a sliding weight 
is most satisfactory. If no such scales are accessible, how- 
ever, a spring balance is better than nothing. 
A child should always be weighed under the same con- 
ditions as respects its mealtimes. The best way is to weigh 
it naked in the morning immediately after its bath. The 
weight should always be recorded. 
If question arises as to the sufficiency or amount of mother’s 
milk it may be answered by weighing the child before and 
after nursing, provided sufficiently delicate scales are used. 
It is not necessary to take into account the clothes of the 
child if they remain the same in both weighings. 
A normal child, to make a satisfactory gain in weight, will 
generally need from one-eighth to one-tenth of its weight of 
mother’s milk every twenty-four hours. A premature child 312 
THE INFANT 
will require proportionally more (see p. 323). Ordinarily 
one may determine, in the course of four or five days, the 
proper routine for the nursing of the baby. If the child is 
very weak or premature it may be necessary to nurse it 
oftener than once in two hours. In the case of a fairly well- 
developed child this is the shortest period. About half of 
all babies may be fed every two and a half to three hours 
Fig. 120.—Baby scale. 
during the daytime, that is, from seven to eight o’clock in 
the morning until eight to ten o’clock at night. During the 
night, of course, the child is allowed to sleep all that it will. 
During the daytime it should be awakened at the nursing 
time, when the proper interval has been established. In 
the rest of the cases it may be found desirable to let the baby 
nurse every four hours. FEEDING 
313 
Ordinarily the baby gets sufficient milk from one breast, 
and it is convenient for the mother to nurse the breasts 
alternately. If, however, the child does not get sufficient 
from one breast it is best to give both at one time. This 
is a good practice, as it stimulates the breasts, and thus 
increases the amount of milk secreted by them. It should 
not remain at the breast longer than fifteen minutes or at 
the most twenty minutes. If it holds the nipple too long 
in the mouth the nipple becomes macerated and more easily 
wounded. Besides, the mother is exhausted. 
Occasionally a child is unable to obtain sufficient milk 
from the breast, either because the milk does not flow well 
through partly obstructed or very small milk ducts, or the 
nipples are depressed or small or hard to grasp, or because 
the baby is too weak to make any nursing efforts. This 
trouble generally confronts us during the first four or five 
days of the child’s life. If the child can be nourished for a 
few days it will become strong enough to get milk from the 
breast, if the mother has a sufficient secretion for it. In 
these cases the nurse must get the milk from the breast and 
feed it to the child. At first she may be able to obtain only a 
teaspoonful at a time; after a day or two she can generally 
get 3 or 4 teaspoonfuls. The milk can be gotten by 
carefully milking the breast with the hands Sometimes a 
breast-pump may work better, but, as a rule, a skilful nurse 
can do as well with the hand as with the pump and cause less 
pain. When possible, if the mother is not diseased, a more 
vigorous healthy baby may be applied to stimulate and 
develop the breasts. The milk can be collected in a small 
cup, warmed by setting the cup into a large vessel of hot 
water, and fed to the baby with a teaspoon. If only a tea- 
spoonful of milk can be obtained at a time it may be necessary 
to feed the child each hour. Sometimes the physician may 
order a little stimulant to be added to the milk, a drop or 
two of brandy. In these cases it is desirable to give the 
baby as much sweetened water as it will take, for sugar and 
water are important elements of the child’s food While 
the child is thus fed it should be put to the breast every three 
or four hours in order to try and discover if it will not nurse. 314 
THE INFANT 
After it begins to draw from the breast it should still be fed 
on the mother’s milk with the spoon until the mother and 
nurse are convinced that it gets sufficient by nursing. 
When no milk can be obtained from the breast for several 
days it may be necessary to feed the child something more 
than sweetened water. Sometimes because of sore breasts 
or on account of sickness of the mother artificial feeding 
temporarily or permanently must be resorted to. The physi- 
cian will of course prescribe the food and the method of 
preparing and giving it. 
In order to understand why cows’ milk, which would 
seem to be the most natural food for children, may not be 
a good food for young babies, we must, for a moment, study 
its composition and compare it with woman’s milk. As is 
well known, milk is a complex food containing, besides water 
and certain mineral salts, sugar, i. e., milk-sugar, fat, i. e., 
butter, and proteid substances, one of which, casein, is the 
important part of cheese. Milk is normally curdled in the 
stomach juice. The kind of curd that is formed by milk 
depends upon the amount and kind of proteid that is present 
in it. Cows’ milk differs from woman’s milk in having a 
larger proportion of casein. Moreover the casein of cows’ 
milk forms a denser, tougher curd than does that of woman’s 
milk. Hence it follows that if unchanged cows’ milk be 
given to babies, tough indigestible curds may be formed which 
can cause stomach and bowel disturbances. 
To change the cows’ milk so that it will answer better 
for an infant’s food, water is added to dilute the proteid. 
This dilution, however, makes the milk poor, as it diminishes 
also the proportion of sugar and fat. To counteract this 
objection, fat, in the shape of cream, and sugar are added to 
the diluted milk. What amounts to the same thing for small 
babies as diluting milk and adding cream is diluting cream. 
In order to see more clearly the changes that take place 
by this process of modifying milk, let us look at the composi- 
tion of woman’s milk and cow’s milk and cream. 
Woman’s milk contains in 100 parts: 
Proteids 1 to 2 parts 
Sugar, about 6 parts 
Fat, about 3 parts FEEDING 
315 
Cow’s milk contains in 100 parts: 
Proteids 3 to 4 parts 
Fat, about 4 parts 
Sugar, about 4 parts 
A good cream will contain in 100 parts: 
Proteids 3 to 4 parts 
Fat 16 parts 
Sugar 4 parts 
Now it will be seen that when we dilute this cream with 
three times its bulk of water the mixture will contain in 100 
parts: 
Proteids, about 1 part 
Fat 4 parts 
Sugar 1 part 
If to such a mixture milk-sugar or dextrose be added to 
make it as sweet as ordinary milk we will have a food very 
nearly approaching the composition of mother’s milk. This 
is a good substitute for breast milk for young infants. 
It is, of course, important that the cream used in making 
this modification should have a definite composition. 
Such precautions are taken, in the production and care of 
certified milk and cream, that it reaches the consumer very 
little contaminated and can be given to the child without 
sterilizing. 
The ordinary market milk is not so carefully handled and 
is generally considerably contaminated when it is delivered, 
so that it should be sterilized always before it is given to 
infants. Boiling is the simplest way of sterilizing. The 
mixture is put into an enamelware basin and carefully boiled 
for three to five minutes on a stove or over a gas flame. Of 
course care must be taken not to burn the milk. The water 
that is lost by evaporation should be replaced or, better, a 
sufficient extra amount of water should be added beforehand 
to leave the proper quantity after evaporation. The milk 
may also be put into nursing bottles and sterilized by steam 
in an Arnold or a similar steam sterilizer. Careful boiling, 
however, answers every purpose and for the small amount 316 
THE INFANT 
generally needed temporarily with infants it is perhaps pref- 
erable. 
In many cities and large towns there are dairies that 
produce milk under such conditions that it is practically 
sterile and needs no boiling. This is the certified milk that 
is produced in accordance with the rules made by milk com- 
missions established by medical societies. Such milk is 
also of definite composition and should always be preferred 
when it can be obtained. 
Fig. 121.—Siphoning lower milk to leave top milk in bottle. 
Another method of modifying the chemical composition 
of milk is to use a certain amount of the top milk of a bottle 
obtained by siphoning off the lower portion of the milk. 
The upper 8 ounces of a pint of milk will contain nearly all 
the fat and hence would have about the following composi- 
tion: proteids, 4 per cent; fat, 7 to 8 per cent; sugar, 4 per 
cent. This diluted with a pint of water would have 1.33 
per cent proteids and 2.33 to 2.66 per cent fat. This 
sweetened properly by adding a well-rounded tablespoonful 
of cane-sugar gives the proper proportion of carbohydrates FEEDING 
317 
and is a very good mixture for supplementary feeding of a 
new-born child. 
The quantity that should be given to a child depends 
upon its age and condition and upon the frequency of feed- 
ing. During the first two weeks \ to 1 ounce may be given 
every two hours, while during the next two weeks 1 to 2\ 
Fig. 122.—Good and bad nursing bottles: 1, ordinary small-neck nursing 
bottle as sold in drug-stores (8-ounce); 2, improved large-neck nursing bottle 
(made in 5- and 10-ounce sizes); 3, Hygeia nursing bottle. 
ounces may be given every two or three hours. The milk 
may be given with a spoon or with a nursing bottle. If the 
artificial feeding is temporary it is better to use a spoon. 
Even when a child is fed continuously there are some advan- 
tages in feeding with a spoon. The chief advantage is the 
absence of danger of contamination of the nursing bottle. 
The bother of cleaning properly the bottle and nipple is 318 
THE INFANT 
also avoided. If a bottle is used the Hygeia bottle can be 
recommended (see Fig. 122) as one that can be thoroughly 
and easily cleaned. If the ordinary nursing bottle is used it 
must be cleaned with a bottle brush and boiled after each 
feeding. The care of the nipple is the same as the care of the 
breast shield (see p. 255). 
If for any reason the physician prefers to use some other 
kind of food than modified milk he will prescribe the method 
of its preparation and the quantity to be used, or the nurse 
will rely upon the directions which accompany the packages. 
The other substitutes for mother’s milk, like condensed milk 
or the various infant foods, are not so extensively used now- 
Fig. 123.—Showing comparative sizes of necks of bottles shown in Fig. 122. 
adays as they were before the methods of sterilization and 
modification made cows’ milk available. Some of the foods 
are often used, however, in the modification of cows’ milk 
either in place of sugar to help sweeten it or to improve its 
digestibility. 
Premature Children.—The death of three-eighths (37.5 per 
cent) of all children that die during the first month of life 
is attributable to prematurity; 15 per cent more die because 
of congenital debility, which is no doubt assigned as the 
cause of death in many premature children. From these 
two causes about 70,000 children die every year in the United 
States. This fact shows the very great importance of this 
subject. PREMATURE CHILDREN 
319 
Definition of Prematurity.—A child is premature if it is born 
before forty weeks from the date of conception. Frequently 
however, we cannot determine the exact duration of life in 
the uterus and hence we may say that a child is premature 
if it weighs at birth less than 5| pounds and is less than 48 
cm. or 19 inches long. 
Dangers to Which Premature Children are Exposed.—The 
chief dangers to which the premature infant is exposed are 
chilling and starving. Unless great care is taken immediately 
after birth to keep the baby warm, its temperature will fall 
in a half hour to 93° F. or under. Unless the child is quickly 
warmed it will be seriously injured. A temperature of 90° 
is apt to prove fatal. This rapid cooling is due largely to 
the fact that the surface of the body is relatively much greater 
in proportion to the weight than in adults or large children, 
and hence the radiation of heat is much faster. Also the 
absence of a protective layer of fat in the skin favors a dis- 
persion of heat. Moreover the nerve centers which control 
the heat production and loss are apt to be unstable. 
To prevent the chilling immediately after birth the child 
must be kept well covered until separated from the mother 
and then put at once into an incubator or a very warm room. 
If it should become cold it must be put into a warm bath of a 
temperature of 102° to 105° F. and its rectal temperature 
raised to normal. 
Home or Incubator Station.—If the child is born at home 
and can receive there proper nursing and incubation arrange- 
ments should be made at once for its future care if this has 
not been attended to beforehand. When the home surround- 
ings are such as to make the proper care doubtful the child 
and if possible the mother should be sent to an incubator 
station. Such a station should be in connection with a 
maternity hospital or a maternity ward of a general hospital, 
so that the proper food, mother’s milk, may be secured in 
case the mother is dead or her milk fails or if for any reason 
she cannot accompany her child to the station. In trans- 
porting the baby it should be warmly wrapped, and if neces- 
sary, carried in a large basket, which may also contain hot- 
water bottles or bags. 320 
THE INFANT 
Warm Room.—To keep the child warm it must stay either 
in a warm room or in an incubator. If a small room is avail- 
able that can be kept at a temperature of about 85° F., with 
moist fresh air nothing better can be asked. As such an 
arrangement is rarely possible we must generally rely upon 
an incubator. 
Fig. 124.—Diagram of incubator. 
Incubator.—An incubator for children is simply a box or 
small chamber in which the child lies surrounded by a con- 
tinually changing current of fresh, warm, moist air. Elab- 
orate electrically heated incubators may be desirable in an 
incubator station. A simple and good kind, especially for 
private houses or small hospitals, is represented in Fig. 124. 
The box, 17 x 19 x 22 inches, has in the bottom a large tank 
capable of holding 8 quarts of hot water. This tank is con- 
nected by a tube with a small filling reservoir on the outside 
of the box and emptied through a spout closed with a stop- 
cock which comes from the lower part of the tank, Under- 321 
PREMATURE CHILDREN 
neath the tank is a shallow air space into which air enters 
from the outside through holes in the end of the box. The 
current of air passes under the tank, around its end, over 
the tank and under the shelf on which the baby lies, then 
around the shelf over the baby and out of the hole in the 
cover. A small revolving windmill may be inserted into 
this opening to serve as an indicator of the pressure and 
strength of the air current, but is not necessary. A basin 
attached to the side of the box, holds a wet sponge which 
moistens the air. A thermometer on the shelf beside the 
baby indicates the temperature of the interior. A glass 
door is in the top of the incubator. The air admitted to 
the incubator may be taken from the room or by means of a 
tube from the outside of the house. As the ventilation or the 
velocity of the air current will depend upon the difference 
in the temperature of the air before admission and that of 
the incubator it is well that the room be not too warm or 
that the air be supplied from the outside of the house. 
The temperature of the incubator is kept constant by 
withdrawing 2 to 4 quarts of water from the tank every 
two to four hours and replacing it with boiling water. The 
temperature of the room and of the admitted air determine 
the quantity of boiling water needed and the frequency of 
the change. 
The temperature of the inside depends upon the needs of 
the child. A very frail and small child weighing less than 
4 pounds may require at first a temperature of 90° F. As it 
grows the temperature may be gradually reduced. A child 
weighing 4 to 5 pounds may start with an incubator temper- 
ature of 87° F. It should keep a normal rectal temperature 
without sweating. Gradually the temperature of the incuba- 
tor may be reduced to 80° F. By this time the child is left out 
of the box a considerable part of the daytime and returned 
to it at night. 
When a child is vigorous and develops rapidly it may be 
necessary to keep it in the incubator only a few days, while 
a puny child may require it two or three months. 
It is frequently necessary or desirable to remove the child 
from the incubator to feed it. The room temperature should 322 
THE INFANT 
not be below 70° F. for feeding or belowr 80° F. for cleaning and 
dressing, and it should be wrapped in warm blankets as much 
as possible while outside. The breathing of colder air for 
five or ten minutes may act as a tonic, while a long, thorough 
cooling would be fatal. 
Fig. 125.—Hess water-jacketed infant bed, 
The incubator must be kept clean, else it may become a 
source of infection. It should always be thoroughly dis- 
infected before receiving a new patient. If in use for some 
time it should be thoroughly cleaned every three to four 
days. 
Hess Incubator.—This is a warm-jacketed tub, in which 
the water in the jacket is warmed by electricity. For a 
hospital as well as for a private house where the cost is not 
prohibitive it is the best incubator on the market because PREMATURE CHILDREN 
323 
it is simple, affords good ventilation, and the greatest facility 
in watching and caring for the child. 
Feeding.—The second danger to which the premature 
infant is especially exposed is starvation. It needs relatively 
a large amount of food while its digestive system is not very 
well developed. If it gets too little food it starves; if it gets 
too much or improper food, digestive disturbances arise. 
Woman’s milk is almost absolutely essential. If it cannot 
be obtained from the mother it should be procured from 
some other nursing woman. If necessary such milk can be 
collected in small bottles, kept cool, and transported like 
cows’ milk. Feeding should begin at birth and the amount 
given increased as rapidly as possible until the normal amount 
for the child is reached. As a general rule a premature child 
child requires per day about one-sixth of its weight of good 
average milk to supply its needs and make the proper gain 
in weight. It probably will be necessary to begin with 2 or 
3 ounces a day and increase to the normal quantity in the 
course of a week. The number of feedings per day will 
depend upon the quantity that can be given at a time. 
Sometimes the child can retain only \ to 1 dram, and then 
it should be fed each hour, day and night. Later, as it can 
take a larger quantity at a time, the number of feedings a 
day is diminished. 
As the premature infant cannot ordinarily nurse and 
because nursing, even if possible, might be undesirable on 
account of the danger of exposure, it is best to feed the child 
with a dropper or with a feeder such as represented in Fig. 
126. Occasionally a small catheter introduced into the 
stomach through the nose has been used as a stomach tube 
for gavage, but the patient use of the dropper or feeder is 
preferable. When the child is able to nurse it should be 
weighed on an accurate scale before and after nursing to 
determine the amount obtained so that a deficiency can be 
made up by feeding. After feeding, the child should be 
carefully watched in the incubator for some minutes on 
account of the danger of regurgitation which might cause 
choking. 324 
THE INFANT 
Oxygen for Cyanosis.—During the first two or three days 
of its life the premature child is in danger of asphyxia due 
often to atelectasis or imperfect dilatation of the lungs and 
manifested by cyanosis. This is best treated by the adminis- 
tration of oxygen. When the child is in the box-incubator 
the tube from the oxygen tank may be introduced into one 
Fig. 126.—Breck’s tube for premature infants. (Koplik.) 
of the air-holes and, if necessary, one or more of the other 
holes closed. The color of the baby’s face is the index of the 
cyanosis and determines the amount of oxygen needed. 
Dressing and Bathing.—In the incubator the child needs 
but little clothing, a diaper and a bag gown (see p. 307). 
It should lie on a thick layer of absorbent cotton. It can 
generally be removed from the incubator for cleaning and a PREMATURE CHILDREN 
325 
daily warm bath can be given provided the temperature of 
the room can be brought to 90° F. Otherwise it is probably 
better to oil the baby in place of a full bath. 
During the first days of its life the temperature of the child 
may fluctuate rapidly. In this case the room in which the 
child is cared for and the bath should be kept in constant 
readiness. If the child’s temperature falls much below 
normal it should be put into a warm bath of about 103° F. 
until the temperature rises to normal. If the temperature 
of the child is 103° F. or more it should be put and kept in 
a cooling bath of about 96° F. until the fever is controlled. 
Subsequent History of Premature Children.—Data show 
that the chance of life of the premature child is equal to 
that of the full-term child if the former is cared for properly 
and not discharged until it is as large as a mature infant and 
receives thereafter reasonable care. Its future prospects 
for a healthy and well-developed physical and mental organ- 
ism are equal to those of a child carried to term. 
Incubator for Other Debilitated Conditions.—Children injured 
during birth and those born partially asphyxiated are often 
in a precarious condition for some days and can be treated 
with advantage in an incubator and along the lines laid 
down for the management of premature children. Atelec- 
tasis, bronchitis, and acute lung infections are also cases for 
incubator care. INDEX. 
A 
Abdomen, pendulous, 99 
striae of, 67 
Abdominal binder, 220 
distention, 67 
examination, 141 
Abortion, 84 
causes of, 85 
complete, 85 
criminal, 85, 188 
for hyperemesis, 75 
incomplete, 85 
induction of, 188 
inevitable, 86 
prevention of, 85, 100 
symptoms of, 86, 100 
therapeutic, 188 
threatened, 86 
treatment of, 86 
tubal, 86 
Abscess of breast, 256 
pelvic, 225 
Absolute indication for Caesarean 
section, 203 
Accouchement, 102 
forc6, 192 
Acid, boric, 253, 283, 304 
carbolic, 92, 130, 137, 254 
Acini of the breast, 50 
Adherent foreskin, 297 
placenta, 172, 184 
After-birth, 60 
pains, 110 
After-pains, 109 
Agalactia, 257 
Air embolus, 261 
Albuminuria in pregnancy, 76 
Alcohol, 125, 129, 253, 295 
Allantois, 61 
Ammonia water, 73 
Amnion, 56, 161 
Amniotic fluid, 61 
Analgesia in labor, 157 
Anesthesia in labor, 157 
Antiseptics, 128 
Anuria of infants, 310 
Anus, 49 
j Apnea neonatorum, 270 
Areola of breast, 51, 69 
Artificial respiration, 271 
Asphyxia neonatorum, 270 
bath for, 273 
Byrd method for, 275 
combined Byrd and Sylves- 
ter method for, 276 
insufflation for, 279 
Laborde method for, 274 
livida, 271 
oxygen insufflation for, 281 
lung motor in, 281 
pallida, 271 
Schultze method for, 277 
slapping for, 271 
Sylvester method for, 276 
Aspirating catheter, 271 
needle, 256 
Atelectasis, 324 
Atonic hemorrhage, 168, 174 
I Atony of uterus, 168 
j Attitude of fetus, 110 
Auscultation of the abdomen, 146 
I Auvard’s cranioclast, 212 
Axillary glands, 258 
Axis of pelvis, 33 
traction forceps, 203 
B 
Baby. See Infants and New-born. 
Bachelle’shebosteotomy needle, 194 
Bacillus acidophilus, 301 
Note.—Since the meaning of practically all the words used in this 
book can be determined from the text and context, a glossary is omitted 
in the belief that the index freely and properly used will supply its place. 328 
INDEX 
Bacillus bifidus, 301 
lactis aerogenus, 301 
Bag of waters, 106 
Bandage, abdominal, 220 
for breast, 244 
for leg, 83 
in pregnancy, 98, 99 
Bartholin’s glands, 37 
Basiotribe, 212 
Bath, antepartum, 131 
for asphyxia neonatorum, 273 
baby’s, 290 
for incubator child, 325 
shower, 131 
tub, 131 
Bathing in pregnancy, 96 
Bed for baby, 309 
exercises in puerperium, 263 
for labor, 132 
in puerperium, 220 
sheets, 126, 135 
Bier’s suction of the breast, 257 
Binder. See Bandage. 
Birth injuries, 288 
Bladder, 47 
care of, in labor, 155 
in puerperium, 231 
Blanket, baby’s, 308 
Bleeding. See Hemorrhage. 
Blisters of nipple, 252 
Blood in embryo, 60 
Blood-pressure, 80 
Body stalk, 55, 58 
Bony pelvis, 31 
Boric acid, 253, 283, 304 
Bossi dilator, 193 
Bottle, nursing, 317 
Bow legs of new-born, 286 
Bowel, inflammation of, 303 
Braun hook, 213 
Braxton Hicks’ version, 195 
Breast, 50, 241 
abscess of, 256 
anatomy of, 50 
areola of, 51, 69 
bandage of, 244 
Bier suction of, 257 
caked, 242 
care of, in lactation, 253 
in pregnancy, 101, 253 
development of, 50, 69 
distention of, 242 
function of, 50 
ice-bags for, 247 
Breast, infection of, 250 
massage of, 247 
of new-born, 299 
pumping of, 243 
secretion of, 69, 242 
shield, 254 
striae of, 69 
Breathing, artificial. See As- 
phyxia. 
Breck’s feeding tube, 324 
Breech presentation, 111, 197, 199 
Brick-dust urine, 285, 303 
Brim of pelvis, 32 
Broad ligament, 41 
Brow presentation, 111 
Byrd method of artificial respira- 
tion, 275 
C 
Cesarean section, 203 
cervical transperitoneal, 209 
conservative, 208 
extraperitoneal, 208 
Porro-, 208 
postmortem, 209 
vaginal, 209 
Caked breast, 242 
Canal, obstetrical, 32 
Cancer of the cervix, 88, 94 
Caput succedaneum, 117, 287 
Carbolic acid, 92, 130, 137, 254 
Card record, 25 
Caries, dental, 76 
Carunculae myrtiformes, 36 
Casebook, objection to, 24 
Casein, 314 
Catheter, aspirating, 271 
bladder, 156, 233 
tracheal, 271 
Catheterization during labor, 156 
puerperium, 233 
Cephalhematoma, 288 
Cephalic presentation, 111 
version, 195 
Cephalotribe, 212 
Cervix, cancer of, 88, 94 
dilatation of, 192 
effacement of, 106 
Child. See also Infants and New- 
born, 
viable, 85 
Childbed, 218 
Chill, 226 INDEX 
329 
Chloral in labor, 157 
Chloroform, 158 
Chorion, 60, 62 
origin of, 60 
villi of, 60, 63 
Cilia of Fallopian tubes, 62 
Circulation, in embryo, 60 
in emesis of pregnancy, 71 
Circumcision, 298 
Cleaning of baby, 293 
of external genitals, 136 
Cleft palate, 286 
Cleidotomy scissors, 212 
Climacteric, 44 
Clitoris, 35 
prepuce of, 35 
Clothing. See Dress. 
Coccyx, 31 
Colds, 19 
Colic, 303 
Collodion, 195 
Colon bacillus, 301 
location of, 235 
Colostrum, 69, 242, 299 
Combined digital version, 195 
manual version, 195 
Complete abortion, 85 
Confinement, 102 
date of, 66 
Conservative Caesarean section, 20S 
Constipation in infants, 302 
in pregnancy, 75 
in puerperium, 234 
Contracted pelvis, 33, 182 
Contractions of uterus, 103 
Convulsions, eclamptic, 77, 82 
in new-born, 288 
puerperal, 78 
uremic, 77 
Cord, knot in, 271 
ligation of, 164 
prolapse of, 183 
short, 183 
tying of, 284 
Corpus luteum, 46 
of uterus, 38 
Corsets in pregnancy, 97 
Cow’s milk, 314 
Cracked nipples, 251 
Cranioclasis, 212 
Cranioclast, 212 
Craniotomy, 211 
Crede expression of placenta, 172 
instillation of eyes, 283 
Criminal abortion, 85, 188 . 
Cross-presentation, 142, 183 
Cry, first, 270 
Curettement, 188 
Cyanosis, oxygen for, 324 
Cystitis in puerperium, 233 
D 
Date of confinement, 66 
Decapitation, 213 
Decidua, 62 
reflexa, 62 
Deformed nipples, 251 
pelvis, 33, 182 
Delivery of body, 163 
Dental caries, 76 
Descent, 112 
Diaper, 306 
Diarrhea in infants, 301 
Diet in eclamptogenic toxemia of 
pregnancy, 80 
in lactation, 239 
in pregnancy, 95 
in puerperium, 237 
in vomiting of pregnancy, 72, 73 
Dilatation of cervix, 192 
Disinfection of genitalia, 135 
of hands, 128 
Displacements of uterus, 43 
Distention of breast, 242 
Doederlein’s hebosteotomy needle, 
194 
Dorsal flexion, 196 
Douche bag, 139 
intra-uterine, 216 
pan, 138 
for postpartum hemorrhage, 175 
vaginal, 137, 175, 215 
Drainage pad, 136 
Dress during labor, 132 
for incubator, 324 
of infant, 305 
in pregnancy, 97 
Dublin expression of placenta, 172 
Duncan’s method of expulsion of 
placenta, 121 
Duration of labor, 102 • 
of pregnancy, 66 
of puerperium, 218 
Dystocia, 102, 181 
fetal, 182 
from abnormal forces, 181 
, passages, 182 330 
INDEX 
Dystocia from abnormalities of 
passenger, 182 
from accidents, 184 
from lacerations, 184 
from prolapse of cord, 183 
from rupture of uterus, 184 
from short cord, 183 
from tumors, 182 
Dysuria, 231 
E 
Ears, care of, 303 
Eclampsia, 78 
treatment of, 82 
Eclamptogenic toxemia of preg- 
nancy, 77 
diet in, 80 
nature of, 77 
sweats in, 81 
symptoms of, 77 
treatment of, 80 
Eczema of infant, 289 
Edema, general, 83 
of legs, 83 
Edgar method of dilating cervix, 
192 
Egg, 46, 51 
development of, 51 
migration of, 62 
nidation of, 62 
structure of, 51 
Effacement of cervix, 106 
Embolism, pulmonary, 261 
Embryo, beginning of, 56 
Embryology, 51 
Embryotomy, 211 
Emesis, causes of, 71 
gravidarum, 70 
management of, 71 
Enema, 73, 130, 235 
nutritive, 74 
Engagment of nurse, 29 
English forceps lock, 202 
Enteroptosis, 262, 267 
Etgot, 177 
Eruptions of new-born, 289 
Erythema neonatorum, 289 
Ether, 158 
Eutocia, 102 
Examination, abdominal, 141 
internal, 151 
of patient, 141 
rectal, 152 
Examination, vaginal, 152 
Exercise in pregnancy, 99 
in puerperium, 263 
Exit of body, 120 
of head, 118 
Expression of fetus, 198 
of head, 199 
Expulsion of placenta, 121 
Extension of head, 120 
External genital organs, 35 
cleaning of, 136 
External os, 40 
version, 195 
Extraction, 199 
Extra-uterine pregnancy, 86 
symptoms of, 87 
treatment of, 87 
Eyes, care of, 304 
Crede instillation 283 
subconjunctival hemorrhage of, 
305 
F 
Face presentation, 11, 196 
Facial paralysis, 289 
Fallopian tubes, 45 
functions of, 45 
structure of, 45 
Fecal contamination in labor, 160 
impaction, 236 
Feces of infant, 294 
Feeding of infant, 310 
of premature child, 323 
Female pronucleus, 53 
Fertilization, 52 
Fetal appendages, 60 
heart beats, rapidity of, 148 
tones, 145 
tumors, 182 
Fetus, beginning of, 58 
movements of, 67 
relation of, to mother, 64 
Fever, inanition, 303 
milk, 227, 243 
puerperal, 223 
First cry, 270 
stage of labor, 104 
Fissure of nipple, 251 
Flat pelvis, 33 
Flexion, 117, 196 
Follicle, Graafian, 46 
Foot presentation, 111 
Forceps, 201 INDEX 
331 
Forces of labor, 103 
Formation of bag of waters, 106 
Foreskin, adherent, 297 
Fore water, 106 
Fornix of vagina, 37 
Fourchette, 35 
Fractures at birth, 289 
French forceps, 202 
Frenum, 300 
Frequent micturition, 83 
Fruit water, 200 
Fundus of uterus, 39 
Fungi in stomach, 74 
Funnel pelvis, 33 
G 
Galactagogue, 239 
Galactorrhea, 257 
Galbiati knife, 194 
Generally contracted pelvis, 33 
Genital wound infection, 223 
Genitalia, care of, 297 
disinfection of, 135 
Gestation. See Pregnancy. 
Gigli saw, 194 
Glands, Bartholin’s, 37 
Montgomery’s, 51, 69, 250, 254 
Gians, adhesion of prepuce to, 
297 
of clitoris, 35 
Gloves, 127 
Gonorrheal infection in puer- 
perium, 225 
of urinary organs, 297 
ophthalmia, 304 
vulvitis, 297 
Graafian follicle, 46 
Growth of infant, 311 
H 
Hair, care of, in labor, 132 
Hands, cleaning of, 128 
Hare-lip, 286 
Harris method of dilating cervix, 
192 
Head, exit of, 117 
Headache in toxemia, 77 
Hebosteotomy, 194 
Hemorrhage, atonic, 168 
from deficient coagulation of 
blood, 170 
Hemorrhage from inversion of 
uterus, 171 
from partial detachment of 
placenta, 169 
intracranial, 288 
postpartum, 167 
prevention of, 172 
in puerperium, 219 
subconjunctival, 305 
traumatic, 170 
Hernia, umbilical, 287, 296 
Hess incubator, 322 
High forceps, 203 
Hofmeier expression, 198 
Home care of premature infant, 
319 
Hook, Braun, 213 
in forceps handle, 201 
Hot douche, 175 
Hydatid mole, 94, 95 
Hydrocephalus, 182 
Hymen, 36 
Hyperemesis gravidarum, 70 
causes of, 71 
induction of abortion for, 75 
management of, 72 
Hypodermoclysis, 179, 217 
Hypertrophy of axillary sweat 
glands, 258 
Hysterectomy, 208 
I 
Ice-bag for breast, 247 
Icterus of child, 290 
Ilium, 31 
Imperforate anus, 287 
urethra, 287 
vagina, 287 
Impregnation, 52 
Inanition fever, 303 
Incisions of cervix, 193 
Incomplete abortion, 85 
Incubation, 319 
Incubator, 320 
Hess, 322 
station, 319 
Induction of abortion, 188 
of labor, 189 
indications for, 189 
methods of, 190 
preparation for, 190 
Inevitable abortion, 86 332 
INDEX 
Infancy, menstruation in, 297 
Infants, 269. See New-born. 
Infection of breast, 250 
of genital wound, 223 
Infectious disease in nurse, 19 
Influenza in nurse, 19 
Injuries of birth, 288 
Inlet forceps, 203 
of pelvis, 32 
Innominate bone, 31 
Insanity, puerperal, 230 
Inspection, 141 
of genital region, 149 
Instruments for Caesarean section 
205 
for dilating cervix, 192 
for embryotomy, 211, 213 
for extraperitoneal Caesarean sec- 
tion, 208 
for hebosteotomy, 194 
for induction of abortion, 188 
for intra-uterine douche, 216 
for metreurysis, 191 
for Porro-Caesarean section, 208 
for postmortem Caesarean sec- 
tion, 209 
for repair operation, 214 
for symphyseotomy, 193 
for tamponade, 216 
for vaginal Caesarean section, 
210 
for version, 195 
forceps, 201 
Insufflation for asphyxia neona- 
torum, 279 
Interlocking twins, 182 
Intermittent contractions of uterus, 
103 
Internal examination, 151 
genitalia, 37 
os, 40 
Intertrigo of infant, 289 
Intestine, 49 
Intra-uterine douche, 216 
Inversion of uterus, 171 
Inverted nipple, 253 
Involution, 218 
Ischium, 31 
J 
Jacket for baby, 308 
Jaundice of child, 290 
K 
Kelly drainage pad, 135 
Kidney of pregnancy, 76 
Knee-chest posture, 183 
Knot in cord, 271 
Kristeller expression, 198 
L 
Labia majora, 35 
minora, 35 
Labor, 102 
abdominal examination in, 141 
abnormal, 102, 181 
accidents of, 184 
analgesia in, 157 
anesthesia in, 157 
anesthetics in, 158 
artificial, 102 
auscultation in, 146 
bag of waters in, 106 
bath in, 131 
bed for, 132 
bladder in, care of, 155 
catheterization in, 156 
causes of, 102 
chloroform in, 158 
cleaning in, 136 
complications of, 181 
contractions of, 103 
Crede expression in, 172 
definition of, 102 
delayed, 102 
delivery of body in, 120 
of shoulders in, 121 
descent of fetus in, 112 
dilation of os in, 104 
disinfection of genitals in, 135 
distention of perineum in, 119 
douche during, 175 
dress in, 132 
duration of, 102 
effacement of cervix in, 106 
enema during, 130 
ergot during, 177 
ether in, 158 
examination in, 141 
exit of body in, 120 
of head in, 118 
expression of placenta in, 172 
expulsion of placenta in, 121 
extension of head in, 118 INDEX 
333 
Labor, external examination in, 141 
first stage of, 104 
flexion of fetus in, 112 
forces of, 103 
head deliver in, 118 
rotation in, 117 
hemorrhage in, 167 
hot douche in, 175 
hypodermoclysis in, 179 
induction of, 189 
inspection of genital region in, 
149 
internal examination in, 151 
inversion of uterus in, 171 
involuntary forces in, 103 
laceration of perineum in, 184 
ligation of cord in, 164 
management of, 123 
of third stage, 165 
manual removal of placenta in, 
173 
mechanism of, 110 
missed, 102 
moral support in, 157 
morphine in, 157 
moulding of head in, 117 
normal, 102 
nourishment in, 156 
outfit of nurse for, 124 
of patient for, 124 
oxytocics in, 177 
pads for, 135, 138 
painless, 103 
pains of, 103 
palpation in, 142 
of perineum in, 150 
perineal laceration in, 184 
pituitary extract in, 177 
position of fetus in, 110 
posture of fetus in, 110 
of patient in, 163 
precipitate, 102 
premature, 102 
preparation of nurse for, 127 
of patient for, 130 
presentation of child in, 111 
prolonged, 102 
pulling in, 160 
rapid, 102 
retarded, 102 
room, 139 
rubber gloves in, 127 
rupture of membranes in, 106 
of uterus in, 184 
Labor, scopolamine in, 157 
second stage of, 108 
shaving in, 136 
show in, 106, 108 
slow, 102 
solutions for, 138 
spontaneous, 102 
stages of, 104 
station of child in, 112 
support of back in, 159 
of perineum in, 161 
at term, 102 
third stage of, 109, 165 
translation of fetus in, 112 
twilight sleep in, 157 
use of closet during, 131 
uterine contractions in, 103 
vaginal douches in, 175 
examination in, 151 
Walcher position in, 198 
Laborde method of artificial 
respiration, 274 
Laceration of perineum, 184 
of vagina, 184 
of vulva, 184 
Lactation, 242 
Lactiferous ducts, 50 
Laxatives, 75 
Leggins, 126 
Legholder, 186, 187 
Ligaments, broad, 41 
round, 39, 41 
utero-sacral, 41 
Ligation of cords, 164 
Linea alba, 67 
nigra, 67 
Liquor amnii, 61 
Lithotomy position, 187 
Liver in pregnancy, 77 
Lochia, 219 
Locked twins, 182 
Lockjaw in new-born, 295 
in puerpera, 230 
Lower uterine segment, 106 
Lung motor, 281 
Luteum cells, 47 
Lying-in, 102 
room, 139 
Lymphangitis, 226 
M 
Male pronucleus, 53 
Malformations of new-born, 286 334 
INDEX 
Mammary abscess, 255 
gland, 50 
Management of labor, 123 
of pregnancy, 95 
Mania, puerperal, 230 
Manual dilatation of cervix, 192 
extraction, 199 
removal of placenta, 173 
version, 195 
Marginal placenta previa, 88 
Massage of breast, 247 
of colon, 234 
of stomach, 241 
for postpartum hemorrhage, 174 
in puerperium, 262 
Mastitis, 250 
Maternal impressions, 64 
Meat diet in toxemia of preg- 
nancy, 80 
Mechanism of labor, 110 
abnormal, 183 
Meconium, 285 
Membranes, 60 
examination of, 166 
retention of, 165 
Menopause, 44 
Menstruation, 44 
beginning of, 44 
ending of, 44 
in infancy, 297 
Metreurynter, 190 
Metreurysis, 190 
Micturition, difficult, 231 
Milk leg, 226 
stool, 301 
witch’s, 299 
Milne Murray forceps, 201 
Miscarriage, 84 
Missed labor, 102 
Modified milk, 314 
Mole, hydatid, 95 
Monsters, 286 
Mons Veneris, 35 
Montgomery’s gland, 51, 69, 250, 
254 
Morning sickness, 70 
Morula, 57 
Mother marks, 64 
Moulding of head, 287 
Mouth, care of, 299 
Movements of fetus, 67 
Mulberry stage, 57 
Multiple pregnancy, 182 
Mutilating operations, 211 
N 
Naegele forceps, 201 
pelvis, 33 
Nail brush, 124, 128 
Nausea and vomiting, due to 
toxemia, 77 
of pregnancy, 70 
Navel, care of, 295 
infection of, 290, 295 
Needle, Bachelle’s, 194 
Doederlein’s, 194 
Nephritis of pregnancy, 76 
Neugebauer speculum, 216 
New-born, apnea of, 270 
artificial feeding of, 313 
respiration of, 271 
asphyxia of, 270 
bath of, 290 
bed of, 309 
bowel of, 285 
breast of, 299 
care of eyes of, 269, 283, 304 
circumcision of, 298 
cleaning of, 293 
clothing of, 305 
colic of, 303 
condition of, 284 
constipation of, 302 
convulsions of, 288 
cry of, 270 
cyanosis of, 324 
definition of, 269 
diarrhea of, 301 
dress of, 305 
ears of, 303 
eczema of, 289 
eyes of, 269, 283, 285, 303 
feces of, 285 
feeding of, 310 
first care of, 269 
fractures in, 289 
genitalia of, care of, 297 
growth of, 311 
head of, 287 
hemorrhage from cord of, 284 
hernia of, 287, 296 
icterus of, 290 
inanition fever in, 303 
influenza of, 300 
injuries of, 288 
intertrigo of, 289 
jaundice of, 290 
malformations of, 286 INDEX 
335 
New-born, marks of, 286 
meconium of, 285 
menstruation of, 297 
milk in breast of, 299 
mouth of, 299 
navel of, 295 
nevi of, 286 
nose of, 300 
nursing of, 310 
ophthalmia of, 304 
outfit of, 306 
pulse of, 285 
pustules of, 289 
respiration of, 285 
resuscitation of, 271 
skin of, 285, 289 
sleep of, 306, 309 
stools of, 285, 301 
temperature of, 285 
tetanus of, 295 
thrush of, 299 
tongue-tie of, 300 
training of, 28 
umbilical cord of, 284 
urine of, 285 
vernix caseosa of, 285 
vomiting of, 301 
weight of, 285 
Nipple, 50 
injury of, 251 
shield, 254 
Nitrous oxide in labor, 159 
Nose, care of, 300 
gonorrhea of, 300 
Nourishment in labor, 156 
Nurse as an example, 29 
as a teacher, 29 
duties of, to doctor, 22 
be loyal, 26 
keep records, 24 
report mistakes, 23 
to patient, 26 
to self, 18 
to avoid bad breath, 20 
gossiping, 27 
infectious diseases, 19 
perfumes, 21 
perspiration odors, 21 
to care for bowels, 20 
for clothing, 21 
for diet, 19 
for exercise, 22 
for hands, 21 
for health, 18 
Nurse, duties to self, to care for 
lunch, 19 
for night-clothing, 22 
for skin, 21 
for sleep, 22 
for stomach, 20 
for teeth, 20 
engagement of, 29 
outfit of, 124 
preparation of, for care of labor, 
127 
Nursing bottles, 317 
private, or in hospital, 17 
Nymphse, 35 
O 
Obstetrical operations, 185 
(See also Table of contents.) 
Occiput, 111 
posterior position, 197 
Operating room, 186 
Operations, obstetrical, 185 
preparation for, 186 
Ophthalmia neonatorum, 304 
Os uteri, 40 
Outfit of nurse, 124 
of patient, 124 
Outlet of pelvis, 32 
Ovary, 46 
Ovulation, 46 
Ovum, 51 
development of, 51 
structure of, 51 
Oxygen for cyanosis, 324 
insufflation, 281 
Oxytocics, 177 
P 
Pad, obstetrical, 135 
vulvar, 138 
Pains, after, 109 
after-birth, 109 
bearing-down, 108 
dilating, 104 
expelling, 108 
false, 104 
of labor, 103 
of pregnancy, 104 
Palpation of abdomen, 142 
of perineum, 109, 150 
Paralysis of face, 289 33G 
INDEX 
Paraphimosis, 298 
Passages, 102, 182 
Passenger, 182 
Patient, examination of, 141 
outfit of, 124 
position of, in labor, 163 
preparation of, 134 
Pelvic floor, 37 
Pelvis, 31 
bones of, 31 
brim of, 32 
cavity of, 32 
contracted, 33 
flat, 33 
floor of, 37 
funnel, 33 
inlet of, 32 
outlet of, 32 
rachitic, 34 
Pendulous abdomen, 99 
Perforation, 211 
Perforator, 211 
Perineal region, 37 
Perineum, 37 
support of, 161 
Peritoneum, 49 
Peritonitis, 225 
Pernicious vomiting of preg- 
nancy, 70 
management of, 72. See 
Hyperemesis gravi- 
darum. 
Pfannenstiel incision, 208 
Phimosis, 298 
Phlebitis, 226 
Phlegmasia alba dolens, 226 
Physiology, 31 
Physostigmine, 207 
Pinning blankets, 307 
Pituitary extract for postpartum 
hemorrhage, 177 
Placenta, 63 
adherent, 172, 184 
anatomy of, 63 
Crede method of expression, 
172 
delivery of, 165 
development of, 63 
examination of, 166 
expulsion of, 121 
formation of, 64 
function of, 64 
manual removal of, 173 
mechanism of separation of, 121 
Placenta, origin of, 63 
partial detachment of, 169 
premature separation of, 93 
previa, 88 
retention of, 174 
Podalic version, 195 
Polydactylism, 287 
Polygalactia, 257 
Porro-Csesarean section, 208 
Portio vaginalis, 38 
Position, 110. (See also Posture.) 
of patient in labor, 163 
Positive signs of pregnancy, 84 
Postmortem Caesarean section, 209 
Postpartum chill, 226 
hemorrhage, 167 
Posture, 110. See Position. 
in puerperium, 261 
Precipitate labor, 102 
Pregnancy, abortion in, 84 
albuminuria in, 76 
bandage in, 99 
bathing in, 96 
bladder in, 83 
blood-pressure in, 80 
breast in, 101 
cancer of uterus in, 94 
care of nipples in, 101 
cessation of menstruation in, 70 
changes in abdomen in, 67 
in breasts in, 69 
in genital organs in, 69 
in kidneys in, 76 
in liver in, 77 
in nervous system in, 70 
pathological, 70 
physiological, 66 
in uterine ligament in, 69 
in uterus in, 66 
in vagina in, 69 
clothing in, 97 
colostrum in, 69 
constipation in, 75 
contraction of uterus in, 104 
corpus luteum of, 46 
corsets in, 97 
dancing in, 100 
dental caries in, 76 
diagnosis of, 83 
diet of, 95 
dress in, 97 
duration of, 66 
eclampsia in, 78 
eclamptogenic toxemia of, 77 INDEX 
337 
Pregnancy, ectopic, 86 
edema in, 83 
of legs in, 83 
enlargement of abdomen in, 67 
exercise in, 99 
' extra-uterine, 86 
frequent micturition in, 83 
height of uterus in, 67 
hydatid mole in, 94, 95 
hygiene of, 95 
hyperemesis in, 70 
kidney in, 76 
linea alba in, 67 
nigra in, 67 
liver in, 77 
management of, 95 
maternal impressions in, 64 
menstruation in, 70 
mole, 94, 95 
Montgomery’s glands in, 69 
morning sickness in, 70 
movements of fetus in, 67 
nausea of, 70 
nephritis in, 76 
nervous system in, 70 
pernicious vomiting of, 70 
placenta previa in, 88 
positive signs of, 84 
probable signs of, 83 
quickening in, 67 
riding in, 100 
separation of placenta in, 93 
signs of, 83 
sinking of uterus in, 67 
skin in, 69 
striae of, 67, 69 
suppression of menses in, 70 
teeth in, 76 
toxemia of, 77 
tubal, 86 
twin, 182 
urine in, 78 
uterine ligaments in, 69 
uterus in, 66 
vagina in, 69 
varicosities in, 83 
vomiting of, 70 
walking in, 100 
Premature detachments of pla- 
centa, 93 
infant, 318 
labor, 102 
induction of, 189 
Premature separation of placenta, 
93 
Prematurity, 318 
Preparation of nurse, 127 
of patient, 130 
Prepuce, adherent, 297 
Presentation, 111 
Probable signs of pregnancy, 84 
Prolapse of cord, 183 
Promontory or sacrum, 32 
Pronucleus, 53 
Proteids, 314 
Puberty, 44 
Pubes, 31 
Pubic bones, 31 
Pubiotomy, 194 
Puerperal convulsions, 78 
fever, 223 
insanity, 230 
tetanus, 230 
ulcer, 225 
Puerperium, 218 
abdominal bandage in, 220 
after-pains in, 109 
asepsis in, 220 
bath in, 268 
bed exercise in, 263 
bladder in, 231 
bowels in, 234 
breasts in, 241 
catheterization in, 233 
chill in, 226 
conduct of nurse in, 259 
constipation in, 234 
diet in, 237 
duration of, 218 
enema in, 235 
engorgement of breast in, 242 
exercise in, 263 
fever in, 223 
gonorrheal infection in, 224 
hemorrhage in, 219 
insanity in, 230 
involution of uterus in, 218 
laxatives in, 234 
lochia in, 219 
massage in, 262 
mastitis in, 250 
milk fever in, 227, 243 
secretion in, 242 
nipples in, 250 
passive movements in, 262 
phlegmasia alba dolens of, 226 
posture in, 261 338 
INDEX 
Puerperium, pulse in, 228 
rest in, 259 
septicemia in, 225 
sleep in, 261 
stomach in, 240 
temperature in, 227 
urination in, 231 
uterus in, 218 
Pulling in labor, 160 
Pulmonary embolism, 261 
Pulse in childbed, 228 
Pumping of breast, 243 
Pustules on new-born, 289 
Pyemia, 225 
Pylorus, obstruction of, 301 
Q 
Quickening, 67 
R 
Rachitic pelvis, 34 
Rachitis, 34 
Records, 23 
card form of, 25 
danger from false, 24 
importance of, 24 
objection to case book, 24 
to whom they belong, 24 
Rectal tube, 74 
examination, 152 
Rectum, 49 
ampulla of, 49 
perineal, 49 
washing out of, 131 
Regurgitation of milk in new- 
born, 301 
Relative indications for Caesarean 
section, 204 
Removal of placenta, 213 
Repair operations, 213 
Rest of mother, 259 
Resuscitation of asphyxiated child, 
271 
Retained placenta, 174 
Retroflexion of uterus, 43 
Retroversion of uterus, 43 
Ritgen expression, 199 
Rotation, 112, 117 
occiput posterior, 197 
Round ligament, 39, 41 
Rubber draw-sheet, 134, 175 
gloves, 124, 127, 130, 153, 229 
254 
Rupture of membranes, 106 
of uterus, 184 
S 
Sacro-utekine ligament, 41 
Sacrum, 31 
promontory of, 32 
Saline infusion, 179 
Saw, Gigli, 194 
Scales, infant, 311 
Schultze method of artificial res- 
piration, 277 
of expulsion of placenta, 121 
Scopolamine, 157 
Sebaceous glands, 285 
Second stage of labor, 108 
Segmentation, 56 
Semen, 52 
Separation of normally seated 
placenta, 93 
Septicemia, 225 
Shaving of genital region, 136 
Sheets, bed, 135 
rubber, 134 
Shield, nipple, 254 
Shoes, nurses*1, 21 
Short cord, 183 
Show, 106 
Signs of pregnancy, 83 
Silver nitrate, 283 
•Simpson, Sir James Y., 158 
Simpson’s forceps, 202 
Sim’s position or posture, 92 
speculum, 92 
Siphon, milk, 316 
Skin of new-born, 289 
Sleep of infant, 309 
Small parts of fetus, 142 
Smegma, 298 
Smellie’s perforator, 212 
Snuffles, 300 
Solutions, disinfecting, 138 
Spermatozoa, 52 
Sphygmomanometer, 80 
Spina bifida, 286 
Stages of labor, 104 
Staphylococcus, 250 
Station, 112 
Sterile water, 138 INDEX 
339 
Streptococcus, 250 
Striae gravidarum, 67 
Stool, green, 301 
meconium, 285 
milk, 301 
Sublimate solution, 137, 229, 254 
tablets, 124, 125 
Sutures of head, 287 
Sweat glands, axillary, 258 
Sylvester method of artificial 
respiration, 276 
Symphyseotomy, 193 
Symphysis pubis, 31 
T 
Tamponade, uterine, 86, 178, 216 
vaginal, 92 
Tarnier forceps, 201, 203 
T-binder, 222 
Teeth in pregnancy, 76 
Tenaculum forceps, 205, 211, 215 
216. See Volsellum forceps. 
Testicle, descent of, 287 
undescended, 287, 299 
Tetanus, puerperal, 230 
Therapeutic abortion, 188 
Third stage of labor, 109, 165 
Threatened abortion, 85 
Thrush, 299 
Tongue-tie, 300 
Toothache in pregnancy, 76 
Toxemia in pregnancy, 77 
Tracheal catheter, 272 
Translation, 112 
Transverse presentation, 142, 183 
Traumatic hemorrhage, 170 
Trendelenburg posture or posi- 
tion, 208 
Triplets, 182 
Tubal abortion, 87 
pregnancy, 86 
rupture, 86 
Tubes, Fallopian, 45 
Turkish bath, 127 
Turning, 195 
Twilight sleep in labor, 157 
Twins, 164, 182 
Tying of cord, 284 
U 
Ulcer, puerperal, 225 
of eyes, 304 
Umbilical cord, coils of, 183 
compression of, 199 
development of, 62 
dressing for, 295 
function of, 62 
hemorrhage from, 284 
hernia of, 296 
infection of, 295 
knots in, 271 
ligation of, 164 
loops of, in vagina, 164 
prolapse of, 183 
pulse of, 282 
reposition of, 183 
short, 183 
structure of, 62 
traction on, 171, 172 
tying of, 284 
vessels of, 62 
Undescended testicles, 287, 299 
Uremic convulsions, 77 
Ureter, 47 
Urethra, 48 
Urinary colic, 303 
organs, 47 
Urine, collection of, 79 
in eclamptogenic toxemia, 78 
examination of, 79 
in new-born, 285 
in pregnancy, 78 
Urinometer, 79 
Utero-sacral ligament, 41 
Uterus, 38 
anatomy of, 38 
base of, 39 
cancer of, 94 
cervix of, 38 
changes of, in labor, 103 
in menstruation, 44 
in pregnancy, 66 
in puerperium, 218 
in size, 66 
contraction of, 103 
in labor, 103 
in pregnancy, 104 
in third stage, 109 
corpus of, 38 
functions of, 43 
fundus of, 39 
inversion of, 171 
involution of, 218 
ligaments of, 41 
menstrual cycle of, 45 
retroflexion of, 43 340 
INDEX 
Uterus, retroversion of, 43 
rupture of, 184 
sinking of, 67 
V 
Vagina, 37 
changes of, in pregnancy, 69 
color of, in pregnancy, 69 
fornix of, 37 
functions of, 37 
lacerations of, 184 
Vaginal Caesarean section, 209 
douche, 137, 175, 215 
examination, 152 
lacerations, 184 
tampon, 92 
Varicosities in pregnancy, 83 
Ventral flexion, 196 
Vernix caseosa, 285 
Version, 195 
Braxton Hicks, 195 
in breech presentation, 195 
cephalic, 195 
combined, 195 
external, 195 
podalic, 195 
in transverse position, 195 
Vertex presentation, 112 
Vestibule, 35 
Viable child, 85 
Villi, chorionic, 60 
Visitors, 28 
Volsellum forceps, 190. See Ten 
aculum forceps. 
Vomiting in infants, 301 
pernicious, 70 
of pregnancy, 70 
Voorhees’ bag, 190 
Vulva, anatomy of, 35 
change in, in pregnancy, 69 
infection of, 225 
injuries of, 184 
varices of, 83 
Vulvar douche, 222 
dressing, 221 
lacerations, 184 
pad, 138 
Vulvo-vaginal gland, 37 
Vulvo-vaginitis, 297 
W 
Walcher posture, 198 
Walking in pregnancy, 100 
Water-closet, 131 
Weight, loss of, in labor, 238 
of new-born, 311 
Womb. See Uterus. 
Y 
Yolk, 61 
separation of, from body, 58