WY 157 C124m 1922 54510010R NLM D5Efl7437 1 NATIONAL LIBRARY OF MEDICINE y SURGEON GENERAL'S OFFICE LIBRARY. Section — No. 113, W.U.S. G.O. No ..2>..±31&4- NLM052874371 AUG 3 1922 SURGEON GFNRAL'S ^.OFFICE A Manual of Obstetrical Nursing Prepared for Use in Connection with Textbooks of Obstetrics By Nancy E. Cadmus, R.N. General Director of tl.L wlaternity Center Association Graduate of the Presbyterian Hospital School of Nursing of the City of New York; former Superintendent of the Manhattan Maternity and Dispensary; former Member of the New York State Board of Nurse Examiners; former President of the New York State League of Nursing Education G. P. Putnam's Sons New York and London Gbe Umicfeerbocfter press 1922 157 l92Vi Copyright, 192a by Nancy E. Cadmus Made in the United States of Amerioa ©CI.A674567 JUN 13 1922 To All Who by Precept and Practice are Striving to Raise the Standards in Maternity Nursing ACKNOWLEDGMENTS In the preparation of a Manual of Obstetrical Nursing I have found valuable guidance in the following authoritative textbooks, by a close study of which I have supplemented my own acquaintance with principles and practices in obstetrics gained from long association with the work at the Man- hattan Maternity and Dispensary: The Standard Curriculum for Schools of Nursing, prepared by the Committee on Education of the National League of Nursing Education. The Practice of Obstetrics, by J. Clifton Edgar, M.D. (Though primarily "designed for medical students and practitioners," this book has been most helpful in the verification and arrangement of the Nursing Manual.) Obstretrics for Nurses, by Joseph B. De Lee, A. M., M. D. My thanks are due Lydia E. Anderson, R.N., President of the New York State Board of Nurse Examiners, Frances Smith, R.N., Instructor of V vi ACKNOWLEDGMENTS Nurses at the Woman's Hospital of the City of New York, and Mary B. Dowling, R.N., my able assistant at the Manhattan Maternity and Dispensary, for their encouragement and for their helpful suggestions as to the arrangement of material. To Anne A. Stevens, R. N., the former General Director of the Maternity Center Association, New York City, must be given full credit for the method of presenting the Division on Nurse Visiting, which will, I believe, prove to be one of the most valuable features of this Manual. In endorsement of this Manual of Obstetrical Nurs- ing as a type of book that should meet a distinct need, the following representative members of the medical and nursing professions have kindly consented to permit their names to be used: J. Clifton Edgar, M.D., Professor of Obstetrics and Clinical Midwifery in the Cornell Medical Col- lege; Visiting Obstetrician to Bellevue Hospital, New York City; Surgeon to the Manhattan Ma- ternity and Dispensary, New York City. Anna C. Maxwell, R.N., B.A., Former Director of the Presbyterian Hospital School of Nursing. Annie W. Goodrich, R.N., Sc.D., Assistant Professor of Nursing and Health, Teachers College, Col- umbia University, New York City; Director, ACKNOWLEDGMENTS vii Visiting Nurse Service, Henry Street Settlement, New York City. Elizabeth C. Burgess, R.N., Secretary to the Board of Nurse Examiners, New York State Depart- ment of Education. Elizabeth A. Greener, R.N., President of the New York State League of Nursing Education, Su- perintendent and Principal of the School of Nursing, Mount Sinai Hospital, New York City > FOREWORD The general intent and purpose of a Manual of Obstetrical Nursing may perhaps be best defined by borrowing these sentences from the Introduction to the Standard Curriculum for the Schools of Nursing: "In sending out this Curriculum, the Committee desires to emphasize afresh its hope that there will be no failure to understand its purpose. It is not offered as a " model'' curriculum. It realizes that, under the varying condi- tions existing in hospitals at present, a relative con- formity is not attainable or advisable. " The work of the professional nurse is practically the same in all the States of the Union, and it would seem perfectly evident that the training which is to guarantee a certain acceptable measure of competence, would need to follow somewhat similar lines, whether the nurse is trained in California or New York. " The main difficulty is the lack of a clear understanding of what the function of a modern nurse is, or what the purpose and scope of her training should be. '' Nursing is in a very special sense a national service, and training of the nurse is a matter of vital concern not only to her hospital and to herself, but the country at large." A resume of the causes which led to the appearance of the present work and a statement of the conditions ix X FOREWORD which it is hoped the Manual may help to remedy will explain in large measure the scope and arrangement of the book. Out of her experience as Superintendent of the Manhattan Maternity and Dispensary of the City of New York for a period of eleven years, during six of which (1911-1917) she served as a member of the New York State Board of Nurse Examiners, having the subject of Obstetrical Nursing assigned to her, there grew upon the author a conviction of the press- ing necessity for improved methods in the teach- ing, study, and supervisory work of this branch of nursing. Provision for acquiring proficiency in obstetrical and gynecological nursing is distressingly inadequate. The teaching of obstetrical nursing is conducted under one of two conditions,—either through affili- ation with special maternity hospitals and maternity departments of large general hospitals; or as a part of the general course, in which latter case there is apt to be little or no physical separation of maternity from the general work of the hospital. The number of special maternity hospitals is comparatively small. Even with the addition of well-defined maternity divisions in the large hospitals, the facilities for meeting affiliations are insufficient. When instruc- tion in this particular branch of nursing is given as FOREWORD xi part of the general course, its value is lessened by the lack of proper physical separation of the work, noted above, and further by the frequent absence of a sympathetic attitude toward attempts to impart correct and related nursing procedures. Failure to make proper provision for linking obstetrical nursing with that closely allied branch, gynecological nursing, is another serious handicap to the student nurse and one with which she often has to cope. The imperfections and inadequacies of the usual course in obstetrical nursing are doubtless due to the astonishingly widespread belief that maternity is a simple, natural process, and that consequently a minimum of specialized training is required for the nursing of maternity cases. This limited and mis- taken point of view is reflected by the young women entering the schools of nursing, whose attitude toward obstetrics is too often one of indifference or prejudice. They bring little interest to the course, and they are inspired with little interest in it. Hap- pily there is evidence that the general public is awakening to a better understanding of the import- ance of this department of nursing. Such evidence is furnished in the increased demands for public health nursing in maternity cases; and all feel assured that support will be forthcoming for those who are xii FOREWORD responsible for the training of student nurses in obstetrics, if they meet their responsibility by de- manding higher standards in their departments. There must be a keener interest on the part of the instructors and the development in the instructed of an intelligent appreciation of the tremendous re- sponsibility which must be carried by a nurse in this particular field of work. Their own wrong approach to the subject, their underestimate of its importance, is not the only limitation imposed upon the progress of student nurses in obstetrics. The experience of the author has disclosed a prevalence among such students of a deficient knowledge of the anatomy concerned in child-bearing, with a further lack of good basic under- standing of the fundamentals of physiology as related to pregnancy, labor and the puerperium. The result of such ignorance of fundamentals is a delayed correlation of theory and practice. The ability to closely associate the theory with the practice is peculiarly necessary in obstetrical nursing. The nurse may be most fluent in reciting the stages of labor, and woefully deficient in associating the theory with actual labor. In no field of nursing should there be a broader regard for the psychology inherent in the experience of both patient and nurse than in the one under dis- FOREWORD xiii cussion, and here again there has been a distinct failure to meet the demands of the situation. It is the purpose in teaching obstetrics, as in teach- ing any other subject, to instill in the mind of the student sound basic theory, but a peculiar difficulty is encountered in this department because of the sharp divergence of its theoretic basis from that of other branches of nursing. Here the theory rests primarily upon a hypothesis of perfect physiological conditions and the pathological is given second place: this is true of no other branch of nursing. General nursing presupposes the presence of disease; obstetrical nursing presupposes the absence of disease. Undoubtedly many of the difficulties in teaching obstetrical nursing are caused by the confusion of these facts. The nurse to-day has a bigger opportunity and a larger responsibility toward the community than she has ever had before. Especially important is her work in the prevention of disease. But in no field does she deal so largely with the concrete as in active obstetrical nursing, and here her ability to exercise successful vigilance must depend upon her grasp of fundamentals, which should have been secured during her period of preparation. Defective points in the ordinarily accepted training in obstetrical nursing may be noted as follows: the xiv FOREWORD comparatively few prepared instructors and super- visors, the limited and uncertain time devoted to this subject because of multiplicity of duties, inadequate teaching personnel, difficulty in holding permanent and efficient supervisory workers, and poor co-opera- tion between supervisors and instructors. As always, it is easier to detect the causes which lead to unsatisfactory conditions than it is to remedy such conditions, but the present Manual has been prepared in the earnest hope that it may supply the schools with an aid to a gradual development of these remedies. N. E. C. New York. May, 1922. CONTENTS Acknowledgments . Foreword Part I.—Class Work Part II.—Lectures Part III.—Quizzes Part IV.—Practical Demonstrations in Ob stetrical Nursing . Part V.—Maternity Nurse Visiting XV A Manual of Obstetrical Nursing PART I CLASS WORK i PART I CLASS WORK Introductory. The following outlines are believed to have poten- tial value both for the instructor and the student in obstetrical nursing. They are so classified as to present systematically the anatomical, physiological and functional features of reproduction, with due regard to pathological conditions which may arise in the reproductive cycle. Following a natural order, prominence has been given to the physiological and normal, while the pathological and abnormal have been classed as disorders, complications and accidents. In preparing the outlines, it has not been the intention to restrict the student to an arbitrary and rigid plan of study; on the contrary every effort has been made to inject sufficient elasticity of arrangement to permit of adaptation to local require- ments. Division of the class work into twelve lessons has been made because that seems to be the maximum 3 4 MANUAL OF OBSTETRICAL NURSING number that the schedules of the majority of schools can accommodate, but an expansion may easily be made. Note: The nursing of obstetrical cases in the home should not be overlooked but owing to the limited number of lessons, it has seemed wiser to consider this phase of the subject under the head of Practical Demon- strations, where attention may appropriately be given to the development of procedure and ethics peculiar to that type of nursing. LESSON I PARTS AND ORGANS INVOLVED IN THE FUNCTION OF REPRODUCTION The Pelvis. f position i.—The bony pelvis \ divisions [ structure [ kinds of tissue 2.—The soft parts -j purposes { distribution [ four chief ones 3.—Varieties of pelves -j effects upon childbirth i causes 4.—Organs and parts composing internal and external genitalia. f position ! structure f position The uterus \ divisions The ovaries j structure size I function [ function Fallopian tubes Ligaments:—broad ligaments, noting surfaces covered by them, lateral terminations and the structures found between their folds. 6 MANUAL OF OBSTETRICAL NURSING Carefully develop an understanding of what constitutes the external genitalia, also of organs and parts closely related to pregnancy, labor and the puerperium, i.e.. peritoneal pouches, perineum, bladder, rectum, etc. f extent 5.—The parturient canal I structure I shape I function 6.—Accessory organs, the breasts essential to life of infant structure function nipples ( normal abnormal Define:—true pelvis, false pelvis, brim, outlet, quad- rants, reproduction, parturition, Accou- cheur, congenital. LESSON II THE PHYSIOLOGY OF REPRODUCTION I. Ovulation; history of the ovumi . , -. 1 impregnated 2.—Preparation of the uterine wall for the impreg- nated ovum. Deciduae. early characteristics source of nutrition oxygenization 3.—Development of the embryo and differentiation of parts protective nutritive placenta umbilical cord 4.—Characteristics marking 5.—Fetal circulation 6.—Puberty, its pheno mena origin structure position function structure size and length attachments function termination of embryonic life beginning of fetal life, physical psychic 8 MANUAL OF OBSTETRICAL NURSING general local period conditions influencing physical psychic 7.—Menstruation—its manifestations 8.—Menopause,— phenomena Question—What, if any, are the relations of menstru- ation and ovulation, and menstruation and impregnation ? circulation metabolism digestion oxygenation assimilation elimination -Physiology of fetus in utero Define:—liquor amnii, term, conception and synonymous terms, embryo, fetus. LESSON III PHYSIOLOGICAL PREGNANCY I.—Phenomena external genitalia accessory organs, the breasts salivary glands Local vagina ' muscular tissue blood vessels and lymphatics uterus size weight . cervix f circulation General J eliminating organs | blood [ nervous system 2.—Diagnosis of pregnancy Probable morning sickness cessation of menses signs mammary signs pigmentation Positive palpation fetal heart sounds signs quickem ballottei mg nent 9 io MANUAL OF OBSTETRICAL NURSING Uncertain [ reflex disturbances and doubt- j changes in shape and size ful signs [ pressure and congestive signs Note:—presumptive tests, as that of blood serum should be noted. In giving the above signs it must be borne in mind that authorities differ widely, parti- cularly on the "positive" signs. 3.—Duration of pregnancy 4.—Methods of reckoning date of termination dress 5.—Hygiene and manage- ment 6.—Viability diet skin elimination ■ kidney exercise [ intestine mental attitude (interruption of pregnancy before | interruption of pregnancy after Define:—primigravida, primipara, multipara, pelvimeter. LESSON IV PHYSIOLOGICAL LABOR A clear understanding of normal labor, its mechanism and conduct, is most essential to obstetrical nursing, therefore it is very helpful to have the lecture on the '' mechanism of labor " closely associated with this lesson. powers I.—The mechanism of labor j passages l passenger 2.—Positions and presentations „r r , * 1 i I" lightening 3.—Warnings of the onset of labor, i , reliability of these signs 1 f early in labor 4.—Rupture of membranes \ dry labor I desirable time 5.—Stages of labor First, or period of dilatation phenomena duration contractions progress bag of waters 'v psychological j primipara [ multipara 12 MANUAL OF OBSTETRICAL NURSING Second stage, or period of expulsion phenomena duration Question:—Use of anaesthesia Third, or pla- cental stage 6.—After pains phenomena f contractions I descent of pre- | senting part [ expulsion of fetus ' contractions the umbilical cord placenta and secundines physiological duration indications exciting causes treatment Define:—show, position, presentation, pains, puer- perium, involution. LESSON V protective measures NURSING CARE DURING LABOR It would seem advisable to closely associate this with Lesson IV thus linking the nursing care with the conduct and management of labor. { surroundings \ patient I nurse bathing elimination nourishment genitals clothing sleep freedom from needless re- strictions. preparations for physician's examinations records control of patient summoning of physician where should patient be kept and why? further preparation of patient 13 1.—During first stage preparation of patient 2.—During second stage 14 MANUAL OF OBSTETRICAL NURSING 3-- -During second stage -During third stage examination after rupture of mem- branes aids for patient preparation for repair work procedure if physician is not present ' concerning general condition concerning the pulse concerning uterus and hemorrhage Special duties Questions of vaginal examinations, the giving of anaesthetics by nurses, calling of physician, or delivery by nurse if physician is not present, and duties in respect to infant, must be expected to arise, hence instructions on these points should be emphasized. LESSON VI PHYSIOLOGICAL PUERPERIUM I.—Duration 2.—Pheno- mena f temperature, pulse, respiration general j elimination sensitiveness to influences I local retro- gressive ■ changes pro- gressive changes external genitalia internal genitalia where found purpose colos lac- tation trum engorge- ment 3.—The nursing care being the outstanding factor in the management of the puerperium, and inseparable from its technic, this lesson is made to embrace both cleansing warmth Immediate care mother watching for emergencies rest [ hemorrhage ] collapse [ convulsions 15 16 MANUAL OF OBSTETRICAL NURSING Immediate care child asepsis dressings mucous asphyxia eyes warmth watching for emergencies sleep mother nurse intervals utensils equipment use of gloves use of binders surroundings care as a bed patient bowel and bladder douches, enemata, cathe- terization diet sleep visitors 4.—Care of sutures Define:—lactation, colostrum, meconium, lochia, galactorrhea, agalactia, engorgement. special features LESSON VII THE NEWBORN CHILD, ITS CARE DURING FIRST WEEKS OF LIFE I.—General phenomena at birth, and first hours of life 2.—Hygiene and management 3.—Technic of in- fant nursing establishment of respiration • due to f stimulation of nerve centres changes in circulation of blood digestion excretion further physio- logical changes from birth to first bath the bath care of cord surroundings, warmth, light, air, dress bowel and bladder first 24 hours—number of feedings, intervals and use of water second 24 hours—as above and use of supplied foods from third day on—number of daily feedings, intervals for day and night 17 18 MANUAL OF OBSTETRICAL NURSING -Technic of in- fant nursing -Nursing measures preparation of infant for feedings preparation of mother for feedings overfeeding underfeeding [ when infant fails to nurse—causes •j when milk is insufficient [ when milk is too abundant 5.—Contra-indications to breast feeding 6.—Composition of human and cow's milk obtaining breast milk for analysis determining effects of [ weight the nursing upon in-j bowel fant [ bladder method of obtaining daily average secretion capacity of infant's stomach Define:—meconium, caput succedaneum, suture, fontanel. 7.—General points LESSON VIII PATHOLOGY OF PREGNANCY I.—Conditions bordering on the patho- logic -Accidents of pregnancy 3.—Complications of pregnancy ■ simple nausea and vomiting \ . { persistent oedema varicosity syncope pains in abdomen psychical [ abortion prematurity -j miscarriage [ premature labor hemorrhage placental detachment placenta f symptoms praevia \ treatment ectopic gestation toxemia with [ causes or without] symptoms eclampsia [ treatment symptoms rules as to light, noise, etc. eclampsia 1 effect upon fetus prognosis for both mother and child treatment Define:—gestation, parturient, moulding, rotation. 19 LESSON IX PATHOLOGY OF LABOR AND THE PUERPERIUM due to maternal condition I.—Variations found in j due to fetal labor conditions due to pla cental condi tions abnormalities of cord f —Compli- cations of the puerperium hemor- rhages pelvic deformities age previous pelvic surgery precipitate labor diseases parturient tract delayed labor faulty position faulty presentation prolapse of cord length insertion coiling malformations, deform- ities oversize [low implantation j placenta { praevia diseases detached post- f primary partum j secondary f general | local symptoms treatment causes 20 CLASS WORK 21 genitals 2.—Compli cations of the puerperium infections breasts extension by continuity extension by lymphatics extension by veins effects causes varieties symptoms treatment effects upon nursing in- fant 3.—Embolism 4.—Puerperal mania 5.—Rectal and urinary troubles 6.—Define:—mastitis, puerperal, thrombosis. LESSON X PATHOLOGY OF THE NEWBORN CHILD I.—Premature birth incubation 2.—Atelectasis Neonatorum prematurity I causes \ degree, and its effects initial loss of weight general appearance respiration cry swallowing size compressibility of head susceptibility to heat, cold, light, as com- pared with full term child f heat making powers respiratory functions regaining initial weight susceptibility to trau- matisms of labor general char- acteristics of premature infants physiological peculiarities as manifested in f object 3.—Asphyxia Neonatorum 1 causes degrees [ prognosis i management I advantages asphyxia livida asphyxia pallida 22 CLASS WORK 23 f too frequent nursings j irregularity causes j too rapid feeding {exposure to cold colic 4" -Indigestion vomiting symptoms constipation diarrhoea gas treatment [ conjunctivitis eyes •{ ophthalmia (origin [ neonatorum [ treatment 5-" —Infection navel due to respiratory tract bacteria gastro-intestinal cutaneous pustules blood abscesses erysipelas [1 jrophylaxis aphthae j ( characteristics 6.- —Infections 11 treatment due to fungi (l Drophylaxis thrush j < characteristics [1 :reatment f general 7" —Hemor- j navel rhage 1 bowel [ mucous surf a ces f operative del ivery 8.- —Injuries due to \ precipitate b J„1---A T-^V+V irth 9-__Define:—jaundice, caking of breasts, convulsions. LESSON XI OBSTETRIC SURGERY The fundamentals of nursing technic in obstetric and general surgery are precisely the same, but in order to be an efficient assistant in obstetric surgery, the nurse should be well versed in the characteristics peculiar to this type of patient, parts involved, and purpose of operation. Operations preparatory to delivery rupture of membranes induction manual and instrumental dilatation f cervical incisions \ vaginal [ labial version pubiotomy symphysiotomy embryotomy craniotomy Operations for delivery fdilatation Accouchement force* -j version {extraction 24 CLASS WORK 25 flow forceps | medium I high Caesarian section Operations in placental stage external pressure manual extraction instrumental extraction Operations for injuries cervix vagina perineum rectum Note:—In hospitals located in regions where graduates from their schools frequently attend confine- ments in the home, the training given student nurses should include special preparation for this type of work. LESSON XII SOME OTHER FACTORS IN OBSTETRICAL NURSING I.—The patient [ during pregnancy Diet j during labor [ during the puerperium Certain diet controlling features in each of above periods. Special exercises in the puerperium. 2.—The nurse contact with infections wearing on street sleeves shoes wearing of rings special covering of hair use of face mask shoes use of gloves regard for psychology peculiar to parturient women conversing over patient in labor giving and receiving orders in hear- ing of patient 26 Dress on general or floor duty In operating or delivery room Deportment PART II LECTURES 27 PART II LECTURES Explanatory. In a course of ten lectures, exhaustive treatment of the subject of obstetrics cannot be expected, but as it is realized that some schools may be unable to present even ten lectures, the inclusion of a greater number in the suggested course does not seem to be justified. The outlines for lectures found in the Standard Curriculum, pages 104-106, have provided the basis for a large part of the following plan. It is expected that the majority of the lectures will be given by mem- bers of the medical staff of any hospital using the Manual, and the purpose of these outlines is simply to suggest a plan of instruction. 29 OUTLINES FOR LECTURES LECTURE I Introductory I.—History of obstetrics; its place in medicine 2.—Factors influencing heredity 3.—Purpose and scope of eugenics 4.—Birth control Note:—With the wide publicity now given to child bear- ing and related subjects, young women are asking questions which should be answered by those fitted to do so. LECTURE II Reproduction . (the lower animals 1.—As related to \ . , (the human species 2.—Ovulation LECTURE III Anatomy of female pelvis Varieties of pelves as related to child bearing ^ ... (external Genitalia \. A . [ internal 30 LECTURES 3i LECTURE IV Pregnancy Physiological, its diagnosis and management Pathological, its disorders and diseases Note:—This affords the physician an opportunity to discuss the deeper physiological changes due to pregnancy. LECTURE V Labor Theories as to cause Its mechanism Conduct Anaesthesia Nursing technic Preparations for operative measures LECTURE VI Obstetric Surgery Operative deliveries Inducing premature births Repair of lacerations LECTURE VII Accidents and Complications In pregnancy, labor and the puerperium Note:—These refer to both mother, fetus and child. 32 MANUAL OF OBSTETRICAL NURSING LECTURE VIII The Newborn Child and its Care At birth The first fortnight Premature child Incubation General follow-up care LECTURE IX The Puerperium Anatomical changes Physiological changes Pathological conditions that may arise Note:—Include both mother and child in this discussion. LECTURE X Social Aspects of Obstetrical Nursing. See Page 106—Standard Curriculum. PART III QUIZZES 33 PART III QUIZZES In the correlation of theory with practice, the value of quizzes cannot be overestimated. It is suggested that, so far as circumstances will permit, the quizzes be given to small groups and clinical methods used. It is also recommended that they be associated with the lectures for the stimu- lation of the students' interest in the subjects presented. Quiz I.—Use Lectures I and II as basis of this quiz. Quiz II.—Prenatal nursing care. Hygiene of pregnancy. Ethics of the nurse's relation to medical responsibility. Quiz III.—Obstetrical terms. Nursing in the stages of labor. Quiz IV.—Management of emergencies in pregnancy, labor and the puerperium. Quiz V.—The psychology of obstetrical nursing, particularly "the principles that are the direct concern of the nurse." 35 36 MANUAL OF OBSTETRICAL NURSING Quiz VI.—The care of the normal baby from birth to end of puerperium. Responsibility of the nurse in promoting breast feeding. General care of mother. Artificial feeding and regulation of nurs- ing periods. Technic in preparation of artificial feedings. PART IV PRACTICAL DEMONSTRATIONS IN OBSTETRICAL NURSING 37 PART IV PRACTICAL DEMONSTRATIONS IN OBSTETRICAL NURSING The practical demonstration has an established and undisputed value in any system of instruction in nursing procedures. The benefit to be derived by the student depends upon the recognition of such demonstrations as part of the curriculum and upon the careful supervision thereof. Two considerations which must be accepted as modifying a special course of this kind are (i) the demands of the individual hospital in the care of its patients, and (2) the provision made for standardized instruction. The reception and discharge of groups of affiliating students must necessarily be more or less subject to local conditions. A rule which is quite generally followed in arranging affiliated courses in obstetrics for undergraduates is to receive a new group semi- monthly, excusing at the same time another group which has completed the prescribed course. Ideally the introduction of new groups would be so arranged 39 40 MANUAL OF OBSTETRICAL NURSING as to free the students from the exigencies of the daily routine, but in practice this is, as a rule, impracticable. However, the following outline in use at the Woman's Hospital Post Graduate School for Nurses in the City of New York, presents an admirable plan of intro- duction under these more ideal conditions. (This schedule includes both obstetrical and gynecological nursing). Where such a plan is not feasible, it is suggested that the demonstrations be given to small groups and made to fit into the regular routine so far as possible. The accompanying outlines for demonstrations in details have been prepared with special reference to the system of admitting affiliating students at semi- monthly periods for a three months' course, a system followed by several of the special maternity hospitals in New York City. WOMAN'S HOSPITAL Post Graduate school for Nurses Grid----...,.,— , .,19..^.,School of Nursing of.----- Hnnp. CLASS Class Pupi! Dem. Surg. Wd Sarg. Wd. Ob. Dept. Clinic OR. , Standardized Orders . Hospital Rpds . Prep ff,r Phys. Fvamin^tinn'i , Medirine Tray nnd TWhnir Encm«—MeHifafpd, „ Colonic Irrigation Harris Solution and Technic Saline Enema Proctoclysis Prep, for Hypodermoclysis Prep, for Infusion t SnreioM Prenaration . Care of Perineal Sutures . Prep, for Sure. Dressings Removal of Sutures. Ahd. and Per Hosd. Binders Cupping; Hot Packs Baby Baths Hot Fomentations Mustard Piaster Prep, for Stomach Lavage and Gava?e Bladder Lavage 41 DEMONSTRATION I INTRODUCTION TO THE NURSERY AND THE BABY'S BATH Introduction of the nurse through the nursery is advised because of the psychological effect produced by contact with the babies, very often a factor in securing "a radical change of attitude toward obstetrics." In this experience the nurse is brought to an actual realization of the distinguishing char- acteristic of obstetrical nursing,—that it is not "nursing in disease." Point One : Insistence upon systematic care of the nursery in respect to appearance. Crib Beds. I. Method of making r , -, ,• [ soiled a.—care of bedding \ {unsoiled b.—care of protector c.—care of mattress d.—care of frame 2. Method of airing 3. Method of making a.—for open bed b.—of opening without baby 43 44 MANUAL OF OBSTETRICAL NURSING c.—for closed bed d.—of opening with baby Point Two: Instruction concerning use of all means of identification of baby. Point Three-. Regulations and use of scale with weigh- ing blanket. Point Four : Assembling of articles necessary for bath and dressing of the baby. The nurse a.—care of hands and nails b.—precautions as to position, etc. The baby a.—handling and position b.—removal of garments c.—inspection d.—weighing e.—preparation of bath water f.—precautions. The bath a.—procedure b.—care of cord and cord dressing c.—indications for use of powder and method of applying d.—indications for use of albolene e.—observance of identifications Dressing the baby a.—putting on shirt b.—diapering c.—putting on gertrude and dress Other points care of mouth, nose, ears, eyes, nails, hair, genitals and breasts. care of articles and utensils after use PRACTICAL DEMONSTRATIONS 45 Tub bath a.—when indicated b.—temperature of water c.—position of baby d.—procedure. DEMONSTRATION II SUGGESTED PROCEDURE FOLLOWING DEMONSTRATION IN NURSERY The importance of making an opportunity for incoming students to meet the Director of the school and the Superintendent of the hospital during their first day is evident. It is of course both natural and necessary that new students should meet the Director, but a formal recognition and welcome by the Superintendent will give them a sense of inclusion in the activities of the particular institution with which they are affiliated. Such a feeling can but react favorably upon their interest and their enthusiasm for the work. During the visit to the school office, instruction should be given in local conditions and requirements, with clarifying explanations of administrative details peculiar to the hospital and the school. 46 DEMONSTRATION III POSTPARTUM DRESSINGS I.—Instructions concerning factors peculiar to the puer- peral period Lochia a.—its characteristics [ to mother b.—its dangers j to baby [ to nurse Breasts a.—colostrum b.—lactation Intervals between dressings a.—what and why b.—question of evacuation of bladder and bowel 2.—Preparation a.—bed and patient b.—use of draping sheet c.—assembling required articles and utensils d.—method of handling sterile dressings e.—conveyance for waste f.—preparation of the nurse. 3.—Procedure a.—use of gloves? b.—bed pan c.—removal of soiled dressings 47 48 MANUAL OF OBSTETRICAL NURSING d.—cleansing of patient e.—placing of sterile dressings f.—after care of patient g.—after care of utensils, etc. 4.—Records a.—time [ lochia b.—observations j fundus [ the unusual c.—excretions. 5.—When sutures are present a.—special features b.—precautions c.—preparation of the nurse d.—procedure Note: Methods of procedure in perineal dressings vary greatly; simplicity is suggested. DEMONSTRATION IV CATHETERIZATION, ENEMATA, TREATMENTS, ETC. The Mother Students are expected to be familiar with any procedure required in general nursing, and the pur- pose of this demonstration is to develop points pecu- liar to obstetrical nursing. i.—Catheterization a.-before delivery { sPecia; dan2ers [ special precautions f lochia b.—after delivery \ difficulties peculiar to this [ type of patient 2.—Enemata precautions difficulties observations ( special points b.—after delivery \ precautions [ observations 3.—Douching a.—preparation for intra-uterine : "- - ' , • , (method "' *•• •' b.—vaginal \ [ precautions Note: While the giving of douches is being practiced less and less, nurses are still expected to give 4 49 a.—before delivery 50 MANUAL OF OBSTETRICAL NURSING them in some instances. The nurse should not give intra-uterine douches. 4.—Treatments for a.—toxaemia b.—eclampsia c.—phlegmasia dolens d.—engorgement threatened f—mastitis 5.—The baby Irrigations [ operative articles needed position a.—eyes j methods protection of nurse precautions relating to baby articles needed position b.—rectal \ precautions temperature observations ' indication temperature Mustard bath amount mustard method after care Lavage and gavage Note:—Demonstrations of the various trays, fully equipped, are advisable. DEMONSTRATION V LABOR ROOM AND MANAGEMENT OF PREPARATION OF PATIENT This demonstration is arranged on the supposition that the labor or stage room, and a separate delivery room are available. Ideally the maternity patient should be apart from all other patients. The usual practice is to keep private patients in their rooms until ready for final preparation and delivery. Ward patients are removed to stage room at the beginning of labor, and transferred to delivery table when first stage is well advanced. The ward patient is in mind when giving the following: furnishings beds utensils I.—Preparation of stage ' solutions room sterile goods for articles patient emergencies records 51 52 MANUAL OF OBSTETRICAL NURSING 2.—First preparation of patient 3.—Management ■ general (clipping shaving routine technic till second preparation flying position of patient I sitting [ walking special duties of nurse nourishment temperature bowel bladder treatment 4.—Examinations by physicians [ruptured {dangers 5.—Membranes j [ precautions [ intact I general condition contractions bladder judging of progress records _ . (what to prepare for 7.—Emergencies ■ , , , . , ' duty of nurse in each DEMONSTRATION VI DELIVERY ROOM. THE NURSE. PREPARATION OF PATIENT, ETC. In maternity hospitals preparations for deliveries are routine and nurses usually receive the demon- strations individually and in actual preparation for the delivery. Previous operating room service is indispensable for the nurse and the safety of the patient. Immediately following a delivery the nurse re- moves all evidences and proceeds to "set up" for the next. Special dresses and shoes are worn by nurses on service with labor cases. by whom ordered Removal of patient to table 2. The clean nurse may nurse judge use of anaesthesia given by whom precautions preparation of hands gloves gown cap mask 53 MANUAL OF OBSTETRICAL NURSING [routine Ifield. [position Preparation of { ^^^^ in keeping technic patient ^ coverings precautions Duties of clean nurse during second stage Duties of assisting nurse mouth Immediate care of baby— eyes by whom 1 cord [ inunctions Duties of clean nurse during third stage Final preparation of mother before leaving table. DEMONSTRATION VII PREPARATION OF BABY FEEDINGS I. The milk 2. The room furnishings choice pasteurization sterilization general management Cheat J Hght j plumbing [ refrigeration stock utensils daily care conveyances for bottles [nurse's dress, hands, hair, etc. care of returned bottles preparation of bottles for filling care of utensils. Special process in obtaining, caring for, and giving of breast milk Note: No phase of obstetrical nursing should receive more detailed and exact demonstration of method than that pertaining to the feeding of the infant. All formulas are naturally of local determination, but every nurse should be thoroughly taught the technic of preparation and use. 55 3. The routine 4- DEMONSTRATION VIII GYNECOLOGICAL NURSING Introductory. Strictly speaking, this field of nursing deals with disease, but because the affected organs are those concerned in reproduction, and because gynecological measures are frequently indicated in cases of child bearing, familiarity with the requirements of gyne- cological nursing is an essential qualification for ob- stetrical nursing. Therefore outlines for a practical demonstration in gynecological procedures, prefaced by a brief quiz, are presented. QUIZ I.—Define gynecology 2.—Nature and causes of disease in the reproduc- tive organs 3.—Explain the linking of gynecology and obstetrics. 56 PRACTICAL DEMONSTRATIONS 57 DEMONSTRATIONS Positions and drapings 2.—Contents and arrange ment of trays Demonstration of the preparation of the patient for gynecological examinations, treatments and operations. squatting dorsal Sims knee chest standing Trendelenburg Fowlers solutions medications sterile articles enemata catheterization douches infusion hypodermoclysis I emergencies ' names and uses holding Sims speculum special precautions in use of instru- ments [ preparations \ purposes [ dangers giving of bedpan for ordinary evacua- tions of bowel and bladder (vaginal [ Patient intestinal PurPose vesical danSers and Pre' cautions Instruments and appliances tampons and pessaries Treat- ments douches 58 MANUAL OF OBSTETRICAL NURSING 4. Treat- ments Note: methods of giving saline sutures enema protoclysis or Murphy method hypodermoclysis infusion (care 1 removal tamponing The number of demonstrations to be given from the foregoing outlines is left to the judgment of the users. PART V MATERNITY NURSE VISITING 59 PART V MATERNITY NURSE VISITING Introductory The conception of a hospital as an institution intended solely for the treatment of the sick is fast giving way to the broader vision of a community health center. The public has been educated to the expectation that the hospital organization will not rest content with its efforts to cure the disease that is brought to its doors, but that it will guide and ac- tively assist the community in avoiding disease. The visiting nurse plays a most important part in the modern plan for carrying health training from the hospital into the home and it is possible in connection with any recognized school of nursing to arrange for some form of undergraduate nurse visiting. Such arrangements for undergraduate nursing prove doubly beneficial. They help the community and they also help the student nurse by separating her for a period from the atmosphere and routine of the hospital and placing her in a position to put theory into practice. The "social vision" which she 61 62 MANUAL OF OBSTETRICAL NURSING develops in her work is an immediate stimulus and should prove a continuing incentive. But a service of this type should never be regarded as apart from the most careful and certain control, nor should it be exploited. It is imperative that complete medical co-operation be secured, without which the service would better be abandoned. And above all, it must always be borne in mind that the nurse is an undergraduate, one of a student body. Supervising nurses who have not yet secured a wide, practical experience are apt to overlook this point. In cities and towns where some form of nurse visiting is already organized, affiliations for under- graduates suggest themselves, but where no organ- ized staff of graduate nurses exists, some plan must be evolved whereby the hospital and school authori- ties are in direct control. Many communities can supply agencies through which a system of undergraduate nurse visiting may be developed, as for example town and country nurs- ing service; nurse visiting in connection with the great insurance companies; school nursing; industrial interests; State Board of Health centers; and doubt- less many others peculiar to given communities. When such agencies are not available, the hospital itself should initiate some practical system. If the problem of financing the scheme presents difficulties, MATERNITY NURSE VISITING 63 they will probably not prove insuperable, as private individuals are nearly always to be found who will assume this responsibility, if thereby the community can be benefited. This particular field of nursing must of necessity be bounded, so to speak, by local conditions. Hence the following precepts (based in large measure upon the experience of the Maternity Center Association and the Henry Street Settlement Home Nursing Ser- vice) are submitted as suggestions, rather than rules. General Suggestions:— 1. Avoid any breach of ethics in respect to medical, hospital, or any other nursing service, conducted with a patient. 2. Avoid being perfunctory. Determine visit by degree of responsiveness exhibited by patient, i.e., do not force a visit upon her. 3. Gain a knowledge of social agencies. Note: For the undergraduate this knowledge is mainly necessary in enabling her to realize that suitable care can be provided for the needy patient even if outside the intention of the nurse's particular hospital. 4. Co-operation—winning patient to accept methods suggested. 5. Adaptation of hospital routine to altered condi- 64 MANUAL OF OBSTETRICAL NURSING ditions as found in the home. Base all pro- cedures upon the principles of nursing technic, but be adaptable. 6. Realization of the power of example in acts of nursing. Remember the patient is even a keener critic than the head nurse. 7. Reports. Teach the object and value of care- fully prepared reports. Prenatal Visits: Objects: 1. To make observations in relation to patient's environment. 2. To gain patient's confidence, and learn what causes mental disturbances, if any are discovered. 3. To make plain the harmful reactions of mental disturbances upon the physical conditions. 4. To teach patient the possible reactions from unhygienic living upon the expected baby. 5. To teach the expectant mothers what to look for as the lying-in period approaches. Delivery: The nurse is present as the doctor's assistant. She is responsible for her nursing technic, the doctor is responsible for the delivery. Note: Thorough training in the principles of obstetrical nursing, a previous delivery room MATERNITY NURSE VISITING 65 service, and adaptability to home conditions are indispensible. Postnatal Visits: 1. By example, teach the mother the essentials of her own care. 2. Again by example, teach the mother how to care for the baby, emphasizing the importance of regularity in its training. 3. Urge post-partum examinations and the getting and preserving of birth certificates. 4. Observe and aid the mother while she, for the first time, bathes the baby. The actual realization that a certain theory can be put into practice is far more stimulating to a student than consideration of the theory in the abstract. Therefore it is believed that the most effective way to teach the undergraduate just what results can be accomplished by the visiting nurse, is to show her what results have been accomplished. The urgent necessity for spreading the gospel of health conservation, particularly as it involves maternity cases, calls for systematic, organized effort. Every community needs to be educated to a sense of individual and civic responsibility for the pro- tection of mother and child life; and this education must be given by properly qualified and efficiently organized agencies. Whenever service of this char- 5 66 MANUAL OF OBSTETRICAL NURSING acter is undertaken, the visiting nurse is discovered to be practically an indispensable unit in the organi- zation. Thus the importance of the nurse to the work and the importance of the work to the nurse seem to justify a departure from ordinary textbook con- ventions and the inclusion in the Manual of a sketch of the current activities of a particular group of specialized workers. The concrete example chosen to illustrate for the student the opportunities and responsibilities for which her instruction is fitting her, is the Maternity Center Association of the City of New York. Before detailing the methods by which the Maternity Center Association meets the situation, however, it seems wise to explain briefly just what the situation is which has to be met and what the demands of that situation are. Some Facts about the Needless Loss of Life in Child-Birth (Supplied by the Federal Children's Bureau of the U. S. Department of Labor and the New York City Department of Health) Maternal Deaths.I I. More women of child-bearing age (15 to 45) 1 Note: It should be. noted that the figures are not of very recent date. MATERNITY NURSE VISITING 67 die in the United States from causes incident to child-bearing than from any other cause except tuberculosis. For women, maternity is a scourge second only to the White Plague. Infant Deaths. 1. 12,657 babies under 1 year of age died in New York City in 1918, 35% of these died as the result of conditions arising before birth or accidents at birth, mostly preventable. 2. 5,818 babies under 1 month of age died in New York City in 1918. 75% of these died as the result of conditions arising before birth or at birth, largely preventable. 3. The number of still-births reported in New York City in 1918 was 6,793. Only a small porportion are reported and the total loss of life including miscarriages and interrupted pregnancies is very much larger. Hundreds of these losses are preventable. THE PROPOSED REMEDY Careful physicians have so developed the methods of caring for their private cases that maternal deaths from causes related to child-birth are rare in their practice. The basic method used has been early examination and supervision throughout the whole 68 MANUAL OF OBSTETRICAL NURSING period of pregnancy combined with aseptic delivery and adequate after-care. These same methods have also markedly reduced the number of infant deaths from causes arising before birth and at birth, the number of still-births and the number of miscarriages. The Ideal. Every pregnant mother should be brought under medical and nursing supervision; every child born should have proper care before birth, at birth and during the days immediately following birth; the methods by which the obstetricians have proven they can reduce the maternal and infant death-rates among their private patients should be applied generally to the population, to those who can afford to pay for medical service and to those who cannot. The Method. i. Conduct an educational campaign to teach all men and women the need for, and the value of, maternity care. 2. Urge the adoption of a uniform high standard of prenatal supervision, obstetrical methods and obstetrical nursing practice by the social agencies and health agenices working on maternity problems throughout the given community. MATERNITY NURSE VISITING 69 After this preliminary statement of present facts, proposed remedies, ideal conditions, and suggested methods in approaching the ideal, it is in order to describe the operating machinery by which the Maternity Center Association deals with facts and works for better conditions. Some of the routines of the Maternity Center Association naturally apply to a special field, but are sufficiently general to serve as illustration and suggestion in almost any well-defined field. EXHIBIT I CLINIC ROUTINE Conduct .your clinic so as to assure privacy to each patient examined, and the same treatment which she would receive if she were the only patient in the office of one of our best obstetricians. Wear your graduate uniform during clinic and office hours. NURSE'S DUTIES i. Preparation of Clinic Room: pads of doctor's record slips, pencils, examining table, side tables, sterilizer, basins, instruments, supply of clean dry gloves, Department of Health materials for taking Wassermann cultures and smears, cotton balls, tampons, throat sticks, sheets, pillow cases, sounding towels, adequate supply of clinic drugs, solutions, thermometers in glass full of 50 per cent alcohol, jar of cotton. To be ready one-half hour before the time set for clinic. 2. Preparation of Dressing Rooms for patients. Screens or curtains arranged to form individual dressing rooms, a sufficient number of clean clinic 70 MATERNITY NURSE VISITING 71 gowns, separate chair provided for each patient to leave her clothes on, unless room is provided with racks or hooks. 3. Preparation for Urinalysis. Unless the urinaly- sis is made so near the toilet that the waste urine may be thrown directly into the toilet, a covered pail is to be provided, one-quarter full of 1 per cent lysol solution. All waste urine and washings from the test tubes to be thrown into this pail, and under no circumstances is waste urine to be thrown into any sink or wash basin, even though the basin is not used for wash basin. Test tubes, sterno, litmus, acetic acid 2 per cent, funnel, filter paper, test tube holder, ves- sel for collecting specimen, basin of 1 per cent lysol solution and cotton balls for patients to cleanse vulva with before voiding, basin for used cotton balls, pro- vision for patients to wash hands. To be in readi- ness one-half hour before the time set for clinic. 4. Preparation of the patient for examination. Each patient to completely undress, except her shoes and stockings, and to put on clean gown supplied by the clinic. Her shoes to be unfastened so that the doctor may examine her ankles for oedema, her temperature to be taken and a urinalysis made before the patient is seen by the doctor. 5. Assisting doctor in Examining Room. Make notes on the record pad at the doctor's dictation, ^]2 MANUAL OF OBSTETRICAL NURSING reminding him tactfully of any omissions made in his dictation. Conduct examination in the follow- ing order: Head, chest, breasts, blood pressure, abdominal, foetal heart, measurements, ankles, vaginal, Wasser- mann's, and smears when necessary. Note: Prep- aration for vaginal examination. Sponge vulva with I per cent lysol solution, using four cotton balls. Give doctor fresh gloves for each patient. (The nurse, not the doctor, is responsible for the technic in the clinic room.) If the doctor wishes to do a vaginal examination on a patient more than eight months pregnant, or one who is bleeding, take the same precaution as when examining a patient in labor; clip, scrub with green soap and water, then I per cent lysol, give doctor freshly boiled, sterile gloves. 6. Arrangement of Examining Room after Clinic. Soiled linen in laundry bags, fresh linen on tables, tables covered, all used instruments to be washed (scrubbed when necessary), boiled five minutes, dried and put away; all gloves used to be washed in cool water and green soap and thoroughly rinsed, wrapped in a towel, dropped in boiling water and boiled five minutes, then dried, powdered and put away in a clean towel ready for use at the next clinic. Solution basins to be emptied, washed and dried; all waste to MATERNITY NURSE VISITING be securely wrapped in newspaper and put in the house garbage can. Supply of drugs to be checked and replenished when necessary. 7. Records. All doctor's record cards to be written up and filed; Maternity Records to be filed in date file before the nurse goes off duty. DOCTOR'S DUTIES AS OUTLINED ON DOCTOR'S RECORD 1. One complete physical examination, including head, heart, lungs, breasts, blood pressure, abdominal examination, fcetal heart, pelvic measurements, va- ginal examinations, Wassermann, and G. C. smear on all patients with a suspicious history. Notes on this examination to be dictated to the nurse. 2. Blood pressure; abdominal; urinalysis; on return visits and notes on such other observations as she may wish to make. 3. One post-partum examination on every patient; including a statement on general condition; examin- ation of the breasts; vagina; uterus; perineum; and notes on the result of any intercurrent disease. 4. Recording advice given to patient. 5. Instructing patients when to return to see the doctor. Note: All patients not registered with a hospital 74 MANUAL OF OBSTETRICAL NURSING or private doctor to be seen by the clinic doctor once a month up to the seventh month, and once in two weeks or oftener as case requires thereafter. Duties of Clinic Assistants: At those clinics where a lay woman acts as assistant to the nurse, the following duties (and no others without special permission), may be assigned to the assistant: i. Greeting the patient, and from name on her card getting her Maternity Record from file and send- ing to nurse. 2. Taking temperature (a record of which is sent to the nurse on a scratch pad slip and copied by her on the doctor's record slip). 3. Urinalysis. 4. Helping patient to undress and dress. 5. Care of any children who may come with patients. 6. See that patients understand when to return and that cards are so marked before they leave. CLINIC EQUIPMENT STANDARD Requirements: Room for examining and dressing screens, running water, gas, near a toilet, urinalysis facilities, good light: Chair..................1 Clips................q. s. Desk..................1 Ruler.............. t MATERNITY NURSE VISITING Blotting Pad...........I Waste basket...........2 Blotter................1 Hand blotters..........12 Ink-well...............1 Ink, red and black...... Penholder..............2 Charities Directory......1 Pens.................. Map of Manhattan in Erasers............... Sanitary areas.........1 Pencil.................1 Report on vital statistics. 1 Ink....................1 Babies' Welfare directory. 1 Red pencil.............1 Guide Cards, Baby Health Rubber bands........... Station...............1 Examining Room: Table..................1 Foot bench.............1 Pad...................1 Shelves or side table for Pillow.................1 supplies, etc.......1 set Garbage pail...........1 Erlemeyer flasks for green Pelvimeter.............1 soap and lysol.........2 Tape measure..........1 Medicine glass..........1 Stethoscope............1 Hand scrub.............2 Spatula..............100 Rubber gloves, No. 7^, Haemoglobinometer prs...................6 (Tahlquist)..........1 Absorbent cotton, lbs. ... 1 Needle (skin)........... String, balls.............1 Wassermann sets from D Sterilizer burner.........1 of H1 Metal shelf or table for G. C. smear sets from D gas sterilizer of H Scott tissue towels.......6 Culture tubes from D of H Urinalysis outfit.........6 Bandages (Ace).........6 Test tube rack........1 Sterilizer...............1 Test tubes...........12 Tenaculum.............1 Test tube holder.......1 Scissors................1 Urinometer...........1 1 Department of Health. 76 MANUAL OF OBSTETRICAL NURSING Bivalve speculum.......i Uterine dressing forceps.. I Blood pressure machine (Tycos)..............i Thermometers..........3 Thermometer glasses (1 for cotton)...........2 Enamel jars for tampons and pledgets..........2 Large basin............1 Small basin.............1 Linen: Sounding towels (for use in listening to F. H.). .6 Sheets.................6 Pillow cases............3 Doctors' gowns.........2 Sewing Bag: Cotton 70 Cotton 30 Needles, assorted Thimble Drugs: KY Lysol Green soap Boro glycerine Breast Care: Tray holding Castile soap in dish Small bowl Sterno............... Matches............. Enamel measure.......1 Dish (chamber).......1 Litmus.............. Acetic Acid 2%....... Toilet paper.......... Funnel...............1 Filter paper........... Covered pail.......... Dusters................6 Gowns for patients.....12 Covers for tables......q. s. Laundry bags...........2 Towels.................6 Tape measure Tape Safety pins Plain pins Alcohol Iodine Albolene Jar of cotton balls Soft tooth brush Bottle of albolene MATERNITY NURSE VISITING Exhibition Table: Patterns for baby clothes Complete layette. Slip and petticoat open in back Basket for baby bed Pad (of Felt or Hair mattress) Rubber Pillow cases Blanket (Crib) Doll (baby) dressed Suspender garter for mother; abdominal support with garters Patient's bed prepared for time of delivery, newspaper pads Toilet Tray: Jar of boiled water (for washing mother's nipples) Jar of oil (mineral oil best) Jar of boric acid, 2%, for baby's eyes Jar of breast swabs Jar of small swabs Absorbent cotton in container (hair receiver) Soap in dish Soap with safety pins, instead of pincushion Jar for clean nipples Bottle, nipple or cup and spoon for giving baby water Bottle of boiled water (day's supply boiled fresh each day) and kept corked Newspaper cornucopia for waste. 78 MANUAL OF OBSTETRICAL NURSING ROUTINE FOR PRE-NATAL VISITS First Visit: Get acquainted with the patient and get her confidence. Learn if she has made any arrangements for her care at time of delivery. If a doctor or midwife has been engaged, communicate with him or her. If the patient is registered with a hospital, or is under other nursing care, note that on your record, also on slip sent to Central Office. Always ask to see patient's hospital or clinic card, or any card which she may have been given by any nurse or other visitor. Give patient card. Explain simply the reason for an expectant mother seeing a doctor and nurse early and regularly. Invite the patient to come to a clinic. Ask her in a general way about herself, when the baby is expected, other pregnancies and deliveries, and illnesses; other members of her family. Direct your conversation so as to get as much data as possible without asking a direct question. Do not attempt a full nursing visit unless the patient meets you more than half way. Every patient is to be encouraged to come to the clinic for as much of the nursing care as is possible for that individual woman. In the care of all patients it is the nurse's responsibility to make every effort to solve (by working with every existing agency) such home problems as might effect the MATERNITY NURSE VISITING health of the mother or baby or disturb the mother's peace of mind. Complete Nursing Visit: Ask the patient about any aches, pains, troubles of any kind, directing your questions to cover all items on record. Select a table, chair, machine top, or end of mantle, to use as work table, and place on it: Newspaper for protection Tycos Paper napkin as cover Bottle for specimen; or test Nurse's soap, hand scrub tube and holder and towel Urinometer Watch Litmus paper Fountain pen Acetic acid, 2% M. Record Sterno Thermometer Matches Take temperature, pulse, respirations and blood pressure. To take blood pressure adjust sleeve, get radial pulse, pump until obliterated, let out air and read dial at moment pulse returns. See Tycos Manual for full detail. Wash thermometer thor- oughly with soap and water, dry and return to case. Scrub hands. Inspect or demonstrate the care of nipples; to be done daily after the fifth month, not before. Use cotton ball (or soft tooth brush previously scalded and kept for this purpose). Scrub each nipple thoroughly with warm water and white soap, and dry with a clean towel. Apply albolene, pulling out the nipple. Do not handle breasts. 80 MANUAL OF OBSTETRICAL NURSING Listen to foetal heart. If unable to hear, make note on record. If foetal movements are felt by nurse, put an "x," if patient says she feels the baby move, put "xx" in space on record for recording foetal heart rate. Look for oedema, varicose veins. Do not take the patient's word for these symptoms. Apply bandage for varicose veins, and teach patient right angle position. Get specimen of urine, either to take to a station for examination or to examine at once for specific gravity, reaction and albumen, in accordance with instruction given on page 30, La- boratory Technique—Wood, Vogel and Famulener. Have the patient cleanse vulva before voiding, and void in clean vessel. Teach patient proper disposal of urine, emphasizing why kitchen sink is not to be used. If any abnormality in amount, color, specific gravity, or trace of albumen, report to the doctor, midwife, or hospital in charge of the patient, if the patient has engaged one. If not, use every effort to get the patient under care of doctor. Teach patient to measure amount of urine voided in 24 hours. Tell her to void in toilet on getting up in the morning. Then, for the rest of that day and night and the following morning, to void in a suit- able vessel and measure in a tomato can (in absence of suitable vessel), and keep count of how many times she fills the can. MATERNITY NURSE VISITING 81 On an early visit, examine teeth and show how to keep clean. Where possible, urge a visit to the den- tist or dental clinic for prophylactic treatment. Explain that it is not wise to have extractions done during pregnancy without consulting a doctor, but that cleansing and temporary fillings may be done with much saving of teeth. On one visit, as early as possible, ask to see the layette and advise about it, going over the list of baby supplies. Urge the patient to visit the clinic to see a model layette, and get help in the choice of mate- rials and patterns. Note on the record if layette is not complete by the eighth month. Demonstrate the preparation of bed for the baby, made from clothes basket, soap box, or in a baby carriage similar to the model. If the patient is to be delivered at home, some time after the seventh month, ask to see the mother's supplies, going over the list. The patient should be advised against the use of oilcloth from the kitchen table as a bed protector, and espec- ially urged to prepare newspaper pads like the model shown. Note on the report if the mother's supplies are not complete by the eighth month. Advise about the arrangement of the room for delivery, and demonstrate the preparation of the mother's bed like the model shown. No treatment or medicine to be advised except in 6 82 MANUAL OF OBSTETRICAL NURSING accordance with standing orders, private physician's orders, hospital orders and accepted routines (note on record which).x CONTENTS OF NURSE'S BAG i mouth thermometer i rectal I baby scale acetic acid, 2% 1 test tube 1 test tube holder 1 test tube brush 1 blue litmus 1 urinometer 1 sterno 1 box matches 2 specimen bottles paper napkins soap and hand scrub in bag 1 flash light 1 fountain pen 1 Babies Welfare Directory 1 Board of Health Station card 1 sounding towel in en- velope 1 abs. cotton in envelope 1 scratch pad addressed postals advice to mothers letterhead memo, pad and envelopes cards M. R.'s for patients to be visited blank M. R.'s Prudential Ins. Co. Baby Primer 1 Tycos blood pressure apparatus 3 Ace bandages 1 street directory. 1 Note: The above implies prepared model layette, bed for baby, and lying-in bed. g i i < I I a ■ a a i 5 3, s | 1 1 13 i | | i •f i ■ if Is* j M I * 1 ? 1 83 i & 3 s s i | E 3 I j o 2 s | 3 8 S IS 3 £ 5 I 1 | i f i | f S 2 i 1 I * | 2 0 t | o 1 84 MATERNITY RECORD NAME OF PATIENT PARA NAME DF HUSBAND ADDRESS FLOOR I.M. ni« m7 niv SEP nrn date c+ kunniAoe ■AIDCM NAMI PHYSICIAN, HOSPITJ ---------------M|DW|FE---------------- PERSONAL AND SOCIAL HISTORY or Mo-nivi BIRTHPLACE COLOR AQE YEARS IN U.S. ENGLISH CITIZEN OCCUPATION OUT »n. THE^EE ««» P. H. AND PRESENT -» AMOUNT WITH WHOM R H. HOUSINC INMATES INCOME PER WEEK flEHT ---' ~-TECH ■'""" *wp BMRoewa '""""' CH"-0""' ----'■«»■ ..OW.W ■°",c" TOTAL PER WEEK REMARKS REFERRED FOR FURTHER TREATMENT I Ill r -• -1 i i tUOliQdUltNl hi 1 E I s«§ I : »,«..-« E a II ™; "".".I jj A0«»< .OT13A U.H. .«„„„„„ .ou«.xwoo »™» pi A»0 ■„•, ,M '!S™ "J'iSS«™ mm"« s M«ss «..«. 30» s >1»1A« An, A,,*, 1 s i 2 a 3 I 3 1 s i 8 |1 lis 52 if ||„ s! 15; "I ss I S n i ■ s P- ? t P- « tr s Li. LU U. ro () 0 ^ r- Q U tt Z L5 86 £ « a i a 8! 5J! N " j£ £ | = ii *i ' . i- N »i * 1 §ti Is i | | s S * 2 3 ; 1 4 . n I 87 i| 1 S 8 3 § i 5 1 1 1 - : * X i £ i 1 o f I I ! 1 il" I 2 : t § !i ? ° i 8 3 i i | 1 3 1 i i 1 a i EXHIBIT II ADVICE FOR MOTHERS Motherhood is natural and normal. If you do as the doctor and nurse ask you to, you have no reason to worry about having your baby. Diet Eat the food you are used to. Do not eat what you know gives you indigestion. Do not eat too much at any one meal. Drink 8 glasses of water every day. Drink all the milk you can. Do not drink any beer, whiskey, wine or other alcohol. These hurt the kidneys and thus may poison the baby. Eat meat, meat-soup or eggs and drink tea or coffee only once a day. Sleep At least 8 hours every night with windows open. Exercise Do your regular house work, but lie down several times a day if only for five minutes. If possible, take 89 90 MANUAL OF OBSTETRICAL NURSING a walk out of doors. Fresh air is good for your baby. If you cannot get out, keep the windows open while you work indoors. Do not do heavy work; it will hurt your baby. Bathing Wash all over every day with warm (not hot) water but do not get into a tub after the seventh month. Garters Do not wear round garters or any tight bands. The nurse will show you how to make suspender garters. Constipation If you are constipated, drink a cup of coffee (no cream or sugar) before breakfast, hot milk (not boiled) with breakfast, go to the toilet at the same time every day (after breakfast best). During the day eat coarse bread, green vegetables, stewed fruit, drink no tea, but all the water you can, at least 8 glasses, hot or cold. Cook 2 tablespoonfuls of senna leaves with a pound of prunes and eat four to six prunes every day. If you have hemorrhoids (piles) hold a cold compress to anus for five minutes after bowels move and do not let yourself get constipated. MATERNITY NURSE VISITING 91 Never take any cathartics unless your doctor, mid- wife or nurse tells you to. Important If you have severe headache, vomiting, spots before your eyes, if your face, hands or feet swell, let your hospital, doctor or midwife and nurse know at once. Labor begins with pains in back or abdomen; with bleeding or watery discharge. If you have any labor pains or bleeding before the time you expect your baby, go to bed and send word to your hospital, doc- tor or midwife and nurse at once. If you are going to the hospital, have ready after the 8th month one set of baby clothes, to take with you to put on the baby when you bring him home. Do not take anything else with you, the hospital will supply all you need. As soon as labor begins, go to the hospital. If you are to be confined at home, as soon as labor begins send for the doctor or midwife. If the doctor is one of the hospital doctors, follow the directions on your card from the clinic. While waiting for the doctor, boil a large quantity of water in a covered vessel and set aside to cool. Prepare your bed as the nurse has shown you, take 92 MANUAL OF OBSTETRICAL NURSING a warm sponge bath, braid your hair in two braids, get out a set of baby clothes ready for the nurse to dress the baby. Get out supplies needed for your- self. Mother's Supplies 2 Gowns Cotton (absorbent) i Pair white stockings 2 Wash-cloths 4 Sheets 2 Towels 6 Bed pads 4 Oz. Lysol Vulva pads or supply of 1 Bedpan freshly laundered old muslin The bed pads are made from 6 thicknesses of newspaper opened to full size and covered with freshly laundered old muslin tacked in place. No other protection for bed is necessary. As a pre- caution, when possible, the entire mattress may be covered with oilcloth, not from the kitchen table, put on under the bottom sheet. See model at clinic. All washable supplies for mother and baby should be freshly laundered and put away in pillow-cases or clean, ironed paper until they are needed. Baby's Supplies The following is a list of the complete outfit of baby clothes and toilet necessities. It may be modified MATERNITY NURSE VISITING as to material, quantity and quality to suit the individual taste and pocketbook. 12 Diapers 18 x 18 inches 3 Bands 6 x 27 inches 3 Shirts size 2, cotton and wool 3 Petticoats 3 Slips 2 Squares 36 x 36 inches Note: The squares are used instead of coat and bonnet until the baby is more than 2 months old. See model at the center. 1 Oilcloth or rubber 12 x 18 inches 12 Large safety pins 12 Small safety pins 1 Basket or box for bed 15 x 30 in. 1 Felt pad or folded blan- ket or hair pillow for mattress. 1 Oilcloth case for mat- tress 2 Muslin pillow-cases for mattress 2 Crib blankets, small size 2 Towels 2 Wash-cloths, old pieces of linen 1 Piece Castile soap. 8 Oz. boric acid powder 1 Package absorbent cot- ton Y2 Pint oil—sweet or al- bolene 1 Package toothpicks Tray—fitted with: Glass jar for boric acid solution " " " nipple swabs " " " oil " " " small toothpick swabs Dish for soap Cake of soap to stick pins in instead of a pin cushion Hair receiver for absorbent cotton Newspaper cornucopias for waste Bottle and nipple for giving baby water 94 MANUAL OF OBSTETRICAL NURSING Covered pail of Borax water for soiled diapers Jars for tray may be empty cheese, candy or jelly jars Routine of Post-Natal Follow- Up Work Purpose: I. To follow patient until sure that she knows how to care for baby. 2. To supervise her condition until post-partum examination, which should be made not later than six weeks, nor earlier than four weeks post-partum. 3. To see that home conditions are so arranged as to give the mother the greatest possible rest. Make as many visits as necessary, at least one each week, beginning as soon after delivery or discharge from hospital as possible. On each visit emphasize the necessity of post-partum examination, import- ance of getting and preserving birth certificate, and of taking baby regularly to Baby Health Station (unless under the care of a physician). Arrange for post-partum examination at the hospital where delivered (if hospital makes such examination) or at your own clinic (if hospital does not; if private doctor has discharged; if midwife delivered). If birth certificate has not been received when baby is one month old, take measures to secure it and deliver to patient. Arrange for mother to take baby to nearest Baby Health Station if such is available. MATERNITY NURSE VISITING 95 If any abnormality arises in the condition of the mother or baby, if a hospital delivery, report at once and carry out medical orders and advice; if a physi- cian's delivery, report to him unless he has discharged the patient, in which case persuade the patient to call him again or to go to a dispensary; if a midwife delivery, explain the abnormality to her and have her persuade the patient to get a doctor or go to a dispensary. Dismiss no patient until she has had a post-partum examination, or you are sure you cannot persuade her to have one. Dismiss no patient whose history suggests syphilis, without a Wassermann and arrang- ing for treatment when report is positive, unless you are sure you cannot persuade her to have treatment. The routine follow-up care is to be given to every patient cared for as a pre-natal patient, unless trans- ferred to a hospital which gives such care itself; to a doctor who has refused permission to nurse his patients; or to other visiting nurse for post-partum nursing. EXHIBIT III Routine Care of Babies Uniform Rules for Public Health Nurses to Use in Teaching Mothers {Approved by Committee on Health Stations,Babies' Welfare Federation) Layette. Diaper: 18 x 18 inches of flannelette or birdseye, hemmed. Diaper to be put on '' square way. Care of Diapers: Soiled diapers to be brushed clean under toilet flush before being put in pail. Covered pail of borax solution (i tbsp. to quart) to be kept, in which to put diapers unless they are washed at once. Fresh solution to be made each day. Diapers to be rinsed through two waters and dried. Twice a week all diapers to be boiled in soap solution, rinsed through three waters and dried. Never to be blued. Soap used to be Ivory or other mild white soap. Band; Band of flannelette 6x27 inches, pinked on 96 MATERNITY NURSE VISITING edges to be used as long as cord dressing is necessary. If it is necessary to dress the cord, the nurse will apply only a dry sterile dressing of gauze unless otherwise ordered by physician in charge of case. Then to be replaced by woven band with shoulder straps and diaper tabs. Shirt: A coat shirt of cotton and wool or silk and wool, or a Ruben shirt of cotton and wool or silk and wool. Petticoat: A Gertrude of flannelette or baby flannel made either open down the back or opened on the shoulder. Slips: A kimono slip of either flannelette or some thin white material made either open down the back or with a placket fastened with tapes. Squares: 36 inch squares of flannelette or baby flannel to be advised to fold around baby instead of coat and bonnet until baby is three months old. No socks or booties to be advised. Pads: Quilted pad or diaper to be used to cover rubber or oilcloth 15 x 15 inches to be used under baby. Toilet Tray. Tray fitted with:— Glass jar for boiled water (for washing mother's nipples). 98 MANUAL OF OBSTETRICAL NURSING Glass jar for boric acid solution 2% (for baby's eyes). Glass jar for nipple swabs. Glass jar for oil (mineral oil best because it does not deteriorate). Glass jars for small toothpick swabs. Dish for soap. Cake of soap to stick pins in instead of pin cushion. Hair receiver for absorbent cotton. Newspaper cornucopias for waste. Bottle and nipple or cup and spoon for giving baby water. Jar for clean nipples (nipple to be boiled after each using and put in dry jar). Hygeia or anti-colic nip- ples to be advised. Bottle of boiled water (day's supply to be boiled fresh each day and kept corked). Jars for tray may be empty cheese, candy or jelly jars. Bath. Bathe at least once a day in tub after the cord is off; on mother's lap or on table, before cord is off. Eyes: Washed once a day, 2% boric acid solution. Lids not to be pulled open.J Mouth: Not to be washed unless ordered by doctor. 1 No washing of eyes is widely advocated. MATERNITY NURSE VISITING 99 Ears and Nose: To be cleansed when necessary with small, well-made swabs, dipped in oil. Buttocks: To be cleansed with oil, using cotton. Excess of oil to be wiped from cracks and creases. This procedure to be followed twice a day and after every stool. Retract foreskin when bathing baby. Water. 3-4 ozs. daily. Given when convenient before bath and preparing for bed is suggested, but never immediately before or after feeding unless so ordered by doctor. Nursing. Advise 3-4 hour interval depending on size and vigor of baby, unless otherwise ordered by doctor. Crib. Crib to be any box or basket 30 x 15 ins. with hair pad or folded blanket (never feather pillow) for mattress, protected with oilcloth or rubber and put in pillow case, baby in one or more squares to be covered with crib blanket, small size. Specially made sheets not necessary because crib blanket is so small it is easily washed, or it may be slipped into pillow cases for protection if desired ioo MANUAL OF OBSTETRICAL NURSING Fresh Air. Baby should be put out of doors, shielded from wind, or kept indoors with windows open, provided baby is not in draft. A system must always meet the test of results, and the student who has been interested in the fore- going routines will naturally ask what the Maternity Center Association has accomplished by the use thereof. It is too early in the history of the Associ- ation to generalize to any extent upon the results of the work, nor is it ever easy to estimate values that are largely human and social, but the following statement gives definite, concrete information. A preliminary report of the beginning of the analysis of cases closed up to December, 1920, shows a reduction in the maternal death rate for patients under the Association's care to one-third of the rate for the city at large; also a reduction in the deaths of babies and in still-births to one-half of that for the city. To quote from the report,—"This gives an exact measure of the value of the work." Ji Selection from the Catalogue of G. P. PUTNAM'S SONS Complete Catalogues sent on application Practical Nursing A Text-Book for Nurses By Anna Caroline Maxwell Superintendent of the Presbyterian Hospital School of Nursing and Amy Elizabeth Pope Formerly Instructor in the Presbyterian Hospital School of Nursing; Instructor in School of Nursing, St. Luke's Hospital, San Francisco, Cal. Third Edition, Revised. Crown 8°. About 900 pages. With 91 Illustrations Of the various editions of this book, upwards of 200,000 copies have been sold. The new edi- tion has been entirely re-written, thoroughly revised, and contains over 50 per cent, more material than the earlier book. No pains have been spared to bring the book in line with the latest developments in practical nursing. The best methods used in various hospitals are presented. G. P. Putnam's Sons New York London Text-Book o! Anatomy and Physiology For Nurses by Amy E. Pope Author, with Anna Caroline Maxwell, of "Practical Nursing," and Former Instructor in Practical Nurs- ing and Dietetics in the Presbyterian Hospital School of Nursing. Third Edition, Revised and Enlarged Crown 8°. With 135 Illustrations, many in color The object of this work is to provide a text-book containing more physiology than the books on anatomy and physi- ology hitherto provided for nurses. The book is very fully illustrated. Ge P. Putnam's Sons New York London The Psychology of Nursing By Aileen Cleveland Higgins, A. B., R. N. (Mrs. John Archibald Sinclair) War Relief Superintendent, Stanford School for Nurses Instructor in War Emergency Courses, University of California 800. 332 Pages This Volume Meets a Long-felt Need in the Field of Nursing Its purpose is to give the nurse a grasp upon the elements of psychology so essential in her work, and to enable her to apply them in a practical way. The committee on Education of the National League of Nursing Education now recommends that Psychology be included in the first year of a nurse's study. At last this important science is compelling a place that is definite in the in- struction of nurses. The time will come, inevi- tably, when all training schools of high standing will include this subject in the course of study, to the unmeasurable increase in the power of the profession. As each takes up the subject, this new Psychology of Nursing will be found almost indispensable. Its practical treatment of the subject, and its sensible viewpoint, will inevi- tably recommend it for use in hundreds of Hospital Training Schools. G. P. Putnam's Sons New York Educational Department ion&on AText-Bookof Materia Medica for Nurses Compiled by Lavinia L. Dock Graduate of Bellevue Training School for Nurses, Secretary of the American Federation of Nurses and of the International Council of Nurses, etc. Sixth edition, revised and enlarged. 12 . " The work is interesting, valuable, and wor- thy a position in any library."—A7. Y. Medical Record. "It is written very concisely, and little can be found in it to criticize unfavorably, except the in- evitable danger that the student will imagine after reading it that the whole subject has been mastered. The subject of therapeutics has been omitted as not a part of a nurse's study, and this omission is highly to be commended. It will prove a valuable book for the purpose for which it is intended."—N. Y. Medical Journal G. P. Putnam's Sons New York London w* ^ rvv ts WY 157 C124m 1922 54510010R NLM Q5EA7M37 1 :%^%' NATIONAL LIBRARY OF MEOICINE NLM052874371