nij.i. ■■ il-.; 1i:„ llH'!!!,;!:": i!il!J;i' 1 Ifi il ii \ ii! i A i I. ': 't ' liiill |>!|| h" ■!'T: fii|. «#'M.hpiip; ill;:!!!:!1,^!:-1;' '■■'■;• III* Bftn.ii- iii! Jl'li I ' .ji : I ! II! !!jli|i'H,|i!||!!l; ;!:,-.::|i. i Ii Mi III1: Ii SI fli'lii! ■liii'iiiii1! j|,«|IM\>e: />—•'' Fig. 13.—Graafian follicles. One contains two ovules which, if fertilized, will produce twins. If all three ovules are fertilized, triplets will result' (Bumm.) Meanwhile, the psychic and bodily conditions have not remained unaffected. The nervous system is dis- turbed, the disposition is irritable and capricious and the head may ache. The woman takes cold easily. She is indisposed to exertion from a sense of languor and malaise. Pain may develop in the back, or cramps in the pelvis, so severe as to keep the woman in bed. Fre- quently the approach of the period is signalized by skin changes, such as a marked odor or an eruption of acne pustules. 36 OBSTETRICS FOR NURSES The flow usually returns every twenty-eight days, but it may vary Avithin normal limits from twenty-one to thirty days. The Aoav continues at such intervals regu- larly from puberty to the menopause (change of life), Avhich occurs betAveen the ages of forty-five and fifty. Conception, or Fertilization.—This is the process Avherein the male element (spermatozoon) meets and unites with the female egg. From what is known from investigations of loAver animals, this meeting usu- ally takes place in the Fallopian tube. Fig. 14.—Human spermatozoa, h, head; c, intermediate portion; t, tail. (Williams.) The egg expelled from the ovary is carried into the open end of the tube by peritoneal currents and passed on toward the uterus by the waving action of the hair-like outgrowths of the cells (cilise) that line the tube, aided, possibly, by the tubal muscle. The spermatozoon makes its Avay upAvard from the vagina by means of its tail. This activity, like the tail of a fish, or snake, or as a boat is sculled, drives the cell PHYSIOLOGY 37 forAvard through the thin layer of fluid that covers the mucous membranes. The arroAV-shaped spermatozoon travels at a rate that completes the passage to the ovary in twenty-four hours, but spermatozoa may lie in Avait for the egg a con- siderable time, as is shoAvn by the fact that they have been found alive in Fallopian tubes removed three and a half Aveeks after copulation. As soon as the male and female elements approach each other, they exercise a poAverful magnetic attraction, Avhich draAvs them to- gether, and as soon as they touch, the two cells unite and the spermatozoon almost immediately disappears. Only one spermatozoon is required for the fertiliza- tion of an egg, and hence enormous numbers must per- ish Avithout achieving their destiny. The fertilized egi^ has become the ovum, and origi- nally 1/125 of an inch in diameter, it now begins to grow, and filled Avith a neAv energy, it passes doAvn the tube and enters the uterus. Here it comes into contact Avith the soft mucosa and digs a hole for itself—a nest, very much as a Avarm bullet might sink into ice or snoAV—and is soon completely surrounded by a proliferating tissue called the decidua. The Avoman is iioav pregnant. The menstrual Aoav does not appear, and local and system- atic changes are inaugurated. The egg enlarges rapidly. Little gloAre-finger-like pro- jections (the villi) appear on its surface and dip doAvn into the maternal tissues. Through these villi the egg gets nourishment until about the tAvelfth Aveek, Avhen the placenta forms. Externally the ovum resem- bles a chestnut burr. As the egg groAvs, the villi on the surface find it more and more difficult to secure nutriment, and except at one place, all gradually shrink and disappear. At this significant point, they increase 38 OBSTETRICS FOR NURSES greatly in size, number, and complexity to form the thick, cake-like placenta. The egg or ovum is simply a growing cyst, filled with a fluid, normally sterile, in Avhich the developing em- byro lives and swims. This fluid is the liquor amnii and it is retained by a cystic Avail made up of two layers- Fig. 15.—The chorionic villi about the third week of pregnancy. (Edgar.) the chorion, Avhich represents the original cell membrane, and the amnion, Avhich develops out of the foetus. At maturity, the ovum Avill contain from one to tAvo pints of liquor amnii. The Liquor Amnii.—The liquor amnii is of vast im- portance to the child. It alloAvs free movement for the groAving limbs and body, protects the child from sud- den changes of temperature, prevents injury both from PHYSIOLOGY 39 Avithout and Avithin, saA'es the child from birthmarks and deformities by keeping it from contact Avith the surrounding Avails, and in labor lubricates the passages for the adA'ancing part. In a measure, too, it probably Fig. 16.—Diagram illustrating relations of structures of the human uterus at the end of the seventh week of pregnancy. (American Text Book.) serves as a food. In labor it forms a pouch called the bag of waters, Avhicli aids in dilating the os. Gradually, as nutrition becomes more abundant at the site of the groAving placenta, a stalk-like structure thrusts out from the foetal abdomen and forms an at- 40 OBSTETRICS FOR NURSES tachment with the formative placenta. This is called the ventral stalk and as soon as the communication with the placenta is established, it is combined Avith other parallel structures and becomes vascularized, to form the umbilical cord. Fig. 17.—Maternal surface of the placenta and membranes. The cord pro- trudes from the cavity which held the fcetus. (Edgar.) The Umbilical Cord.—The umbilical cord at maturity measures from five to fifty inches in length and from one-half to one inch in thickness. The cord is composed of a gelatinous connective tissue, called Wharton's jelly, in the midst of Avhich lie the tAvisted vessels (tAvo PHYSIOLOGY 41 arteries and a vein) that supply the embryo Avith air and food and carry off the waste. The Placenta.—The placenta or "after-birth" is an Fig. 18.—Fcetal surface of human placenta. (Eden.) oval or circular somewhat flattened disc, six to ten inches in diameter, and three-quarters to one and one-half inches thick. It weighs about a pound and a half. It is the organ of respiration and nutrition for the foetus. 42 OBSTETRICS FOR NURSKS It is formed about the third month outside the mem- branes covering the child and is more or less loosely at- tached to the uterine Avail. The umbilical cord is at- tached to its foetal surface, inside the ovum. Like a flat Fig. 19.—The egg at term with uterus removed and child showing through the membranes. (Edgar.) sponge it takes oxygen, blood, and the nourishing fluids from the blood vessels in the uterine Avail, carries them to the child by means of the umbilical vein, and carries back PHYSIOLOGY 43 Fig. 20.—Normal attitude of fcetus (complete flexion). (Barbour.) the carbonized blood and Avaste products by the umbil- ical arteries to the placenta, and there returns them to the maternal blood for disposal. The blood of the veins is bright red, and of the arteries, dark and turbid. There is no direct communication betAveen the ma- ternal tissues and the placenta, hence all the changes occur by osmosis, and by the activity of the cells Avhich form the Avails of the A'illi. 44 OBSTETRICS FOR NURSES The liver of the child is large and active. The stom- ach and intestines functionate mildly. The kidneys act, and urine is discharged into the liquor amnii, Avhich the child occasionally SAvalloAVS. During development, the movements of the child be- come more and more pronounced. Arms, legs, and en- tire body participate in turn. Periods of rest are also observed. Gradually the child assumes a definite at- titude in the uterus. It becomes more and more folded and flexed to accommodate its size to the limitations of Fig. 21.—Fcetal skulls showing sutures. Note the differences between the anterior and posterior fontanelles. (Eden.) space. The head bends on the chest, the arms are folded, the thighs flex against the abdomen, the legs on the thighs, and even the back ultimately becomes convex. It attains a complete flexion, the normal atti- tude of the child. As maturity approaches, the head becomes more and more palpable and seeks its usual lo- cation in the loAver pole of the uterus, resting on the pelvic brim. The foetal skull at maturity (at term) is still incom- Fig. 22 A.—Child's head at term (from side), showing diameter. (American Text Book.) Fig. 22 B.—The child's head at term (from above), showing diameters and fontanelles. (American Text Book.) 46 OBSTETRICS FOR NURSES pletely ossified. The bones are thin and pliable and separated at their edges by intervals of unossified mem- brane which form the sutures and fontanelles. Thus the skull is compressible to a slight degree and capable of much change in shape. It can be measurably moulded by the uterine contractions to suit the pelvis. In front, the tAvo coronary sutures meet the frontal and sagittal sutures to produce a kite-shaped figure, called the large or anterior fontanelle, or the bregma. Behind, the lambdoidal suture meets the sagittal suture to form the small or posterior fontanelle. The large fontanelle is made up of four bones and four angles; the small, of three bones and three angles, and are usually easy to differentiate. Furthermore, the difference betAveen these fontanelles is of great im- portance in labor, since by it the observer is enabled to determine the position of the head. In America, the shape of the head is that of an ovoid Avith the long diameter anteroposterior (Dolico-cephalic). Thus it happens that when the head is completely flexed, the smallest diameters are presented for delivery. The important diameters of the head, Avith their meas- urements and names, are as follows: Xape of neck to center of bregma, 9.5 cm.—Suboccip- ito-bregmatic diameter. Occipital protuberance to root of nose, 11.25 cm.—Occipito-frontal diameter. BetAveen the eminences of parietal bones, 9.25 cm.—Biparietal diameter. BetAveen anterior ends of coronal sutures, 8 cm.—Bitemporal diameter. The smallest circumference is that of the suboccip- ito-bregmatic plane, AAmich comes into relation with the brim of the pelvis when the flexion of the head is complete. It measures 27.5 centimeters. The foetus grows at a definite rate throughout gesta- PHYSIOLOGY 47 tion and so regularly that the increase is rarely simu- lated by any other condition. To find the probable length of the foetus at any given time, square the month of the pregnancy (up to five) and the result is the foetal length in centimeters. After the fifth month, multiply the number of the month by five. Thus: 7th month x5=35 cm., the approximate length of the foetus at the lunar month.—(Hasse's rule.) The Mature Foetus.—Although subject to considerable variation, the foetus at term will weigh about seven and one-fourth pounds, and measure 50 cm. in length. The Aveight is far more uncertain than the length, and there- fore not so reliable as a sign of maturity. To obtain an estimate of the Aveight of the child at any given month of the pregnancy, the number of lunar months minus 2, is squared and diAdded by 2, and the result is the average Aveight of the child at that time in hundreds of grams. Thus: 8th month -2=6. 6x6=36. 36-2=18, or in hundreds of grams, 1800, the weight of the child.—(Tuttle's rule.) Differences betAveen the mature and immature foetus: Mature 1. Skin smooth, plump, pink covered with vernix caseosa. 2. Generous amount of subcu- taneous fat. 3. Hair abundant and from 1 to 2 inches long. 4. Lanugo mostly absent. 5. Nails project from finger tips. Immature 1. Skin lax, wrinkled, dull red in color; little vernix case- osa. 2. Subcutaneous fat scanty. 3. Hair on scalp short. 4. Lanugo present all over body. 5. Short nails on fingers and toes. 48 OBSTETRICS FOR NURSES Mature (Cont'd.) Immature (Cont'd.) 6. Skull bones in contact ex- 6. Skull sutures open. cept at fontanelles. 7. Length 50 cm. 7. Moves and cries feebly when born. 8. Weight five to eight pounds. 8. AVeight less than five pounds. 9. Cartilage in ear well de- veloped. 10. Navel in middle of body. 11. Testes have descended in the male, and the labia majora in the female usu- ally cover the labia minora. 12. Moves and cries vigorously when born. The Foetal Circulation.—The placenta is an organ of nutrition as ay ell as respiration, and through the umbilical vessels the food materials are brought to the foetus and the Avaste products removed. Surrounded by the jelly of Wharton that fills out the cord, and running in and out betAveen the tAvo arteries, the umbilical vein passes into the foetal abdomen and di- vides into two branches, one, the larger, short-circuits di- rectly into the inferior vena caA^a. This branch is called the ductus A^enosus. The other joins the portal A^ein and passes through the liver, after Avhich it also enters the vena caA-a. Thus the heart is fed with a mixed blood, part com- ing fresh from the placenta and part coming up from the lower half of the foetus. This blood is poured into the right auricle, Avhere it becomes mixed again Avith the blood coming down from the upper pole of the foetus through the superior vena cava. Noav a small part goes doAvn into the right ventricle and is forced into the pulmonary arteries to supply the lungs. But the lungs are not functionating, hence PHYSIOLOGY 49 =Venous blood, from head, neck viscera, and extremities. £g = Arterial blood frmn placenta. HMIr= Mixed blood. Fig. 23.—The fcetal circulation. (Edgar.) 50 OBSTETRICS FOR NURSES the greater part is again short-circuited through the duc- tus arteriosus into the arch of the aorta, where it meets with the great volume of blood which passed over into the left auricle through the hole in the septum betAveen the right and left auricles, called the foramen ovate, thence doAvn into the left ventricle and out through the aorta to supply the rest of the foetal body. With the exception of the ductus venosus and the ductus arteriosus and the foramen ovale, the circula- tion is the same as in the adult. The blood in the descending aorta again divides and part goes on to supply the loAver extremities Avhile the greater part leaA^es the internal iliac arteries by means of the hypogastric vessels and returns through the um- bilical arteries to the placenta for oxygenation. As soon as the child is born, the foetal structures are altered. The child breathes, the pulmonary circulation is established and the ductus arteriosus is closed. The placental circulation is abolished, and the ductus ATeno- sus and the hypogastric arteries are converted into solid fibrous cords. OAving to the immediate change of pres- sure in the auricles, the foramen ovale (doses and the circulation assumes the adult type. CHAPTER III NORMAL PREOXAXCY The entire body participates in the changes brought about by pregnancy. The hips and breasts become fuller, the back broadens, and the Avoman puts on fat. She becomes mature in appearance, but, of course, the phenomena connected Avith alterations in the breasts and genitals are most important, and late in pregnancy, most conspicuous. The uterus exhibits the most marked alteration. From an organ that Aveighs two ounces, it becomes the largest in the body, and increases in size from two and one-half or three inches to fifteen inches. The typical pear-shape becomes spheroidal near the end of the third month, becomes pyriform again at the fifth month, and continues thus until term. Up to the fourth month the Avails become thicker, heavier and more muscular, but as pregnancy adAranccs, more and more tissue is demanded, until at the end, a muscle Avail of only moderate thickness protects the ovum. MeaiiAvhile the muscular functions of contrac- tibility and irritability are greatly increased. At the fourth month the Avomb, Avhich has occupied a position of anteversion against the bladder, rises out of the pelvis. It is uoav an abdominal organ and as it gets heavier and heavier, it rests a certain amount of its bulk on the brim of the pelvis. About the sixth month, the uppermost part of the uterus (fundus) is at the level of the umbilicus. At the eighth month, the fundus is found a little more than midAvay betAveen the 51 52 OBSTETRICS FOR NURSES umbilicus and the ensiform cartilage. About tAvo weeks before term, it reaches its highest point, the ensiform cartilage, and then sometimes sinks a little loAver in the abdomen. The ovum, or egg, does not completely fill the uterine cavity at first, but grows from its side like a fungus until Fig. 24.—Gravid uterus at the end of the eighth week. (Braune.) the third month. Then the uterine cavity is entirely oc- cupied and thereafter the egg and the uterus develop at an equal rate. As the uterus rises in the abdomen, it rotates to one side, usually the right, forAvard on its A-ertical axis. The blood vessels and lymphatics also increase in size, number, and tortuosity. Many of the veins become NORMAL PREGNANCY 53 sinuses as large as the little finger. This increased amount of fluid both within and without the uterus has a marked effect upon its consistency. The Avails of the uterus, vagina, and cervix become softened, infiltrated and more distensible. There is also an increase in size and in number of the muscle cells. During pregnancy the uterine muscle exhibits a def- inite functional activity. Intermittent contractions oc- cur, feeble at first, but groAving markedly stronger as pregnancy advances. These are the contractions of Braxton Hicks. They are irregular and painless, but can be felt by the examining hand. At term they merge into, and are lost in, the regular, painful contractions of labor. The breasts can not be said to be fully developed until lactation has occurred, nevertheless, the glands show pronounced changes as a result of marriage and preg- nancy. The size of the gland, as Avell as the size and appear- ance of the nipple and areola, varies greatly in different women; but under the stimulation of pregnancy the Avhole gland enlarges, including the connective tissue stroma. About the fourth month a pale yelloAv secretion can be squeezed from the nipple. This is called colostrum. The pigmentation extends OArer a Avider area and deep- ens in color, Avhile the increased vascularity is shoAvn by the appearance of the blue Areins under the thin ten- der skin. Light pinkish lines sometimes radiate from the nipple. These are striae and are more evident in blondes. The milk comes into the breasts about the third day after labor, and normally continues to Aoav for six, to ten or tAvelve months. 54 OBSTETRICS FOR NURSES Why the pregnancy and labor induce such marked mammary activity is not knoAvn, but the fact is patent. The skin reacts both mechanically and biologically to the stimulus of pregnancy. >___________________:____________r'^.'^i^, Fig. 25.—Striae Gravidarum. (Edgar.) Strke Gravidarum.—Strife gravidarum appear on the abdomen similar to those obseiwed on the breasts and are due to the same cause—mechanical stretching. When fresh, they are pinkish in color and variable in length and breadth, but attain the greatest size beloAv NORMAL PREGNANCY 55 the umbilicus. Occasionally they extend to the thighs and buttocks. After labor, they become pale, silvery, and scar-like and arc called linea albicantes. They are sometimes found in other conditions than pregnancy, such as tu- mors or ascites. Increased Pigmentation.—Pigmentation is not limited to the breasts. On the abdomen, a dark line Avill appear betAveen the umbilicus and the pubes. This is the linea nigra, and it becomes most conspicuous in the latter half of pregnancy. In the groins, the axillae, and over the genitals, the deposit is common, and sometimes patches appear on the face, either discrete or in coales- cence, to form a continuous discoloration, called chlo- asma; or Avhen extensive, the "mask of pregnancy." The pigmentation is absorbed, or at least greatly dimin- ished, after labor. The sebaceous and sweat glands are more active. The hair may fall out and the teeth decay. "With every child a tooth," is the cry of tradition. These changes are due to imperfect nutrition, or to the pres- ence of toxins in the circulation. Eruptions of an erythematous, eczematous, papular oi1 pustular type are not uncommon; and itching, either local or general, may make life miserable. The blood undergoes certain modifications that are fairly constant. The total amount is increased, but the quality is poorer, especially by an increase in Avater and Avhite cells and a diminution of red cells. The amount of calcium is slightly increased and the fibrin is dimin- ished up to the sixth month, Avhen it rises to normal again at term. The heart is slightly hypertrophied on the right side and blood pressure somewhat raised. A marked in- crease in blood pressure is suggestive of eclampsia. 56 OBSTETRICS FOR NURSES The thyroid gland enlarges frequently, both as a con- sequence of menstrual irritation and of pregnancy. (foiters may shoAV an increase of development, Avhich remains after labor. The urine is diminished in amount, but increased in frequency of evacuation. The bladder is more irritable during the first and last months, and micturition may be painful and unsatisfactory. The kidneys must be watched carefully during gestation. The nervous system is disordered in most women, but especially in those of neurotic tendencies. Irritability, insomnia, neuralgia of face or teeth, or perversion of appetite in the so-called "longings" are the more common manifestations. Cramps occur in the muscles of the legs, owing to varicose veins or pressure upon the lumbar and sacral plexus of nerves. The lungs are crowded by the growing uterus and the respiration interfered Avith. The liver is enlarged, but functionally it is less com- petent, and constipation is common. It is probable that most of the changes enumerated above are due to the circulation through the body of some definite product of foetal activity, which is more or less toxic in character. The more pronounced effects of this toxin Avill be studied under the abnormal conditions of pregnancy. Generally, if the pregnancy is normal, the whole body responds to the stimulating influence. After the nau- sea and vomiting of the early months subside, the woman feels energetic and ambitious. She is eager to do something at all times and feels fatigue but slightly. Music, literature or houseAvork engages her attention and is zealously and joyfully practiced. The world NORMAL PREGNANCY '■)( seems bright and the thought of her labor does not bring solicitude, but pleasant anticipations. The body fills out in all directions and the Avoman takes on the appearance of maturity. DIAGNOSIS OF PREGNANCY The presence of pregnancy is naturally determined by the recognition of those changes in the maternal system which the growing ovum produces. During the second half of the period the foetus can be made out distinctly by palpation, or by its move- ments, and the heart tones observed by auscultation. During the first half this is impossible and the diag- nosis must be made from subjective symptoms elicited from the patient and upon physical signs observed by the physician. It is of extreme practical importance to be able to recognize a pregnancy at all periods. The subjective symptoms of the first half are—amenorrhea, morning sickness, irritability of the bladder, discomfort and sAvelling of the breasts, enlargement of the abdomen and quickening; but the appearance of any or all of these phenomena is not to be regarded as conclusive, but merely as a presumption that pregnancy exists. Either through ignorance, intent to deceive, or from pathological conditions, any or all of these symptoms may be present, but not until the tenth Aveek are the changes in the uterus sufficiently definite to confirm a diagnosis unless the circumstances are especially favor- able. Amenorrhea.—Cessation of the menses is practically invariable in pregnancy. One or tAvo periods may occur after conception, but care must be used to exclude other causes of haemorrhage. Sudden cessation of the peri- 58 OBSTETRICS FOR NURSES ods in a healthy woman of regular habits Avho is not near the menopause, is strongly suggestive of preg- nancy. Why a developing ovum causes an immediate arrest of menstruation is not understood. Amenorrhcea may occur in consequence of chlorosis, heart disease, hysteria, tuberculosis, fright, grief, and some forms of insanity; a change from a Ioav to a high altitude, or an ocean voyage not infrequently causes the flow to remain absent for one or more months. In addition to its value as a presumptive symptom, the amenorrhcea affords a common and convenient method of estimating the date of confinement. The method is fallacious but practical, and will be discussed later. Morning Sickness.—This symptom is not invariable. It is most frequent in primiparas, but not so likely to occur in subsequent pregnancies. It usually appears about the second month, shortly after the first period missed. It varies in intensity. Some women have a little nausea on arising and no further trouble during the day, others are nauseated and vomit either on ris- ing or after the first meal, and yet others after each meal; but the general health is not ordinarily affected and the tongue remains clean. Some cases are of ex- treme severity (hyperemesis) and will be discussed elseAA'here. The morning sickness is probably toxic in origin. It must be remembered that chronic alcoholism is accom- panied by morning sickness, but Avith it the tongue is furred. Irritability of bladder is shown by a frequency of urination. It is caused by the congestion and stretch- ing of the tissues that lie betAveen the uterus and bladder and hold them in relation to one another. After the third month an accommodation is established and the symptom does not reappear until late in pregnancy, NORMAL PREGNANCY 59 when the pressure of the heavy uterus tends to keep the bladder empty. If especially annoying, this irrita- bility may be much relieved by putting the patient in the knee-chest position night and morning. Enlargement of the breasts is common in primiparas, but this, with changes in the areola, may occur at men- strual periods in nei'Arous Avomen. Tingling, pricking and shooting sensations may also be noted. Enlargement of the abdomen is only noticeable to- ward the latter part of the first half, Avhen the uterus rises out of the abdomen. Quickening means "coming to life," and refers to the first movements of the foetus that are felt by the mother. It is described as similar to the flutter of a bird in the closed hand. It is sometimes accompanied by nausea and faintness. Quickening usually occurs about the seventeenth Aveek of pregnancy, and continues to the end. Gas in the intestines will sometimes simulate quickening. The moA'ements are important in the second half as indicating that the child is alive. Physical Signs.—During the first Aveeks no conclu- sive changes occur that can be detected by examination, and unless conditions are especially favorable, the ear- liest time for the definite diagnosis of pregnancy is the eighth Aveek. Previous to this it is presumptive only. At the eighth Aveek, the breasts may sIioav enlarge- ment and tenderness, Avith some secretion. In the multi- para, this sign has no significance. Secretion is present sometimes in the breast of nonpregnant women Avith uterine disease (fibroids). Examination of the abdomen at this time is of little value, but changes in the uterus can be detected by careful bimanual examination. It is needless to say 60 OBSTETRICS FOR NURSES that all internal examinations should be made Avith the utmost care and gentleness. Softening of the lips of the os (Goodell's sign) may be found, but it must not be confused Avith erosions of the os. The os of a nonpregnant woman feels like the Fig. 26.—Bimanual examination. (Edgar.) tip of the nose, and that of the pregnant Avoman like the lips. The increased size and globular shape must also be considered as confirmatory. Hegar's Sign.—The upper part of the uterus is soft and distended by the ovum, the loAver part is soft and not filled out by the ovum. BetAveen the tAvo is an NORMAL PREGNANCY 61 isthmus that is compressible betAveen the fingers of one hand in the vagina, and of the other upon the abdomen. When found, this sign is of great value. At the eighth Aveek, pregnancy can be regarded as highly probable by the conjunction of the following symptoms and signs: Amenorrhcea, morning sickness, irritability of bladder, slight breast changes in primi- paras, lips of os externum softened, uterine body en- larged, softened, and nearly globular in shape, and llegar's sign. Abderhalden's test is a serum reaction based on the Avell established principle that the introduction into the blood of an organic foreign substance leads to the for- mation of a ferment to destroy it. Abderhalden's plan Avas to discover Avhether the blood of a pregnant Avoman contained a ferment capable of destroying placental protein. It is a very complicated test, and subject to many inaccuracies and numerous sources of error. At the same time, the main features of this reaction have been confirmed, and Avhen it is Avorkecl out, it Avill be of immense A'alue not alone in early uterine pregnancies, but in extrauterine pregnancy. This vieAv very prop- erly demands that pregnancy be regarded as a parasitic disease. It is practicable as early as the sixth Aveek to make a diagnosis, and it only fails in possibly ten per cent of the cases. The negative test is equally definite as eliminating pregnancy. Sixteenth Week.—Morning sickness and urinary symptoms haAre disappeared but amenorrhcea remains. Enlargement of the breasts is noticeable, as Avell as the increased pigmentation. The uterus begins to rise above the symphysis as an elastic, someAvhat ill-defined, boggy mass. The cervix is softer. The characteristic dull lavender coloration of the vulvar mucous membrane is 62 OBSTETRICS FOR NURSES now evident. It is due to the congestion and is called Jacquemins' sign. Two New Signs.—Irregular, painless contractions of the uterus (Braxton Hicks' sign), and ballottement. The contractions of Braxton Hicks iioav become moro easily palpable. Ballottement consists in the detection in the uterus of a movable solid body surrounded by fluid. In a standing position, the foetus rests in the loAver part of the uterus, just above the cervix. The Avoman stands Avith one foot on a Ioav stool, and tAvo fingers of one hand are pushed into the vagina until they touch the cervix, the other hand is placed on the fundus. A smart upAvard blow by the internal hand is transmitted to the foetus, and it can be felt to leave the cervix, strike lightly the tissues underneath the external hand, and return to the cervix. It is simulated by so feAV things, and so rarely, that in practice it must be re- garded as a positive sign. During the second half, the subjective symptoms are of minor importance since unmistakable evidence is furnished by the physical signs. The symptoms of this period are mostly discomforts. Increased intraabdom- inal pressure brings on edema of the feet, cramps in the legs, varicose veins of the legs and vulva, dyspnoea, and palpitations. Twenty-sixth Week.—About the twenty-sixth week, or, at the end of the sixth calendar month, the hyper- trophy of the breasts, the presence of secretion, and the marked pigmentation are unmistakable. The abdominal protrusion is now clearly visible, and the fundus will be found at the level of the upper border of the um- bilicus. Spontaneous foetal movements appear and may be felt by the palpating hand. NORMAL PREGNANCY 63 Auscultation reveals the uterine souffle and the fcetal heart sounds. The heart sounds and the fcetal move- ments, Avhen obtained by the observer, are positive signs. Uterine souffle is a soft, bloAving murmur, synchro- nous Avith the mother's pulse. It is best heard at the lower parts of the lateral borders of the uterus. It is Fig. 27.—Abdominal enlargement at third, sixth, ninth, and tenth months of pregnancy. (Williams.) due to the passage of blood through the greatly dilated uterine arteries. It may be heard also in cases of fibroid tumors of the uterus. The fcetal heart sounds are the most anxiously sought for of all the signs of pregnancy. They are conclusive. They not only determine the diagnosis, but afford valu- 64 OBSTETRICS FOR NURSES able information during labor, and nurse and student should lose no opportunity of beconung familiar Avith them. The heart tones can be heard as early as the • ^0 4 1 v**s&**^'' ,■ ------_____ 1 «&.». f* \v'^ yW- -• I !/•.'••' j'f ^ I Fig. 28.—Height of the uterus at various months of pregnancy. (Bumm.) tAventy-sixth Aveek, but they become more and more dis- tinct as pregnancy advances. They vary from 140 to 160 beats to the minute at the tAventy-sixth week, and at NORMAL PREGNANCY 65 term, from 120 to 140. When they rise above 160 or sink beloAv 120, some danger threatens the child. The foetal heart tones have no significance as an indication of sex. Funic souffle is the sound made by the passage of blood through the umbilical cord Avhen a loop acciden- tally lies under the tip of the stethoscope. It is syn- chronous Avith the fcetal heart tones, but of no great practical importance Avhen the heart tones can be ob- tained. Determination of the period to Avhich pregnancy has adAranced is sometimes important. This can be approx- imated by a calculation of the time that has elapsed since the last period, or from the date on Avhich quickening has occurred. Measurement of the height of the fundus and comparison Avith such scales as Spiegelberg's, may be carried out, but it is not often required. A method of estimation in gross, that is approxi- mately correct, in many cases depends on the obserA^a- tion of the steady groAvth of the Avomb. Thus, the uterus rises out of the pelvis at the fourth month, and may be found Avell above the symphysis pubis. At the fifth month the fundus is midAvay between the symphysis and the umbilicus. At the sixth month it reaches the umbilical leA'el. At the eighth month it is a little more than midway betAveen the umbilicus and the ensiform cartilage, Avhich it attains in another month, the ninth. Then it usually sinks a little, especially in primiparas during the last tAvo or three Aveeks. This is called lightening. CHAPTER IV HYGIENE OF NORMAL PREGNANCY The time of confinement can never be accurately de- termined, because the onset of labor is purely an accident, dependent on many factors. Furthermore, conception does not take place necessarily at the time of intercourse, and Ave have no means of knowing whether conception occurred just after the last period present or just before the first period missed. So there is always a possible error of three Aveeks. Pregnancy in the human family normally lasts from 275 to 280 days, and the approximate date of confine- ment can be obtained by the folloAving convenient rules: 1. Take the first day of the last menstruation, count back three months and add seven days. 2. Or, assuming that quickening occurs at the seven- teenth Aveek, count ahead tAventy-two weeks from the day on Avhich quickening Avas observed. 3. Or, count two Aveeks from the day of lightening. 4. Or, Avith a pelvimeter, get the length of the foetus by Ahlfeld's rule (measure from symphysis to breech of child, subtract two cm. for thickness of abdominal wall and multiply by two. The result is the length of the child in centimeters) and compare Avith fifty centimeters, Avhich is the average length of a mature child. After the seventh month, the child in utero groAvs at the rate of about 1 cm. a Aveek (0.9 cm.). 5. Or, by the tape, according to Spiegelberg's stand- ard of groAvth, as previously mentioned. The hygienic rules to be observed during pregnancy 66 HYGIENE OF NORMAL PREGNANCY 67 are founded on three basic principles: (1) To watch attentively the different organs and see that they func- tionate normally; (2) To eliminate all those conditions that favor the premature expulsion of the egg; and (3) To provide, so far as possible, for the normal gestation and the physiological delivery of the child. These fac- tors Avill be taken up in detail. The Diet.—The appetite is usually somewhat in- creased, but it is unnecessary to indulge the stomach on the ground that the mother "must eat for two." Long- ings, however, should be gratified so far as the demand is not for unwholesome things. Food should be simple and plainly cooked. Meat is permitted in moderation unless some organic change exists to contraindicate it. Rich pastries and gravies should be avoided, but cereals, fruits and vegetables should be used in abundance. It may be better to eat four times a day instead of three. Fluids should be taken freely, from one to two quarts daily. Milk is especially valuable, and alkaline, natural and charged waters, such as Vichy and seltzer, are use- ful. Wine, beer and other alcohols should not be taken, or if the patient is habituated to their use, the amount should be restricted on account of danger to the preg- nancy and danger to the child. In contracted pefves it is sometimes desired to fur- nish a special diet,, with the idea of controlling the size of the child (see Prochownick's Diet, p. 332) but this is an emergency. Certain books on maternity, designed for popular reading, advocate diets that are supposed, by depriving the child of lime salts, to keep its bones soft and make the labor easy. If it succeeds, the child Avill be injuriously affected. If it does not succeed, the claim is false. Exercise.—Exercise should be taken, but it should not be violent, nor attended by risk. Golf, swimming, ten- 68 OBSTETRICS FOR NURSES nis, dancing, horseback or bicycle riding and fast driA-- ing in automobiles should be forbidden, lest abortion follow. General exhaustion must be avoided and all conditions that even approximate traumatism. Walk- ing and slow driving are best, and houseAVork is excel- lent up to a mild degree of fatigue. Travel should be restricted. If exercise is not feasible, massage will furnish the required stimulation to the circulation. The menstrual epochs are peculiarly favorable to abor- tive influences. The Bowels.—Most Avomen have a tendency to consti- pation during pregnancy. Many times this can be cor- rected by increasing the "roughening" in the food; more vegetables and fruits, bran bread and muffins, whole Avheat bread, spinach, beans, carrots, turnips, peas and especially potatoes, baked and eaten, skin and all. Prunes, figs, and dates are valuable aids. Agar may be eaten three or four times daily. Russian oil (liquid petrolatum), taken in tablespoon doses three times daily, is an adjuvant, and finally, some form of cascara or aperient pill may be taken, if necessary. Violent cathartics should not be used at all, and enemas as little as possible; only Avhen quick results are necessary. Heartburn.—Heartburn is a frequent complication, especially in the later months. It is due to an inordi- nate secretion of acid in the stomach. Soda mint tab- lets, bicarbonate of soda, and magnesia, in cake or as milk of magnesia, will relieve. The magnesia is also a laxative. The kidneys require particular care during preg- nancy, and in every case the urine should be examined monthly, up to the fifth month, and every tAvo Aveeks thereafter, until the last six Aveeks, Avhen a weekly test should be made. HYGIENE OF NORMAL PREGNANCY 69 The amount passed in twenty-four hours should be measured. Three pints is an aATerage quantity. Al- bumin, sugar, and casts must be looked for and re- ported. Albumin may or may not be a serious symp- tom. Casts are significant of nephritis and indicate danger. Sugar may be lactose and be derived from the milk secreted in the breast. Edema of feet, hands and eyelids must ahvays be investigated, Avith the possibil- ity in mind, of heart and kidney lesions. Blindness, dizzy spells, headaches and spots before the eyes are ahvays alarming symptoms until their innocence is established. Through constant Avatchfulness of the urine, many cases of eclampsia may be aA'erted. Bathing is more important in pregnancy than at other times. The more the skin secretes, the less the burden on the kidneys. The skin must be kept Avarm, clean, and active. Then again, during pregnancy the skin is often unusually sensitive and only the mildest soaps and bland- est applications can be used. The Avater must be neither hot nor cold, but just a comfortable temperature. Cold bathing, Avhether shoAver, plunge, or sitz, must be denied. Sea bathing is also unwise. The Avarm tub bath of plain Avater or Avith bran ansAvers all conditions until the ex- pected labor is near, then the Avarm shoAver or sponge bath should be substituted, lest germs from the bath water enter the vagina. If the kidneys need aid, a hot pack may be used; but in all cases, frequent rubbing of the skin Avith a coarse toAvel should folloAV the bath. The dress must be Avarm, loose, simple and suspended from the shoulders. To prevent chilling, avooI or silk, or a mixture of both, should be Avorn next to the skin,— light in summer and heaA'y in Avinter. The patient must be sensibly clad in broad, loose, Ioav- 70 OBSTETRICS FOR NURSES heeled shoes. There should be no constriction about chest or abdomen. Circular garters must not be Avorn. If a corset is insisted upon, it must support the abdo- men from beloAv and lift it up. No corset is admissible that pushes doAATi on the abdomen. This is especially true if the Avoman has borne one or more children and has a pendulous abdomen. The breasts may get heaAW and require the rest and ease supplied by a properly fitting bust supporter. Fainting is an annoying symptom in some Avomen. It may come Avhen quickening is first perceived, or from the excitement of croAvds, or from hysteria. It usually passes quickly. The pallor is not deep, the pulse is not affected, and consciousness is not lost. It does not af- fect the ovum. Heart trouble should be excluded, and the daily habits of dress, diet, and boAvels investigated. Smelling salts wall usually suffice for the attack. The abdominal walls may be strengthened by appro- priate exercise before and after gestation, so that the muscles will preserve their tone. After delivery nurs- ing the child will help greatly in the preservation of the waist line and figure, by aiding involution. About the seventh month in primiparas, the abdo- men gets very tense and in places the skin is stretched until it gives way and forms striae. This tightness can be relieved to a considerable degree by inunctions of cocoanut oil or albolene. Pain in the abdomen at this time may be due to me- chanical distention, to strain on the muscles, to stretch- ing of operative adhesions, to gas, constipation, or ap- pendicitis. The physician should be informed of it. In every case, constipation, swelling of feet, hands or eye- lids, blurring of vision, ringing in the ears, vomiting, persistent backache, or the passage of blood, no matter how slight, should be reported to the doctor. HYGIENE OF NORMAL PREGNANCY 71 The Breasts.—There should be no pressure on the glands and they should be Avarmly covered. The nip- ples must be kept clean and soft by soap and water, and about a month before the labor is expected, the nipple should be anointed Avith albolene or cocoanut oil and rubbed and pulled for a few minutes every night. This remoA^es the crusts and dried secretions that collect on the nipple and prepare it for the macerating action of the baby's mouth. No alcohol or strongly astringent Avashes should be used. Injuries must be avoided. If the nipples become tender they may be protected from external irritation by the lead nipple shield or by a Avooden shield Avith a holloAv center, such as Williams recommends. Leucorrhcea.—This is one of the commonest discom- forts of pregnancy, and the sense of uncleanlincss, if the discharge is excessive, as Avell as the resulting irri- tation, may demand attention. It must be kept in mind, hoAvever, that the normal vaginal discharge of a healthy pregnant Avoman is strongly germicidal and should not be douched aAvay Avithout definite indications. Vaginal douches of Avarm boric acid solution Avill do for cleanliness, but the douche bag must not be higher than the Avaist. Stronger and more antiseptic solutions are potassium permanganate 1:5000, or chinosol 1:1000. A suppository may be used, consisting of extract bel- ladonna, gr. ss; tannic acid, gr. v, and boroglyceride dr. ss. Sexual intercourse is distasteful to most pregnant women, but sometimes the inclination is intensified. Coitus often causes much pelvic discomfort and may be an influential factor in producing abortion. It should be forbidden during the early months, at all menstrual epochs, and for at least tAvo Aveeks before labor. The 72 OBSTETRICS FOR NURSES uterus may be infected by germs beneath the foreskin and haemorrhage may folloAV the act if the placenta is Ioav. In healthy persons, at the instance of the female, intercourse in moderation is permissible. The mental condition should be placid without either excitement or fatigue. Anxiety should be dissipated by cheerful company and surroundings. Judicious amuse- ment is desirable and a congenial occupation, but neigh- bors Avho tell frightful tales of disaster in labor, or nurses who relate the details of their critical cases, are equally to be avoided. Many Avomen of neurotic temperament dread the la- bor desperately. They are sure that death impends and they dwell Avith tragic interest on the stories of compli- cated cases related by thoughtless or malicious neighbors. The nurse can do much to allay these apprehensions by cheerfulness, optimism, and gentleness. Her buoyant temperament will drive aAvay the patient's fears just as effectively as the assurances of the physician. Great alloAvances must be made for attacks of irrita- bility, for the changes going on in the woman's pelvis keep her in a capricious and Avhimsical condition. A good book to read at this time is, the "Prospective Mother," by Slemons. The subject of maternal impressions is the cause of much anxiety during pregnancy. It is safe to assure the mother that it is nearly impossible to mark her child by emotional stress. There is no demonstrable nervous communication between mother and child, and most of the deformities that occur and are attributable to shock, etc., can be explained by our knoAvledge of intrauterine changes. Furthermore, the same deformi- ties occur in lower animals, to which it is difficult to as- cribe such high nervous organization. Many of the birthmarks, supposedly due to shock HYGIENE OF NORMAL PREGNANCY 73 occur too late in the pregnancy to affect the child, even if it Avere possible, for the child is completely formed be- fore the fourteenth Aveek. The Determination of Sex.—It is not possible to know in advance of delivery Avhether the child Avill be a male or a female. It is equally impossible to determine or even to influence the sex of the coming child. Many theories have been advanced, and much talent has been Avasted in trying to solve this problem. Reasoning by analogy from the facts obtained from lower animals, the sex of the child is unalterably de- cided the moment conception occurs. The responsibil- ity for the decisions seems to lie Avith the male cell. All avc really know is that the sexes appear in the ra- tio of 100 girls to 106 boys. CHAPTER V AIJ NORMAL PREGNANCY After the diagnosis of pregnancy has been satisfac- torily established, no further internal examinations arc necessary in the absence of special indications, until about the thirtieth Aveek. At this time a series of complete physical examina- tions may be required to determine the presentation and position of the child, the presence and rate of foetal heart tones, the diameters of the head, the length and approximate maturity of the child, as well as the con- dition of the bony and soft passages of the mother. It is thus that an appreciation of the obstetrical prob- lem is secured and a course laid out for its successful solution. Pregnancy is not a disease, but a normal function; but the woman is exposed, nevertheless, to many grave risks that are peculiar to her condition and to many complications accidental or otherwise which are more serious on account of her pregnancy. The Toxaemias.—The groAving ovum brings about changes in the maternal metabolism that are manifested by characteristic symptoms which in other better known conditions are recognized as due to toxaemia. Therefore, Avhile there is no positive proof as yet that these symptoms, arising during pregnancy, are toxaemic in origin, the evidence goes to sIioav that they are; and, therefore, should be classified as toxic. Postmortem findings in eclampsia and pernicious 74 ABNORMAL PREGNANCY 75 vomiting such as extensive thromboses, cell necrosis, and interstitial haemorrhages are A^ery suggesthre. Clinical findings in regard to the excretion of nitro- gen (urea, ammonia, uric acid, etc.), the occurrence of acidosis, elevation of blood pressure, fever, diminished excretion, coma and convulsions, all point to toxamia. It is the minor disturbances, hoAvever, that the nurse Avill come in contact Avith most. They are nearly all toxa'mic in origin, and a brief description of them must be given, together Avith suggestions for their manage- ment. Salivation or Ptyalism.—In the majority of cases, sa- liva is not especially noticeable; but at times the secre- tion shoAArs an enormous increase, and may even demand abortion. Patients Avill have saliva running constantly from the mouth. The amount may reach a pint or a quart a day, and the skin of the loAver lip becomes greatly inflamed. The only satisfactory treatment is a rigorous milk diet on the theory that the disturbance is an intoxica- tion. In extreme cases abortion may be indicated. Gingivitis.—The gums may become inflamed, spongy and haemorrhagic during pregnancy, usually in patients of Ioav Adtality. If a generous diet and astringent mouth Avashes do not relieve the condition, the milk diet should be considered. Toothache and Dental Decay.—The patient may be given hypophosphites, and the teeth should be put in good condition by a dentist. Constipation has already been referred to. Strong cathartics should be avoided lest abortion folloAV. Condylomata of pregnancy occur most frequently around the labia, perineum, and anus. They are avart- like groAvths that develop sloAvly or quickly and may 76 OBSTETRICS FOR NURSES remain discrete or cover the entire area with masses as small as beans or as large as cauliflowers, Avhich in ap- pearance they much resemble. The etiology is obscure, but they are generally associated with irritating vagi- nal discharges, such as an old gonorrhoea. Treatment consists in stopping the discharge or neu- tralizing it, and in keeping the growths dry Avith a sali- cylic acid dusting powder. (See Therapeutic Index.) Pruritus is often distressing. The itching may be limited to the genitals or appear on other parts of the body. It may be due to the irritation of local discharges or to a condition of the nervous system, arising from toxaemia. Astringent douches and protective ointments Avill relieA^e some cases. Bromides and milk diet, bran or alkaline baths give good results, and local applications of sedative lotions and ointments containing menthol, carbolic acid or co- caine (cautiously) will aid. The woman in some in- stances becomes almost frantic, and tears at the vulva Avith her nails until it bleeds. The iodine treatment of Hensler is simple and often effective. If no skin changes are visible and but little leucorrhoea, the vulva is thoroughly prepared as for a vaginal operation, dried and painted Avith a 10 per cent solution of tincture of iodine. Generally one applica- tion suffices, but when the leucorrhoea is bad, it may be necessary to repeat the treatment on the third and fifth day thereafter. Between treatments, the vulvar sur- faces and even the vaginal Avails (by insufflation) are kept dry Avith zinc oxide poAvder. If all measures fail and exhaustion is imminent, emptying the uterus may be advisable. Herpes is an inflammatory, superficial eruption, char- acterized by red patches, blisters, or pustules. It is ABNORMAL PREGNANCY 77 accompanied by burning, itching, and nervous depres- sion. The origin is probably toxic and the termination may be fatal. Milk diet, soothing lotions, and, if neces- sary, abortion, constitute the means of treatment. Areas of pigmentation (the chloasmata) are not ame- nable to treatment. They usually disappear after labor. Albuminuria of Pregnancy.—Albuminuria is so com- mon as to be almost physiological Avhen the amount of albumin is small. When the amount of albumin in the urine is large, it may be due to pre-existing disease, Avhich is first discovered Avhen the urinalysis is made during pregnancy. (Chronic nephritis?). If it makes its debut during gestation and continues as a mere trace without casts, it is spoken of as the al- buminuria of pregnancy, but the patient must be Avatched Avith great care, since the albuminuria may be a pre- monitory sign of eclampsia. Albuminuria and eclampsia must be considered to- gether, because, Avhile the two conditions may exist separately, they are most frequently associated, and it is believed that they have a common causation. It is true that most cases of albuminuria terminate favorably, yet the higher the albumin content, the greater the danger of eclampsia. Albumin appears in the urine in from three to five per cent of all pregnancies. It is more common in the latter half of gestation and the attacks differ greatly in severity. Symptoms.—In the early stages the urine shoAVs an abundant, pale fluid of Ioav specific gravity. The seriousness of the case is generally indicated by the amount of albumin, although this is not a reliable guide as to the danger of eclampsia. Casts and red and white blood corpuscles are occasionally found. The 78 OBSTETRICS FOR NURSES output of urea usually remains normal, but diminution usually occurs in connection Avith eclampsia. Anaemia and anasarca are common, but it is a hopeful clinical sign that the cases of extensive edema rarely develop eclampsia. In albuminuria of pregnancy there is a large foetal mortality Avhich, to a degree, is independent of eclampsia. The infant dies in utero or is born feeble, or prematurely. Eclampsia is the sudden appearance of convulsions in the course of pregnancy. It may precede, folloAV, or accompany albuminuria. It occurs rarely in the ab- sence of albuminuria in a Avoman avIio Avas apparently in good health. The tAvo phenomena are best explained as a consequence of toxaemia due to poisons at present unidentified. Treatment of the albuminuria is treatment for im- pending eclampsia. Regular examination of the urine is indispensable. The presence of albumin suggests toxaemia. The daily output of urine and the output of urea must be compared, for a fall in urea is a premoni- tory sign of eclampsia. The boAvels and the skin should be stimulated, respecthrely, by saline cathartics, hot baths and packs. The digestive organs must be spared as much Avork as possible, especially the liver. Water is given in abundance, and milk is the staple diet. Kou- miss, butter milk and ice cream may be alloAved. As the patient improves, vegetables are alloAved. The food should be salt-free; and alcohol, as Avell as rich, indi- gestible things should be forbidden. In the milder cases boiled fish and a little chicken may be permitted. The course of the disease and the condition of the patient is determined by frequent examinations of the urine, Avhile in all serious cases an examination of the ABNORMAL PREGNANCY 79 fundus of the eye must be made to detect a possible albuminuric retinitis. The treatment of eclampsia Avill be considered un- der the complications of labor, Avhere the attack usually begins. Pyelitis of pregnancy is an acute, and rarely, a chronic infection of the pelvis of the kidney, due to the Bacil- lus coli. It usually appears after the fourth month (fifth to eighth) and attacks by preference the right side. Extension to the kidney substance, ureters, and bladder is occasionally observed. Symptoms.—Sudden, acute abdominal pain, at first diffuse, but after a feAV hours, becoming localized in the right side, and on this account is often confused Avith appendicitis, especially as vomiting is not infrequent. A chill may mark the onset and the temperature rise to 103° F. or 104° F. The boAvels are constipated, the tongue coated, and there is tenderness over the kid- ney. The urine is scanty, turbid, slightly albuminous and contains pus and epithelium in the urinary canal. A culture reveals the bacillus Avhich has obtained access to the kidney, either by extension of the ureter from the bladder, by direct invasion of the tissues from the ad- jacent colon, or through the circulation. Treatment.—The diet should be fluid and mostly milk, the boAvels should be moved freely and frequently. The urine is alkalinized Avith sodium citrate, since the Bacil- lus coli lives only in an acid medium. As the symp- toms subside, urotropin may be administered. If the patient does not improve Avithin tAvo Aveeks, abortion must be sei'iouslv considered. Nephrotomy is not to be thought of unless abortion has failed. Hyperemesis Gravidarum.—The nausea and vomiting of pregnancy is so usual as to be regarded as normal. 80 OBSTETRICS FOR NURSES It usually ceases from the fourth to the fifth month spontaneously; has no ill effect upon the ovum, and may respond readily to treatment. Hyperemesis comes on at the same period and ex- hibits all stages of violence, from the mild form above described, to cases that end fatally. Three classes of this serious disorder may be distin- guished as associated (Eden), neurotic, and toxaemic vomiting. Associated vomiting is the vomiting that comes Avith gastric ulcer or cancer, chronic gastritis, cirrhosis of the liver, and cerebral disease. These conditions must be excluded in diagnosis. Neurotic vomiting—seArere and persistent nausea and retching—is common in pregnant women of the nervous type. It does not lead to loss of flesh ordinarily; the urine is somewhat diminished in quantity from the lack of fluids, but the amount of nitrogen excreted re- mains normal. This is important. Toxaemic vomiting includes a small but very import- ant class of cases, for all are severe and intractable and some end in death. Clinical Features.—The normal nausea and vomiting may seem unusually severe. It persists and gets worse. Then vomiting occurs Avhen no food is taken and nothing is held on the stomach. The vomit is stained Avith bile or blood. The tongue remains clean, and the general condition is good. Next, Aveight is lost and the pulse quickens. A per- sistent pulse of over 100 is serious. The tongue be- comes coated, sordes develops, sleeplessness and muscu- lar twitching appear, and the patient complains of epi- gastric pain. Abortion may now occur and the condition clear up. ABNORMAL PREGNANCY 81 In its final stage, the urine becomes scanty and albu- minous, icterus may appear and the temperature rise to 100° F. or more, though sometimes it is subnormal. The pulse may go to 120. Delirium and coma supervene, and emptying the uterus is of no value. Fifty per cent of these bad cases die. The especially prominent points to be noted are the urine, Avhich shoAvs acetone, albumin and blood, either one or all, as Avell as an increased amount of ammonia. A persistently rapid pulse, marked loss of flesh, coated tongue, jaundice and delirium are regularly present. Treatment.—Organic disease must be excluded and a diagnosis of pregnancy strongly evident. For the neurotic type, the patient must be segregated from her friends, and a competent, cheerful nurse put in charge. A cool, darkened room is best. If the pa- tient can be transferred to a hospital, the results are more satisfactory. Here the isolation from external interests and irritations can be made complete: The pa- tient does not talk, even the nurse comes with food, at- tends to the obvious necessities, and departs in silence. Once a day a sedative bath is given (see Baths, p. 325) and medication in kind and frequency as the conditions demand. In any case, the patient should be put to bed and fed carefully every tAvo or three hours on milk, peptonized food or barley Avater. If this is not retained, albumin Avater may be given for twenty-four hours at regular intervals, or rectal alimentation may be tried after stop- ping all foods by mouth. Iced champagne, seltzer or Vichy, either alone or Avith milk, may be tried. A dry diet is sometimes effective, rusk, toast, toasted shredded Avheat biscuit, crackers, etc., taken early in the morn- ing, as one eats cheese. No exercise is permitted ex- 82 OBSTETRICS FOR NURSES cept such muscular and nervous excitation as may be derived from massage or the sedative bath. Drugs are sometimes of great value—the bromides, in full doses, or 1 m. doses of tincture of iodine, well diluted, every hour; or bismuth with hydrocyanic acid; or co- caine or oxalate of cerium. Occasionally good results are reported from a capsule of pepsin, 2 gr. and Vi gr. silver nitrate given just before meals; and adrenalin in 10 drop doses may be considered. Extract of corpus lutea has been tried by Hirst Avith fa Adorable results. Sinapisms to the epigastrium and ice bags to the spine have been found useful, and Avashing out the stomach is efficient at times. In washing out the stomach, be sure the stomach tube is iced before it is introduced. When the case gets worse in spite of treatment and acidosis supervenes, bicarbonate of soda may be given in sixty grain doses every four hours, by rectum, if necessary, until the urine gives an alkaline reaction. Glucose as a readily assimilable carbohydrate may be given in doses up to 10 oz. of a 6 per cent solution (Eden) or sugar infusions by rectum, 1000 c.c. in twen- ty-four hours by drop method. The obstetric treatment is the emptying of the uterus. To be effective the abortion must be done before the condition of the patient is desperate. It is most favor- able before the febrile stage. If the vomiting persists in spite of treatment and is accompanied by emaciation, a pulse of over 100, albumin in the urine, Avith an in- crease of the ammonia output, the pregnancy should be terminated at once. If the patient can not go to a hospital, the nurse should prepare the room as described for operations. After emptying the uterus, the vomiting usually ceases but much labor is thrown upon the nurse in sup- ABNORMAL PREGNANCY 83 plying nourishment and caring for an exhausted and Avhimsical patient. The back must be inspected daily for decubitus (bed sores) and her position changed frequently. A daily rub with alcohol and water (50 per cent) followed by an oil inunction will be valuable. The teeth and gums should be cleaned with gauze, wrapped around the Fig. 29.—Twins. (Lenoir and Tarnier.) finger and dipped in solution of boric acid. No brush should be used. Multiple Pregnancy.—Twins occur about once in ninety labors, triplets, once in seven thousand. Heredity and multiparity seem to be the only recog- nized predisposing factors. The more pregnancies °a woman has, the more liable she is to have twins. Twins may occur through a division of the primitive cell through the fertilization of two ova from the same 84 OBSTETRICS FOR NURSES or different ovaries, or by fertilization of a single ovum having two nuclei. (See Fig. 13). The former are called binovular twins, and may or may not be of the same sex. The latter are called uniovular twins and are ahvays of the same sex. Twins are usually some- what smaller than a single child, and frequently asso- ciated with hydramnios. Binovular twins have separate placentae and uniovular twins have one placenta, with separate cords. TAvin pregnancies usually go into labor earlier than the single child, possibly on account of the over-disten- tion of the uterus. The diagnosis is occasionally difficult and at other times easy. Tayo sets of heart tones must be distin- guished and differentiated by their variation in fre- quency, heard at the same time by different observers. The presence of twins may be strongly suspected also Avhen the external measurements of child and uterus greatly exceed the average. In such cases a systematic and persistent search must be made for the two foetal heart tones. The delivery is generally uncomplicated, unless the chins become locked. Displacements of the Uterus.—In most cases displace- ments of the uterus are a consequence of conception in organs that are previously retroflected or retroArerted. They rarely produce symptoms until the end of the third month, Avhen the attention is directed to the bladder. There may be absolute retention or a constant drib- bling from a full bladder (ischuria paradoxa), possibly associated Avith pain. If recognized early, an attempt should be made to replace the uterus by posture (knee chest) and Avhen replaced, to hold it by pessary or tam- pon. The prone position in bed Avill aid. ABNORMAL PREGNANCY 85 After retention has occurred, the patient should be put to bed and the bladder catheterized regularly every eight or ten hours for three or four days. As a rule, the organ Avill rise spontaneously into the abdomen. If it does not, it is probably incarcerated under the promon- tory, and the physician must try to replace the uterus by manipulation or by continuous pressure, but in bad eases, he will empty the uterus before the condition of the patient becomes too serious. In multiparas Avith Aveak abdominal Avails, or Avomen with spinal curvature or contracted pelves, the uterus may fall fonvard and. passing betAveen the recti mus- cles, continue to drop until the fundus lies loAver than the symphysis pubis. Management, until labor occurs, may be made more ef- fective by using a strong, Avell-fitting abdominal bandage. Malformation of the uterus may possess an obstet- ric interest at time-j. The double uterus (uterus didel- phys) and the uterus Avith a rudimentary horn (uterus bicornis) are examples. These are congenital condi- tions, due to imperfect development, and pregnancy may take place in one or both sides. If in one side only, the other half Avill also exhibit the softening and other changes as in normal eases. Binovular tAvins may be the result of a pregnancy in each side. Pressure Symptoms.—Edema of legs and sometimes of the vulva occurs during the last trimester. It is due to increased intraabdominal pressure and to direct in- terference Avith the return circulation by the pressure of the heavy uterus on the iliac A-eins at the brim of the pelvis. The urine should be examined for albumin and the patient put in the horizontal position if the edema is troublesome. 1 ^ricose veins of legs and vulva may cause much dis- 86 OBSTETRICS FOR NURSES tress. The limbs should be bound Avith flannel spirals or Avith rubber bandages in the recumbent position, or elastic stockings may be obtained. Operation during pregnancy is not to be considered. The vulva can only be relieved by a double bandage, Avhich is seAvcd at the point Avhere it crosses the vulva, and buckled or tied to a Avaistband above the hips, both before and behind. This brings support to the vulva. If the veins rupture, the part should be elevated and compressed with an asep- tic pad. H B.—Side view. r-r^^^WWI^pijIHI^ijsa!, Fig. 47.—Internal anterior rotation and extension of the head in a left occipitoanterior position. (American Text Book.) passage; but upon passing this strait and entering the roomy, true pelvis, the head must rotate so that the long diameter of the head Avill conform to the long di- MECHANISM OF NORMAL LABOR 125 lig. 48.—rxtension. A, the chin Eaves the ch;st; B, extension in progress. ll'.atn ; #/;■>■• - * ft V- '~-\ /. Fig. 49.—A, extension completed; B, expulsion. (Eden.) ameter of the pelvic outlet, Avhich lies in a direction just opposite to the long diameter of the inlet or brim; 126 OBSTETRICS FOR NURSES hence, the occiput turns forward under the pubic arch. This movement is due largely to the sloping pelvic floor and the necessity of accommodation betAveen the head and pelvis as the child is driven foi'Avard. Rotation is much retarded or entirely stopped when the head is extended instead of flexed or when it enters the inlet with the occiput posterior instead of anterior. Extension.—After internal, anterior rotation, the head emerges at the vulva, the occiput coming out first, then in succession the vertex, forehead and face and chin. As the chin rolls out over the perineum, it moves away from the chest Avail—it becomes extended. External Restitution.—While the head is passing through the outlet, the shoulders are entering the pel- vic inlet, and so soon as the head is released from the restraint of the vagina, it naturally falls into its normal relation to the foetal back; hence in the position now dis- cussed, it turns toAvard the left. Therefore, Ave may summarize the mechanism in a normal left-occipito-anterior position of the head by saying: The head is flexed and forced into the pelvis. It descends to the pelvic floor. The occiput rotates to the front of the pelvis and impinges against the sym- physis. Extension ensues in consequence of the neces- sity for an accommodation between the pelvis and the advancing head, and during this extension, the head de- livers over the perineum. External restitution folloAVS. The Effect of Labor on the Fcetal Head.—As the head passes through the canal, it is moulded by contact with the resistances. The degree of moulding is proportion- ate to the pressure required to drive it through. Thus, in a large head, or a relatively small pelvis, the mould- ing may be extreme, and changes in the scalp are com- mon. MECHANISM OF NORMAL LABOR 127 Caput Succedaneum.—Since all parts of the scalp are in contact with a resistant Avail, except in the center of the birth canal, an effusion of serum takes place here, Fig. SO.—A cephalh.-ematomata. Do not confuse with caput succedaneum. (Bumm.) Avhich is due to the obstruction of the venous circula- tion. Swelling occurs in the subcutaneous cellular tissue, and a tumor forms—the caput succedaneum—Avhich spontaneously disappears in tAventy-four or forty-eight 128 OBSTETRICS FOR NURSES hours. It is useful in confirming the diagnosis of the position. Cephalhematoma.—FolloAving labor a tumor is some- times found upon the head, Avhich is often confused with a caput succedaneum. This tumor is caused by an effusion of blood beneath the periosteum or the covering of the bone—usually a parietal bone. It is sometimes single and sometimes double, and it varies in size from a filbert to a peach. The swelling never extends across a suture. The effu- sion takes place gradually, and may not appear for a day or so after birth. The cause is unknoAvn, for it oc- curs after normal and easy, as Avell as after difficult, deliveries, and after breech, as well as vertex, cases. At first it fluctuates, then becomes hard, and in a few Aveeks or months is gradually absorbed. If symp- toms of cerebral pressure develop, it must be remem- bered that hamiatoma ma)* occur inside as Avell as out- side the cranium. No treatment is necessary. Puncture is inadvisable. In extremely rare instances the tumor may suppurate and require incision. CHAPTER IN THE CARE OF THE PATIENT DURING! NORMAL LABOR Every case of labor must be conducted with the most scrupulous attention to surgical cleanliness on the part of the patient, doctor and nurse. Puerperal infection in most cases is due to the introduction of disease-pro- ducing microbes into the Avounded genital canal. To be sure, the successful enforcement of surgical cleanliness is attained only in good hospitals, but it can be approxi- mated in a private house if the patient insists upon de- livery at home. A nurse or doctor Avho is clean of person, is most apt to have an "aseptic conscience." The possession of such a conscience may entail financial sacrifices, but it has many compensations. Neither the nurse nor the doctor is doing justice to the patient, nor to the profes- sion, Avho indiscriminately takes pus cases, contagious diseases, and confinements. The public Avill soon learn that such a nurse and such a doctor are unsafe attend- ants. Hoav may the nurse knoAV that the patient is in labor? This is the final assumption that must be confirmed or refuted when the nurse is called to her case. It is ascertained partly by the history and partly by the conditions found. Thus, the patient may report the passage of a piece of blood-stained mucus, and the nurse Avill observe that the contractions of the uterus are regular, rhvth 129 130 OBSTETRICS FOR NURSES mical and painful. She Avill observe that Avhen the pa- tient complains of pain, the uterus gets hard. She Avill also observe the definite regularity of the contractions by timing them. Under such conditions, the doctor should be called at once if the symptoms develop between 7 a. m. and Fig. 51.—Points of greatest intensity of fcetal heart tones. V vertex pre- sentations; B, breech presentations. (Eden.) 11 p. m. If the pains begin in the night, say from 11 a. m. to 7 p. m., the doctor need not be called unless he has requested it, or, unless in the judgment of the nurse or the anxiety of the patient, it is desirable for him to see her. CARE OF PATIENT DURING LABOR 131 When the doctor is notified he will Avant to knoAv, and the well trained nurse will be able to inform him, when the pains began, their strength, duration and frequency. He Avill Avant to know Avhether or not the membranes have ruptured. Many doctors also require, and a Avell trained nurse who specializes in obstetrics should be able to say by external examination, Avhether the head seems high or Ioav, as Avell as the position and frequency of the fn>tal heart tones. In the hospital the following rules for summoning the resident physician may be found useful: 1. For multipara, when [tains are regular and five minutes apart. 2. For primipara, when pains are regular and two minutes apart, or when head is visible if pains are less frequent. 3. If a precipitate is imminent, delivery must, be delayed until arrival of attending man by— (a) Turning patient on side with legs straight; (b) Instructing patient to breathe deeply or to cry out Avith mouth wide open; then (c) Place sterile towel over vulva, and at time of pain prevent expulsion by compressing the head by means of locking the hands over a towel on the vulva. It is possible thus to delay delivery tAvo hours, or until the doctor arrives. Do not permit a precipitate. After the nurse has completed her preliminary ob- servation, she starts her history, notes the character of the pains, the pulse, temperature and respiration. All unusual phenomena should be recorded; and after the visit of her attending man, his examination, if any, and the conditions found, are put doAvn. Then she prepares the patient and sets up the room for the delivery. Preparation.—As soon as the patient is knoAvn to be in labor, the boAvels are thoroughly cleansed Avith a soap- suds enema. A toilet jar should be used and not the 132 OBSTETRICS FOR NURSES water closet. The bladder must be emptied at the time of preparation and at frequent intervals throughout the labor. As soon as the bowels and bladder are emptied, the patient is given a bath and thoroughly soaped. The shower is preferred lest the water, contaminated by bacteria from the skin and external genitals, should en- ter and pollute the A-agina. Fig. 52.—Handling forceps, kept sterile in a jar of alcohol. The hair should be braided in two braids. The vulva and perineum are shaved. No patient will object to this when its importance as a feature of protection against blood poisoning is explained to her. Scrub thighs, hips, and abdomen as far as the navel Avith soap and Avarm water, then sterile Avater, folloAved CARE OF PATIENT DURING LABOR 133 by a 2 per cent solution of lysol. Care must be taken to remove the smegma and dried secretions from the folds of the vulva. Put on a fresh pad, a clean gown, and long stockings. A loose Avrapper over all permits the patient to move about. (See Chapter XXIII.) Guests are forbidden, and the immediate family is kept at a distance—if possible. An air of buoyancy, composure, and competence should prevail in the sick room, and the patient should be cheered and encouraged in every possible Avay. During the first stage, the patient may be up and about, as this diverts tlie mind. She may assist in the arrangement of the room Avhich should ahvays be the best room in the house. It should be Avell warmed and close to the bathroom. All unnecessary furniture and hangings should be removed, as previously described. After the room has been put in order, the bed is made. Making the Bed.—Put mattress pad over mattress and cover Avith rubber sheet or oil cloth, and spread a sheet over all. Then a smaller rubber sheet is put on, ex- tending from under the pilloAvs to a couple of feet from the foot. A plain muslin sheet goes over the rubber, then the delivery pad. AY hen the bed is ready, a small table or stand should be placed near the head, on which is put the anaesthetic, the mask and the oil or cold cream. The patient may be lightly covered Avith a sheet or a sheet and blanket. During the first stage, light and easily digested food and drinks may be served, either cold or hot, as the pa- tient prefers. AY hen the doctor arrives he may Avant to examine the patient either externally or internally, or both. So a sheet is throAvn across the loAver part of the body and the night-dress pulled up as far as the breasts, 134 OBSTETRICS FOR NURSES For the external examination the doctor Avashes his hands in warm water and green soap and scrubs Avith the nail brush for five minutes. This period should be prolonged to fifteen minutes, if, by any mischance, the hands have been in contact Avith pus or infectious ma- terial. It is extremely difficult to get them even ap- proximately clean after such an experience. Fig. 53.—Palpation. What is in the pelvis? (Eden.) He iioav palpates the abdomen, notes the location of the head and back, finds and counts the heart tones, measures the pelvis and child, estimates the descent of the head and the character of the pains. If he thinks an internal examination is necessary, he will now return to the bathroom, pare and clean his nails, scrub hands and arms to elbows for ten minutes CARE OF PATIENT DURING LABOR 135 in running Avater Avith green soap and a sterile brush, soak the hands in lysol solution 0.5 per cent for five min- utes. Bichloride of mercury solutions have no place in obstetrics. They ruin instruments and hands, and are valueless for asepsis since the mercury unites with the albumin of the mucoid discharges and forms an al- buminate of mercury, Avhich is inert. The bichloride Fig. 54.—Palpation. What is in the fundus? (Eden.) solutions also are nonlubricating, harsh and astringent, as Avell as poisonous, as soon as the mucoid protection has been removed. When the doctor takes his hands from the lysol solution, they should be wiped on a sterile towel. A sterile gOAvn is put on, if possible. If it is not avail- able, he should be careful not to touch anything that may destroy or contaminate his preparation. The hands 136 OBSTETRICS FOR NURSES are powdered and sterile rubber gloves pulled on (one will do.). The nurse, meanwhile, has Avrapped the legs of the patient in the ends of a sterile sheet, the bulk of which covers the abdomen. The knees are spread apart. The Fig. 55.—Palpation. AA'hcre is the back? Where are the small parts? (Eden.) vulva cleansed Avith pledgets of cotton soaked in lysol solution. One or tAvo pledgets are used on either side of the vulva and the same number for cleansing the in- troitus. The fingers are noAv introduced. The internal examination may be conveniently post- poned until the Avaters break, or it may be omitted alto- CARE OF PATIENT DURING LABOR 137 gether if the heart tones of the child remain good, the labor progressive, and the head continually advances into the pelvis, as determined by the external examina- tion. The great advantage of an internal examination at this time is the diagnosis of the degree of dilatation and the assurance that the cord has not been Avashed doAvn into the vagina by the rush of fluid. If the first stage is prolonged, the nurse should try to Fig. 56.—Patient draped for internal examination. (AA'illiams.) get the patient to rest, and she should herself snatch a feAV moments of repose if possible. The condition of the os and the character of the pains may make the doctor feel safe in leaving the house, but his Avhereabouts and telephone number should be ascertained and the exact time of his return. Second Stage.—During this stage, the patient should go to bed and the doctor should remain nearby. The 138 OBSTETRICS FOR NURSES nurse may observe the vulva at intervals and note bulg- ing, if present, or she may press a finger against the soft parts outside the labia and see if the hard resistant head has come into the outlet. The pains are seA^ere and all accessory muscles are called into action. Partial anaesthesia should be main- tained in most cases, AAliich should merge into complete narcosis as the head passes the vulva. The nurse may have to administer this. When this stage begins, or is well under Avay, the patient should be prepared. A sterile pad should be placed under her, then a sterile bed pan. The nurse having prepared her hands and arms as previously di- rected for the doctor, scrubs abdomen, legs, and vulva Avith green soap and warm Avater, folloAved by lysol so- lution 0.5 per cent and a rinsing Avith sterile water. The cleansing of the patient should take about ten min- utes. Cover with a sterile toAvel and put on the sterile linen. If in the hospital, the drums have been packed for sterilization so that A\\hen they are opened each article Avill appear in the order of its need: No. 1. (Beginning at the bottom.) A receiving blanket, which has a ticket, marked with the weight of the blank- et, attached to it. 1 abdominal binder with pad holder attached. 1 pillow slip folded half way back. 1 gown for patient. 2 surgeon's gowns. 3 sheets. 1 pair surgical stockings folded half way. 1 surgeon's gown for nurse. No. 2 contains cotton pledgets. No. 3 contains strips of gauze and combination pads. Application of Sterile Linen—Normal Case.—Sterile linen is to be applied as folloAvs, by a clean nurse: CARE OF PATIENT DURING LABOR 139 1. Lay sheet across foot of bed and half way up. 2. Put surgical stocking on one foot and draw sheet up for foot to rest upon. 3. Second foot as above. 4. Lay sterile sheet across bed under patient, letting ends hang. 5. Lay sterile sheet over abdomen of patient. In many hospitals the sterile stockings and protective sheet are all made in one piece, Avhich greatly simplifies the application of the linen. As soon as the second stage begins, the packet con- taining the perineorrhaphy and cord set, carefully ster- ilized, is brought out and placed in convenient reach of the doctor. This set contains— s in. forceps. 2 scissors curved on the flat. 1 dissecting forceps. 1 duck bill speculum. 1 needle holder. 1 metal catheter. 8 gauze sponges. 1 medicine dropper. 1 cord clamp, or 2 cord tapes. 2 case numbers, attached. 12 needles, 4 round, 4 half curved cervix needles, and 4 skin needles. This is the stage of expulsion and the patient may Avant to pull or push on something to aid the straining effort. Unless the nurse needs time to set up the room or to get the docor, this tendency may be encouraged. A sterile sheet may be attached to the foot of the bed and the ends (corners) given into the patient's hands as a knot or loop to pull on, or she may push upAvard against the head of the bed. Under no circumstances must she be permitted to touch or contaminate the clean 140 OBSTETRICS FOR NURSES linen in her movements, either consciously or uncon- sciously. The hands should be restrained, if necessary, to aA^oid this. The face may be sponged and a cold towel laid across the eyes. Rubbing of the back and legs Avill bring great comfort, and cramps of the limbs may be removed by straightening the legs and rubbing the muscles under- neath. Everything is iioav ready for the delivery. If the husband insists upon being in the room, he should take off his coat and Arest and Avear a goAvn, or if the labor is in the home, drop a clean night robe over his clothes. The prepared room Avill sIioav at close hand-reach, the basins of solutions, the pledgets of cotton, tape or clamp for cord, scissors, nitrate of silver solution (1 per cent) for the eyes, with dropper, the sterile douche can in readiness for haemorrhage and a large reserve of sup- plies. AYhatever anaesthetic has been chosen for the second stage, is iioav administered. Throughout this stage, the heart tones of the child must be Avatched, as well as those of the mother, for intra-partum death may occur at any moment. A second examination may be desirable iioav to con- firm the diagnosis and to secure an estimate of the advance. As a rule, the examinations should be as feAV as possible on account of the danger of infection. This is the period of greatest responsibility for the doctor Avhose duty it is to Avatch and, if necessary, to restrain the advance of the head in order to protect the perineum from rupture. This may be done at times most successfully, or in the case of too feAV assistants, most desirably, Iry delivery on the side. To secure this, as the head becomes more and more visible, the Avoman is turned upon her left CARE OF PATIENT DURING LABOR 141 side; a pillow rolled tightly and pinned in a sterile covering is placed betAveen the knees, and a sheet flung across the body. Fig. 57.—Delivery in side position. The hands should be gloved and the upper leg raised on a hard cushion or pillow. (American Text Book.) The hips must be brought to the edge of the bed Avhile the chest and head are pulled over to the other edge of the bed, leaving the legs just enough space to 142 OBSTETRICS FOR NURSES double up along the side of the bed parallel Avith its long axis. The doctor may noAv sit on the edge of the bed, or on a high stool at the back of the patient and facing the buttocks. This is a most convenient and easily man- aged position. As the head is born, the faecal matter, blood and dis- charges must be sponged aAvay, and the field kept clean, Avith the whole perineum visible. Always sponge from vagina toAvard rectum and throAV aAvay the sponge. Should the hand touch nonsterile things or septic ma- terial, like faeces, the glove must be changed. The hands must be kept surgically clean. It is a part of the nurse's duty tactfully to Avarn the doctor when such a thing occurs, as it may happen ac- cidentally Avhile his attention is concentrated elseAvhere, and a conscientious man Avill be grateful for the infor- mation. As the head passes the perineum the anaesthesia should be deepened. As soon as the head is born and the first respiration established (see Asphyxia, p. 278), the cord is cut and clamped. There is rarely any necessity for haste in this maneuver. The eyes are treated, and if in a hospital, a numbered tape is tied about the Avrist and a tape Avith a corresponding number about the mother's Avrist. The baby is iioav placed in the receiving blanket on its right side, Avith artificial Avarmth at its back and feet. The head must be lower than the body so any re- tained mucus can drain out of nose and mouth. Mean- while, the doctor (or nurse) keeps a hand on the fundus of the uterus to Avatch its contraction, see that it does not balloon up, and massage it occasionally if necessary Avhile he aAvaits the onset of the third stage. Third Stage.—The patient is turned upon her back as CARE OF PATIENT AFTER LABOR 143 soon as the child is delivered. The pulse and face must be Avatched for signs of haemorrhage. AYhile Avaiting for the placenta, the perineum is examined to note the de- gree of laceration, if any. To do this, the vulva must be spread apart Avith clean fingers so as to bring the pos- terior Avail into vieAv, and the discharge is sponged aAvay Avith cotton pledgets taken from the lysol solution and squeezed dry. The patient may iioav have the saturated dressings re- moved and clean, dry ones substituted. The neAV pads catch the oozing blood and gh^e an estimate of its amount. At this time, if desirable, the perineum can be re- paired. The Avoman is partly unconscious, the tissues numbed, and the needle hurts much less than it -will later. Nevertheless, anaesthesia may be required. In a period varying from a feAV minutes to an hour, the hand on the uterus Avill note a hardening, the mass Avill become smaller, more globular, and rise slightly in the abdomen. A gush of blood appears at the vulva and usually the placenta folloAvs. If it does not, or if haemorrhage or the condition of the mother requires it earlier, the uterus may be compressed (see Crede ex- pression) and the placenta constrained to deliver. The nurse holds a sterile basin for its reception. As the mass drops into the pan, the membranes drag after and it should be gently twisted, or the loose portions dravra upon until the end slips out. The placenta is set aside for examination, and ergot or pituitrin may be given to enforce the uterine contraction. The process of expulsion is generally assisted by a strong voluntary contraction of the abdominal muscles. After a short rest, the blood is Avashed off the geni- tals, clean linen and clean pads applied, and the abdom- 144 OBSTETRICS FOR NURSES inal binder or girdle is put on to hold the pads. Warm blankets are throAvn over the patient and Avithin an hour, a glass of hot milk is administered. The legs should be kept together, and in case of haem- orrhage, the feet crossed. The placenta is iioav inspected and not only its com- pleteness or incompleteness noted, but anomalies of ev- ery kind should be looked for. IMMEDIATELY AFTER LABOR Perinorrhaphy must be done if required. A lacerated cervix is not to be repaired at this time, except in case of haemorrhage, for the tissues are greatly SAvollen, and if sutures are put in tight enough to allow for sufficient shrinkage, they will cut through; Avhile if not tight, they Avill be useless in tAventy-four hours. Care of Mother.— 1. Cleanse genitals wkn lysol solution 0.5 per cent from above downward. 2. Put on sterile pad, with pad holder and binder. 3. Wash face and hands. 4. Take temperature, pulse, and respiration. 5. Glass of hot milk. 6. Keep on back four hours. Watch uterus for haemorrhage and keep firm by occasional massage. 7. Put tape with case number on arm. Care of Child.— 1. Clamp for the cord. 2. Place on right side with head lower than breech. 3. Keep warm and watch for cord haemorrhage. 4. Treat eyes with silver nitrate solution 1 per cent, or argyrol solution, 15 per cent. Do not neutralize the 1 per cent silver nitrate solution. 5. Put tape with case number corresponding, to mother's on arm. CARE OF PATIENT AFTER LABOR 145 To preserve the perineum from rupture is an import- ant duty, and in a definite percentage of cases, unsuc- cessful. Nevertheless, it is a duty, Avhich, in the absence of the doctor, may fall upon the nurse. How shall she meet it? The greatest danger to the perineum comes from a too rapid advance of the head; hence, the nurse retards the delivery by putting the woman on her side Avhere she can not bear down so successfully, and instructs her to cry out Avith her pains. She may also delay the labor by holding the head back with a clean pad until the vulva stretches to its fullest capacity. The rules which the doctor follows in protecting the perineum as the head advances, may be thus sum- marized. 1. Deliver the patient on her side. 2. Maintain flexion of head. 3. Delay extension of the head. 4. Give chloroform to retard delivery and to prevent pre- cipitate delivery. 5. Deliver between pains, if possible, by Eitgen's maneuver (modified). 6. Do episiotomy, if necessary. Perineorrhaphy.—Lacerations of the perineum occur in about 30 per cent of all primiparas and in from 10 to 15 per cent of multiparas. They occur Avhen the child is large or too rapidly delivered, and when the orifice is small or the tissues inelastic. For convenience, the lacerations of the perineum are divided for description into three degrees. The first degree involves only the fourchette and a small portion of the mucosa. It is rarely more than one- half an inch in depth and requires no attention except cleanliness by the nurse. The second degree may tear a variable distance into 146 OBSTETRICS FOR NURSES the perineal body, sometimes so deeply as to expose the sphincter ani. It is usually on one side, but may appear on both sides, and be accompanied by prolongations into the vagina. The third degree passes through the sphincter and sometimes well up the rectal Avail. This is also called a complete tear. The lacerations of the perineum Avhich require sutures should be attended to at once unless the patient's con- dition is critical. In such cases the repair may Avait from twelve to twenty-four hours. For this operation the nurse will assemble and boil for fifteen minutes: 2 pairs of scissors. 2 tissue forceps, one with teeth and one without. 1 bull-dog forceps. 3 artery forceps. 6 needles, 3 full and 3 half-curved. 1 dressing forceps. 1 needle holder. Suture material of catgut and silkworm gut should be ready in sterile containers. The catgut should be the tAventy-day chromicized, No. 3 and 4. Even then the strands are quickly absorbed when the lochial secre- tions floAV over them. Silkworm gut is better, but hard to remove from the vagina; hence it is customary to use catgut inside the vagina and silkAvorm gut for the sutures outside. The nurse reneAvs the supplies of gauze and cotton sponges. Hot solutions are prepared, and the patient brought into a position on table or across the bed so that the best light may be had. The legs may be held by the husband or nurse, or both. If help is inadequate, a sheet sling can be utilized. This is made by tAvisting CARE OF PATIENT AFTER LABOR 147 the sheet from corner to corner and passing it rope-like over the shoulders, and back of the neck. Then each end is tied above the patient's knee on either side as the legs are flexed in an exaggerated lithotomy position. The sutures are iioav introduced and tied loosely from below upAvard and from Avithin outAvard. If tied too tightly, they Avill cut through. The success of the oper- ation depends on tAvo things: the care Avith which the levator ani, if torn, is found and restored; and the Fig. 58.—Sheet twisted into a sling. The patient lies on the unrolled portion. The rolled cords bearing against the shoulders are tied to the legs below the knees. See Fig. 102. (American Text Book.) scrupulous cleanliness obtained by the nurse in her after-care. If the stitches become sore, a few drops of sterile glycerine should be applied Avith an applicator. If catgut is used inside the vagina, the counting of the stitches is gratuitous, since they absorb Avithout re- moval. If silkworm gut is used, the number of sutures must be recorded, lest one be overlooked in removal. Binding the legs together after repair is not required, but the sutures must be given aseptic care after each 148 OBSTETRICS FOR NURSES boAvel movement, each urination, and Avhen the pads are changed, if they have become contaminated. The su- tures are removed on the tenth day. After complete tears, the boAvels are kept constipated for two or three days, and then moved Avith a high enema Fig. 59.—Repair of perineum. Sutures in place. (Hammerschlag.) of SAveet oil, folloAved by castor oil by mouth. After the boAvel movement, the nurse should Avash out the rectum with normal saline solution. The nurse must look care- fully at the stitches every time the pad is changed and note if the SAvelling is increasing or diminishing, if CARE OF PATIENT AFTER LABOR 149 there is irritation or tenderness, or if they are cutting out through the tissues. The external sutures are usually left long and tied to- gether in a knot, to prevent the ends from sticking into the patient. If she complains of this, the ends may be Avrapped in sterile gauze. During the progress of the case the nurse must Avatch for and report any sign of fluid passing from boAvel through the vagina. The perineorrhaphy being completed, the woman is permitted to rest though the nurse Avill make frequent examinations of pulse and respiration. She Avill note the look of the face and the hardness of the uterus. The pad should be Avatched and the amount of blood discharged, duly estimated. If the Aoav does not di- minish or if the uterus should balloon up, the doctor should be notified and the nurse meanwhile should give a dram of ergot (fluid extract) by mouth or an ampoule of aseptic ergot hypodermically. The doctor should remain Avithin call of the patient for at least an hour after delivery. In the hospital the folloAving rules may be used as a concise guide for the conduct of the third stage: Conduct op Third Stags. Keep patient on back and keep a hand on fundus. Note amount of blood lost, its character, its flow, and whether steady or in gushes. The placenta should detach itself normally in thirty minutes. After thirty minutes, expulsion may be assisted by— (1) Early expression. (a) Massage, rub and knead the uterus, until it hardens under the hand. (b) Seize contracted uterus by fundus with full hand, fingers behind and thumb in front. (c) Push slowly but firmly toward the pelvic outlet. 150 OBSTETRICS FOR NURSES (2) Crede expression. Same maneuver as above, except that the fundus is compressed between thumb and fingers while the downward movement is progressing. Conditions for Crede expression: (a) Uterus must be contracted. (b) Uterus must be in median line. (c) Bladder must be empty. If not successful, wait ten minutes and then repeat maneu- ver. Never make traction on the cord. Never use ergot until uterus is empty. If placenta does not come away within an hour, manual removal must be considered. In case of haemorrhage, it must be removed at once. Carefull.v inspect placenta and be sure it is complete. (See Post Partum Haemorrhage, p. 232.) AA'hen the patient is put to bed, the bloody sheets and towels are put to soak in cold water, and after several rinsings, may be sent to the laundry. Drapings stained with faecal matter must be cleansed separately. CHAPTER X THE NORMAL PUERPERIUM The puerperium is the name given to the period suc- ceeding the birth of the child as far as the time of the complete restoration of the genitals. It may last from six to ten weeks, or eA^en longer if complicated. When the labor is completed, the most urgent desire of the patient is for rest. She is thoroughly exhausted in neiwes and body. A post partum chill may appear,— a slight shiver that may last a quarter of an hour. Since the pulse and temperature remain unaffected, this phe- nomenon may be regarded merely as a sign of prostra- tion or nervous revulsion. In the course of the first three days, the temperature may rise to 100° F. in a case entirely normal. It has no pathological significance unless persistent or increasing. The temperature should be taken night and morning, and in complicated cases every four hours. All tem- peratures over 100° F., after the initial rise and descent just described, must be regarded as septic. The pulse does not rise with the temperature of the first three days, but remains firm or even falls a little. AYhen the pulse rises and the temperature sinks, it means haemorrhage. The urine is usually increased for the first few days and then returns to the normal for that patient. The labor affects the patient like a surgical operation. The digestion is disturbed. The appetite is gone, and 351 152 OBSTETRICS FOR NURSES the stomach must be treated gently until its tone is restored. The body in repose is less urgent in its de- mands for food. Liquids in abundance form the staple diet for the first two days. For the next three days, semisolids may be added, and after the milk is Avell es- tablished, a general diet is desirable; but so long as the Fig. 60.—The progress of involution on the various days of the puerperium. (von Winchkel, from Knapp.) mother nurses her child, the liquids must preponderate in most cases. MeanAvhile, certain changes are taking place in the pelvis that are highly important. Involution is the process undergone by the uterus in returning to its normal nonpregnant state. This shrinkage can be folloAved abdominally and is registered by the nurse in the number of finger-breadths or centimeters above the symphysis pubis. THE NORMAL PUERPERIUM 153 Edgar gives the rate of shrinkage as foIIoavs : After delivery, 5.!»2 in. long, or 15.S cm. 2nd day, 4.63 in. long, or 11.30 cm. 3rd day, 4.37 in. long, or 11.10 cm. 6th day, 3.42 in. long, or N.4S cm. Sth day, 2.55 in. long, or 6.40 cm. 10th day, 2.22 in. long, or 5.60 cm. The rate of involution not only Agarics greatly with different women, but varies much after the different labors of the same woman. Ordinarily at the end of the first Aveek the fundus should lie midAvay betAveen the naArel and the pubes, and should shrink rapidly thereafter. The necessity for A\atelling the rate of involution is imperative for a number of reasons. If hwolution is sIoav, or stops, it may indicate fatigue of the muscle from multiparity or oA'er-distention (twins, hydramnios, etc.) or it may follow a post partum haemorrhage. Sub- involution may also indicate infection, the retention of clots, or pieces of placenta. It happens also Avhen the woman gets up too soon or does not nurse her child and thereby delays the restoration of her waistline, as Avell as diminishes her resistance to disease. The binder is objectionable to some doctors on the ground that it favors retroversion of the uterus during involution. This Avould be a plausible theory Avhen the uterus is high, if it Avere not that the vertebrae of the patient and the pelvic brim keeps the uterus from being pushed out of its place and after the uterus descends into the pelvis the gentle pressure of the binder evenly distrib- uted over the abdomen can not affect it appreciably. Furthermore, the uterus in hwolution shoAvs a persistent tendency toAvard anteflexion and anteversion. The binder is merely a girdle put on just tight enough 154 OBSTETRICS FOR NURSES to hold in place the bandage that supports the perineal pads and to allow the patient more easily to grow ac- customed to the sudden change in intraabdominal pres- sure Avhich the delivery of the child creates. HoAvever, if the doctor objects to a binder, it may be left off Avith safety. The Lochia.—When the placenta is delivered, the uterus normally closes down and all gross haemorrhages cease; but for the next Iavo weeks or possibly longer, a vaginal discharge continues. For the first feAV days it is haemorrhagic in character and it is called lochia rubra, and consists mostly of fluid blood with occasional small clots. By the fourth day, usually it has become broAvn and thinner. It is now called lochia serosa. By the tenth day, it is yellowish-Avhite, and is called lochia alba. The lochia is the Avastage from the shrinking uterus, and is made up of red blood corpuscles, epithelial cells, leucocytes, and pieces of broken-down deciduae. The entire lining of the uterus is loosened, discharged and a new one formed during the puerperium. The lochia is regularly infected by bacteria in the vagina. If involu- tion is slow, the lochial discharge may be prolonged. The After-Pains—The puerperium is not infrequently accompanied by painful contractions of the uterus called after-pains. These are more common in multiparas and serve a useful purpose in maintaining a definite contrac- tion of the uterus. If the pains are at all severe, they are a suggestive symptom of the retention of blood clots, a fragment of placenta, or of membrane. This, of course, will occur either in a primipara or multipara. In all cases the after-pains must be differentiated from gas and from the pains of pelvic inflammation. Gas pains can be relieved by hot spiced drinks, asa- foetida and the high rectal tube. THE NORMAL PUERPERIUM 155 Subinvolution is treated by the administration of fluid extract of ergot, in tAventy to tAventy-five drop doses, three or four times daily. This will bring about the dis- charge of the irritating fragment or clot, and the nurse can aid the process by gently massaging the uterus several times daily or by giving a hot vaginal douche. Codeine may be used for after-pains if absolutely neces- sary. Diet in Normal Cases.—There is no restriction on the kind of food the patient may take, so long as she can digest it cleanly and Avithout gas. Acids or alkalies, cold or hot, rich or otherAvise, fruits, meats or vege- tables, all go to the formation of good milk if properly digested. The old idea that acids should not be eaten is fallacious. There is more acid in the stomach nor- mally, than could be added in a meal made up entirely of citrus fruits. At the same time, the heavy foods should be avoided on account of the serious demand on the liver and kidneys in the absence of exercise. On the other hand, if the breasts are engorged, the fluids must be reduced to a minimum, and a relatively dry diet enforced. The patient loses about one-ninth of her previous body Aveight in the course of labor and the puerperium. The breasts are made ready for lactation tAvelve hours after delivery by cleansing Avith sterile green soap and Avarm water and bathing in 50 per cent alcohol. Next, the nipple is attended to, and the infant is put to the breast. The nipple is prepared by cleansing it Avith an ap- plicator soaked in fresh boric acid solution, and after nursing, the same process is repeated. This is routine, Avhether the mother is in bed or Avalking about. In the latter case, the mother must be taught to care for her OAvn breasts. 156 OBSTETRICS FOR NURSES The child is put to the breast every three hours and given six feedings a day. This leaves a six hour interval at night, Avhich is very necessary for the mother's rest and for the child. If the babe is feeble, seven or eight feedings in the tAventy-four hours may be required for the first tAvo Aveeks. At first the breast only secretes a thick, yellowish se- cretion called colostrum, of Avhich the child gets from a drachm to an ounce. It is a mild laxative. The irritation of the nipple by the child's mouth is begun as early as possible in order to stimulate the breasts to secrete milk and the uterus to contract, and thus aid hwolution and the preservation of the ma- ternal figure. The milk usually "comes in" on the third day and is accompanied by a sense of distention and moderate pains in the breasts. The glands may be hot, hard and SAvollen, but normally there is no rise of temperature Avith the infloAV of the milk, except Avith nervous Avomen Avho stand pain badly. There is no such thing as milk fever. If fever appears at this time, an infection must be suspected. The engorgement of the glands may become so great that the nipples are draAvn in and nothing is left for the child to grasp. If the engorgement becomes too painful, fluids are removed from the diet list, and saline cathar- tics administered, Avhile ice packs are applied to both breasts. Heat should never be used except for the pur- pose of hastening suppuration. This engorgement, or so-called "caking" of the breasts is not due to the milk, but to the infiltration of the con- nective tissue around the glands Avith serum and blood which stimulate the glands to secrete. The distention usually disappears in twenty-four or forty-eight hours, especially if the child is sturdy. Massage of the breasts THE NORMAL PUERPERIUM 157 only increases their activity and tends to make the trouble Avorse. The Aveight of the glands may be considerable and require the application of a light supporting breast- binder. PilloAvs under them Avill also give relief at times. In putting the child to breast, the mother should lie on the side with the arm raised and the child is dropped into the IioIIoav thus created, facing the mother (see Fig. 113). In this position the nipple Avill most easily and con- veniently slip into the child's mouth. The child should nurse fifteen or twenty minutes and then be removed. The toilet of tlie nipple is made by cleansing Avith boric solu- tion as previously described, and then placing not gauze but a piece of aseptic cotton cloth over it, after which the binder is readjusted. (See Breast Covers, p. 326.) The menstrual flow ceases during lactation as a rule, but not invariably. The iioav returns in from four to six Aveeks after delivery, if the child is not nursing, and about the same time after lactation ceases. There is a popular idea that conception can not occur during lac- tation, and many women injuriously prolong lactation in the hope of avoiding another child. The theory is fallacious and conception during lactation is not un- common. The Bowels.—A lying-in Avoman is regularly consti- pated. Lack of exercise, a nutritious diet, but one Avith a minimum of Avastagc, together Avith relaxed abdominal AAalls, contribute to a condition that is primarily due to changes in intraabdominal pressure, Avhich folloAV the delivery. For weeks the intestines have been under pressure and irritation by the groAving uterus, and when this is suddenly removed the intestines become sluggish. On the morning of the second day the patient should 158 OBSTETRICS FOR NURSES receive an ounce of castor oil. This dose, suspended in black coffee, beer, orange juice, or sherry Avine can be taken by nearly everyone. In from four to six hours a normal saline, or soapsuds enema is given. The enema may be repeated daily, or if this is objectionable to the patient, the castor oil or Russian oil, may be given as a routine. Saline cathartics should not be used unless there is an oversupply of milk. There is sometimes a good deal of gas following labor, Avhich can be removed by the 1-2-3 enema (see Enema, p. 335). In giving enemas, the nurse must use great care to avoid touching or infecting an injured perineum. Many Avomen secrete less gas and are agreeably in- fluenced mentally by a five grain pill of asafoetida taken thrice daily. Urination.—One of the commonest difficulties after labor concerns micturition. (hving to the SAvollen and bruised condition of the urethra and the nerves supplying the neck of the blad- der, the usual stimuli do not act and the woman, con- scious of a painful distention, is unable to pass water. The helplessness is increased by her position in bed. The nurse must make every effort to have the bladder emptied naturally. The process is aided by letting the Avater run from the faucet into the toilet basin, by using hot applications to bladder or vulva, by allowing warm, sterile Avater to run doAvn over the vulva and perineum, by an enema, by putting smelling salts to the nose, by using slight pressure over the bladder, or by having the patient sit up on the bedpan. If these measures fail and moral suasion is fruitless, the bladder must be catheterized at the end of tAvelve hours. The two dangers of catheterization are injury to mucous membrane, and infection. Many cases of cys- THE NORMAL PUERPERIUM 159 litis have resulted from an unclean catheter or the im- proper use of a sterile instrument. To catheterize a patient, she is first given aseptic care during A\diich particular attention is paid to the meatus. This should be cleansed Avith an applicator dipped in a solution of boric acid. Next, the nurse prepares her hands by scrubbing ten minutes in hot running Avater Avith sterile nail brush and green soap. The catheter either of soft rubber or glass, is boiled for fifteen min- utes and passed, not by touch, but by sight, and the flow is receh^ed in a clean basin and the amount re- corded. As soon as the urine ceases to flow freely, the tip of the index finger is placed tightly over the end of the catheter and the instrument is gently withdraAvn. The finger is placed over the end of the catheter not only to avoid the dripping of urine as it is removed, but espe- cially to prevent the disagreeable sensations produced by the inrush of air. Usually one catheterization is sufficient, and every time the bladder fills, the nurse must take the time and trouble to make the patient urinate spontaneously, if possible, for some women form a catheter habit, from Avhich it is difficult to break them. After natural urina- tion and after catheterization, the aseptic care should be repeated. The Genitals.—The vulvar pads should be changed as often as they are soiled. Four a day is an average num- ber, and six or eight in the first three days is not un- usual. Every time the pad is changed, the nurse should give aseptic care, and extra attention Avhenever the bowels and bladder are emptied. The dried secretions should be washed off Avith sterile sponges, wiping ahvays toward the rectum and throw- ing away the sponge. Smegma collects in the folds of the labia and about the clitoris. This should be care- 160 OBSTETRICS FOR NURSES fully sponged away. If it becomes dry and hard, oil or albolene will soften it and facilitate its removal. Plenty of soap and Avarm Avater should be used, then with a pitcher or douche point, the A\liole area is irrigated Avith a solution of lysol 1 per cent. Especial care is given to the stitches if any are present. No traction must be made on the ends of the sutures, and if unusual soreness is complained of, the doctor should inspect them at his next visit. The nurse should be careful not to get lochia on her hands as the discharge contains germs which she may carry to herself, to the baby, or to the patient's breasts or eyes. Painful SAvelling of the vulva, or edema of the rectal protrusion may be relieved by hot boric dressings or by ice bags to the anus. The vaginal douche is rarely employed at present ex- cept under specific indications. If the involution is slow, it is safer to use ergot by mouth, rather than the hot vaginal douche, as sometimes recommended. The douche is a frequent source of in- fection, as Avell as a useless procedure. Nevertheless, a dainty Avoman gets much comfort mentally, as well as physically, if she is kept clean and free from odors; hence if the lochial discharge becomes offensive on the fifth day or sixth day, as sometimes happens, a single hot vaginal douche may be permitted. A 1:5000 solution of potassium permanganate, or a teaspoonful of for- maldehyde to a quart of Avater, or a chinosol solution 1:1000 may be used. Rest.—Since the patient Avill be in bed from eight days to tAvo Aveeks in normal cases, she must be made as happy and comfortable as possible, and nothing con- tributes so much to her satisfaction as a cheerful, compe- tent nurse. Her mind is at ease about herself and her THE NORMAL PUERPERIUM 161 child, and the companionship of the nurse can be made one of the pleasantest recollections of her illness. Any patient avIio is at all reasonable can be managed by a tactful nurse Avithout the consciousness of being opposed or directed. Gossip, hospital stories, criticism of other cases, other nurses, or of doctors should be avoided. The patient is deeply interested in her oavh case, and the private troubles of the nurse do not con- cern her nor enlist her attention for more than a feAV polite but unpleasant moments. The nerves of the patient are highly sensitized, and therefore she should sleep as much as possible at night, and take an additional nap in the afternoon. Only the members of the family should be alloAved to see the pa- tient the first Aveek, and they but for a short time. It takes the strength of the patient unnecessarily to see guests even though they be close friends. Importunate visitors may be pacified frequently by a view of the baby. The patient must be spared all household responsibili- ties, and if necessary, the nurse must take charge. Tact must be used to avoid being dictatorial, either to family or serATants. If anything unusual arises, the nurse must shoAV no surprise, annoyance, or beAvilderment. Every- thing is attended to quietly, firmly, and Avithout friction. Getting Up.—It is a tradition that the Avoman is lazy Avho does not get out of bed by the ninth day. There are three factors to be considered, the progres- sive involution of the uterus, the strength of the patient, and the presence of stitches. Involution may be com- plete on the fifth day, but the prostration from the labor may make the woman indifferent to arising. She may be strong enough to rise on the third day, but the uterus is large and heavy, and the erect position will put an unnecessary strain on the supports Avhich may retard 162 OBSTETRICS FOR NURSES involution and cause displacement or disease later. Also, it is not desirable for a Avoman to sit up until her perinenum is Avell on the road to restoration. In general, the Avoman should not get up until the uterus has gone down into the pelvis and is nonpalpable. If this is the case on the fifth day and she feels strong, she may get up. If she is not strong, time Avill be saved by staying in bed until her vigor returns, Avhether it is ten days or tAventy. Getting up may be folloAved by a return of the bloody discharge. This may come from subinvolution, from a relaxed and flabby uterus, from a cervical tear, or from change in posture. If there has been a retroversion before pregnancy, ly- ing prone Avith an occasional knee chest position for a feAV moments Avill aid. Massage and passive exercises Avhile in bed Avill aid the patient to recover and to main- tain her strength. Even after she is up and about, she should lie doAvn frequently during the day and ahvays when nursing the babe, until she feels quite normal again. For the hospital the folloAving standing orders may be folloAved: Standing Orders—Puerperium Breasts: 1. Prepare for lactation 12 hours after delivery. (a) Clean breasts and nipples with soapy water and green soap. (b) Sponge with sterile water. (c) Sponge with boric solution. (d) Sterile compresses over nipples and adjust binder. 2. Babe to breast immediately after breast preparation. 3. Every morning apply fresh compresses over nipples and oftener, if necessary. 4. Cleanse nipples with boric solution (use applicator) be- fore and after each nursing. THE NORMAL PUERPERIUM 163 To dry up milk: Restrict fluids; give saline cathartics; apply ice bags to breasts, as needed; for pain give codeine solution y± to y> gr. hypodermically, if necessary. Do not massage, do not bind, do not pump. Let breasts alone. When breast is inflamed: Apply ice bags constantly until pain subsides and tempera- ture goes down. AA'atch for signs of suppuration. (lenitals: 1. S.S. enema each morning, followed by aseptic care. Cleanse from above downward—1 per cent solution of lysol and cotton pledgets. 1 pledget for each side. 1 pledget for center. 1 pledget for rectum (last). External douche of sterile water. Dry sterile pad. 2. Aseptic care following all bowel movements and urination. Iiout-ine: 1. Record pulse and temperature twice a day, unless other- wise ordered. 2. Bladder must be emptied in twelve hours. If all per- suasive means fail (may sit up in bed), catheterize. 3. Make daily records of conditions of uterus (firmness and height), breasts and nipples. 4. No vaginal douche unless ordered. 5. Diet: liquid two days; semisolid two days; then general. 6. AATatch for haemorrhage. 7. Keep uterus firm by occasional massage. 8. All cases to have castor oil, 1 ounce within thirty-six hours after delivery (before noon). 9. Woman may get up as soon as uterus can not be felt above pubes, if there is no contraindication. The history sheet should be kept accurately and should shoAV every incident in the course of the lying-in period. The condition of the boAvels, bladder, and lochia, the temperature, pulse and respiration and the height of the fundus above the symphysis from day to day must be set doAvn in fingerbreadths or centimeters. For the hospital, the folloAving system will he found useful in establishing a routine. 164 OBSTETRICS FOR NURSES Nurse's Record First Stage. 1. When pains began. 2. Frequency and duration of pains. 3. Character vaginal discharge. 4. Time membranes ruptured. (a) Artificial. (b) Spontaneous. Second Stage. 1. Time second stage began and ended. 2. Anaesthetic. 3. Mode of delivery. 4. Who delivered. 5. Sex of child. (a) Living. (b) Dead. 6. Perineum. (a) Condition. (b) Repair. Third Stage. 1. Method. (a) Spontaneous. (b) Early expression. (c) Crede expression. (d) Manual removal. 2. Placenta delivery. (a) Time. (b) Size. (c) Complete or incomplete. (d) Length of cord. 3. Note. (a) Haemorrhage. (b) Quantity. (c) Color. (d) Clots. General condition—was case number put on mother and child? Other treatments. Medications. Condition of uterus. Temperature, pulse and respiration before leaving delivery room. Signed .................................... (Nurse's Name.) CHAPTER XI UNUSUAL PRESENTATIONS AND POSITIONS Breech Presentation.—The pelvic pole enters the inlet first, once in thirty cases and more commonly in primi- paras than othei'Avise. Etiology.—Anything that interferes Avith or deranges the laAvs of normal gestation will predispose to, or pro- duce this anomaly. Thus, if the head is too large, as in hydrocephalus, or if the foetus is too movable, as in hydramnios, or if an obstacle, like placenta previa, contracted pelvis or tu- mors prevent the proper approach of the head to the inlet, the mechanism will be disturbed and a breech or possibly a shoulder presentation will result. Abnormal flaccidity of the uterine or abdominal walls, prematurity or twins also contribute definitely to its oc- currence. The attitude of the child generally retains its normal aspect of complete flexion. This pose, hoAvever, is not maintained invariably for on occasion the buttocks and genitals may rest upon the inlet Avhile one or both feet may be extended on the thighs and lie beside the neck, or the thighs may be extended AAdiile the knees remain flexed, and Avhat is knoAvn as a knee presentation, or if the foot comes doAvn, a footling presentation results. Positions.—The sacrum is the most prominent bony landmark of the breech, hence the positions are named from the relation this bone bears to the four quadrants of the inlet. We haA^e therefore in their order of frequency the 165 166 OBSTETRICS FOR NURSES following designations: Left-sacro-anterior, Avhere the sacrum lies to the left of the median line of the mother's body and in front; right-sacro-anterior, AAdiere the sa- Fig. 61.—The breech. Left-sacro-anterior position. (Lenoir and Tarnier.) crum lies to the right and in front; right-sacro-posterior, Avhere the bone lies near the mother's vertebral column, and on the right side; and the left-sacro-posterior posi- UNUSUAL PRESENTATIONS AND POSITIONS 167 tion, where the bone occupies a corresponding place on the left side. Diagnosis.—The recognition of this presentation is Fig. 62.—The breech. Left-sacro-posterior position. (Lenoir and Tarnier.) most easily secured by external abdominal palpation in pregnancy, AAliich may be reinforced during labor by the internal examination, 16K OBSTETRICS FOR NURSKS Externally the palpating fingers at the pelvis brim Avill note the absence of the hard, round head, and feel a mass, softer, quite irregular in shape, and less defined than customary. Movements also may be appreciated that Avould be too far doAvn in the uterus if the head was presenting. Next the hard, spherical tumor of the head can be outlined someAvhere in the fundus, and the heart tones, instead of being beloAv the umbilicus will be on the same leA^el or even higher. Vaginally the cervix is not filled out, the presenting part does not come doAvn, but after labor has begun the distinctive features of the breech gradually become more evident, as they are driven into the pelvis. One or both feet, or the buttocks, may be recognized. The examining finger may possibly enter the anus and be stained with meconium or pinched by the sphincter, Avhich differentiates this orifice from the mouth. One after another the characteristic landmarks ap- pear until the diagnosis can not be doubtful. As soon as the sacrum is found or the legs definitely placed, the position can be named. Mechanism.—The hips ahvays enter the inlet in one of the oblique diameters and the back is turned to the same part of the uterine Avail as in the corresponding vertex positions. The acts described in the mechanism for vertex deliv- eries shoAV a somewhat different order. Descent is first. then comes internal anterior rotation, A\hich brings the anterior hip under the symphysis and its delivery is quickly folloAved by the posterior hip, Avhich rolls out over the perineum. The body advances, as a rule, Avith the back toAvard the front of the mother. The shoulders Avith arms folded UNUSUAL PRESENTATIONS AND POSITIONS 169 move under the pubic arch and then the head delivers in a state of flexion. The head, of course, has no caput and it is not moulded. This mechanism may be greatly impeded or compli- cated at any stage of the movement. The advance may be retarded to a pathological degree, the belly may be large and as it passes along the canal one or both arms may be stripped up alongside the head or even into the back of the neck. The head may be arrested at the inlet by the arms, by its degree of deflexion, or by pelvic con- traction. The rotation may not take place, or it may be abnor- mal, and the belly of the child look foi'Avard toAvard the mother's. Any of these variations adds further to the difficulty of the labor and to the danger of the partners in the event. Artificial aid may be required Avhich brings Avith it the possibility of sepsis. The foetal mortality Avhich averages five per cent is due mostly to asphyxiation. Interference Avith the sup- ply of oxygen begins as soon as the cord passes the vuhTa and the child must be delivered in eight minutes from that time, or perish. Partial detachment of the placenta may also cut off the oxygen to a fatal degree, and the child may be unable to breathe Avhen born on account of mucus sucked into the trachea by prema- ture efforts at respiration. Minor accidents also occur, such as fractures, dislo- cations, and paralysis from injury to the nerve trunks. Management.—In the interest of the child, this pre- sentation is occasionally converted into a vertex by ex- ternal version during the last Aveeks of pregnancy or in labor before the membranes have ruptured. It is difficult, hoAvever, to maintain the vertex over the inlet. 170 OBSTETRICS FOR NURSES The Avoman must be kept quiet in a horizontal posture and long roller splints applied to the side of the child in utero and bound on. In primiparas, this is nearly impossible, and it is Aviser, in the absence of some great necessity to warn the parents of the conditions and dangers and let them share in the responsibility. Fig. 63.—Extraction of the breech. Traction on one leg. (Hammerschlag.) When the labor begins, the bag of Avaters must be kept from rupture as long as possible and when it finally breaks, an internal examination should be made to see if the cord has come doAvn. If this happens it may be necessary to expedite the delivery by external assist- ance, UNUSUAL PRESENTATIONS AND POSITIONS 171 The doctor brings doAvn a foot, if it is not already down, or pulls on the breech until the feet drop out. Compression of the cord must be ahvays in mind. It is ahvays compressed after the umbilicus has passed the navel. The shoulders are delivered by seizing the feet with the operating hand and SAvinging the body out of the Avay. This brings the posterior shoulder, which Fig. 64.—Breech delivery. Kxtraction of the trunk by pulling on the hips. (Hammerschlag.) should be first, into the hollow of the pelvis. Extraction is then completed by Avhat is called the Smellie-A'eit maneuver. The child is put astride one arm, the first finger of Avhich is hooked into the child's mouth to main- tain flexion. The fingers of the other hand then grasp the shoulders of the child astride the back of the neck 172 OBSTETRICS FOR NURSKS Fig. 65.—Breech delivery. Delivering the shoulder. The body is swung strongly upward and outward to bring posterior shoulder into the pelvis. (Hammerschlag.) Fig. 66.—The delivery of the after coming head by the Smellie-Veit maneuver. C"2 (Hammerschlag.) %Z UNUSUAL PRESENTATIONS AND POSITIONS 173 and traction is made dowmvard in the axis of the inlet until the head slips into the excavation. If the head is delayed at the inlet, it may be neces- sary to put the Avoman in the Walchcr position (q. v.) and for the nurse to use the Wiegand compression Fig. 67.—Shoulder presentation. Left-scapulo-anterior position. (Eenoir and Tarnier.) (q. v.). The feet must not be fastened in stirrups for breech cases. Forceps are not recommended for application to the breech as they do not fit and are liable to slip off and injure both child and mother. The fingers are best. 174 OBSTETRICS FOR NURSES Forceps are not recommended for the after-coming head unless the child is dead. If the child lives, the Smellie-Veit is more successful; and if the child dies, the cranioclast, if possible, Avill save the mother much suffering and avoid some injury to the tissues. Transverse or Shoulder Presentations.—These are cases in Avhich the long axis of the child lies directly across or obliquely across the long axis of the uterus. The shoulder (scapula) is the bony landmark, and the part Avhich most frequently impends over the inlet. This presentation probably occurs once in two hundred labors. It is due to the same conditions that Avere ghren for breech cases; namely, Aveak abdominal or uterine mus- cles, pelvic contraction, placenta previa, hydramnios, and tAvins. It is easily recognized in pregnancy, and must not be neglected, for it is impossible of deliA-ery Avithout first changing it into a longitudinal presentation. If this correction is not done, rupture of the uterus is liable to occur, Avith the consequent death of both mother and child. The treatment is invariably version. Face and Brow Presentations.—The face presents once in about three hundred labors. In this case, the head is completely extended so that the occiput rests against the back of the neck. The trunk and spine are straightened out Avhile the legs and arms remain in the normal attitude of flexion. The causes of these anomalies must be sought in those conditions Avhich bring about the deflexion of the chin. The most common are pelvic contraction, large child UNUSUAL PRESENTATIONS AND POSITIONS 175 placenta previa, hydramnios, goiter, anencephalus and multiparity. Face positions take their names from the location of Fig. 68.—Face presentation. (Bumm.) the chin (mentuni—Latin). Thus the most frequent face position is the right-mento-posterior. The diagnosis is not easy and may not be conclusive 176 OBSTETRICS FOR NURSKS until the bony prominences of the face, such as the nose and orbital ridges can be distinguished by vaginal ex- amination. The delivery is protracted from three to five hours be- yond the average by this complication, and the mor- tality is higher both for mother and child. The face is badly SAvollen and disfigured, but the normal condition of the tissues Avill be restored by the end of a Aveek. Fig. 69.—Descent of the chin in face presentation. (Bumm.) Most face cases terminate spontaneously, but operative interference is not infrequent on account of danger to mother or child. Version or manual correction of the presentation may be done before engagement. Forceps is the operation of choice after the head is fixed in the pelvis, but it may be necessary to precede the delivery by a preparatory pubiotomv, or in case of failure, to do a craniotomy on the dead child. UNUSUAL PRESENTATIONS AND POSITIONS 177 If the chin does not rotate forward under the sym- physis, the labor is impossible Avithout pubiotomy or the destruction of the child. In general, the case should be left to nature unless some definite indication to inter- fere develops. The brow presents much more rarely than the face, Fig. 70.—Delivery in face presentation. (Bumm.) possibly once in a thousand labors. It is due to the same conditions as bring about the presentation of the face. The mortality for both mother and child is higher than in face cases. The Avhole labor is harder and longer, besides being more dangerous to life and to tissues. This presentation, if recognized before the head is 178 OBSTETRICS FOR NURSES fixed, should be converted into a breech by version, but after the head comes doAvn, it may be possible by hand or forceps to deliver either as a face or as an occipito- posterior, but otherAvise the cranioclast must be con- sidered. Occipito-posterior position is the name given to ver- tex cases Avherein the occiput lies in one or the other of the two posterior quadrants of the pelvic inlet. These labors are necessarily prolonged, both in the first and second stages, because the mechanism of de- livery is deranged by the larger diameters brought into relation Avith the bony canal and by the ineffectiA^eness of the contractions. The pains in the second stage may become violent and extremely painful, but the labor does not advance appreciably. After a little experience, mere observa- tion of the course of the labor Avill cause the suspicion to arise in the mind of a competent nurse that the occi- put is posterior. The diagnosis Avill be cleared up by the doctor's internal examination, Avhich shoAvs the large fontanelle anterior and the sagittal suture run- ning backAvard. The head is partially deflexed and it may not be pos- sible at first to find the small fontanelle. The position terminates by delivery uncorrected, by spontaneous rotation into an anterior position, or is cor- rected by the doctor. Correction should not be attempted until it is appar- ent that the anomaly Avill not right itself, Avhich it will do in four cases out of five. CHAPTER XII OPERATIONS Complications during labor may arise from abnormal positions of the head, such as face or broAv; from ab- normal presentations of the child, such as breech, trans- verse or shoulder; from twin labors; or from prolapse of a part like the foot, arm or cord. The mother may be responsible for some of these abnormalities through having a contracted pelvis, a rigid os, or a rigid pelvic floor. The uterus, too, may functionate abnormally by act- ing too vigorously, as in precipitate labor, or too sloAvly, as in uterine inertia. The membranes may rupture prematurely and produce a dry birth. There may be haemorrhages before labor (ante partum haemorrhage) during labor (intra partum), and after labor (post partum haemorrhage), or the labor may be preceded, accompanied, or folloAved by that extreme example of toxaemia knoAvn as eclampsia. Face and broAv presentations are rare and come to the attention of the nurse only Avhen an operation is re- quired for their relief. Further conditions may arise, such as danger to mother or child, Avhich demand an ac- celeration of the labor. If the head is engaged, forceps is the operation most commonly undertaken, and if not engaged, the problem may be solved either by an early version and extraction or by forceps later. The dangers to the mother are not usually difficult to diagnose if the case has been folloAved carefully. 179 180 OBSTETRICS FOR NURSES Signs of danger to child must be looked for con- stantly. Such are: (a) Alteration of the heart tones. (b) Retardation of pulse in cord betAveen pains. (c) Escape of meconium is not significant unless oc- curring in the pain-free interval, when it may signify hypercarbonization of blood and a threat of asphyxia- tion. The preliminaries for the performance of these opera- tions may noAv be described, and the indications and conditions briefly tabulated. The preparation should be standardized so that the same set-up of the room Avill do for all of the major obstetrical operations, except Caesarean section. The kitchen table is generally regarded as a satis- factory operating table. Its length is sufficient for deliv- ery when the legs are doubled up. The table should be covered with a blanket or comfort on which it laid a clean sheet. A rubber blanket or piece of oil cloth is put on, so folded aboA^e the place for the patient's hips, and so pinned at the sides, that all drainage will Aoav off into a bucket or jar at the foot. In front of the table is placed a straight-backed chair with flat scat. To the right of the operator, as he faces the table, stands a bench, or Iavo chairs, side by side; or, if possible, another table. This is covered Avith a clean sheet for the reception of the instruments. To the operator's left, another table similarly prepared carries the solutions, sponges, etc. Every operation for delivery should have tape and cord scissors within easy reach, as Avell as facilities for the resuscitation of the child. The light should come from behind the operator and fall full upon the field of operation. The room should be Avarm. OPERATIONS 181 The patient is laid upon the table and her knees ele- vated in the exaggerated lithotomy position. If there are assistants enough, one can stand on either side and hold a knee, if not, a sheet sling can be made and slung round the patient's shoulders and tied to the knees as previously described. Fig. 71.—Exaggerated lithotomy position. The legs are held by a sheet sling. The vulva should be shaved. (Williams.) Aii anaesthetic Avill be required. If a doctor can not be had, this duty Avill fall to the nurse. A sterile douche bag hangs near the table. A bath tub of hot water must be provided and a tracheal cath- eter must be ready for the removal of mucus from the child's Avindpipe. An abundance of hot and cold sterile water must not be overlooked. In the hospital the fol- 182 OBSTETRICS FOR NURSES loAving synopsis for the placing of the linen may be found useful: Sterile Linen for Operative Case.— Bring patient to foot of bed. Put in the stirrups. (For breech deliveries do not use stir- rups.) Same order as for normal case except that feet are put in stirrups instead of on bed. Fig. 72.—Dorsal position when assistants are available. (Hammerschlag.) Sterile sheet under patient extends now from basin under bed to buttocks. Combination pad over field of operation. Sterile sheet over abdomen. The genitals of the patient are iioav cleansed Avith all care and attention described for labor. If this has been done Avithin an hour, she need only be sponged off thoroughly Avith lysol solution (1 per cent). The feet and legs are covered Avith stockings, the body kept Avarm, and protected by sheets and blankets, if necessary. OPERATIONS 183 Every operative delivery is preceded by catheteriza- tion. All instruments are boiled for thirty minutes and brought to the table in the same container in Avhich they are sterilized. The hot water has been poured off and a cool, weak solution of lysol (0.5 per cent) added. Forceps.—Before using forceps it should be deter- mined that the woman can not deliver the child un- A B CD Fig. 73.—Instruments for artificial delivery of the head. A. Braun's blunt hook; B, Cranioclast (Auvard) ; C, Axis traction forceps (Webster); D, Low forceps (Simpson). aided, or can not be permitted to do so Avithout too great expenditure of physical and nervous energy. The exact conditions must be recognized as to the location and position of the head, the condition of the foetal heart tones and the size of the pelvis. AVhen the head is high up, the axis-traction instrument is employed 184 OBSTETRICS FOR NURSES and patient put in Walcher's position for the traction. Axis traction forceps are extremely dangerous to mother and child, and should be avoided wherever pos- sible. The following instruments are required: The obstetric forceps. 2 eight-inch forceps. 6 artery forceps. 1 vulsellum forceps. 1 tissue forceps. 1 needle forceps and 6 needles. 2 vaginal retractors. 1 pair dressing forceps. 1 douche point. 1 silver catheter. Suture material—both catgut and silkworm gut. Besides these instruments, the nurse will also have solution basins as described for normal labor. For operations outside of hospitals, the nurse need not be clean, as her duties Avill consist for the most part in changing solutions, refilling basins, handing toAvels, etc., all of Avhich can be done with sterile forceps. The folloAving summary may be serviceable for ad- vanced study or reference: Preparation.— - Thorough asepsis, both subjective and objective. Patient should be pulled down to the foot of the labor bed with feet in the stirrups, or put upon the kitchen table or across the bed with the legs held in the lithotomy posi- tion. (For breech cases, legs should not be fastened.) Bladder and rectum must be empty. Anaesthetic is necessary. The position of the head must be accurately known. Facilities for the treatment of asphyxia neonatorum must be at hand. Conditions.— Cervix effaced and os dilated, except when maternal or fcetal life is threatened. OPERATIONS 185 Bag of waters must be ruptured. The head must be engaged. The child should be living. Indications.— Insufficiency of the powers of labor. Deep transverse arrest of the head. Complications in labor, such as: Eclampsia. Fever. Acute or chronic disease. Hernia—especially if incarcerated. Placenta previa. Prolapse of the cord. Face and brow presentations. Contracted pelvis. Occipito-posterior positions. Dangers From Forceps.— Injuries to Child.—Overcompression, especially with axis trac- tion forceps or in contracted pelvis. Crushing of soft parts, or such lesions as abrasions, pres- sure marks, haematomata, swelling of face and eyelids. Bone injuries: Spoon-shaped depression where the head has been dragged through a narrow inlet; fissures in the parietal or frontal bones; fractures. AA7hen axis traction forceps are applied antero-posteriorly, the occipital bone may be sprung inwards until it cuts the medulla. Compression of the cord, especially if it is around the neck. Haemorrhage from the middle meningeal artery. Injury to eye. Erb's paralysis. Laceration of ears when the forceps are removed. Facial paralysis from pressure of the blade. Injury to Mothers.— Infection. Improper application of the blades outside the cervix uteri. Soft parts torn by too rapid extraction. W'hen os is not dilated, it is first pulled down and then torn. The tear may extend into the vaginal vault. Fistulas may be produced. Prolapse of the uterus from prolonged traction. Vaginal tears from the blades or from malplaccd head. Slipping of blades. Traction must be not against the sym- physis, but down. 186 OBSTETRICS FOR NURSES The forceps commonly used in this country (Simp- son or Elliott) are so made that the left blade must be introduced first on account of the lock. The mortality for the child in forceps cases is about six per cent. The axis traction instrument is used but seldom by good Fig. 74.—Forceps operation. The left blade, in the left hand, is intro- duced first into the left side of the mother so that the curve of the blade fits the child's head (inside the cervix). (Hammerschlag.) obstetricians, since the danger to mother and child in this operation is very serious and it should be reserved for emergencies of exceptional character Pubiotomy may precede the operation with advantage in many cases. Asphyxia of the child and maternal haemorrhage must be prepared for. Fig. 75.—Forceps operation. The introduction of the right blade. (Hammerschlag.) Fig. 76.—Forceps operation. Locking the handles. (Hammerschlag.) 188 OBSTETRICS FOR NURSES Fig. 77.—Forceps operation. The way the blades should grasp the foetal head. (Hammerschlag.) OPERATIONS 189 Fig. 78.—Forceps operation. Traction on the handles. (Hammerschlag.) I'ig. 79.—Forceps operation. The delivery of the head. (Hammerschlag.) 190 OBSTETRICS FOR NURSES Fig. 80.—Aversion. Seizing a foot. (Hammerschlag.) Version (Turning).—Version is a maneuver for alter- ing the presentation of the child Avhile it is still in the uterus. A vertex may be converted into a breech, a breech into a vertex or a transverse into either a ver- tex or a breech. Version usually means that a transverse or a vertex OPERATIONS 191 Fig. 81.—Version. The child rotates as pressure is made upon the head and traction upon the foot. (Hammerschlag.) presentation is changed into a breech and is folloAved by the extraction of the child. The operation is serious and not to be undertaken Avithout definite indications. There is ahvays the risk of sepsis and rupture of the uterus as well as a high probability of a dead child. 192 OBSTETRICS FOR NURSES Perineorrhaphy is, if anything, more frequent after this operation than after forceps. Preparations.—The room and patient are arranged as for forceps, except that the stirrups can not be put in. The legs must be held by assistants, for the delivery of Fig. 82.—Version is complete when the knee appears at the vulva. (Hammerschlag.) the aftcrcoming head may be complicated and require the AValcher position, Avhich can not be quickly obtained if the legs are fast. Only eight minutes are alloAved for the delivery of the child after the navel passes the vulva, if it is expected to live. Operations 19:1 The bladder and rectum must be empty. Asepsis must be rigid and both subjective and objective. The dorsal position on a table is imperative. The diagnosis must be accurate and the anaesthesia carried to the surgical degree. Facilities for treating asphyxia neonatorum must be pro- vided. The folloAving summary of the indications and condi- tions may be convenient for reference. Indications.—Contracted pelvis. (Consider pubiotomy.) Abnormal position of the head. (Face position with chin posterior.) Prolapse of cord or an extremity with a presentation of the head. Placenta previa. Transverse position after the seventh month. Any condition requiring rapid delivery. Conditions.—Cervix effaced and os dilated. Uterus not. in tetanus nor contracted down over the child. The foetus must be movable. The head should not be engaged. The Watcher position is produced by bringing the pa- tient down to the end of the table so that the sacrum rests upon the edge. The thighs and legs are alloAved to hang doAvn of their oayii Aveight and the patient is restrained from falling off by traction upAvards on the axillae. In the Walcher position the diameter of the pelvic inlet is increased from 1 3 to y2 inch (1 cm.) and thereby the delivery of heads that otherAvise could not pass becomes possible. In addition to the Walcher position other measures may be required to help the head through. Thus, trac- tion from beloAv may be carried to the limit of safety and in spite of the Walcher position the head may not pass the inlet. 194 OBSTETRICS for nurses Then" pressure from above is added. This maneuver Avill haA-e to be executed in many cases by the nurse. The fingers palpate the head above the pubes. Then one or both fists are placed upon the abdomen over the head and force is exerted to croAvd the head down into the pelvis. This is known as the 'Wiegand compression. For the operations destructive to the child, craniot- omy or decapitation, the same arrangements are made. Cranioclasis is the crushing of the foetal skull so that Fig. 83.—The AA'alcher position. (American Text Book.J in its reduced condition the child can be delivered and the mother's life spared. In addition to the solutions, the only instruments required are the Auvard cranio- clast, a Naegele perforator, and a douche bag with glass, or any tip that can be sterilized. In many of these cases, both mother and child could be saved if seen early enough to have a Caesarean opera- tion. Decapitation is done to save the maternal life in cases of transverse or shoulder presentation. The prepara- OPERATIONS 195 tions are the same as already described for forceps and version and the only instrument needed is a Braun blunt hook. (Fig. 73.) Fig. 84.—The Wiegand compression of the child's head to force it into the pelvis. (Hammerschlag.) Cesarean section is the delivery of the child through an opening in the abdomen. It is made necessary by contraction of the pelvic 196 OBSTETRICS FOR NURSES bones, or by the presence of a fleshy or bony mass which diminishes the size of the inlet. It may be required on account of the closure of the vagina or cervix by scars or on account of urgent conditions of the mother, such as eclampsia, heart disease, and sometimes placenta previa. The technic is simple, but good judgment must be used in knoAving Avhen to do it. .Many operators find it so easy that they prefer it to the harder but safer obstetrical operations. The time of election is Avhen the woman is at term but not in labor. This, of course, can be determined by Fig. 85.—The Naegele perforator. (Hammerschlag.) the history, but more certainly by careful measurements of the child. When it becomes necessary to operate on a woman Avho has been in labor a long time and especially if she has been examined frequently, the mortality is dispro- portionately high. It is a hospital operation, but may be done in the house. If not an emergency, the boAvels are emptied by a laxative and enema the day before. Regular prepara- tions for laparotomy are made, plus the equipment necessary for tieing the cord and resuscitating the child. A table must be found large enough to hold the patient in the horizontal position at full length. Solu- tions of lysol 1 per cent and sterile water are placed on OPERATIONS 197 each side of the table. The instrument table carries toAvels and suture material as well. On a stand behind the operator is placed the hot bath and tracheal catheter. This center is presided over by someone skilled in the treatment of respiratory difficul- ties in the neAv born. Altogether, five assistants are required for the operation: an anaesthetizer, a clean nurse, and a nonsterile nurse to manage supplies, an operating assistant and one to take charge of the child. Rubber gloves must be Avorn by the clean assistants. Instruments.—■ 2 scalpels. 2 scissors. 8 eight-inch forceps. 10 six-inch artery forceps. 4 sponge carriers. 4 tenaculum forceps. 2 rat-toothed tissue forceps. 4 full curved round needles for uterine wall. 4 smaller needles for the fascia. 2 Hagcdorn needles for the skin. 2 needle holders. 1 dressing forceps. Plenty of suture material, both catgut (No. 3 and 4) and silkworm gut for the abdominal wall. Supplies.—■ 1 doz. laparotomy sponges with metal rings sewed in or a long tape attached. 6 large laparotomy pads. 1 large pillow slip full of sterile cotton. Sponges. 1 laparotomy sheet. 1 dozen towels. 1 pair of leggins. downs and head dressings (gauze will do) for the operator and assistants; rubber gloves, basins and accessories. All are sterilized. If the woman has been examined, the vagina should be sponged out with tincture of iodine. The abdomen is 198 OBSTETRICS FOR NURSES shaved, scrubbed with green soap, nail brush, and hot water for five minutes. It is then rinsed with ether and painted with iodine. The presentation of the child, the presence and location of the heart tones must be determined before operation. The patient is aiuesthctized Avith ether, chloroform or gas. The incisions are made; the child delivered to the proper assistant; the placenta and membranes removed; the sponges counted; and the uterus and abdominal wall sutured. After-care.—The nurse Avatches the patient for sigh- ing respiration, rapid pulse, pallor, and other symptoms of haemorrhage, either external or internal. Artificial heat is supplied. Haemorrhage from vagina should be looked for. It is normal. Salt solution by hypodermoclysis may be required. Hot water by mouth in small sips or tap Avater by rectum (drop method) Avill relieve the thirst. Morphine may be given if pain is extreme. An enema may be given on the second day or calomel may be started in the morning of the second day. Distention from gas, Avith or Avithout nausea and vomiting, hic- cough and rise of temperature are all signs of danger. No milk should ever be given on account of the gas it causes. The child is put to breast as usual after tAvelve hours. The stitches are to be taken out on the tenth or tAvelfth day. Symphyseotomy is a separation of the pelvis at the pubic joint and is done Avith a scalpel or a specially de- vised knife. Pubiotomy is the division of the pelvis, three or four centimeters to the right or left of the pubic joint. The division passes through the pubic bone and is usually OPERATIONS 199 done Avith a serrated Avire called the (iigli saAV. It is introduced subcutaneously by a special instrument called a pubiotomy needle. Both symphyseotomy and pubiotomy are preparatory to delivery. Pubiotomy is the more desirable and successful operation. The ends of the severed bones separate from one and a half to tAvo inches, and the child delivers easily through the en- closed opening. The after-care is usually simple. Instruments.— 1 scalpel. 2 Gigli saws. 1 pubiotomy needle. 6 artery forceps. 3 eight-inch forceps. 1 needle holder. 2 retractors. Suture material and sponges as usual. The hips are strapped in circumference with zinc ad- hesive plaster to support the bones. The danger of infection of the Avound from the lochia is ahvays present. The main difficulty is in moving the patient, Avho is more than usually helpless. The bony ring of the pelvis is broken and she can not raise her leg. The repair is cartilaginous at first, but solidifies in a feAV months so that locomotion is not impaired. Es- pecial pains must be taken to avoid bed sores. CHAPTER XIII MINOR OPERATIONS Aseptic Care.—Place patient on a clean bed pan. It need not be sterile. Drape Avith a sheet and arrange it so the fold may be easily raised by nurse's elboAv. Have sterile basin Avith cotton pledgets to be filled with solu- tion of lysol 1 per cent. Lysol must be put in basin first and the water added. Take to bedside. Nurse scrubs her hands ten minutes Avith a sterile brush, hot Avater, and green soap. Use no tOAvel, no gloves. Keep hands Avet and clean. Cleanse vulva Avith Avet pledgets from above doAvmvard. Apply sterile pad. Sterile Specimen.—To get a sterile specimen of urine Avithout catheter, give aseptic care, tampon vagina Avith large pledget of sterile cotton. Have patient urinate in a sterile basin. RemoAre tampon. Sterile Specimen from Child.—Take a glass test tube and thrust its round end through a hole in a square piece of adhesive plaster. Push it doAvn until the plas- ter is caught and stopped by the enlarged rim at the mouth of the tube, Avith adhesive side of plaster on same side as opening of tube. Fasten the tube over the male penis or female vulva by applying the plaster to the sur- rounding skin. Leave until full. Aseptic Douche.—Boil douche point and basin. Leave point in sterile basin. Fill douche can Avith sterile water, temperature 104° to 110° F. Put clean bedpan under patient Avho is draped Avith a sheet. Have at hand a sterile basin containing solution of 200 MINOR OPERATION'S 201 lysol 0.5 per cent, or boric acid 5 per cent in which col- ton pledgets are immersed. Scrub the hands as for asep- Fig. 86.—Apparatus for getting a sterile specimen of urine from an infant. tic care. Cleanse the vuha Avith cotton pledgets, wash- ing ahvays toAvard the anus, and use each pledget but once. Adjust the douche point and introduce it just 202 OBSTETRICS FOR NURSES inside the labia. The douche can should be only a trifle higher than the pelvis. When can is empty, apply a sterile pad. If the douche is to be used as a deodorant after the fifth day of the puerperium, either of the following solutions may be employed: Potassium permanganate, 1:5000; formaldehyde 1 dram to quart, or chinosol 1:1000. The vaginal douche may be used in cases of gonor- rhoeal infection in pregnancy during the last Aveeks, in the hope of avoiding infection of the child's eyes. It is given like the aseptic douche (q. v.) Avith potas- sium permanganate 1:5000, or 'chinosol 1:1000. It should be hot (112° to 120° F.), and be begun not long before term, so that in case labor comes on, the danger to the child Avill be minimized. The reservoir must not be too high, nor the douche point inserted much beyond the labia. The woman should be on her back and the douche point should be rubber or glass. Removal of Sutures.—On, or about, the tenth day the removal of sutures is required. The nurse will sterilize by boiling, 1 pair of long- handled, sharp-pointed scissors, 1 pair of tissue forceps, and if the sutures extend far into the Aragina, a vaginal retractor. A basin of lysol solution (1 per cent) Avith cotton sponges, a sterile tOAvel to lay the instruments on, a dish to receive the soiled dressings, sutures and dis- carded sponges, completes the arrangement. The patient is iioav draped with sheets as for exam- ination. The doctor prepares his hands as for operation. The nurse holds the limbs of the patient in lithotomy position and the operation is begun. Uterine Tampon.—Packing the uterus is mostly em- ployed for haemorrhage after labor. The patient, there- MINOR OPERATIONS 203 fore, has been prepared and only fresh sponging Avith lysol solution is required. The instruments are, 1 vaginal retractor, 1 pair of dressing forceps, 1 vulsellum forceps and a jar of gauze, four to six inches Avide and ten or tAvelve feet long. Al- Avays use a single continuous strip. A very large quan- tity is necessary to fill the uterine cavity. Any sterile gauze may be used, but Aveak iodoform is satisfactory. Fig. 87.—Tampon of the uterus. (Hammerschlag.) The vagina is held open with retractors, the cervix seized Avith a tenaculum and pulled doAvn, the end of the gauze strip is then carried into the uterus as far as the fundus, the dressing forceps AvithdraAvn and a neAV length carried in until the cavity is packed tightly from the fundus clear to the os. Care must be taken that the strip of gauze is not con- taminated by vaginal contact during the introduction. A pad and binder are now applied. If no instruments are at hand, or there is not time to sterilize, then the 204 OBSTETRICS FOR NURSES nurse can grasp the fundus through the abdominal wall Avith her hand and push the cervix doAvn to the vulva where the gauze can be pushed in by the doctor's fing- ers, if necessary. The tampon acts as a haemostatic through its direct mechanical pressure, and dynamically by stimulating the uterus to contract. It should be removed in from twelve to tAventy-four hours. To tampon the vagina the Avoman lies on her back across the bed, Avith her feet on the knees of the doctor, Fig. 88.—Tampon of vagina. (American Text Book.) Avho sits facing her. A sterile retractor holds back the posterior Avail of the vagina. With a pair of dressing forceps the doctor seizes the pledgets of cotton or gauze out of the lysol solution and carries them one by one as far as they will go, in various directions around the cervix. One is pushed forwards toAvard the bladder, the next back toward the rectum, the next in the middle, and so on until no more can be introduced. A pad and binder are applied tightly. MINOR OPERATIONS 205 The uterine douche is sometimes employed for haemor- rhage. The field of operation and the doctor's hands are prepared as usual. The nurse cools the boiled douche water down to 120 F. and if ordered, adds 2 drams of sterile salt to each quart. The instruments are a vaginal retractor, a long uter- ine douche point, and one vulsellum forceps. The cervix is seized and brought doAvn, the long douche point connected Avith the tube from the reservoir is carried to the fundus and the Avater started. Care must be used that the return Aoav is free and unob- structed. This method is most satisfactory in uterine haemor- rhage after the uterus has been entirely emptied. It stimulates a prolonged and profound uterine contrac- tion. Intravenous Injections.—The vein in the front of the elboAv is usually chosen. (Median basilic or median cephalic.) A rubber bandage or tourniquet is Avound tightly about the middle of the upper arm to make the veins stand out prominently. The surface of the skin should be sterilized for operation by scrubbing Avith green soap and hot -water and rinsing Avith 50 per cent alcohol, folloAved by 1:2000 solution of bichloride, or by the application of tincture of iodine. The hypodermic needle is then introduced after ex- pulsion of all the contained air and the piston is draAATi up until the blood enters. This assures the operator that the needle has entered the vein. The bandage is iioav loosened and the solution of the drug is introduced very slowly. Intravenous infusion or transfusion is given in the same Avay. The fluid (normal saline?) must be running from the needle as it is introduced. 206 OBSTETRICS FOR NURSES Hypodermoclysis is the introduction of normal saline solution, under the skin, or under the breasts. The so- lution may be transfused also into a vein. By this operation, the quantity of fluid in the ves- sels is greatly increased and a circulatory stimulant is proAdded. Normal saline also promotes diuresis and aids in the removal of Avastage. The principal dangers arise from too great rapidity or too large a quantity of the Aoav. The skin should be sterilized at the point of attack by a coating of tincture of iodine. The instruments required are, a bath thermometer, a douche can (fountain syringe) Avith long tubes and an aspirating needle. A hypodermic needle Avill do, but the reservoir must be Avell eleATated since the caliber is so small. Ordinarily the reservoir need be held only tAvo or three feet above the point of discharge. The water should be floAving through the needle when it enters the tissues. If the fluid is to be introduced under the skin, the best place is in the loose region betAveen the hips and the ribs in front. If under the mammary gland, the needle must go below and under the gland from the out- side edge, not into the gland. If into a vein, such addi- tional instruments Avill be needed as a rat-toothed tis- sue forceps, a pair of sharp-pointed scissors, a knife and some fine catgut. From four to sixteen ounces of fluid may be used at a temperature varying from 105° to 110° F. The openings Avhere the needles entered are closed by cotton and collodion. Curettage of uterus is done for abortion or puerperal sepsis when foreign fragments are left in the uterus. The room is prepared as for delivery. MINOR OPERATIONS 207 The instruments are: 1 vaginal retractor. 1 vulsellum forceps. 1 long uterine douche point. 2 dull curettes. 2 sharp curettes of different sizes, together with gauze for packing the uterus. Rubber gloA'es should be Avorn both by nurse and physician as much for personal protection as for the patient's safety. In many cases of incomplete abortion or of puerperal sepsis the endometrium is more satisfac- torily curetted Avith the gloved fingers. Abortion may be indicated in many of the early com- plications of pregnancy, such as hyperemesis, nephri- tis, uncompensated heart lesions, tuberculosis, insanity, hydramnios, incarcerated retroversions of the uterus and the presence of haemorrhage. These cases require the operation to be undertaken and finished by the doc- tor, but other conditions deA, Fig. 93.—Various forms of pelvic deformity compared with the normal inlet. (Bumm.) The circumference of the hips just below the iliac crests and above the trochanters—90 cm. It is taken Avith a tape line. These are the usual external measure- ments. The internal measurements are made with the fingers. The diagonal conjugate is the distance from the lower 216 OKSTKTRICS FOR NURSES Fig. 94.—The pelvimeter. Fig. 95.—The various diameters of the inlet with the lengths given in cubic centimeters. (Williams.) COMPLICATIONS IN LABOR 217 border of the symphysis to the promontory of the sa- crum. It should measure 12.5 cm. The first and second fingers are passed into the A'agina and pushed up until the tip of the second finger touches the promontory of Fig. 96.—Measuring the distance between the anterior superior spines of the pelvis. (Williams.) the sacrum. The finger of the other hand marks the depth of the examining fingers just below the sym- physis. The distance is measured when the finger is with- drawn, and 1.5 cm. is subtracted. The result is the true 218 OBSTETRICS FOR NURSES conjugate. These measurements carefully made and the deduction judicially estimated, give one a fairly ap- proximate idea of size and shape of the pelvic inlet. The aim of nearly all the pelvic measurements is to get Fig. 97.—Measuring the external conjugate. (Williams.) not only the size and shape of the inlet, but so far as possible, a working estimate of the anteroposterior diam- eter of the brim, Avhich is the most important of all the diameters. In normal cases this should be 11 cm. COMPLICATIONS IN LABOR 219 Thus, taking 9.5 cm. from the external conjugate (20.5 cm.) gives 11 cm. Subtracting 1.5 cm. from the diagonal conjugate as obtained Avith the fingers as above described, (12.5 cm.) gives 11 cm. The subtraction is made to compensate for the thickness of the pubic bone and its inclination outwards. A circumference of 90 cm. corresponds to an inlet of Fig. 98.—Measuring the diagonal conjugate with the finger. (Eden.) 11 cm. in its anteroposterior diameter, and every A'aria- tion of 5 cm. in this circumference makes a difference of 1 cm. (either larger or smaller) in the anteroposterior diameter. Thus, 95 cm. in circumference = 12 cm. in the diam- eter; and 85 cm. in circumference=10 cm. Complications increase in proportion to the degree of contraction in the pelvis. The most frequent difficulties superinduced by the 220 OBSTETRICS FOR NURSES small pelvis are prolapse of the cord, malpresentation and malpositions of the head, prolonged labor, and a large increase in the number of assisted deliveries. All the possibilities and probabilities in a given case Avill be carefully worked out before labor by the con- scientious obstetrician, and Casarean section, induction of premature labor, pubiotomy, forceps, or version and extraction, Avill be done with a sure foreknoAA'ledge. Prolapse of the cord complicates labor once in about tAvo hundred cases. It is most likely to occur Avhen the presenting part does not enter or does not entirely fill the opening, as in transverse or shoulder presentations, or vertex presentations Avith small inlets. The mother is not endangered by this mishap, but the babe is lost in from 35 to 60 per cent of the cases. The diagnosis is easily made when, a loop of cord pro- trudes from cervix or vulva, and the pulsation will dif- ferentiate it from everything else. If the cord does not pulsate, the family should be in- formed that the child is dead and the case may be al- loAved to terminate normally. If it still pulsates, the Avoman should be placed in the knee-chest position for ten or fifteen minutes, then upon the side, opposite to that on Avhich the cord has prolapsed, and back again as soon as possible to the knee-chest position. A chair may be used to produce ;i Trendelenburg position by placing it so that the edge of seat and top of back rest on the bed. Then the patient puts her legs over the loAver rungs and lies Avith her back against the chair back and her head on the bed. If the cervix is effaced and the os partly dilated, re- position may be attempted either with the finger or a male catheter. COMPLICATIONS IN LABOR 221 The operation Avill, of course, succeed most easily if done in the knee-chest position, Avith graAdty to aid. If the cord can be pushed back, a Vorhees bag may be inserted to keep it from coming doAvn again. This holds back the cord, dilates the canal and stimulates the pains. When the bag comes out, A-ersion and extraction can and should be done at once. In general, the folloAving summary may be useful: Prolapse of Cord Causes.—■ Contracted pelves. Breech and transverse presentations. Malposition of head, or face and forehead presentation. Hydramnios. Accident. Low insertion of placenta. Diagnosis.— Before rupture of membranes careful examination will show pulsating cord in advance of head. After rupture the cord may be felt in vagina. Dangers.—• To mother:—None but those due to causative condition. To child:—Compression of the cord and asphyxiation. Contraction of exposed vessels of cord. Patient may lie on cord. Twenty-five per cent die as a rule under best conditions. Fifty per cent when left to nature. Treatment of Cephalic Presentation.— Extraction of child or reposition of cord, depending upon the degree of dilatation. If cervix is small, replace and till cervix with Vorhees bag. AA'hen cervix admits hand, either replace or do version and extraction. AA'ith head engaged, reposition or version is not possible. Child living:—Eapid delivery with forceps. Child dead:—Craniotomy or leave to nature. Prolapse of one or both hands may take place. If the head is engaged, no interference should be attempted. If not, replacement or version may be done. 222 OBSTETRICS FOR NURSES The soft parts may also complicate the labor process. No time need be spent here on the rarer forms of ob- struction due to uterine or ovarian tumors. Rigidity of the cervix, or os is not uncommon. This may be due to a dense, almost cartilaginous con- sistence of that tissue, to premature rupture of the bag of Avaters, to Aveak, inefficient contractions in the first stage, or to a steel-spring-like contraction of the mus- cular fibers of the os. In all cases the first stage of labor is greatly pro- longed, but so long as the membranes are intact, the child is in no danger. Tavo kinds of cases are met Avith, those in Avhich the pains are \nolent, and those in A\rhich they are Aveak and shalloAv. In the first class, as soon as the condition is recognized, a dose of morphine sulphate, 1 6 gr. and scopolamine hydrobromide 1/150 gr. should be given hy- podermically. The rigid ring relaxes under the influence of the narcotic, and labor proceeds rapidly and almost painlessly. Chloroform may be substituted if the mor- phine and scopolamine are not at hand. If the cervix is effaced and only the rigid ring of the os prevents the completion of the labor, or if the above methods fail, then the patient may be anaesthetized and the rigidity overcome by the fingers. This is an emergency that should not be attempted until all else has failed and some danger arises that makes it necessary to hasten the delivery. (See Minor Operations, p. 211). Where the constriction is due to unusual density of the cervix or to cicatricial tissue, it is sometimes neces- sary to make incisions under aseptic precautions so that the rigid ring may expand. Weak and inefficient contractions can sometimes be COMPLICATIONS IN LABOR 223 stimulated satisfactorily by the introduction of a Vor- hees bag. Rigidity of the pelvic floor may be due to inadequate elasticity of the tissues as in old primiparas or in young Avomen Avho have ridden horseback for many years in the cross-saddle position. The head may come doAvn to the pelvic floor but will not advance further. If the tissues of the vulva do not, or can not yield sufficiently after appropriate time has been alloAved, episiotomy may be done. (See Minor Operations, p. 211.) The uterus itself may functionate abnormally. Precipitate labor is an over rapid advance of the child Avherein the stages of labor are merged into one another and the child expelled in tAvo or three pains. It may be due to unusual capacity of the pelvis, or to strong contractions which the patient is not aware of, or both. These cases predispose to post partum haemorrhage and to serious lacerations of cervix and perineum. The child is usually delivered in an undesirable place, such as a toilet basin or a street car, and perishes from the fall, from cold, from umbilical hemorrhage, or lack of facilities for reA'ival. The nurse Avho is watching a case is responsible for the prevention of a precipitate. If the event impends, the woman must be placed upon her side Avith legs straight, and she should be instructed to cry out Avith every pain. Chloroform may be given and the head forcibly held back. Uterine Inertia.—A sluggish state of the uterus may characterize the labor and the contractions Avill be sIoav, shalloAV and inefficient. The intervals may be pro- longed, although the patient complains bitterly of pain. 224 OBSTETRICS FOR NURSES The condition is seen most frequently in multiparas and is due to defective innervation of the uterus or to im- perfect reflexes, and in primiparas also it may be due to the neAvness of the function that is suddenly called into play, or to contracted pelvis. Many times the trouble results from overfatigue and want of sleep. If this is the case, the remedy may be found in the administra- tion of morphine sulphate 1/6 gr. and scopolamine 1/150 gr. The pains are diminished or abrogated Avhile the contractions continue. The scopolamine may be re- peated if necessary. Under proper indications and con- ditions this treatment is harmless, both to mother and child, but requires supervision on the part of the nurse or physician. If the patient is not overly fatigued, the introduc- tion of a Vorhees bag, as described under the head of Induction of Labor (p. 208) will dynamically increase the strength and frequency of the contractions, mechan- ically aid the effaeement of the cervix and the dilata- tion of the os, and shorten the first stage anywhere from six to tweh^e hours. As soon as the os is dilated, pituitrin may be given under due precautions, as hereafter indicated. Pitui- trin has but little influence on the noiifunctionating organ, but acts Avell on a uterus Avhich is definitely con- tracting. It should not be given during the first stage, since Avhen the uterus contracts, there must be an ade- quate opening for the advance of the child. Five to seven minims is the usual dose, injected into the deltoid muscle. The injection may be repeated in an hour, if required, since the effects, Avhich begin about five min- utes after the injections, Avill pass off in fifty-five minutes. By the use of pituitin many operative procedures are COMPLICATIONS IN LABOR 225 altered or avoided. A high forceps case may be con- verted into a case for the Ioav instruments, and the latter in many instances avoided altogether. The use of pituitin may be briefly summarized as fol- Ioavs: Pituitrin (Use no alcohol to cleanse syringe or skin before injection.) Indications.— 1. Inertia uteri or weak, shallow pains in second stage. 2. Multiparity. 3. Post partum haemorrhage. 4. To avoid use of forceps or to reduce a high forceps case to a low one. 5. Caesarean section. If the patient is a multipara, sterile linen should be on and attendants ready for the delivery before an injection is given. Conditions.— 1. Cervix effaced. 2. Os admits three fingers. (Better if membranes have rup- tured.) 3. Head should be engaged. 4. No mechanical obstacle to delivery such as tumors or markedly contracted pelvis, etc. Dangers of Long Labors.— Compression of cord. { A'esicovaginal fistulae. Necrosis of maternal tissues.-j Rectovaginal fistula-. Infection—peritonitis. Necrosis of skin over skull. Necrosis of cranium. Fracture of skull. Death of child. Maternal exhaustion and prolonged convalescence. Premature rupture of the membranes not infrequently occurs from over-distention, AA'hen tAvins or hydram- nios is present, or at any stage of the pregnancy when the membranes are weak. The liquor amnii flows off, 226 OBSTETRICS FOR NURSES not all at once, but after the first gush by intermittent discharges, depending on the painless uterine contrac- tions and the accuracy with which the head fits the pelvis. Labor usually comes on in from tAvelve to forty- eight hours, but it may be postponed for a month. The labor is sometimes more painful and prolonged on account of the absence of the fluid wedge and the generous lubrication of the channel which is supplied by the liquor amnii. The danger of infection of the amniotic cavity with con- sequent death of the child is always to be apprehended after the escape of the liquor amnii. Also the foetal parts may prolapse and complicate the labor; or if the cord comes down, the child may be imperiled by its com- pression. If near term, the rupture of the membranes is not of great importance though the case must be watched atten- tively. Daily observation must be made of the foetal heart tones, the amount of liquor amnii flowing away, and the presence or absence of infection. If labor does not determine in a feAV days or if the heart tones rise above 160 or go below 120, labor must be inaugurated. (See Induction of Labor, p. 208.) Rupture of the uterus is the most serious accident that occurs in labor. It happens about once in three thou- sand confinements. The tear is usually in the lower part of the uterus and follows a prolonged period of labor, where the child is in a tranverse presentation, and, therefore, impossible to deliver, or the pelvis is too small or the child too large. It may also follow ill- advised or unskillful efforts to change the presentation by the introduction of the hand into the uterus. Occa- sionally rupture is produced by external violence, such as blows or kicks upon the abdomen. COMPLICATIONS IN LABOR 227 It is imperative to be able to recognize the symptoms Avhen rupture impends or actually occurs. Signs of Threateixd Rupture of Uterus.—- 1. High position of the contracting ring—especially its obliq- uity. The contracting ring is a ridge-like formation that may be found running across the anterior and lower por- tion of the uterus. 2. High position of fundus. 3. Tension of round ligaments. 4. Eotation of uterus about its long axis. 5. Tenderness to pressure of lower uterine segment. 6. Contractions persistent with no pain-free interval. Signs of Actual Rupture of Liter us.— 1. Haemorrhage is one of the earliest and most significant signs, and may be either external or internal. 2. Cessation of uterine contractions either abruptly or gradually. 3. Extreme pain felt by patient. 4. Eecession of presenting part. The patient gives a sharp cry and has the feeling that something has given Avay. Signs of shock rapidly super- vene. A predisposition to rupture may be present from the scars of a Caesarean section, uterine tumors, and de- generation of the muscle. The treatment depends upon the degree of the injury, and if investigation shoAvs that the uterus has opened into the abdominal cavity, immediate laparotomy is done. In other cases, the morcellation and removal of the child by the natural passage may permit the use of a uterine pack and avert the necessity for an abdo- minal operation. The child is usually dead and need not be considered. CHAPTER XV COMPLICATIONS IN LABOR (Cont'd) Vomiting in labor frequently occurs near the end of the first stage. It is due to the sympathetic excitement of the nerves of the stomach as the last fibers of the os uteri give Avay. It requires no treatment. Hyperemesis in labor is very rare, but Avhen it does occur, the delivery should be expedited. Haemorrhages may occur either before, during, or after labor. Haemorrhage is always serious. Haemorrhage before labor arises either from a pre- mature detachment of a normally implanted placenta or from placenta praevia. The first is sometimes called "accidental haemorrhage" to distinguish it from the latter, or "unavoidable haemorrhage." Accidental haemorrhage may be the result of an in- jury or a blow, but in many cases, there is no such his- tory. The hemorrhage is most frequent in the later months of pregnancy, and may be Avithout any apparent cause. The hemorrhage may be entirely inside the uterus (concealed haemorrhage) or it may appear ex- ternally. The haemorrhage, Avhen concealed, takes place back of the placenta or betAveen the membranes and the uterine Avail. If the haemorrhage is concealed, it is usually folloAved by an attempt to expel the child. If the haemorrhage is pronounced, systems of shock appear. The diagnosis is made by the symptoms which are summarized in differentiating this condition from placenta praevia (p. 231). 228 COMPLICATIONS IN LABOR 229 From this affection, nearly all the children and half the mothers die. When the haemorrhage is external and slight, the treatment may possibly be expectant for tAvelve hours, if carefully Avatched, but usually the symptoms become so serious that immediate emptying of the uterus is required either by the Vorhees bag, digital dilatation, version and extraction, or Cesarean section, the method Fig. 99.—ATarious forms of placenta praevia compared with normal attach- ment of the placenta. (American Text Book—Williams.) chosen being dependent upon the amount of the haemor- rhage, the vigor of the mother and the condition of the cervix, os, pelvis, and child. Placenta praevia is the name given to a placenta that is attached Ioav doAvn.in the uterus so that its margin or a large part of its mass overlies the os. This hap- pens through the action of the egg Avhich embeds itself 230 OBSTETRICS FOR NURSES too far down on the endometrium—too close to the cervix. Three different kinds are known and named from their manner of encroaching on the os, as marginal, partial, or central implantation of the placenta. The haemorrhage is from a loosening of the placental attachment owing to the stretching and growth of the uterus. There is only one symptom of placenta pnevia—sud- den, painless, causeless /Hemorrhage. The bleeding seldom appears before the twenty-eighth week, and no suspicion of a placenta praevia may arise before the ap- pearance of haemorrhage, which, as a rule, is soon re- peated. Labor frequently comes on prematurely and malpre- sentations naturally result from the inability of the pre- senting part to fit itself into the pelvis. There is no bag of waters, hence the first stage is* longer and bloodier and fraught with much danger. Interference is regularly indicated to saA'e the life of the mother, while the child also has a high mortality. Puerperal infection is not uncommon. Placenta praevia is ahvays an emergency. If the pa- tient can be kept under observation in a good hospital, one may temporize, but under other conditions the uterus must be emptied at once, even if only a single haemorrhage has developed. The indications are, (a) to control the bleeding, and (b) to empty the uterus. The life of the child must be disregarded and the mother alone considered. If the contractions have not begun, they should be stimulated by the introduction of a Vorhees bag, which, at the same time, dilates the canal and mechanically shuts off the bleeding vessels by compression. In in- COMPLICATIONS IN LABOR 231 troducing the bag, the membranes may be ruptured so the bag will pass into the uterine cavity. When the implantation is central, the finger must tear a hole through the placenta, and through this opening pass the bag inside the uterus. If the os is partially dilated, version may be done, and a foot brought down. The leg may then be pulled upon until it compresses the bleeding area and the traction maintained with a slowly developing pressure sufficient to check the haemorrhage, until dilatation is advanced enough for delivery. Occasionally good results are obtained by tightly packing the cervix and vagina with gauze or cotton. (See Vaginal Tampon, p. 204.) Caesarean section may be done in the interests of the child, as well as the mother. The fcetal mortality in placenta praevia is said to be 60 per cent and the maternal 10 per cent. Differential diagnosis between Accidental haemorrhage and Placenta previa Usually occurs in later months. May be concealed or open. Soon followed by labor pains. Uterus becomes larger if bleed- ing is concealed. Uterus hard and woodeny. In severe cases, signs of shock whether haemorrhage is ex- ternal or internal. No placenta can be felt. Haemorrhage continuous. No history of previous attack. No contractions after labor be- gins in serious cases. Xo bogginess of cervix. Any time after the twenty- eighth week. Always open and external. Labor need not occur. Uterus remains same size. Uterus, normal consistency. In severe cases, signs of shock follow the invariable external haemorrhage. Placenta can be felt through the os. Haemorrhage intermittent. Possibly history of previous at- tack. Contractions as usual. Cervix boggy. 232 OBSTETRICS FOR NURSES Haemorrhages may occur during labor from retention of the major part of the placenta while a portion is detached. This may be due to pre-existent disease, such as endometritis, or from uterine inertia. Normally the placenta will separate and be discharged Avithin an hour after labor and in the absence of haemor- rhage it may go even longer than this Avith safety. The occurrence of severe haemorrhage, hoAveArer, requires the immediate cleaning out of the uterus by inserting the hand and peeling the placenta from its attachments. Post partum haemorrhage includes all haemorrhages that occur after the delivery of the placenta. The "flooding" as it is called by the laity, is most apt to come on either immediately or Avithin an hour or so after labor. If it comes on after the first twenty- four hours, it is called secondary haemorrhage. Such predisposing causes as over-distention from tAvins may be present, but the haemorrhage may folloAV a perfectly easy and apparently normal labor so suddenly and so profusely that the woman may die in half an hour. There are four causes for post partum haemorrhage: namely, (a) uterine exhaustion (atonia uteri) ; (b) mechanical obstacles to retraction, such as clots or re- tention of pieces of placenta or membrane; (<•) and lacerations of some part of genital passage, such as the vulva, vagina, cervix, or lower uterine segment; and (d) the systemic condition known as hemophilia. "Bleeders" (hemophilias) are Avomen Avhose blood lacks coagulability, OAving to the absence of fibrin-pro- ducing elements. Post partum hemorrhage is usually an external hemorrhage, but the Avoman may bleed to death into her oavh uterus. Besides the external signs, the patient may shoAv the 1 I COMPLICATIONS IN LABOR 233 symptoms of acute anemia, such as the rapid pulse, hurried, shalloAV respiration, pallor, cold sweat, yaAvn- ing, dizziness, etc. Nearly all these cases can be saved by prompt recog- nition and efficient treatment. The first step is to grasp the uterus. If the hemor- rhage is due to a tear Ioav doAvn, the uterus may be hard, but generally it is relaxed and requires vigorous mas- sage Avith both hands before it s1ioa\ts any signs of con- traction. In the absence of the doctor, the nurse must knoAV hoAv to undertake this maneuver. The uterus, after labor and especially Avhen relaxed, is sometimes difficult to identify and the nurse can only make deep massage in the pelvis until the organ responds and its hard globular mass can be appreciated. As soon as the uterus contracts, clots and contained blood are expelled, and in many eases its bleeding ceases at once. (See Conduct of Third Stage, p. 149.) It may be necessary to keep the uterus contracted by manual massage in this Avay for several hours. As soon as possible, the nurse, or someone Avhom she directs, prepares a hypodermic of pituitrin—10 to 15 Hi. An injection of ergot may folknv because its effect is more lasting than pituitrin. Next, a hot douche is made ready and the materials for packing the uterus are as- sembled. When the doctor arrives, he sterilizes his hands, puts on gloves and introduces tAvo fingers or the Avhole hand into the uterus to remove clots or any retained frag- ments of placenta. The hot intrauterine douche may follow, and if the contraction is not firm and the hemorrhage checked, the uterus must be packed Avith gauze. If hemorrhage comes from cervix, it should be grasped Avith long for- 234 OBSTETRICS FOR NURSES ceps, pulled down, and sutured. It from perineum, pack first, and afterward sutures may be introduced. If the patient is exsanguinated, the foot of the bed is raised, coffee given by mouth, camphorated oil hypo- dermically, and normal saline transfused under the breasts. Pituitrin may be continued in larger doses. 1 c.c. will raise the blood pressure very definitely. Adrenalin also may be employed for this purpose. The following summary may be found convenient: Post Partum Haemorrhage Etiology, Functional.— Atony of the uterus, especially after rapid artificial or nat- ural emptying of the organ. More common after uterus has previously been greatly dis- tended. Premature version and extraction. Hydramnios and twins. Imperfect development of uterine musculature. Precipitate labors. Haste or improper management of third stage. Etiology, Mechanical.— Retention of placenta—partial, total or solitary cotyledons. Inversion of the uterus. Placenta succenturiata. Inflammation of decidua serotina. Conduct of third stage, i.e., wait until placenta separates. Etiology, Systemic, Haemophilia.— Kind of haemorrhage. Haemorrhage before expulsion of placenta due to laceration of the soft parts, or Partial release of placenta and failure of uterus to con- tract, or Placenta may be attached to periphery or to one side. Attempts to expel placenta without waiting for uterine con- traction are sometimes productive of haemorrhage. Haemorrhage after expulsion of placenta. Haemorrhage in interval between pains—comes from pla- cental site. COMPLICATIONS IN LABOR 235 Ha'inorrhage in stream not checked by uterine contraction is due to laceration of the canal. Haemorrhage in abnormal quantities at beginning of pains. Pure atony—comes early. Haemophilia again. Diagnosis.— Palpation of uterus through abdomen. Placental site excluded from contraction (paralysis). View of vulva. Injuries. Flow continuous, fluid and bright red, shows ar- terial origin, probably from cervix. Examine. Atony—bleeding at intervals, clotted and dark. Haemorrhage from a tear begins at once. Uterus contracted and haemorrhage continues. Look for tear. If haemorrhage does not begin within ten or fifteen minutes after labor it is not from a tear. Always have haemophilia in mind. Management.— Third stage must be conducted properly. Before expulsion of placenta—early expression. Crede or manual removal—then secure contraction by mas- sage. Pituitrin, Ergot, or both. After Third Stage.— Restore an inverted uterus. Repair lacerations. See that cavity is clear and clean. Massage, intrauterine hot water douche, hand in uterus and hand outside and rub, ergot. Pituitrin hypodermically. Pack uterus with sterile gauze or weak iodoform gauze. Strict asepsis for all intra- uterine maneuvers. Treat anaemia with transfusion, elevation of foot of bed, coffee, external heat, hot rectal enemas, stimulation, bandaging of legs. Strychnine sulphate, adrenalin, or camphorated oil may be re- quired in usual dosage. Hypodermoclysis. (See Minor Operations, p. 206.) After the bleeding stops, the food must be most nu- tritious—milk, eggnog, rich soups, chicken and mutton broths, oyster steAv, and beef steak as soon as she can 236 OBSTETRICS FOR NURSES Fig. 100.—The knee-elbow posture. (Bumm.) Fig. 101.—The knee-chest posture. take it. A diet of fluids and stimulating foods that raise the blood pressure will most quickly relieve the symptoms. Eclampsia occurs in the last three months of preg- nancy as a rule, and most frequently just before or during labor. COMPLICATIONS IX LABOR 237 In about one sixth of the cases only, the attack may follow labor. The attack is characterized by violent convulsions, which come on with little or no warning unless the urine has been carefully Avatched. Fig. 102.—The exaggerated lithotomy position obtained with a sheet sling. (American Text Book.) Fig. 103.—The improvised Trendelenburg position. (American Text Book.) The prodromal symptoms have already been de- scribed under albuminuria in pregnancy (p. 77). The marked features may be repeated for emphasis: per- sistent headaches, disorders of. vision, spots before the eyes, blindness, edema of cheeks, eyelids, feet and hands, 238 OBSTETRICS FOR NURSES pain at the pit of the stomach, dizziness, nausea and vomiting and ringing in the ears. Suddenly the con- vulsion occurs, the facial muscles tAvitch, then the limbs and body are shaken by violent muscular spasms. The body becomes rigid, the tongue protrudes and the face is livid and cyanotic. The spasm usually lasts from one to five minutes and is succeeded by coma that lasts an Fig. 104.—The dorsal position with stirrups. (Dorland's Dictionary.) hour or more. In some instances there is no return to consciousness before the next attack, Avhich comes on every hour or half hour, though occasionally only one seizure is noted. The blood pressure is greatly increased and the urine is diminished, the temperature rises to 101° or 102° F. When death ensues, it is most frequently due to edema of the lungs or cerebral hemorrhage. The greater the number of convulsions, the more se- COMPLICATIONS IN LABOR 239 rious the outlook as to life, and it is said that after tAventy seizures fifty per cent of the mothers die. Un- der the best treatment approximately fifty per cent of the babies die. Fig. 105.—Dorsal position across the bed. (Bumm.) There is no routine treatment for eclampsia. The principles of management for the attack are (1) to empty the uterus, on the theory that the disease is a toxemia of gestational origin, (2) to eliminate the poison, and (3) to control the convulsions. 240 OBSTETRICS FOR NURSES The albumin in the urine and other eclamptic symp- toms demand urgent attention in prophylaxis. For the pre-eclamptic period (see Albuminuria of Pregnancy, p. 77) a rigid milk diet is indicated. The boAvels, kidneys, skin and blood vessels must all be brought into service. In the full blooded patient, Arenesection may be done and after draAving off ten or tAvelve ounces of blood, an equal amount of normal saline may be poured into the.same vein. Subcutaneous transfusion or the submammary intro- Fig. 106.—Flexed dorsal position with feet on the table. (American Text Book.) duction of saline solution may be done. The skin is stimulated by hot Avet packs and the boA\rels by saline cathartics and frequent irrigation of the colon. During the attack, the patient must be kept from injuring herself. A spoon Avrapped in gauze or a small, long roller bandage should be slipped betAveen the teeth to keep the tongue from injury. The clothing must be loosened or removed. No food, but only Avater is given by mouth, until the patient is conscious. The compulsions are controlled by morphine, chloral, or both. THE ABNORMAL PUERPERIUM 241 Morphine sulphate, 14 gr. is given hypodermically, folloAved in an hour by 30 gr. of chloral by mouth. Two hours later the morphine is repeated and six hours after the first dose of chloral, it is repeated. In this method (Stroganoff's), four doses of chloral and six of mor- phine are given in twenty-four hours. That is all. When the stomach will not retain the chloral it may be given by rectum in milk. If a general anesthetic is used, it should not be chloroform, but ether. The labor, if begun, should be expedited by forceps, Fig. 107.—The Sims position. (Kelly.) or version and extraction. Bleeding during delivery should be looked upon as desirable, If "more rapid measures of delivery seem demanded and obstacles ex- ist, such as pelvic contraction, imperfect dilatation, or the prospect of a prolonged first stage, Cesarean sec- tion or forcible delivery (accouchment force) may be attempted. If the labor has not begun, when the convulsion oc- curs and a quick delivery by the normal passage does not seem feasible, then the Cesarean operation may be the best treatment. CHAPTER XVI THE ABNORMAL PUERPERIILM The practice of obstetrics has many features that are very gratifying to the nurse and physician. Instead of a surgical operation, Avhich has come un- expectedly and undesired; a disaster in Avhich some part of the body is removed or altered by means of a proce- dure associated Avith extreme pain, mental tribulation and large expense, a much-Avished for addition is brought to the family, Avith pain, to be sure, but a pain that is soon forgotten in the general joy. This is the normal condition that causes the nurse and the doc- tor to rejoice that such a delightful specialty has been chosen. Then comes a case in A\rhich the labor may be com- plicated by some dreadful anomaly, or the puerperium burdened or disordered by some unwelcome invasion that tortures the souls of the family and may cost the life of the mother, or child, or both. At such a time the nurse and the doctor feel the full weight of their responsibility, and after a series of anxious days and sleepless nights, they wonder Avhy they did not choose gardening or a clerical position for their life work. The disorders of the puerperium are many and vari- ous, but naturally the breasts and the pelvic organs are most frequently affected. The breasts of the human female are not reservoirs of milk like the cow's, but a pair of highly sensitive organs that functionate and produce only as the de- 242 THE ABNORMAL PUERPERIUM 243 mand is made. It folloAvs that Avhen the milk comes in, the breasts become engorged and all the neighboring structures are involved in the new process. HoAvever, it is not milk that is overfilling the breasts, but serum, lymph and venous blood, Avhich congest the tissues surrounding the glands and produce a hard painful mass. The breasts become heavy, hot, and painful; super- numerary glands in the axille enlarge, but there is no fever. There is but little more reason for a fever when the mammary gland begins to functionate than Avhen the lungs fill for the first time except in the case of nervous patients aaIio bear discomfort badly. If fever appears simultaneously with the milk, the cause must be sought in some atrium of infection, pos- sibly in the breasts, but usually elsewhere. There is no such thing as "milk fever." The enlarged glands, the tense mottled skin on which blue veins run visibly here and there, the nipple, flattened and drawn into the SAvelling, so that the child can not grasp it with the mouth, all produce a sense of disorder that ought to be associated with fever—but is not, This is the "caked breast" of the laity, and if let alone, the hyper- emia subsides and the function remains. The temper- ature in possibly two cases out of five may rise to 100° F. for twenty-four hours, but it promptly sub- sides. These temperatures generally occur in neurotic women. If the breasts are irritated by binders, breast pumps, or massage,—like the blacksmith's arm, with exercise— the trouble, if not increased, is at least much slower in disappearing. It is reported that the young virgins of some African 244 OBSTETRICS FOR NURSES tribes nurse the babies in the family, the breasts being stimulated to produce milk largely by massage. If the condition of the breasts becomes too painful, the liquids by mouth are reduced to the last degree, saline cathartics are given until frequent Avatery stools result, one or more ice bags are applied to each breast and codeine sulphate may be given at night, The child nurses every four hours only. Williams was the first to show that no tight binder is necessary, but only a support- ing bandage. The tight binder is a cruel and useless bar- barism that has been abandoned by progressive physi- cians. No massage is allowed; no pumps; no irritation whatever, and in twenty-four hours the trouble has dis- appeared. Hot dressings to the breast are equally ar- chaic. They should never be applied to any breast unless it is desired to hasten suppuration. If the child dies, or for any reason can not nurse (inverted nipple, cleft palate, harelip) and it becomes necessary to dry up the milk, the treatment for "caked breast" is continued. After twenty-four hours the breasts are comfortable and rarely give trouble again. Cracks, Fissures and Abrasions of the Nipple.—The care of the nipples should be inaugurated about six Aveeks before labor, as elseAvhere described: The nipple must be inspected and its possibilities determined, early in pregnancy, if possible, for many varieties of badly shaped and ill-developed nipples ex- ist A\liich may make nursing difficult or impossible. Imperfect nipples especially are predisposed to fissure and crack, and Avill require extreme care on the part of the nurse. She should inspect them before and after each nursing and sedulously use cleanliness and asepsis in her management. In normal and tranquil as Avell as in neurotic Avomen, the nipple may become so sore THE ABNORMAL PUERPERIUM 245 as absolutely to preclude nursing, and this entails much additional Avork on the nurse and mother, as Avell as considerable peril for the child. The condition usually begins as a fissure or crack, and is accompanied by much pain. It is serious, furthermore, in another aspect since all breaks in the surface of the nipple are avenues of infection that may result in mastitis. The Fig. 108.—Examples of imperfect nipples. (American Text Book.) child may produce fissures or abrasions by rubbing the nipple Avith his mouth, by pulling too hard, or by the habit of holding it in his mouth and macerating it Avith his gums when he has finished nursing. The child must not be left at the breast after he has nursed, but the nipple should be gently removed from the child's mouth by passing one finger in beside the nipple! Fissures and abrasions usually occur within ten days if at all. Abrasions or erosions are due to 246 OBSTETRICS FOR NURSES the wearing away of the epithelial covering of the nipple in patches more or less extensive. Thin-skinned blonde Avomen suffer more than those with dark, dense oily skins. A fissure is a distinct separation of tissue that goes deeply into the underlying substance. A crack is a long abrasion which may deepen into a fissure. Both fissure and crack may affect the top, the side of the apex, or the base of the nipple. They may be either longitudinal or circular. The entire nipple must Fig. 109.—A standard nipple shield. (American Text Book.) be kept under obseiwation and the instant a raAv sur- face is ■detected, treatment must begin. Compound tincture of benzoin, liberally applied, is a favorite and successful remedy. Our routine is to ap- ply a paste made of equal parts of castor oil and sub- nitrate of bismuth. This is put on after the child nurses, and must be removed carefully before the next nursing. Sometimes the child's stools become black and consti- pated and the trouble may be traced to imperfect re- moval of the bismuth preparation. THE ABNORMAL PUERPERIUM 247 Whatever medication is used, the nipple must be protected from injurious friction by the clothing. This is best done by the hat-shaped lead nipple shield, Avhich is placed over the nipple and held in place by a light binder. The shield should be boiled before use. To protect the nipple during nursing, a glass shield may be used for a day or so, but not long enough for the babe to get accustomed to it, else he Avill form a habit hard to break. This shield must be taken apart after use, Avashed and kept in saturated solution of boric acid until the next nursing. If all these measures fail, the fissure must be touched Avith a nitrate of silver stick once, or have a 2 per cent solution of nitrate of silver applied night and morning. It may be necessary to take the child from the breast for a day or so, in Avhich case he nurses the other breast and the side Avith the bad nipple is pumped. The care of the nipple is highly important since the apprehension and the actual pain of each nursing may prevent sleep, destroy the appetite, and diminish the milk. If begun early, most fissures Avill heal in tAventy- four to forty-eight hours. Mastitis.—From three to five per cent of lying-in Avomen have mastitis in the European clinics, but the records in America sIioav a much smaller number. The disease occurs most frequently in blondes and in primiparas. It is most apt to appear during the first tAvo Aveeks, when the congestion accompanying the new mammary function produces a stasis that favors the growth of germs, which may enter through the abrasion or fissures of the nipple produced by zealous activity of the child's gums. But it may also occur when the child's first teeth come and the nipple is again exposed to in- 248 OBSTETRICS FOR NURSES jury. At times it is impossible to find a plausible excuse for its occurrence. Mastitis is usually described in three forms: The (a) parenchymatous or glandular type, Avhich affects the substance of the gland or the enveloping connective tissue; in (b) subcutaneous mastitis the connective tis- sue beneath the skin is attacked; and in (c) the sub- glandular variety, the infection finds a lodging betAveen the gland and the chest Avail. Mastitis is ahvays due to the presence of micro- organisms Avhich in many cases gain access to the gland through fissures or abrasions by means of the lym- phatics. In other instances the germs may be in the blood and a local stasis may encourage the infection. Still again, they seem to enter through the normal nipple openings. Symptoms.—The parenchymatous inflammation begins with a chill, and the temperature promptly rises to 102° to 105° F. The pulse is high. The patient complains of headache and thirst. Examination reveals hard, tender nodules in some part of the gland. The skin may or may not be reddened. If the trouble has begun in the connective tissue, the skin will be diffusely reddened, the nodule ill- defined, the temperature will rise gradually and the chill may be absent. Treatment.—The breast is put at rest. No tight binder is applied, no breast pump, no massage. No heat is allowable. Ice bags surround the gland night and day. The liquids by mouth are restricted and saline cathartics given. Codeine may be administered for pain. Usu- ally the symptoms subside Avithout suppuration in from one to two days. THE ABNORMAL PUERPERIUM 249 Should the inflammation persist for more than tAvo or three days, in most cases the tissue Avill break doAvn and form a mammary abscess. AVhen it is evident that suppuration has begun, heat may be applied to the gland and the process accelerated. The abscess may be superficial or deep and aaIH be diagnosed by a bog- giness in a circumscribed area or by fluctuation. The abscess must be opened as soon as possible. The nurse sterilizes a bistoury and a pair of long artery forceps. Lysol solution and cotton sponges are made and sterile gauze for packing. The hands are surgically prepared and rubber gloves Avorn. If an anesthetic is required, gas may be used, or chloroform. The incision is made radially from the nipple so as to minimize the injury to the milk ducts. A gauze drain may be required for a feAV days. In the after-care, the nurse must be scrupulously clean and not convey contagion from the breast to the Avoman's genitals, to the child's eyes, navel or vagina, nor to her oavu person. Excess of milk is rare, but may be observed for a short time after the glands fill. It seldom requires treatment, but saline cathartics, restriction of fluids, and putting the child on a four-hour schedule Avill reduce it. Pads may be worn if it runs away freely. . Scarcity of milk is only too common. There may be enough at first and the quantity gradually diminish, or it may be deficient from the very beginning. The faulty secretion may be due to the age of the mother, to disease (anemia), to bad nutrition, or to overAVork. It may folloAV a premature child. Com- pression of the breasts by corsets or tight dresses may prevent de\relopment. The amount of gland tissue is very important. Many women have large, fat breasts, 250 OBSTETRICS FOR NURSKS but a small glandular development. Mental conditions, such as fright, worry, and anxiety, will diminish the floAv of milk or stop it altogether. Symptoms.—The child is fretful, goes to sleep after nursing but soon Avakes up, or may nurse aAvhile, and then finding it useless, will cry and refuse the nipple. He loses Aveight and Avhen Aveighed before and after feeding, the scales scarcely vary. No secretion or very little can be squeezed from the breasts. The child may be given a bottle after Avhich he goes to sleep. Treatment.—When the gland tissue is defective, no treatment can succeed. The appetite must be improved by bitter tonics and the mind relieved of its anxieties, if possible. Change of scenery may help. The fluids must be increased, milk, cocoa, chocolate and gruel must be pushed, and such vegetables added as corn and beets. Oyster steAvs, clams, lobsters, and crabs Avill help. The diet must be full and nutritious with especial stress on those foods that raise the blood pressure. Malt drinks or champagne may avail in some cases. Exercise in moder- ation is desirable. Artificial stimulation of the breast sometimes suc- ceeds. Massage Avill irritate the glands, increase the congestion, and promote functional activity; or a Bier vacuum apparatus may be put over the gland several times a day and the air pumped out, The breast should be kept distended for fifteen to tAventy minutes. There is difficulty in this country in getting glass bells of sufficient size. Galactorrhea is the name applied to an abundant se- cretion of milk poor in quality toAvard the end of a long lactation or after the child is Aveaned. The symp- THE ABNORMAL PUERPERIUM 251 tonis are an almost constant Aoav of milk Avith resultant anemia. Treatment.—Elix. of iron, quinine and strychnine with compression of the gland. A dry diet and the avoidance of all irritation of the breasts will aid. To "dry up the milk," folloAV the treatment for "caked breast." Quality of the milk may be such that the child Avill not take it or, if taken, it fails to nourish. In some cases this is due to overlong, or to irregular, periods betAveen feedings; for Avhen the nursing interval is too Fig. 110.—A standard breast pump. (American Text Book.) short, the milk becomes too rich, Avhen too long, it becomes thinner and less nutritious. Fright, anxiety or anger may change the character of the milk so that colic, vomiting, and diarrhoea and indigestion are produced in the child. A Avet nurse be- comes homesick and the milk dries up. It may become extremely indigestible, as shoAvn in cases Avhere a wet nurse quarrels Avith her husband and her foster child develops green stools. If the mother's milk does not agree, the child may be put on feedings for twenty- four or forty-eight hours, while the milk, pumped from the breast, is sent to a laboratory for analysis. If a 252 OBSTETRICS FOR NURSES return to the breast is unsatisfactory, artificial feedings or a Avet nurse must be supplied. Removal of the child from the breast may be re- quired for a variety of reasons. Thus, the mother's ad- diction to alcohol or opium is good ground for taking aAvay the child. Arsenic, bromides and iodides of potas- sium, saline cathartics, salicylates, alcohol, opium and bel- ladonna must be given to the mother with great caution during lactation, for they pass over into the milk. Acute diseases, such as erysipelas, pneumonia, diph- theria, typhoid, malaria, pronounced puerperal sepsis or persistently high fever from any cause, usually dries up the milk; Avhile cardiac lesions, unless Avell compen- sated, chronic anemia and tuberculosis, obviously de- mand the removal of the child for the sake of both. Sometimes a neAV conception, especially Avhen the milk becomes poor in the last half of gestation, compels the mother to Avean her babe. A syphilitic woman may nurse her OAvn child, pro- vided her condition is good and the child also is syph- ilitic. Theoretically, the return of menstruation in no Avay affects the nursing child, unless the blood is lost to the point of anemia. Yet cases do occur in Avhich the child has indigestion, colic and bad stools, as well as loses weight, Avhen the mother is menstruating. The quality of the milk is sometimes altered, but only for a day or so, and the child should continue at the breast unless some definite indication for removal arises. Weaning ordinarily is completed by the ninth month, but the child should never be carried beyond the tAvelfth month on account of changes in the character of the milk. THE ABNORMAL PUERPERIUM 253 AVhen a child is Aveaned, the substitution of an arti- ficial food may be made gradually,—a bottle a day, Iavo bottles a day, etc., until, in a couple of weeks, the breasts are at rest. The excessive prolongation of lactation is shoAvn upon the mother by impairment of the health. The patient is pale, Aveak, anemic, fretful, and thin. Head- aches, dizziness, loss of appetite, and constant fatigue Avill be complained of. The treatment is to remove the child at once and put the mother on stimulating drugs and foods. A change of air and scenery, if possible, Avill be highly beneficial. The wet nurse is ahvays a tribulation, Avhich must be endured until the child can be put on artificial food. She should haA'e a AVassermann test before entering upon her duties. Syphilis, tuberculosis, and gonorrhoea must be guarded against. She must be kept like the family coav, in a placid frame of mind, fed on nutri- tious food that is not too rich, and exercised enough to keep the blood circulating. Light houseAvork and duties that take her out of doors part of the time are adArisable. Her moral char- acter can only be assured through those Avho haATe knoAvn her. If she brings her oavii child Avith her, she Avill need Avatching to proAlde for an equable distribu- tion of the milk. The first feAV days is never a criterion of a Avet nurse's effectiveness. Change of food and surroundings may interfere Avith her usefulness. Gas may complicate the puerperium after Cesarean section, and even after normal labor. A rectal tube of soft rubber may be passed as high as possible into the boAvel and left for some time, or enemas of S. S., tur- 254 OBSTETRICS FOR NURSES pentine, asafcetida, or milk and molasses may be given. By mouth calomel or mag. cit. is valuable. Headache in the puerperium should be Avatched care- fully, and the cause discovered. Pain in the head may be a habit with the patient, or it may be a symptom of some complication either present or developing, such as toxemia, eclampsia, or acute yellow atrophy of the liver. In general, it is due to milder conditions like exhaustion, too many visitors, excitement, nerves, or insomnia. After-pains.—Sometimes patients are greatly annoyed by after-pains. The pain may be due to a clot retained in the uterus or possibly a stimulation of the uterus Avhen the child goes to breast. Gentle massage of uterus, or ergot, quinine, or codeine may be required to bring about the expulsion of the clot or to control the pain. A reasonable degree of after-pain is of favorable sig- nificance. (See p. 154.) CHAPTER XVII INFECTION Puerperal fever is a Avound infection. The conditions of the pelvic organs during labor and post partum, are Avell adapted to receive and develop microorganisms, for the healthy antimicrobic poAver of the vaginal secretion is absent or diminished. A long and exhausting labor, possibly accompanied by hemorrhage, or terminated by an operation, has diminished the immunity and broken the resistance of the tissues to a dangerous degree. The mucous membrane of vulva and vagina are torn and bruised, the vitality loAvered, and the surface cov- ered Avith bloody lochia, AArhich is an excellent nutri- tive medium for microbic development. The uterus is a vast, open wound, filled Avith fibrin, blood clot, and decomposing tissue, Avhile the Avhole pelvis is main- tained at exactly the proper temperature for germ propagation. Through these Avounds, toxins are carried into the circulation, and germs, nourished upon the abundant and favorable culture media, pass through the uterine walls or by way of the lymph channels first into the adjacent tissues and thence to all parts of the body. Certain definite organisms reach the disintegrating tissues and produce a putrefaction. They do not, hoA\- ever, once their Avork is done, pass into the body. But in producing putrefaction, they also produce injurious poisons, called toxins, Avhich do enter the body and cause an absorbtive fever known as sapremia. 255 256 OBSTETRICS FOR NURSES A~ 3% r^' 4 if \ - X & « *"/.* ,,t> \. ♦>«♦''< •>- \>; |V *>,# »';. 1 " ^ -■ fa* *l .♦,«- •: "'. i* *« Fig. ill.—Germs most frequently found in cases of puerperal fever. (Kellv's Gynecology.) 1, streptococci (in chains); 2, gonococci; 3, tubercle bacilli (not a source of puerperal infection) ; 4, bacillus coli communis; 5, staphylococcus pyogenes aureus; 6, bacillus aerogenes capsulatus. INFECTION 257 Other organisms are the pus microbes, Avhich begin their groAvth in any favorable location and continue to spread and flourish onward and imvard by blood vessel, tissue or lymphatic, until overpoAvered by the resistances of the body, or until by general sepsis, they have killed the patient. These are the streptococcus, staphylococcus, bacillus coli and bacillus pyocyaneus. These are the germs that the nurse or the doctor may bring to the patient on hands, clothing, or hair. These are the organisms against Avhich our scrupulous asepsis and antisepsis is directed. It is against them and their activities that the doctor and nurse prepare by the long and painful scrubbing of the hands and elbows, the rubber gloves, by the shaving and scrubbing of the patient, and by all the paraphernalia and equipment that go to furnish the modern lying-in- chamber or delivery room. It is on account of these germs that the con- scientious doctor or nurse lies awake nights and pain- fully reAdeAvs his teclmic Avhen his patient has a temper- ature, and it is on their account that he shudders at the callous disregard of human life that is shoAvn by those Avho do not observe the knoAvn laAvs of asepsis. It is true that many Avomen escape Avhen the attend- ant is unclean, but this is due to a splendid immunity, and in no Avay absolves the man or Avoman Avho neglects his asepsis and has patient after patient running tem- peratures, some of Avhcm arc bound to die or be crip- pled for life. It is for this reason that a surgeon should do surgery and not general practice; it is for this rea- son that an obstetrician should limit himself to the care of Avomen in childbirth and not endanger them by taking cases of scarlet fever, erysipelas, and unclean surgery. In country practice, all kinds of work must be done 258 OBSTETRICS FOR NURSES since there are not enough men to specialize, but it is inexcusable in the city Avhere a man can ahvays be clean and keep clean, if he is Avilling to forego the in- come derived from attendance upon septic and infec- tious cases. Any article not surgically clean may contaminate the patient by contact; but ulcers, sup- purating wounds, abscesses, and hands improperly or insufficiently cleaned are the deadliest causes of post partum temperature. Infections are said to be either self-produced or brought to the patient from Avithout. The only organism that is demonstrably self-infec- tious is the gonococcus, which may be present in the vagina before labor and may infect the puerperal woman; but it is wiser, safer, and more nearly accords Avith the facts, to regard all infections as alien borne, as brought to the patient and introduced by the unclean hands or instruments of her medical attendants. Prevention.—A conscientious and capable nurse or doctor Avill not go from an infected case to a confine- ment. Both will keep their bodies clean, the teeth filled, and pyorrhoeas scraped and treated. The occur- rence of pus anywhere on the body is sufficient reason for the doctor to give up his confinements for a time, and the nurse to report off duty. No raAv, and but few mucous surfaces should be touched by the fingers of the attendants, Avhere a ster- ile instrument can be used. The nurse should neArer make vaginal examinations unless an emergency exists, and then only Avhen her instruction has been thorough and her experience great. Every examination is a possible source of danger, no matter Iioav carefully the hands and patient are pre- pared. The nurse is not to change the pads without INFECTION 259 Avashing her hands, and she must Avash her hands al- Avays after changing the pads, before dressing the navel of the child. The navel or eyes of the child may be infected easily by the hands of nurse, doctor, or patient. The breasts of the mother may be infected by the hands of nurse, doctor or patient. The vulva and vagina of the puer- peral Avoman is highly susceptible to infection from the hands of nurse, doctor or patient. Rule.—All temperatures arising in the puerperium are due to infection, unless satisfactorily explained by find- ing the source. The possibility of a slightly elevated temperature from insignificant causes may be kept in mind, but such temperatures are transient and yield quickly to appropriate treatment or to none at all. Puerperal infection is most apt to appear during the first Aveek of the lying-in period, and it generally de- velops about the third or fourth day post partum. If the symptoms come on later than this, there is ahvays a hope that the infection has taken its origin in some- thing else than the labor. Symptoms.—In mild cases, a rapid pulse, headache, and a temperature of 101° or 102° F. may be the only symptoms. Severe cases begin Avith a chill, folloAved by a marked rise of temperature. The temperature is al- ways irregular and generally remittent. The pulse rises to 120 or 130 beats a minute, headache and prostration appear, occasionally associated Avith vomiting. The floAV of lochia may be either increased or dimin- ished and either offensive or free from odor. Foul- smelling lochia is a sign of putrefaction but not nec- essarily of sepsis. At the same time there is some tenderness in the 260 OBSTETRICS FOR NURSKS loAver part of the abdomen, usually most marked at the sides of the uterus. The uterus is larger than it should be, and not hard, but doughy and sensitive to touch. The involution is arrested, except in cases of pure septicaemia. This is an important reason for the daily observation and recording of the regular descent of the organ. The disease runs a variable and more or less pro- longed course and the prognosis is ahvays doubtful un- til the event. Signs of graA^e import are: repeated chills, insomnia, pulse above 120, persistent Amounting and meteorism, Avith dry, broAvn tongue. Treatment.—Mild cases without chill when the uterus is large and the lochia sometimes offensive, are usually sapremie. Free catharsis, ergot in full doses, and a half sitting position to aid drainage Avill cause the symptoms to subside in tAvo or three days. In the severe type, the treatment is mostly a case for careful nursing. The more energetically the doctor acts, the more liable he is to do harm. The patient needs all her strength to fight the disease, and should not be required to fight the consequences of injudicious interference. There is still some discussion about the advisability of assuring oneself that the uterus contains no remnants of the labor. Some feel that this should be determined by curetting the uterus Avith finger or instrument and folloAving the operation with an intrauterine douche. If this is the vieAv of the attending man, the nurse must aid, for the responsibility is his and not hers. On the other hand, the aveight of authority at pres- ent seems inclined to the vieAv that any remnant of the labor Avill drain out naturally or be expelled by ergot- INFECTION 261 driven contractions Avithout the necessity of opening up neAV raAV surfaces by interference and thus spread- ing the infection. The main idea is to promote drainage in every Avay possible. No curette, no douche, no uterine packing. Nevertheless, the vulva may be cleansed and the vagina carefully retracted and by appropriate means a culture obtained from the uterus. If this shoAvs streptococci, all local treatment is to be abandoned at once. In general, the food must be fluid, and as nutritious as possible. This means milk, beef and mutton broths, oyster stew, etc. The nourishment must be pushed art- fully and ingeniously. Alcohol is not indicated. The bowels are kept open. Normal saline, drop method, by rectum, Avill pro- mote diuresis, skin action, and supply the body Avith the much needed fluid. Subinvolution is controlled by er- got in full doses. The room must be light and as many AvindoAvs opened as the Aveather Avill permit. Frequent change of posture, from side to side, from dorsal to prone and especially to the half-sitting position, Avill give the patient comfort and prevent decubitus (bed sores). The daily bath Avith an alcohol rub, keeps the skin in good condition and eases the mind. The child should be taken from the breast, because the milk is poor in quality and quantity and it may be infectious. Besides, the mother needs all her strength. Nature usually solves the problem by dry- ing up the milk. All pads soiled by the patient should be collected in paper bags or rolled in neAvspapers and burned. Sheets, tcrwels, and pilloAV slips must be boiled in the house and not sent to the laundry. They should be soaked for half a day in a 2 per cent solution of lysol 262 OBSTETRICS FOR NURSFS before being Avashed, and exposed to the hot sun for a day or so afterAvard, if possible. No comforts should be used on the bed, and the blankets must be left sus- pended in the room when it is fumigated at the con- clusion of the case. All dishes and utensils can be boiled. Plenty of air and sunshine are essential for the cure of the patient and to prevent the spread of the disease. The nurse must use every precaution to avoid carry- ing the infection to herself or others. Rubber gloves should be Avorn A\liile changing the dressing. It is bet- ter to haAe the child cared for by another nurse. The nurse must get her rest and some exercise out of doors every day. It rejuvenates her and reacts to inspire the patient. When she leaves the case the nurse should boil her linen and Avash her hair Avith soapsuds and hot water, and bathe frequently. Milk Leg.—This is an infection characterized by SAvelling of one, or rarely, both, limbs, from the foot to the groin. The leg is Avhite from the edema, and as the condition is associated Avith fever and since the milk diminishes or disappears about the same time, it Avas thought in former days that the milk Avent to the leg. The cause of the swelling is a phlebitis of the exter- nal iliac or femoral vein which becomes thrombosed or so filled with clots that the return circulation is impeded. Symptoms.—The attack is signalized by a rise of tem- perature to 102° to 104° F. There is headache, pain in the affected limb, and general prostration. It is a true sepsis. The disease appears usually in the latter part of the INFECTION 263 second week of puerperium, A\lien the patient has be- gun to congratulate herself that all danger is over. In many cases the doctor has yielded to importunity and let the patient get up before involution Avas suf- ficiently advanced and the patient will report that she got up too early. The limb must be immobilized and kept Avarm. The immobility should be maintained for at least ten days after the fever has subsided and the pain gone. The convalescence may be protracted over Aveeks and months. Bed sores may complicate a long convalescence. Bath- ing Avith alcohol or alcohol and alum, and the frequent change of the patient's position will usually prevent them. Rubber rings and sheeting should not be used if it can be avoided. Ointments containing zinc are of great value in the cure of this affection. Phlebitis, in minor degree or in localized sections, may occur in the Areins of the leg and the site of the invasion Avill be outlined as red lines or as irregular nodules. Some feA^er may attend the condition. Resl of the affected member, Avith ice bags for the pain, con- stitute the treatment. Bed sores must be guarded against. Sudden death in the puerperium is a shocking dis- aster. Rapid death may folloAV the complications of labor accompanied by hemorrhage, such as placenta previa, rupture of the uterus, etc.; but death may be sudden, without warning, from pulmonary embolism, acute myocarditis, fatty degeneration of the heart, or the entrance of air into the uterine veins. This may happen several days after labor in a woman Avho is passing through a convalescence apparently normal in every respect. Such an event is probably due to a thrombus Avhich may form in any of the veins of the 264 OBSTKTHICS FOR NCRSKS body, but more frequently in those of the pelvis and legs. In the latter it may be recognized by hard lumps that form someAvhere along the course of the veins in consequence of a phlebitis. There is ahvays the men- ace that some fragment of this mass, Avhich is merely a hard clot of blood, may become detached and float off in the circulation to other parts of the body, such as heart, lungs, or brain (embolism), and by inter- ference Avith those structures, produce paralysis or in- stant death. AVhen a thrombus is diagnosed, the af- fected part must be kept as quiet as possible. No massage is permissible. Tincture of iodine or 20 per cent ichthyol may be applied. The woman should re- main quiet for at least ten days after the apparent disappearance of the symptoms. CHAPTER XYI1I THE CARE OF THE CHILD Hitherto the mother and the complications and changes peculiar to her condition have been selectively considered, to the neglect of the child; but the labor being over, and the nurse having assured herself that the uterus is hard, that there is no hemorrhage, and that the mother is resting, iioav turns to the child ly- ing in its blanket. A hot Avater bag, carefully tested, should lie at its feet Avrapped in toweling or napkins. The eyes have already received the Crede treatment, 1 per cent solution of silver nitrate or possibly a 15 per cent solution of argyrol for prevention of ophthal- mia, and a thorough cleansing comes next. In a warm room, away from drafts, the nurse takes the child in her lap, or on a table, with a blanket under- neath. She first anoints the child all over, either with benzoated lard, liquid albolene, sterile vaseline, or ol- ive oil. This softens the vernix caseosa that covers the child and aids its remoA^al. The skin is wiped carefully with cotton or a soft cloth, paying particular attention to the folds of the groin, the arm pits, and the genitals. The nostrils are gently wiped out Avith applicators clipped in oil. The child must be covered as much as possible dur- ing the operation and the work finished quickly. The Avhole period should not exceed tAventy minutes. During the cleansing process the nurse should look closely for anomalies or anatomical imperfections, like an imperforate anus or urethra, supernumerary digits, etc. 2fio 266 OBSTETRICS FOR NURSKS The Bath.—Daily, until the cord conies off, the baby is sponged Avith oiled pledgets, folloAved by a spray bath, or a sponging with lukewarm Avater and castile soap. The child must not be put into a full bath tub on account of danger of infecting the umbilicus. The bath Avater in a tub or basin quickly becomes filled Fig. 112.—Rubber bath tub. Avith bacteria from the surface of the child's body and may be conveyed quite easily to a raw wound. All discharges must be Aviped away, and the buttocks cleansed Avith oil. If the skin becomes irritated by urine or otherwise, the child should be Avell covered Avith talcum powder, especially in the folds of the groin CARE OF THE CHILD 267 and in the genital crease. All infants are benefited by a little mild massage after the bath. If other babies are handled, a child with infected eyes, or skin eruptions, must be quarantined and cared for separately by a special nurse. The color of the skin should be pink, changing under manipulation to red. If there is mucus in the mouth, it may be Aviped out Avith an applicator, if in the throat, the child may be held up by the feet and the head drawn back for a feAV minutes so that gravity will aid the discharge of the obstruction. After cleansing the skin, the nurse sterilizes her hands and dresses the cord. The gauze which Avas temporarily Avrapped around the stump is removed, the cord and adjacent skin Avashed Avith alcohol and dried. The stump is powdered above and at the sides Avith a mixture of equal parts of boric acid and subnitrate of bismuth, and then wrapped in gauze. The band is put on, the temperature taken, and the baby dressed. Some physicians prefer to have the cord dressed in 95 per cent alcohol, A\liich is frequently reneAved. The normal separation of the cord takes place through a kind of dry gangrene, AA'hich should be favored by dry rather than Avet dressings. The 95 per cent alcohol does not remain at 95 per cent after it is exposed to air, hence it does not absorb moisture from the cord as absolute alcohol would. However, the attending man is respon- sible, and his orders must be followed. The Umbilicus.—The cord may be severed as soon as the child has cried lustily or the cessation of pulsa- tion may be aAvaited, in either case the child secures a little more blood, Avhich gh^es him a better start in life. Tavo tapes are tied about the cord, one close to the 2(i,S OBSTKTKICS FOR N'CRSKS skin margin of the child and the cord is cut between them. A kind of mummification or dry gangrene nor- mally develops and the stump falls off, as a rule, about the fifth day, leaving a moist, granulating area, Avhich forms the umbilicus. A metal clamp may be used in place of a tape to com- press the cord. The advantage of the clamp is that on account of its greater width and rigidity it does not cut through the cord when applied. Furthermore, it can be made and kept more nearly aseptic. It does not soak up the juices from the cord and form a culture medium for germs. It can be removed on second day. Fig. 113.—The Pettit cord clamp. The cord usually comes off a day or so sooner than Avhen the tape is used. The care of the cord is extremely important, as many infections can be transmitted through it to the child. At each dressing the cord is inspected, and Avhether it is dry or moist, offensive or inodorous, should be noted. These facts, with the falling off of the cord, are put down on the history sheet as they are observed. The binder, after each removal, is not pinned, but sewed on. The sewing should begin beloAv and go up in or- der to have the tightness Ioav down. Eyes.—After the first instillation of silver nitrate so- CARE OF THE CHILD 269 lution, a reaction appears Avith redness, swelling, and discharge, AArhich passes off Avithout treatment in two or three days. During the bath, care must be used not to get anything into the eyes nor anything from the eyes or nose upon the navel. At each dressing the nurse should irrigate the edges of the lids gently Avith boric acid solution. If the eyes become red, SAvollen, and have a purulent discharge after the second day, the case is possibly ophthalmia and they must be Avatched Avith extreme vigilance. A smear should be taken for the microscope and prepa- rations made for energetic treatment. The folloAving summary may be of service in memo- rizing the routine of nursery procedure. Nursery Rules 1. Keep temperature of nursery 68° to 72° F. 2. During bath, keep temperature of nursery 75° to 80° F. 3. Temperature of bath -water 98° to 99° F. 1. Never use a diaper that has not been laundered. 5. Tie case number on child's arm before leaving delivery room. 6. Watch cord for haemorrhage. 7. Record temperature, stools and urine. s. (live water freely between feedings. 9. Put to breast twelve hours after birth, and every three hours thereafter until the child begins to gain, then one and possibly (?) two night feedings may be omitted. 10. Change binder daily. 11. Oil bath first, then shower bath on subsequent days. 12. Dress cord with alcohol 95 per cent, dry and apply bismuth subnitrate and boric acid powder (equal parts) into crevices beneath clamp or tape and under edges of the crust. Change dressing daily. Cord should fall off fifth, day. Report failure to do so. 13. Clamp may be removed on second day. 270 OBSTETRICS FOR NURSES Routine for the Child.— 1. Temperature. 2. Undress. 3. Weight. 4. Shower bath. 5. Dress cord—record condition. 6. Binder daily until discharged. 7. Diaper and dress. 8. Sponge eyes with boric solution. 9. Cleanse nostrils with albolene. 10. Brush hair. 11. Drink of warm water. 12. Observe case number daily. Clothing.—(See Infant's Outfit, p. 101.) The cloth- ing must be light, loose, Avarm, and not irritating to the skin. The outside garment should have Aving sleeves Avhich permit free motion of the hands, but do not per- mit them to reach the eyes. The band of plain outing flannel should always be Avorn for the first feAV weeks. Birds-eye linen makes the best diapers on account of its superior absorbent qualities. The feet must be kept Avarm by stockings, and arti- ficial heat, if necessary. On hot days much of the clothing may be removed and the shirt, band and dia- per may be all that are needed. The care of the shirts and bands is part of the daily duty of the nurse. They must be washed daily, cither by the nurse herself or under her supervision, as they are easily injured. After Avashing, in soft water, if possible, and with wool soap, they must be dried on a stretcher. Diapers must be put directly into cold water. Feces may be brushed off with a Avhisk broom, and the napkin rinsed, boiled and again rinsed. No diaper should be used a second time until this has been done. No bluing may be used on the diapers and the soap CARE OF THE CHILD 271 must be mild, otherAvise chafing and intertrigo Avill folloAV. The infant's toilet basket must contain: •4 soft bath towels. 1 pound of absorbent cotton. 1 dozen wash cloths of soft material. 1 small hair brush. 1 pair nail scissors. Talcum powder. Bath thermometer. Hot water bottle. Albolene. Castile soap. 8 oz. boric acid solution. S oz. benzoated lard. Paper bags for waste. Pitchers and basins. A B C D E Fig. 114.—A, standard breast pump; B, standard nursing bottle; C. the breast tray; D, the Wansbrough lead nipple shield; E, the Brophy nipple for harelip and cleft palate. Weight.—The Aveighing of the child should precede, for convenience, the first cleaning of the skin and the daily bath. The child is either put on the scale naked or Aveighed in a blanket, and the weight of the blanket, 272 OBSTETRICS FOR NURSES ascertained before or after, is subtracted. The daily Aveight record is just as important as the temperature. A scale that registers ounces and fractions thereof must be used, and the child should be guarded from falling during the performance. Usually the child loses from eight ounces to a pound the first Aveek, but it should gain back to its birth Aveight, by the end of the second Aveek. If the child does not gain, it may be due to lack of milk from the breast, and the Aveight may be taken before and after feeding to A-erify or refute the suspicion. The mouth should be inspected each morning, but not cleansed Avith the boric acid solution unless def- initely indicated. Spots or any unusual appearance should be reported. The Genitals.—The vulva of the female infant usu- ally requires but little care besides cleanliness. There is sometimes a whitish discharge Avhich disappears spon- taneously in a feAV days. It is a drainage of vernix, smegma and epithelium from the vagina and labia. AVith a male, the prepuce must be inspected Avhen the child is about a week old. If it is long and the orifice small, circumcision may be suggested! Under any circumstances, the foreskin must be retracted, the iidhesions broken up, and the smegma removed. This must be repeated daily until the adhesions do not re- cur. The maneuver should be done the first feAV times by the physician, for fear of a paraphimosis. Sleep in the neAvborn is normally quite deep and al- most continuous, probably tAventy-tAvo hours a day, for the first Aveek. The rather fast respiration of the child, even Avhen sleeping, is no cause for alarm. A healthy infant breathes about twenty-five times a minute. The child should not be rocked, carried about, exhibited, or CARE OF THE CHILD 273 handled more than necessary. It should not sleep Avith the mother, lest it become too hot or too cold, be over- whelmed by bedding, or OArerlaid by the mother. Bowels.—The first stools are black and tar-like,—this is meconium. It disappears by the end of the first Aveek. The presence or absence and the character of an evacuation, as Avell as the number in twenty-four hours, must be daily recorded. For a breast-fed child, there should be three or four a day, for the first ten days and the number should gradually diminish until a routine of tAvo a day is obtained. The diaper of bird's-eye linen should be large and thick; tAvo may be used if required. They should be carefully Avashed after soiling. Bluing must not be used, because A\'here this substance comes in contact Avith the skin, irritation folloAvs. Weaning should be brought about by the gradual substitution of other foods, someAvhere betAveen the sixth and tAvelfth months. Urination should be copious. The child is ahvays wet, and frequent changes are necessary to keep the skin from getting raAv and sore. Both boAvels and bladder should be emptied Avithin the first tAventy-four hours. Failure to do so should be reported, as an imperforate anus or urethra may exist. Frequently a piece of ice Avhittled out like a lead pencil and passed into the rectum Avill stimulate urina- tion. Catheterization is practically never necessary. The child may go three days Avithout injury, but the con- dition of the bladder above the pubes must be atten- tively Avatched and its degree of fullness appreciated by percussion. Nursing.—The child should be put to the breast 274 OBSTETRICS FOR NURSES tAvelve hours after birth and every three hours there- after—no more and no less Avithout definite reasons. If the child is strong and vigorous, only one feeding may be given at night, and even this may be omitted in some cases A\rhere the child gets an abundance of food. Six or seven feedings a day are enough. The child should stay at the breast from fifteen to tAventy min- utes, depending on its activity and the rapidity of the Fig. 115.—Proper position of mother while nursing child. (Witkowski.) milk floAV, and then be removed. It must not be per- mitted to sleep at the breast. ('are must be used that the child gets the nipple over the tongue and not under it. Many infants have to be taught to nurse. This may be due to a lack of strong animal instinct in many cases. There may be an abun- dance of milk and a good nipple, but the child Avill not learn to nurse Avithout a vast expenditure of time, pa- tience, and energy on the part of the nurse, Squeezing a little milk into the mouth or filling a nipple shield CARE OF THE CHILD 275 Avith milk will sometimes aid in educating the infant, or even starting the supply with a pump, as many nurses do, is advantageous. Certain drugs, like castor oil and turpentine, taken by the mother, may affect the taste of the milk, and be reason enough for the refusal of the child to take hold. Other drugs like mercury, arsenic, potassium iodide, and alcohol may go over in the milk to the nursing child. If the child is Aveak or premature, the milk must be pumped from the breast and fed to it until strength comes. The difficulty about this is the bad habit ac- quired, but there is no Avay to avoid it. A child should get at each feeding half an ounce of milk to each pound of Aveight. The capacity of the stomach at Ararious months is given by Hirst as, first Aveek, 1/2 oz.; second Aveek, 2 1 2 oz.; third and fourth week, 3 oz.; third month, 5 oz.; fifth month, 9 oz.; ninth month, 12 1/2 oz. Holt says that the capacity at birth should be one ounce, and increase at the rate of an ounce a month up to the sixth month. As hunger stimulates the gastric and salivary glands, so the sight of the child arouses some emotional cen- ter in the mother, Avhich starts the milk, and the mouth of the child provides an additional stimulus of great poAver. About fourteen ounces is secreted by the sca'- enth day, and after the second month the daily average rises to three or four pints. Milk secretion is favored by drugs and foods that raise the blood pressure and di- minished by substances that loAver the blood pressure. There may be too little milk in the breasts, and if so, the child Avill lose Aveight daily; also the child will Avaken before nursing time, fret, refuse Avater, but greedily seize the nipple if it is presented. It Avill con- tinue to nurse long after its time is up and cling and 276 OBSTETRICS FOR NURSES cry when removed. The breast itself may seem flabby and loose, and no milk, or xevy little, can be pressed from the nipple. Normally, the breasts feel full and tense, both to pa- tient and nurse, just before feeding time. The real test, hoAvever, is in taking the Aveight of the child be- fore and after feeding. Where the milk is insufficient, the scales will not vary, and after a feAV repetitions the nurse can be certain. An infant should be handled as ? r / Fig. 116.—Proper method of taking rectal temperature. little as possible after feeding lest the milk be vomited. Temperature of the newborn child varies from !)S to !)9° F. It should be taken morning and evening, or oftener, if complications are suspected. The temperature often goes up on the third or fourth day, and may stay up for several days. This phenom- enon is called by some a starvation or inanimation fever. The temperature may go to 106° F. and the rise is gen- erally associated Avith a hot dry skin, dry lips, weak CARK OF THE CHILD 277 pulse, restlessness, and great prostration. The fon- tanelle may be sunken and the cry sinks to a fretful, feeble Avhine. It is important that the fever should be recognized and treated, since the condition may terminate fatally. The etiology is obscure. The fever should not be confounded with pyogenic infections, for these rarely begin before the fifth or sixth day. The treatment is simple. (Jive Avater regularly every Iavo hours by mouth, and rectal flushings of normal sa- line twice daily. The symptoms rapidly subside if the child is properly nourished. I lence the breasts should be inspected and the child Aveighed before and after feed- ing. Usually the milk is poor and scanty. If the tem- perature does not soon fall the child should be put to an- other breast or artificial feedings should be instituted. CHAPTER XIX THE CARE OF THE CHILD (Cont'd) Heart.—The heart tones while in the uterus may vary betAveen 138 and 150 per minute, but when higher than 160 or lower than 120, danger is near. After delivery, the heart runs from 130 to 140, and during the first year gradually drops to 115, approximately. Asphyxia neonatorum is a condition, Avherein, for some reason, the child fails to breathe after delivery. Out of every one hundred babies born, about six will die at birth or A\rithin the first ten days, and a large proportion of them from asphyxia in some form. Asphyxia is found in two degrees: asphyxia livida (blue) and asphyxia pallida (white). In the first, the child is deeply cyanosed. This may be due to patency of the foramen OArale, and yet it is a question whether this cyanosis is not really a normal process. The child does not undertake its first respira- tion because it needs oxygen, but because an excess of carbon dioxide (C02) in the blood acts as a stimulant to the respiratory center, Avhich is thus set to Avork, Avith the result that oxygen is taken in. The blue asphyxias, therefore, may be only the first step in the physiological process of respiration. In these cases, the pulse is strong and full, and the muscular tone is preserved, as well as the sensibility of the skin. In the second degree, the condition is quite different. The face is pale though the lips may be blue. The heart is irregular and many times can not be felt. The cord is soft and flaccid, with its vessels nearly 278 CARE OF THE CHILD 279 empty. The reflexes are abolished, the skin and ex- tremities cold. A feAV convulsive efforts at breathing may occur, but they soon cease. Treatment is directed first, to opening up the respira- tory passage. The child is held up by the feet so the mucus, blood, and fluids may escape from the mouth. Compression of the chest Avail Avill aid. The tracheal catheter is passed into the trachea and the mucus sucked out. Next, the skin reflexes are stimulated by slapping the back, or buttocks, and by blowing upon the face. Fig. 117.—Method of passing the tracheal catheter. (Hammerschlag.) The child at this time may be dipped in a tub of very Avarm Avater, (112° F.) and the chest and face sprinkled Avith cold Avater. Mean while, Laborde's method of traction on the tongue may be tried. The tongue is seized with tongue forceps (handkerchief, napkin, or piece of gauze will do) and rhythmically draAvn out and released about ten times per minute. Further, the Byrd method of artificial respiration must be employed. 280 OBSTETRICS FOR NURSES The back of the child is held in the right hand, so that the thumb and forefinger grasp the neck loosely, Fig. 118.—Byrd's method of artificial respiration. Extension and inspiration. (Edgar.) Fig. 119.—Byrd's method of artificial respiration. Beginning flexion and expiration. (Edgar.) the other hand holds the buttocks from behind and the body is slowly but firmly flexed betAveen them until the thorax is compressed, then the grip is relaxed and CARE OF THE CHILD 281 the body Avidely extended to alloAv the air to rush into the lungs. This maneuArer should be repeated about tAvelve times per minute. AVhen the heart ceases to beat, the child is dead and respiration can not be established. The same treatment is employed for the apnoeic child born in Casarean section and the oligopnocic child born under "TAvilight Sleep." The method called "Schultze Swinging" is not to be recommended generally, on ac- count of the chilling Avhich is so necessarily associated Fig. 120.—Byrd's method of artificial respiration. Flexion and com- pression. Note position of child which aids the escape of fluids from the mouth and nose. (Edgar.) Avith the exposure. The nurse should learn to practice all these methods of resuscitation. After the child breathes it must be Avatched carefully for at least forty-eight hours, lest the symptoms recur, and the child die. Asphyxia Neonatorum— (a) Livida—body congested—blue. (b) Pallida—body limp and pale. llemcmbcr possibility of patent foramen ovale. 282 OBSTETRICS FOR NURSES Etiology.—■ Too long compression of cord. Diminished irritability of medulla. Compression of brain during extraction. Shock during version. Aspiration of mucus. Treatment.— Hold child by heels with head pulled back to straighten the trachea, and wipe out mouth and pharynx gently with cotton wound about the finger. Stimulate skin reflexes by slapping and blowing. Tracheal catheter, artificial respiration (Byrd) 8 to 10 times per minute. Hot and cold bath alternately—rub the skin and knead the muscles. Laborde's method of traction on tongue 10 to 12 times per minute. Continue efforts so long as heart beats. Convulsions occur not infrequently during the first feAV weeks. They may develop as a result of injuries to the head during labor, or as a symptom of toxaemia. They may arise from constipation, from intestinal indi- gestion Avith curds, from fever or from hamophila. Meningitis and other infections are associated Avith this symptom, and occasionally atelectasis. They may also be the manifestation of a spasmophilic diathesis. The attack may begin Avith such premonitory phenomena as restlessness, muscular tAvitching, and staring of the eyes, but more frequently the onset is Avithout warning. The facial muscles are contracted, the neck thrown back, the hands clenched and the extremities spasmod- ically cramped and tightened. There may be frothing of the mouth and consciousness is lost. Respiration is feeble, shalloAv and irregular. The face is discolored and strange rattling noises come from the larynx. The boAvels and bladder may move involuntarily. The at- tack lasts from a feAV minutes to half an hour. CARE OF THE CHILD 283 Convulsions are not serious in all cases. The responsibility for the management of this com- plication usually falls upon the nurse. She calls the doctor, to be sure, but the attacks in many cases have ceased and the child may either be dead or out of danger of a recurrence before his arrival. The hot bath is a universal remedy and quite as effi- cient as anything. The temperature should be taken and the bowels Avashed out. If the fontanelles are tense AA'hen the doctor arrives, a spinal puncture may relieve the tension. A specimen of the blood is draAvn through a needle and sent to the laboratory for examination. The cause must be found, if possible, and removed. A change of food may be all that is required. Cod-liver oil may be added to the diet in dram doses, three times a day, and milk curds, suspended in arroA\-root Avater. For the acute condition, chloral hydrate is best. It is given by rectum, one or tAvo grains in an ounce of Avater, and may be repeated in four hours. Atelectasis is the name gh-en to a failure of the lungs AAdiolly to expand during the efforts at respiration. The child may live for Aveeks Avith this affection, but usually it expires Avithin a feAV days. In this condition, the child has a constant tendency to get blue, the color deepens, and death may occur in spite of eArery aid. The treatment may be perma- nently efficacious in some cases, but in most, the revival is only temporary. Again, the child may live, but in a Aveakly, declining state for days, until death comes. Aside from the physical signs of dullness elicited by percussion over the lungs, the most conspicuous symp- toms are the cyanosis and the intermittent but persistent whining cry. 284 OBSTETRICS FOR NURSES Fig. 121.—Method of giving gavage. (Grulee.) Treatment is by daily or hourly spanking, and by al- ternating hot and cold baths, by sprinkling with cold Avater or by massage to stimulate the skin reflexes. The treatment may have to be repeated every tAventy or thirty minutes, and the earlier it is instituted, the more persistently carried out, the more chance of success. Exercise is just as important to the infant as to the CARE OF THE CHILD 285 adult. The kicking of the legs, moving of the arms and lusty cry are all means of stimulating'the circulation, the muscular development, and the expansion of the lungs. The position should be changed occasionally in the crib from back to side and from side to back. Also the child's legs and back should be rubbed and mas- saged until the skin is red every time the bath is given. Flushings.—The child is laid across the lap, or on a table. A rubber sheet is so arranged that the discharge Avill drain aAvay. A soft rubber catheter, No. 18-20 French scale, is attached to a small funnel. The apparatus is boiled and filled AA'ith normal saline, or sterile Avater, at a tempera- ture of 85° F. to 95° F. Half a pint to a pint may be required. The catheter is oiled and passed into the rectum just beyond the sphincter. It must not go farther. The funnel is then raised and the fluid Aoavs into the boAvel. This flushing must not be confused Avith the administra- tion of an enema for constipation, for Avhich, hoAvevcr, it is often an excellent substitute. Gavage is forced feeding by means of a tube. A soft rubber catheter or tube, about No. 7, French scale, is lubricated Avith albolene, Aaseline or SAveet oil. The up- per end is connected Avith a small tube or glass funnel holding two or three ounces. The child is laid upon its back in the arms of mother or nurse, the baby's arms are held and the head steadied. In case of diphtheria or scarlet fever, the tube may be passed through the nose and doAvn the pharynx and into the o'sophagus five or six inches, or even into the stomach. It is more convenient and easier Avhen possible to pass it through the mouth directly into the stomach. 286 OBSTETRICS FOR NURSES The food is then poured into the funnel, A\liich, by ele- vation, empties itself into the stomach. If regurgitated, more food must be given. When AvithdraAvn, the tube should be pinched to prevent leakage into the trachea. Fig. 122.—Apparatus for gavage or lavage. (Tuley.) The great danger in these cases is the ease of over- feeding. Lavage or washing of the stomach may be performed in the same Avay Avith the above apparatus, when neces- sary. As soon as the stomach is filled, the tube is lowered and the fluid siphoned out. CHAPTER XX THE CARE OF THE CHILD (Cont'd) Tongue-tie is not met Avith so frequently as in the old days. If the child can suck and nurses energetically, this complication can be excluded. It may, hoAvever, occur. In such a case, the fraenum is unusually broad and seems to extend clear to the tip of the tongue, Avhich apparently is bound doAvn to the gum and to the floor of the mouth. The thin membrane may be snipped Avith the scissors close to the tongue and then torn back Avith the finger. Harelip and cleft palate interfere with nursing and require continual attention to keep mucus out of the throat, Brophy has a rubber flap placed over the nipple of the bottle in such a Avay as to occlude the split tissue and thus enables the child to get nourishment. These babies must be fed systematically by gavage, if necessary, until the deformity can be repaired. Hernia at the navel is a common complication of in- fancy. It is not due to crying, to improper tying of the cord, nor to neglect by the nurse, as frequently charged. It is a congenital fault, AA'herein the cord opening does not close, and in time, crying and straining will drive the intestines out of the aperture like a pouch. The defect is revealed by the bulging outAvard of the navel when the child cries. Ordinarily the breach Avill close of its OAvn accord. Treatment consists in folding up the skin of the abdomen so that the groove aaIH be over the umbilicus 2S7 288 OBSTETRICS FOR NURSES Fig. 123.—Cleft palate nipple. (Brophy.) Fig. 124.—The device for feeding the child with cleft palate at the hreast. (Brophy.) CARE OF THE CHILD 289 and include it. Then adhesive tape is put on to hold it. The surfaces of skin thus coming in contact should be dusted Avith rice poAvder or stearate of zinc. Another method of treatment is to place a Avooden button form, round side down, on cotton, over the opening, and bind it on with a zinc adhesive plaster. The dressing should be changed at least once a week. Inguinal hernia usually heals spontaneously also, but n truss may be required. Fig. 125.—Device for assisting the cleft palate child to nurse. (Brophy.) Haemorrhage of the neAvborn is either accidental or spontaneous. Accidental haemorrhage may arise from an imperfectly tied cord, or it may be an effusion, through compression or rupture, into any of the internal organs, such as the brain, lungs, or abdominal viscera. These latter conditions rarely give rise to symptoms, and are seldom recognized during life. There is no treatment. The intracranial haemorrhages are open to diagnosis 2!)0 OBSTETRICS FOR NURSKS through the presence of pressure symptoms, but these, too, are impervious to treatment unless a vessel can be tied, like the middle meningeal artery. Spontaneous haemorrhages may develop during the first feAV days of life from sepsis, syphilis, Buhl's dis- ease, haemophilia, and true melaena neonatorum. The fragile condition of the blood vessels, the great changes in the blood and circulation after birth, as Avell as con- stitutional dyscrasias, are etiological factors of impor- tance. All the causes are not as yet known. Fig. 126.—Method of strapping an umbilical hernia. The blood may come from the umbilicus, the mucous membranes of the eyes, nose, mouth, stomach and intes- tines. It may be effused into the tissues beneath the skin, or into any organ of the body. Marked nosebleed is generally syphilitic in origin. As a rule haemorrhages in the neAvborn are most com- mon in males, and strongly hereditary. The tendency to bleed lasts only a few Aveeks, and if recovery takes place, it is permanent. In some cases, hoAvever, Avhere haemorrhage has developed in the brain, CARE OF THE CHILD 291 clots may form in important centers, and the child be permanently paralyzed in speech, sight, hearing, or in- telligence. Symptoms of haemorrhage begin during the first week and almost never after the tAvelfth day. The appearance of blood is the earliest and the most definite sign. The bleeding may come first from the umbilicus, or from the stomach, or from the intestines (melaena neonatorum). The amount lost is small, but the oozing is continuous. The temperature may be high or subnormal, and may oi' may not be due to the haemorrhage. The skin is pale, the pulse feeble, prostration marked, and Aveight is lost rapidly. Convulsions are not infrequent. The diagnosis of the condition is simple. It is only necessary to be certain that the blood is really effused, and not a temporary or accidental event such as the regurgitation of SAvalloAved blood. Black tarry stools will shoAV blood if placed in Avater. The prognosis is not good. About two-thirds of these babies die. The treatment is to stop the haemorrhage by ligature, suture, or compression if possible and to alter the char- acter of the blood by adding to its fibrin content. This is brought about, if at all, by the administration of coagulose, coagulen ciba, or by transfusion from an adult—preferably the father. Paralysis of the face (Bell's paralysis) may folloAV the use of forceps. The prognosis is favorable. Paralysis of the nerve in the neck (musculospiral) is sometimes knoAvn as Erb's paralysis. It happens in consequence of difficult breech deliveries or of vertex labors when much force is required to extract the shoulders. The deltoid, biceps, and other muscles are affected so that the arm can not be raised. The failure to raise one 292 OBSTETRICS FOR NURSES arm will be the symptom that Avill attract the attention of the nurse. Some cases recover in a month or so, either spontaneously or by the aid of electricity. If not, the injured nerve must be cut doA\n upon and its con- tinuity restored. Ophthalmia neonatorum is an infection of the eyes of the newborn by the gonococcus. The infection occurs as the child passes through the vagina or vulva, or when an unclean finger is put into the eye. The reaction is violent. The discharge at first is thin, then thick, pus. If untreated, the eyesight may be lost by ulceration. In the asylums twenty-five per cent of the inmates are blind from this infection; and as late as 1896, seven per cent of the blindness in the state of NeAV York could be traced to this avoidable disease. The preventive treatment consists in the frequent douching of the A^agina before labor with potassium permanganate solution 1:5000, or chinosol 1:1000. After labor, a drop or so, of 1 per cent solution of nitrate of silver is dropped into each eye and not neutralized. After the infection has occurred, iced compresses are applied to the eye, night and day, and a solution of argyrol 15 to 20 per cent instilled into the outer corner, twice a day. In female infants Avith ophthalmia, the A'a- gina must be watched for discharge which does not fail to appear in most cases. Argyrol (20 per cent) should be injected with a medicine dropper and left to drain out spontaneously. All dressings used about the child should be destroyed, and the nurse should use the most scrupu- lous cleanliness and care of her own person. Separation of the cord may be delayed in puny babies and in cases where the cord is large and thick. Some of these cases are doubtless due to a patency or fistulous condition of the urachus. Usually the separa- CARE OF THE CHILD 293 tion may be hastened by touching the constrictured part with silver nitrate. Or, if the cord does not separate be- fore the second Aveek, it may be desirable to cut off the hanging fragment and touch the base Avith silver nitrate or dust with alum powder. Granulations may protrude like a mulberry from the stump of the navel ("proud flesh"). These are touched Avith nitrate of silver stick. Menstruation may appear occasionally from the vulva of the neAvborn. It is really a haemorrhage, a menstrual floAv, Avhich is associated Avith uterine activity, but rarely significant. There is no treatment. It disappears spontaneously. The breasts of the newborn may fill Avith milk and become indurated and tender. Nothing should be done to them. Let them alone and the SAvelling will subside in a feAV days and the milk ("Avitches' milk") dis- appear. Icterus may develop from the third to the sixth day. The child becomes yellow and stays yellow for a week, when the color gradually leaves. It is thought to be due to the liberation of some embryonic residue in the foetus, but nothing is known certainly. For the simple form no treatment is required. Recovery is prompt and un- eventful. HoAvever, jaundice is associated Avith other conditions that prove fatal, hence every icterus should be Avatched carefully until it disappears. Child's Nails.—The nails are frequently rough and ragged at ends and sides. They should be smoothly trimmed lest they become infected at the junction with the skin and give rise to paronychia. If infection does occur, the skin and flesh may be pushed back with a sterile applicator, and the point touched Avith peroxide 294 OBSTETRICS FOR NURSKS of hydrogen. A syphilitic history may be traced in some of the babies. Thrush is a form of contagious soreness, characterized by Avhite flakes or patches on the mucous membrane of mouth or anus Avhich look like milk, but can not be Aviped off. It is due to a A-egetable fungus and occurs most fre- quently among anaemic or poorly nourished babies or those suffering from harelip. It is associated Avith symp- toms of indigestion. It may ahvays be prevented by keeping the mouth and nipples clean, as directed on another page, and by keeping the bottles and rubber nipples in a solution of boric acid Avhen not in use. When the disease appears, the mouth must be sAvabbed three or four times a day Avith an applicator soaked in saturated solution of boric acid. This is curative. Aphthae or stomatitis is the name given to Avhitish vesicles, folloAved by superficial ulcers that occur upon the inside of mouth and lips of the infant. It is rare in the newborn child. Boric acid solution is cleansing, and stick alum, frequently applied, will effect a cure. Wheals, urticaria or "stomach spots" appear as gen- erally distributed small spots about the size of a split pQa, Avith a AA'hite center and a red periphery. They ap- pear about the third day and last twenty-four hours. They may be mistaken for insect bites and they may, or may not, be accompanied by temperature, Avhich is probably only a coincidence. The Avheals disappear spontaneously Avithout treat- ment. Bednar's disease is characterized by the appearance of Iavo ulcers on the hard palate, one on either side and just aboA^e the spot where the last tooth will erupt. It CARE OF THE CHILD 295 is most liable to occur in sickly infants and supposedly arises from the abrading of the mucous membrane by a rubber nipple or through the rough cleansing of the mouth. Tt is very resistant to treatment. The child must be put in good condition by attention to the nourishment and the spots touched with tincture of io- dine on an applicator. The exudative diathesis is indicated superficially by a definitely bounded red patch on either cheek, Avhich is not relieved, or only temporarily, by the common oint- ments and powders. The mother says the "face is chap- ped," or that the baby has a "milk eczema." Other- Avise the skin is pale. These children are frequently fat, but the tissue is flabby. The urine is sometimes animoniacal. There is no marked disturbance of temperature. Fretfulness and constipation are the principal symptoms. The condition is due to too much fat in the food. A skimmed-milk diet is best for a time. The fat can be added gradually until the limit of tolerance is found. If chalky masses appear in the stools, the fat must be reduced again. Occasionally the child must be taken off the milk entirely, and a soup or gruel diet sub- stituted. For local application, the folloAving formula is some- times beneficial: (Grulee.) R, Naphthalene..................... .. gi Starch ............................3iv Zinc stearate.......................3iv M. Sig. Apply frequently. The "cradle cap" is a frequent sign of the exudative diathesis in its milder stages. The term is applied to a yelloAvish-gray patch over the 296 OBSTETRICS FOR NURXKS large fontanelle. The mother calls it "dirt," Avhich she finds hard to remove and it ahvays recurs. The mass is composed of dry scales, Avhich gradually change into an eczema. Vaseline or sAveet oil left on over night makes the removal of the scales quite easy the next day. If a raAv surface is left, zinc ointment should be applied. The diet must be changed as previously described. Erythema, especially of the diaper region, is some- times a manifestation of congenital syphilis. It is usu- ally limited to the inner side of the thighs, the perineum, scrotum or vulva, and buttocks. It must be associated Avith other and more characteristic signs, hoAvever, such as snuffles, cachexia, etc., before it becomes diagnostic of syphilis. Most erythemas of this area are due to ir- ritation from moist or soiled diapers, but other factors may be important. Bluing in the diaper, gastrointes- tinal troubles, and circulatory disturbances are con- tributing causes. The local treatment is the same as for intertrigo. If the child is syphilitic, systemic meas- ures must be instituted. Intertrigo, or chafing, is a form of eczema due to moisture, bluing in the diapers or uncleanliness. The child should be cleaned Avith oil instead of water, and well powdered with stearate of zinc or zinc ointment may be used. Talcum poAvder which contains boric acid is contraindicated. Pemphigus neonatorum is an eruption of blisters or blebs which seem to follow infection from the maternal passages or to be communicated by other babies Avho have the disease. From three to fourteen days after birth, the blebs develop on the abdomen, neck or thighs, and shoAv a tendency to spread to other parts of the body. The vesicles vary in size from one-fourth of an inch to 1avo CARE OF THE CHILD 297 inches in diameter, and contain a serous, purulent, or bloody fluid. Other signs of general sepsis may appear. In diagnosis care must be used to exclude syphilis, Avhich also exhibits blebs, but usually on the soles of the feet or the palms of the hands. Besides, a nonsyphilific child is generally better nourished. The prognosis is unfavorable if the child is Aveakly, if the blebs spread rapidly over a large area, or if the infection attacks the umbilicus. Treatment.—A rigid quarantine must be enforced. In the hospital no neAV cases can be admitted. The alimentation must be increased, the blisters evacuated, and the surfaces cleaned and covered Avith a 25 per cent ointment of ichthyol, or an ointment of ammoniated mercury 2 per cent. Strophulus, red gum, or miliaria rubra are names ap- plied to an inflammation of the sAveat glands Avhen their secretion is retained. It is a "sweat rash" character- ized by an eruption of scattered red papules or small vesicles Avhich commonly appear on the cheeks or neck of young infants, or where skin surfaces come in contact. It is due to excessive clothing or heat. It is really a prickly heat. The treatment consists in the removal of the cause, and a generous use of stearate of zinc powder or rice powder. CHAPTER XXI THE CARE OF THE CHILD (Cont'd) ' Constipation in the newborn may come from many causes. The amount of food may be so inadequate that no residue is left, and the boAvels move only once in forty-eight hours. Over-stimulation of the bowel by castor oil or colonic flushings in the early weeks of life to correct colic may diminish its sensitiveness and pro- duce atonic constipation. In the artificially fed infant too much fat in the food is a very common cause of the t rouble. Treatment.—Correct the amount of fat in the milk. If the child is breast-fed, the mother's diet should be non-nitrogenous and vegetables should preponderate, Drugs should not be given until all else has been tried. Clluten suppositories Avill furnish a mild irritation to the rectum. Orange juice and prune juice may be given, or Mellin's food or oatmeal Avater added to the milk. Milk of magnesia V2 to 1 teaspoonful, or Hus- band's magnesia, in same dosage, may be given daily. Senna is also efficacious. Diarrhoea is generally significant of an error in diet Avhich is usually a plain indigestion, though there may be too much sugar in the food. The stools are more frequent and always softer than usual, possibly fluid. Diarrhoea means increased intestinal action due to ir- ritation from something. It may be due to indigestion, to the presence of hard curds, to acidosis, or it may ac- company almost any disease of infancy as a symptom 298 CARE OF THE CHILD 299 merely. The odor is due to gases formed in the canal by bacterial action. There is but little odor in fermen- tation, but much in putrefaction. Mucus appears either as balls or strings. The balls come from the small in- testine, strings from colon. Blood indicates ulceration at some point in the boAvel, or an erosion just above the sphincter. Fatty curds may be either Avhite, granular, sand-like Fig. 127.—Proper position for introduction of a suppository. (Grulee.) masses, or small, soft, and yelloAv. The protein curd is large and smooth, or Avhite and bean-like. Both occur only when the artificially fed infant is given raAV milk (Brenneman). If the milk is boiled for tAvo minutes these masses will not form. The cause must be determined. The frequent stools, however, are exhausting, and may have to be checked with opiates or mechanical astringents. 300 OBSTETRICS FOR NURSKS When due to indigestion, all food by mouth may be stopped for two or three days and only barley Avater administered. In a breast-fed child, diarrhoea is sometimes checked by diluting the milk with a little barley water, given just before nursing. With these infants, not much change in the sugar content can be made by alterations of the maternal diet, but Avhere artificial food is used, the amount of sugar is easily reduced to a satisfactory degree. Colic is a cramp-like pain of the bowels. Previous to the attack the child is restless, expels some gas, and has the "colic smile," Avhich leads the mother to believe the child is quite well. When the attack comes on, the thighs are flexed on the abdomen, and the legs on the thighs. The child has a sharp cry, that is nearly con- tinuous, but in some Avay related to the nursing period, for the attack comes on a few minutes, and sometimes an hour, after taking the breast. The belly is rigid, the arms wave aimlessly. Diarrhoea may be present, and the movements are accompanied by much flatus. Dis- tention is nearly always present. When the belly is tapped it gives a drum-like note and the child belches gas, sometimes accompanied by milk, Avhich seems to relieve. Treatment.—Colonic flushings to relieve the bowel of irritating curds. The child may be laid face down with a bag of hot Avater under the belly. Mixture of asafoetida gtts. xx to xl, or Avhiskey and hot Avater should be given for the attack, followed later by a full dose of castor oil. The diet should be rigorously in- vestigated. Vomiting may or may not be serious. The child may nurse too rapidly or too much, and the over-distended CARE OF THE CHILD 301 stomach simply empties itself. Many infants "spit up" their excess of milk, and thus relieve themselves. This is a simple regurgitation, usually of unchanged milk, though it may be acid from admixture with the gastric juice. Vomiting, in a breast-fed child, may come during an attack of colic when the eructations of gas appear. It may be a symptom of gastrointestinal intoxication, of too much fat in the food, too short intervals between feedings, or too much sugar in the food. Projectional vomiting aAvakens suspicion of a pyloric stenosis or meningitis, and must be reported to the physician at once. Vomiting which occurs Avithin tAventy minutes after feedings is not serious ordinarily, even though gas and large curds are expelled, but all vomiting later than this, is significant of a pathology. Treatment.—Regulation of the hours of feeding is most important, and next, the character of the food. If the child vomits an hour or so after nursing, it may be that the milk is too rich (fat). Try a longer inter- val, or give an ounce or so of cereal Avater before put- ling the child to the breast. Prematurity exposes the child to three distinct dan- gers, which arise, respectively, from atmosphere, food, and infection. Very few children born before the seventh month survive. A child born at the eighth month, or Avith a weight of three pounds, or more, can be saved almost ahvays. The premature child up to the time of birth, has been protected very carefully against temperature variations by the liquor amnii, and Avhen suddenly precipitated into a neAV environment, which its vitality barely tolerates, the consequences are serious. 302 OBSTETRICS FOR NURSES These infants have a poor heat production, and the natural warmth of the body must be preserved. This is best done by incubators, which supply air and mois- ture in stable and appropriate amounts. Chilling of the child for even a feAV moments may be fatal. A room may be fitted up to produce the necessary conditions of light, air, heat and moisture. The child, Avrapped in sheets of cotton, except the face, is then covered Avith a blanket, and surrounded by a temperature vary- ing from 88° to 95° F., Avhich is gradually lowered to 80° F. as the child gains strength. An occasional Avhiff of oxygen, as prescribed for an atelectatic child, is sometimes advantageous. Bathing.—Premature infants must not be bathed, but the skin should be cleansed with cotton and warm sweet oil or albolene. All unnecessary handling is to be avoided. Food.—Breast milk is the secret of success with these cases. Since most of the infants are too Aveak to take the nipple, the breasts must be pumped, and the child fed Avith spoon or pipette. The interval betAveen the feedings depends a little on the amount taken, but it should not be less than one and one-half hours, nor more than two hours. As the child gains, the interval may be lengthened to three hours. Lack of sufficient nourishment is sIioavu by cyanosis and loss of Aveight, and overfeeding, by vomit- ing and diarrhoea. The child must be fed by hand until strong enough to nurse the breast. In certain cases of prematurity, as well as in diseases like pneumonia, scarlet fever, and diphtheria, the child must be fed by gavage. Nutritive inunctions of benzoated lard or cod-liver oil are also valuable, not only for the passive exercise supplied, but CARE OF THE CHILD 303 for the absorption of a certain amount of the unguent. Marasmus means Avasting, but the term is applied to infants that steadily lose Aveight. The bodies of infants are so largely composed of fluid, that loss of Aveight occurs quite easily and rapidly. Loss of weight may be sudden or gradual. It comes on rapidly after acute diarrhoea, either Avith or Avithout vomiting, or it may folloAV persistent vomiting Avithout diarrhoea. Malnutrition from defecthe feeding is the most com- mon cause of Avasting in infants. This may be from lack of sufficient food or lack of proper ingredients, as A\-ell as irregularity of intervals, and disease. Rickets, con- genital stenosis of the pylorus, congenital syphilis, and tuberculosis are all possible factors in the etiology. In any case, no treatment can be instituted until these conditions have been confirmed or excluded. Pyloric stenosis (the account folloAvs Grulee) may be a thickening of the muscular coat of the outlet of the stomach (pylorus) or a spasmodic contraction. The condition is most frequent in males and in the first born. Symptoms usually begin before the second Aveek. There is constipation Avith small ribbon-like stools, and the urine is scanty. The most marked sign, hoAvever, Avhen it is present, is the excessive, uncontrollable vom- iting, which ordinarily occurs fifteen to thirty minutes after eating, but may be delayed for several hours. The vomiting may be of the common type, but more fre- quently it is projectile in character, like that seen in meningitis. The contents of the stomach are violently expelled, sometimes several feet. Physical examination may reveal the stomach bulging under the arch of the ribs and peristaltic waves moving back and forth across 304 OBSTETRICS FOR NURSKS its surface. The pylorus itself may sometimes be felt as a lump or tumor. Prognosis.—About fifty per cent die. Treatment.—Dietetic and surgical. Grulce recom- mends small amounts of food, poor in fat, be given at short intervals. If this fails, operation is required. Pneumonia in the neAvborn most frequently results from the aspiration of mucus out of the maternal pas- sages as the child is born. This may happen Avhen the cord is compressed, or at any time Avhen a partial as- phyxiation impels the child to try to breathe. It may also come on Avhen a feeble child has been chilled by a prolonged first bath. The disease develops about twenty-four hours after birth in a child apparently well. The temperature rises, respiration becomes rapid, and cough develops. The child is fretful, restless, refuses the nipple, and gasps for breath. It may become cyanotic. The prognosis in neAv- born infants is very serious. Treatment is stimulation. A mustard bath will bene- fit Avhere the respiration is rapid and the child blue. Tincture of digitalis may be administered in drop doses every three or four hours. Carbonate of ammonia, 1A gr., in mucilage of acacia, half a dram, may be given for cough. Child must be fed on mother's milk pumped from breast. Snuffles may be due to improper clothing, to drafts of air, or to syphilis. If due to cold, camphorated oil may be rubbed on the nose and the passages kept clean Avith an applicator soaked in albolene. If this fails, a small pellicle of anaesthone may be placed in each nostril, and the child laid upon its back until the ointment melts and runs back into the pharynx. CARE OF THE CHILD 305 Furuncles (boils) may be numerous. They come from irritation of the skin by atmosphere, soap, Avater, and clothing, Avhereby infection enters. This is especially liable to occur in the hair. Keep the boils Avashed Avith boric acid solution and open them as soon as the focus, or head, appears. Phimosis is such a close adjustment of the prepuce to the glans penis that it can not be retracted. In some cases there may be obstruction to the outfloAV of urine, but generally a tiny portion of the glans can be seen. The prepuce may or may not be redundant. This condition makes cleanliness impossible and balan- itis may result. On account of the straining required to urinate, pro- lapsus ani, hernia, and hydrocele of the cord sometimes develop. Symptoms may arise from preputial adhe- sions, as well as phimosis. Frequent or difficult mictu- rition, nocturnal incontinence, priapism, pruritus, and masturbation may develop out of the irritation, as Avell as nervous manifestations, such as insomnia and night terrors. The condition should be recognized and corrected in infancy. If the adhesions are dense, an incision can be made doAvn the dorsum of the prepuce, the tissue forci- bly separated from the glans, and the flaps cut off. Stitches may be required. In other cases circumcision may be necessary. Paraphimosis.—When a prepuce Avith a small orifice is forcibly retracted over the glans, it occasionally hap- pens that it cannot be pulled forAvard again. If al- loAved to remain this way, the parts Avill SAvell, and the penis become strangulated as if Avith a ligature. The danger arises from the stoppage of the circulation, which may be followed by ulceration and gangrene. 306 OBSTETRICS FOR NURSES . Reduction must be brought about by manipulation, if possible, but Avhere this fails, the constricting band must be cut through and sedative applications used. Balanitis is inflammation of the prepuce from the de- composition of smegma, Avhich collects under a tight foreskin. The condition is quickly relieved by clean- liness and a feAV applications of vaseline or zinc oxide ointment. Circumcision should not be done until the inflammation has subsided. Circumcision, either as a physical necessity or as a religious rite, is frequently performed. The nurse prepares a table Avith sterile linen, a basin with antiseptic solution and sponges, sterile tOAvel, and sterile A^aseline, with a roll of gauze bandage an inch Avide. The object of the operation is to remove the prepuce and leave the glans exposed. The instruments needed are a pair of sharp scissors, a pair of dissecting forceps, two pairs of artery for- ceps, small, full curved needles, and fine catgut. The nurse gives the child some gauze to suck, which has been soaked in brandy and sugar-Avater, brandy one dram to an ounce of water. Then taking her place at the child's head, she flexes the thighs back upon the abdomen, and widely separates them. The field of op- eration is thoroughly washed with soap and warm Ava- ter, the prepuce is then retracted and the smegma wiped away. Then the body and limbs should be cov- ered with clean linen, except the penis, or a sterile towel may be used with a hole in it through which the penis is drawn. The redundant tissue is removed and fine catgut sutures put in. The operation being completed, the wound is covered CARE OF THE CHILD 307 Avith sterile vaseline and Avrapped Avith a sterile gauze bandage, leaving the end of the glans exposed. The gauze and vaseline are changed Avhenever sat- urated Avith urine. Healing ought to be complete by Fig. 128.—Hydrocephalus. (Bumm.) the seventh day. The nurse should examine the dress- ing at frequent intervals during the first tAventy-four hours, since serious haemorrhages may occur from ves- sels that have not been included in the sutures. 308 OBSTETRICS FOR NURSES Priapism is a condition of functional fullness and firmness of the penis that is more than ordinarily con- stant. Its importance lies in the fact that it may be a symptom of spinal irritation, balanitis, worms, or phimosis. Spina bifida is the most common congenital deform- ity. It is characterized by a fluid tumor, which pro- trudes from an opening in the vertebral column. It may appear anywhere along the spine, but is found most frequently in the lumbar or cervical region. The deformity is supposedly due to an arrest of develop- ment. It is nearly always fatal inside of two Aveeks, Fig. 129.—Anencephalus. (Williams.) though cases have been knoAvn to reach mature years. There is no treatment except protection from injury. Hydrocephalus is sometimes, but not necessarily, as- sociated with spina bifida. The ventricles of the head are filled Avith cerebro- spinal fluid, and the fontanelles are Avidely separated. The cause of the anomaly is unknown. CARE OF THE CHILD 309 This condition may render labor difficult or impos- sible until the diagnosis is made and the skull perfor- ated. Rupture of the uterus may result from the futile efforts to expel the child. If born alive, the child nearly always dies, or if it groAvs up, the intelligence is imperfect in most cases. Anencephalus is a monster, having a body, but only a part of a head. The eyes protrude, the tongue may hang from the mouth, and the brain is under-developed. Sudden death of infants that are apparently healthy comes with a shock to the physician as Avell as the par- ents, and in some instances, no plausible reason can be assigned for it. Apoplexy, pneumonia and stoppage of the trachea by milk curds may explain some cases. Suffocation by lying on the face in wet bedding, or overlying by the mother Avill account for others. In- ternal haemorrhage into lungs, pleura, stomach, or brain is also knoAvn to be causative. CHAPTER XXII INFANT FEEDING A Avell fed infant is a happy little animal, Avho sleeps approximately tAventy-tAvo hours a day, and gains from four to six ounces a Aveek. If properly fed at the breast, this condition is easily obtained; but if artifi- cial food is necessary, the resources and skill of the at- tendants may be tried to the utmost before the Avel- come result is brought about. The feeding of infants may be considered under three heads, (1) the breast; (2) breast and bottle combined (mixed feeding); and (3) artificial, which is really mod- ified coav's milk. Breast feeding has been taken up elseAvhere, but the same care should be taken in feeding from the bottle as in feeding from the breast, so far as concerns the intervals betAveen the feedings and the duration of the same. Since it takes from one to Iavo hours longer for coav's milk to digest than it does for mother's milk the longer interA'al of three or four hours betAveen feedings is better for the artificially fed child. With such an interA'al there Avill be less vomiting, less colic, less ten- dency to overfeed, and a better natured baby. One feeding should be omitted at night, and if pos- sible, two. Length of time for taking the bottle depends some- what on the child, but it should not exceed fifteen min- utes, as a rule. Supplemental Feeding.—A mother who has too little 310 INFANT FEEDING 311 milk may have it supplemented by a modified mixture in one of tAvo Avays. First, the quantity furnished by the breast must be determined by Aveighing the infant before and after feeding, and then the total amount for twenty-four hours can be deduced. With this information, it is not difficult for the doctor to knoAv how much cow's milk to prescribe. The supplemental feeding may be given by alternating the bottle and the breast, or by giving the breast and folloAving it immediately Avith the bot- tle. In the meantime, the mother must be put on tonics with an abundance of fluids, and a generous diet that Avill raise the blood pressure, in the hope that the milk will increase sufficiently to enable her to feed the child entirely from the breast. When it becomes necessary to substitute some other food for the breast milk, it means that the milk of some other mammal must be modified for the purpose. The most convenient and abundant source of supply is the COAV. While in many respects coav's milk is similar to moth- er's milk, it is in reality quite a different product. Mother's milk is taken, undiluted, directly from the breast, Avhile coav's milk is given from a bottle, hours after milking, and not only must it be diluted, but cer- tain ingredients must be added to aid its digestibility. When taken into the stomach in its natural state, mother's milk is a liquid, A\liile under the same con- ditions, coav's milk forms a semisolid gelatinous mass. It is essential that the milk should be as fresh, clean, and free from bacteria as possible, and this can be ap- proximated only in certified milk. This milk is re- quired by law to have its constituents definitely stand- ardized. Thus, there must be 4 per cent of fat, 4 per cent of protein, and 4 per cent of sugar, and it must be so free 312 OBSTETRICS FOR NURSKS from bacteria that not more than 10,000 per cubic cen- timeter can be found. The cattle also are tuberculin tested. The following comparison is from Holt: Mother's Mill: Sp. Gr. av. 1.031 Fat................. 4. % Protein ............ 1.50% Sugars, ............. 7. % Salts ................2 % Water ..............87.3 % Reaction............Alkaline Cow's Milk av. 1.031. Fat................. 4. % Protein ............. 3.50% Sugars .............. 4.50% Salts ................75% Water ..............87.3 % Reaction............Acid Bacteria ............Very few Bacteria ...........Many Both range from 1.026 to 1.06. Fat globules Epithelium Fig. 130.—Elements of human milk. (Eden.) The fats are substantially the same, but the fat of coav's milk is less easily digested than the fat of moth- er's milk. The protein of mother's milk is A'irtually half lact- albumin and half casein, Avhich is only slightly coagu- lated into soft flocculent curds by the action of rennin and acids, while the casein of coav's milk is nearly three INFANT FEEDING 313 times greater in amount than the lactalbumin and is coagulated into coarse, tough curds. The sugars in both cases are lactose in solution, but mother's milk contains a much higher percentage. Cow's milk contains three times the quantity of salts found in human milk, but the Avater is the same in both. So, AA'hile the tAvo milks seem in comparison to be much alike, in reality they are quite different; hence it is necessary to modify coav's milk in such a way as to make it not like mother's milk chemically, but to make it act like mother's milk. It is extremely difficult to bring up an infant on arti- ficial food, and inasmuch as half the infants that die during the first year, perish from intestinal disorders, it is imperative that every resource should be exhausted before the breast feedings are abandoned. It is fal- lacious to believe that anyone can feed a baby, or that feeding consists merely in trying one food after an- other until one is found to agree. Only a competent physician should prescribe the food, and he should study his problem and make his modifications just as he Avould alter his medicines for a particular disease. HoAvever, it Is necessary for the nurse to knoAV how to carry out the doctor's orders intelligently and hoAv to report to him the conditions present. In prescribing for the child, the doctor usually has some definite outline in his mind, such as Age and weight. Example: 3 months old; weight 10 pounds; 7 feedings; 1 every 3 hours. Interval, three hours. Amount in each bottle, four ounces. Formula: Milk, 12 oz. Diluent, 16 oz. (Cereal water or plain water.) Sugar, % oz. Flour ball, if any, y2 oz. Boil if ordered. 314 OBSTETRICS FOR NURSES The infant should not take more than tAvo ounces of milk to a pound of Aveight in each tAventy-four hours. Proprietaries.—Baby foods are not to be recom- mended nor condemned. They are placed on the mar- ket as substitutes for mother's milk with definite in- structions as to preparation. They are also very ex- pensive. They are not to be condemned, because many of them are hiA^aluable Avhen used in connection Avith coav's milk. Sometimes a child Avill not tolerate any- thing but malted or condensed milk, or Nestle's food, for example. The malt sugars, such as Horlick's and Mellin's, are easily assimilated, fattening, and laxative. All foods in the modification of milk should be of the best. The standard sugars are Merck's milk sugar, Mead's Dextri Maltose, Nahrzucker, cane sugar, and Mellin's and Horlick's foods. Robinson's barley flour or Johnson's are the best knoAvn. Imperial granum is a partially dextrinized flour and corresponds to the home-made "flour ball." FOOD PREPARATION Buttermilk Made from a Culture.—Bring two quarts of milk to a boil, cool to the temperature required for inoculation (80° to 100° F., depending on the culture employed). Introduce the culture, and alloAv it to stand at the temperature of the room until a solid clabber forms. Place on ice, Avhip Avith an egg beater or break up Avith a churn before using. If a fat-free butter- milk is desired, use skimmed instead of whole milk. There are many kinds of buttermilk cultures on the market, but Hansen's is considered one of the best, be- cause it is not too acid, besides A\'hich, it has a good flavor, and the culture can be utilized over and over for a week or ten days. INFANT FEEDING 315 In preparing a subsequent portion, it is only neces- sary to use tAvo or three ounces of the first buttermilk, Avhich may be reserved for the purpose. This amount is introduced into the freshly boiled milk, instead of the original powder, and the preparation is continued exactly as described for the mother culture. In every case the mixture must be placed on ice as soon as the clabber forms, as it becomes too sour other- Avise. Eiweiss Milk.—Heat one quart of whole milk to 145° F. and coagulate Avith pepsin, rennin, or chy- mogen, Avhich is 10 per cent rennin. Let it stand until clabbered, Avhich takes about ten minutes. Pour into a gauze bag and let it stand until all the Avhey is drained off. To the dry curd, add 1/2 ounce of flour ball, and one pint of skimmed buttermilk, the Avhole to be rubbed through a A'ery fine Avire mesh sieA'e (as fine as a tea-strainer, at least), three separate times; or, it may be ground tAvice through a special mill to break up the curd as minutely as possible. Add a pint of water and measure. There should be a quart and three or four ounces over. Place upon a sIoav fire and bring to a boil Avhile stirring constantly. Boil tAvo min- utes, then cool, strain, measure, and add Avater to make up for eA^aporation. Shake Avell before measuring, as the curd is heavy and settles to the bottom. Peptonized Milk.—(See p. 338.) Whey.—To a pint of fresh, Avarm coav's milk, add rennin as pepsin, or chymogen, and stir until mixed. Let it stand until coagulation is complete. Then the curd should be broken up Avith a fork, and the Avhey drained off through coarse muslin. This removes the coagulablc proteins from the milk. A ten per cent cream can be had at home by alloAving a quart of milk 316 OBSTETRICS FOR NURSES to stand for six hours and then using the upper one- fourth. Whey-Cream Mixture.—Make whey as described and mix Avith cream, in the proportion of whey 1 1/2 ounces to cream, 1 dram for each feeding. Barley Water. No. 1.—Use one ounce of barley pearls to a quart of Avater. Wash thoroughly, put on a sIoav fire and boil for six hours. Add Avater to make up for evaporation, and add a pinch of salt. Strain and cool rapidly. Barley Water. No. 2.—Use one heaping teaspoonful of Robinson's patent barley flour to each pint of cold Avater. Boil tAventy minutes and add Avater to make up for evaporation. Add a little salt, strain and cool rapidly. Other cereal waters, like rice and oatmeal, are made like barley water No. 1, and in the same proportion. Flour Ball.—Take four cups of ordinary wheat flour and Avrap it in a piece of muslin, and tie it tightly. Drop the mass into boiling Avater and boil six hours. Then take it out, cool it and remove the outer peeling Avith a sharp knife. Break into small pieces, the size of an English Avalnut, and dry thoroughly in a sIoav oven. Pulverize in a mill or meat-grinder, sift and keep in a dry place. Milk may be sterilized, pasteurized, or boiled. Sterilization kills both germs and spores, but it is not nearly so necessary as it is to have the right pro- portion of sugar and fats. Place in an autoclave and keep at a temperature of 160° F. for an hour. Pasteurization is desirable AA'hen a good, clean milk is not attainable. It kills the germs, but not the spores. The process must be carefully attended to, or the milk will sour more easily. Heat a quart of milk to 160° F. for twenty minutes. Cool rapidly to 40° F. INFANT FEEDING 317 Boiling milk for two minutes kills all bacteria, and renders the casein more easy of digestion and prevents the formation of curds. PUTTING FOODS TOGETHER Whole milk contains 4 per cent fat, and must be thoroughly shaken before it is measured, for otherAvise one child will get all the fat and another all the skimmed milk. Fat-free, or skimmed milk, contains about 0.1 per cent fat. The cream has been removed by a siphon or centrifuge. If unable to get a fat-free milk from a dairy, the cream can be removed from a quart of Avhole milk quite easily with a siphon. Sugars and flours should be Aveighed Avhen used, for they vary greatly in volume. In using flour ball or imperial granum, the flour must be mixed Avith Avater or cereal water, to make a smooth paste and brought to a boil. If the milk is to be boiled also, add the milk to the paste and boil all together. Cool and strain. All baby feedings should be strained, as tiny lumps of food Avill clog the rubber nipple and the nurse may think the baby is not taking its feedings well. The fol- lowing is a typical formula: Whole milk 15 oz. Barley water 15 oz. Sugar V-i oz. Flour ball % oz. Boil two minutes. - 5\fix4 Weigh the sugar and flour ball and make a paste with the barley water. Shake the Avhole milk, meas- ure out 15 oz. in the graduate, and add the barley Ava- ter mixture. Boil two minutes. Cool in running Avater, 318 OBSTETRICS FOR NURSES strain bottle and put on ice. The figures at the side mean that five feedings of six ounces each are to be given at four hour intervals. It is necessary to cool all feedings as soon as mod- ified, and keep them on ice for preservation until used. The only accurate Avay is to make up the Avhole quan- tity for tAventy-four hours, put into separate bottles the exact amount of each feeding and give at the time ordered, after the bottle has been properly Avarmed. In warming the food, care must be used to get it nei- ther too hot nor too cold; 100° F., or when it feels warm to the back of the hand, is about right. The child should be held in the arms while taking the bottle. A buttermilk feeding must not be heated to more than 100° F. because it curdles and can not be used. The rubber nipples should be washed thoroughly after use, boiled once a day, and kept in boric acid solution. The necessary articles for home modification of milk can be obtained anywhere. One set of utensils should be kept for this purpose exclusively and boiled each time before the food is prepared. A list is convenient: A 16 ounce glass graduate. One tablespoon and one teaspoon may be used for measur- ing purposes, if unable to get a satisfactory scale. 1 2-quart aluminum cooking dish. 1 long-handled aluminum spoon. 1 fine wire mesh strainer, thirty holes to the inch. 1 dozen bottles, 5 ounce size if the child is small, and 10 ounce if the child takes large feedings. The bottles should have Avide mouths, straight sides, and round bottoms, Avhich clean easily. Paper caps or corks that fit tightly should be used instead of cotton stoppers. Close rubber caps are best, for, as the milk cools, a vacuum is created, the rubber is draAvn in and INFANT FEEDING 319 the milk remains air-tight until opened. If infants are kept on a milk diet alone for too long at a time, they do not thrive so avcII, hence as early as six month/!, other things may be given. At this stage, the most de- sirable additions to the food Avould be cereal, farina or cream of wheat, orange juice, A^egetable broth, toast crumbs, etc. The administration of orange juice should be started A\rhen the child is only a feAV Aveeks old. The quantity of all these foods may be increased as the child gets older, and by the end of a year the diet is broadened still further. Beside a quart of whole milk, it may haA'e thickened soups, vegetables, such as caulifloAver, spinach, carrots, creamed celery and a lit- tle baked potato. Fruits, orange juice, grape fruit juice, prune sauce, apple sauce and scraped apple may be given, but no bread. In place of bread, use toast, Huntley and Palmer Avafers and biscuits, and soda or oatmeal crackers. Sweet desserts should be avoided, but flavored junket or simple custard is unobjectionable. Xo meats are permitted until the child is eighteen months old, except, perhaps, a little crisp bacon, or a bone to suck. None of these supplemental foods should be given be- tAveen meals, but ahvays at the feeding hour. The above list supplies a dietary so varied that no child Avill tire of it. In reporting the condition of the infant to the physi- cian, the folloAving form may be used to advantage. It is a clear cut, concise summary of Avhat he Avishes to knoAV. Infant's Daily Report 1. Food: Does baby take it all? Is he satisfied? 2. Bowel movements: How many in last 24 hours? AA'hat is the color? Are they hard, soft, or watery? Any odor? 320 OBSTETRICS FOR NURSES Any curds? Any slime? Any blood? Any colic? Much gas? 3. Does baby vomit? AA'hen? How much? 4. Does baby sleep well? Is he good naturcd? 5. Any fever? What is the weight? Significant Symptoms and Conditions.—In an artifi- cially fed baby, the normal condition of the boAvels is constipation. The stools are formed, alkaline in reac- tion, rather hard, and usually only one a day. The stools should have a characteristic color, accord- ing to the food taken. Thus: Sugar or starch will color the movement a dark brown, like vaseline. Too much fat gives a pale yellow stool, almost white, like putty. Eiweiss feedings show as a pale yellow, somewhat like the fatty stools, but constipated. Barley water gives a broAvn liquid stool. Starvation stools are thin, slimy, dark brown or green. The consistency of the movements is also important. Too much sugar or starch means diarrhoea, with thin, green, acid stools, and much gas and regurgitation, or, sometimes foamy, mucous discharges. Diarrhoea may also be due to indigestion. Mucus in the stools usually signifies intestinal irritation. Constipation may exceed the normal limits of the arti- ficially fed child when the food contains too much fat. Bad odors of the stools result from putrefaction. Colic means imperfect digestion with gas. There is less colic when the intervals betAveen the feedings are lengthened. Curds are of two kinds. The soft friable ones due to fat, and the hard bean-like masses of protein. Curds occur with feedings of raw milk only, and though as- sociated with symptoms of indigestion, they signify INFANT FEEDING 321 overfeeding. If the sugar content of the food is Ioav, the child Avill gain very slowly. Vomiting is an important phenomenon. It may be due to overfeeding, to excess of sugar or fat in the food, or to pyloric stenosis. Excess of fat is shoAvn by vomiting and regurgitation of small quantities of food one or two hours after feeding. It may be associated with constipation. If vomiting occurs immediately after feeding, it is probably due to the taking of an excessive amount, or to the too rapid ingestion of the regular bottle. If the vomiting takes place later than twenty minutes after feeding, it is probably pathological. It may be the re- sult of indigestion, meningitis, or of pA'loric stenosis (q.v.). For the first Aveeks of life, mother's milk should be obtained at all hazards, if possible, but if this is not to be had, the artificial feedings may be started. A desirable milk modification for the first Aveeks of life should begin with a Ioav food A'alue. For example, a child one week old weighing seA'en pounds, should start on a formula like this: AA'hole milk ...................7 oz. Water .........................7 oz. Cane sugar ....................V2 oz. Boil two minutes. This Avill make seAren feedings of 2 oz. each, and one is given every three hours Avith one feeding omitted at night. Cane sugar is less liable to produce colic than sugar of milk. Lime Avater, or sodium citrate may be added, if the child Admits, or if other indications arise. Both are alkalies. 322 OBSTETRICS FOR NURSES The strength of the mixture, as well as the quantity, must be increased as the child gets older and it is seen that the formula will agree. The percentage of protein is kept doAvn by dilution, Avith plain or cereal Avater, AA'hile fats (as cream) and sugars are added to make up the strength lost by the dilution. CHAPTER XXIII CLEANLINESS AND STERILIZATION The nurse is called to a case on account of her spe- cial qualifications, but also she should lead her patient in all things, e\ren in gentility. It is her part to antici- pate the wants of the patient, and regard it as a re- proach if the patient has to remind her that it is time for food, medicine, bath, or for child to come to the breast. Regularity, promptness, and thoughtfulness must be supreme. Be on hand when the doctor calls and stay until he goes. Be as cheerful as Mark Tapley, hoAA'ever dreary the prospect, and do not make noises either by the SAATish of overstarched skirts, the squeak of shoes, or the moving of equipment. Above all things, the nurse must keep her patient's room, her patient, and her oavii person rigorously clean. She should not alloAV her hands to touch infectious material without protection by rubber gloves. This is as necessary for her own safety as for the patient and family. Her hands should be manicured frequently, her hair sham- pooed at short interA-als, and her teeth kept in order. If the hands get hard, take a teaspoonful of sodium car- bonate and one of chloride of lime, mix in the palm of the hand Avith enough Avater to make a cream, and rub Avell into palms and about the nails. Rinse in clean Avater. (AVeir.) The nurse's dress should be neat, always mended, and carefully adjusted. The nurse who is slovenly in appear- ance Avill be slovenly in her mind and slovenly in her °2° 324 OBSTETRICS FOR NURSES Avork. She should not wear her uniform on the street. It is bad taste, unprofessional, and unsanitary. She should bathe at least three times a week. There is always some odor of perspiration about the body, and especially around the axillary spaces AArhich are filled with hair. Nothing is more offensive and nause- ating than being leaned over and Avaited on by a person AA'ho has a strong body smell. The prodigal use of warm water and soap Avill aid, but there are large sebaceous glands in the armpits and their decomposing excretions are retained by the hair so lastingly that more radical measures are necessary. The axillae should be shaved at least once a month, and then the soap and water becomes more efficacious. After thorough cleansing, the armpits should be dredged with Babcock's Motiya powder, and the an- noying and offensive odor Avill disappear. If the patient is a refined and dainty woman, Avho may happen to be afflicted with the same misfortune, she will be deeply grateful to the nurse Avho tells her hoAV to get rid of it. That some doctors, unfortunately, have strong odors about the person—the mixed effluvia of tobacco, alco- hol, bad teeth, and uncleanliness—is no excuse for the nurse. The doctor should knoAv better, but at all events, his offense rarely needs to be suffered more than a feAV minutes at a time, while the nurse is in constant attendance. The trained nurse should be polite to, but not familiar Avith servants, as she is looked upon as the highest type of the professionally educated gentleAvoman, and she must be constantly alert that her reputation in this respect is not diminished. CLEANLINESS AND STERILIZATION 325 BATHS Hot Baths.—Temperature from 98° F. to 120° F. Water should be tepid at first and the hot AAater gradually added until the required degree is obtained. Warm bath 92° F. to 98° F. Tepid 85° F. to 92° F. Cold 33° F. to 65° F. Sedative Bath.—The patient is stripped and stands for an hour in the hydrotherapy room, Avhile a hot spray is played up and down the spine. The tempera- ture of the Avater is 104° F. to begin with, and gradu- ally increased to the point of toleration. An alkaline bath is prepared by adding an ounce of sodium carbonate to each gallon of water. Bran Bath.—Add two ounces of bran to each gallon of Avater. Mix the bran in a small amount of boiling Avater and add to the bath Avater. Mustard Bath.—To three gallons of water at a tem- perature of 105° F. add a tablespoonful of mustard. Leave the child in the Avater for five minutes, all the Avhile rubbing and stroking the limbs and back. Then Avrap naked in a Avarm blanket and leave for half an hour. STERILE DRESSINGS—ANTISEPTIC SOLUTIONS- STERILIZATION OF INSTRUMENTS The preparation of sterile dressings, antiseptic solu- tions and the sterilization of instruments, is particularly the Avork of the nurse, Avhether in the hospital or in a private home. The folloAA'ing directions are therefore desirable: 326 OBSTETRICS FOR NURSES As soon as the nurse is sure her patient is in labor, she boils a milk bottle, fills it two-thirds full of 95 per cent alcohol, puts a pledget of sterile cotton in the bot- tom and then boils a pair of dressing forceps, Avhich are placed, handle up, in the alcohol. (See Fig. 52, page 132.) With this forceps, she handles all clean dressings, instruments, and rubber goods that may be contaminated by touch. Dressings and Supplies.—The necessary dressings and supplies may be prepared one or tAvo Aveeks before labor according to the following instructions: Five Yard Packing.—Draw threads at either end of five yard lengths of gauze to its full width. Fold the cut edge across until it lies one-third the distance from the opposite side. Next, fold the double edge over, and bring it to the outside edge of the first fold. Keep it perfectly straight. When folded full length, roll from the end and Avrap in strong muslin Avrappers. Sterilize in the autoclave or Arnold sterilizer. Pads for the Vulva.—Unroll a whole bale of common cotton and cover it with a % inch thickness of absorbent cotton. Cut in lengths of 12 in. by 4 in. Avide. Cover with gauze cut 12 by 14 inches, and fold the ends of gauze over absorbent cotton. Roll from the end, wrap in paper, seal, and sterilize. Pledgets.—Tear two yard strips, lengthwise of the roll of absorbent cotton, pull from these, three inch pieces, roll them in the hands until round, place in clean bags, and sterilize. Breast Covers.—Squares of old, soft muslin 4 by 4 inches, Avith all strings removed, make the best dressings for the nipple. Do not use gauze, because the papilla- of the nipple may get caught in the mesh and AA'hen it is taken off, the tender nipple is irritated or abraded. CLEANLINESS AND STERILIZATION 327 Breast Binders.—These are made of single material, because they Avould be too Avarm otherwise. They are sleeveless and jacket-shaped and measure 16 inches from shoulder to waist, 40 inches long, and 10 inches for the arm scallop. A binder of this size, if properly ad- justed, will fit a patient of any size. Three will be sufficient for the case. Abdominal Binders.—The abdominal and breast bind- ers are worn during the bed period only. The abdom- inal binder is made of unbleached muslin, double ma- terial, 14 by 40 inches, and hemmed. In the center of the back, on the loA\Ter edge, a curved space, six inches Avide, is cut out to prevent the binder from getting soiled. To this curAred edge, the pad holder is attached by two safety pins, one on either side. The abdominal binder is adjusted by pinning firmly aboA'e the fundus, and loosely below. Pad holders are made of unbleached muslin, and meas- use 6 by 16 inches. Cord Dressings.—Cut squares of surgical lint 4 by 4 inches, and cut through to the center on one side. Gauze may be used, but it is not ideal. Nursery Cotton.—Tear absorbent cotton into narrow lengths and pull out small one inch pieces. Roll them, place in a clean bag and sterilize. Applicators.—Use absorbent cotton and toothpicks. Tear off small pieces of cotton, moisten the toothpick point with Avater, place in the middle of the cotton, and roll firmly. Gauze Sponges.—Cut gauze into squares 6 by 6 inches, and fold from each side to the center. This brings all the ragged edges inside. Fold into squares, place in jars, and sterilize. Sterilization of Instruments.—Place scalpels in car- 328 OBSTETRICS FOR NURSES bolic acid 95 per cent for ten minutes. Lift with sterile forceps, and put in a basin of 95 per cent alcohol for ten minutes. In the absence of carbolic acid and alcohol, the scalpels may be dropped in a 2 per cent solution of lysol for tAventy minutes. Cleanse Avith hot sterile Avater. (Do not boil scalpels; it dulls the sharp edges.) All other instruments may be placed in a sterilizer (dishpan or Avash boiler) Avith enough Avater to com- pletely cover them; boil twenty minutes. Cool in sterile pan, AA'hich may be set in cold Avater. Do not use soda on the instruments during sterilization, as it makes a thick, gummy precipitate on the metal. The sterile handling forceps must be immersed at all times for two-thirds their length in 95 per cent alcohol. Brushes.—After using, all brushes should be thor- oughly washed, boiled, and dried, Avrapped in Avaxed papers, and sterilized in the autoclaAC. In the absence of the autoclave, boil thirty minutes. Basins, pitchers, anel douche pans are sterilized by Avrapping in strong muslin bags and put to boil for forty-five minutes in the basin boiler or wash boiler. They Avill not remain sterile longer than one Aveek, eA'en AA'hen kept in a clean place and Avell AA'rapped. Bedpans should be Avashed in a strong solution of soap and water, rinsed every morning and boiled for thirty minutes. Sterilization of Rubber Goods.— Tracheal Catheters.—Drop in a solution of bichloride 1: 5000 and leave for tAventy minutes. Lift AA'ith sterile forceps into a basin of Avarm sterile Avater and leave for ten minutes, or until used. Vorhees Bags.—Boil twenty minutes. The bags and catheters may be gwen a longer life by keeping them in a 25 per cent solution of glycerine and Avater when not in use. Kerosene vapor is also preservative. CLEANLINESS ANI) STERILIZATION 329 Rubber Catheter.—Boil twenty minutes. Hot Water Bags, lee Caps, Rubber Bed Rings.—Soak in 10 per cent lysol solution for tAvo hours, Avash Avith Avarm water, and dry thoroughly. The inside of the ice caps can be dusted -with poAA'der. Never leave rubber gloves in a damp place or lying in a solution. It stretches them and Aveakens the rub- ber. To sterilize, they must be Avashed in a strong solu- tion of soap and Avater, dried, and paired. Then they are Avrapped in a heavy cloth covering and put in the autoclave for twenty minutes. Wet Process for Rubber Gloves.—Wrap in gauze or cloth and boil for thirty minutes. Lift Avith sterile for- ceps and place in lysol solution 1 per cent until used. They are easily drawn on by filling them Avith the solu- tion as the hand goes in. The autoclave is not ahvays available, but an Arnold or Rochester sterilizer is readily portable, and takes the place of the hospital machine. Fumigation of rooms is sometimes necessary. Re- moA^e all curtains, bed linen, and other Avashable fabrics from the room. Open the draAvers of dressers, doors of closets, and loosen up and separate everything left so the air can get to it. Close the AvindoAvs and seal the creA'ices Avith cotton and make the room as air-tight as possible. Place a large pan containing six ounces of potassium permanganate crystals in the center of the room. Pour over this tAveh'e ounces of formalin, close and seal the outside doors of the room and leaA^e for tAvelve hours. If the case has been a very septic one, it is always a good plan to Avash the Avails of the room before using again. The insides of the draAvers and the bed should be thoroughly Avashed Avith water and green soap. A formaldehyde lamp is also quite satisfactory if obtainable. CHAPTER XXIY DIETS AND FORMULAE The nurse should serve everything in the most cleanly and appetizing way if it is only a cup of tea; and all Avaste, soiled dishes, napkins, and excreta must be re- moved as delicately as possible. Diet for Pregnancy.—Fresh fish, boiled, broiled or baked; and shell-fish raAv or cooked,—any Avay but fried. Meat, once or tA\lee a day, except AA'hen contra- indicated by condition of the kidneys. Veal is best omitted. All farinaceous foods and Aregetables may be eaten freely. Desserts should be plain, but tempting. No alcohol is taken Avithout direct permission from the doctor, and coffee and tea should be limited. Diet for Puerperium.—First tAvo days, milk, butter- milk, soup, gruel, cocoa, toast and tea, chicken, oyster and clam broth. In the next two days, under ordinary conditions, the diet is increased and made somewhat heavier. Semisolids are added like milk-toast, eggs, poached or boiled soft, oysters, clams and boiled fish. After the milk comes in, the woman is put on a general diet as fast as she can digest it. Farinaceous diet—melons and oranges.— Breakfast.—Cereal, coffee with milk and sugar, if de- sired, bread and butter, corn bread, rolls, toast, muffins, hominy, cereal with cream. 330 DIETS AND FORMULAE 331 Lunch.—Vegetable soups, bread, butter, potatoes, beans, rice, macaroni and cereal, peas, buttermilk, pud- ding, such as rice, tapioca, bread cornstarch, jellies, fruit juices, pumpkin, squash, turnips, tomatoes, etc. Dinner.—Bread, butter, milk-toast, hominy, rice, celery, fruit salads, lettuce, apples, pears, prunes, stewed fruits or fresh melons, etc. The following diets are routine at many hospitals: General Diet.—Full tray of food in season as fur- nished by the hospital. Three meals daily. Light Diet.—Foods from the following list may be selected, and served three or five times daily, as de- sired : Soups of all kinds. When leguminous foods are em- ployed, their outer coverings must be removed by rub- bing them through a sieve or colander. Vegetables of all kinds, except green vegetables (pro- Added they have been reduced to a pasty consistency). Those with excess of fiber or cellulose, such as turnips, celery, asparagus, and cabbage, should be chopped after thorough boiling, then mashed, while those having tunics should be sieved or colandered. Grain foods of all kinds thoroughly cooked, excepting corn preparations containing much cover, as hulled corn. Prepared foods such as tapioca, macaroni, and vermi- celli, require prolonged cooking. Meats, scraped beef. Eggs, soft boiled, raAv or soft poached. Bread of all kinds, stale, homemade. Puddings, ices. Beverages, all kinds unless otherAvise ordered. Forced Diet.—This includes the general diet with the addition of one quart of whole milk and four eggs. The 332 OBSTETRICS FOR NURSES milk may be given plain or as an eggnog at seven, ten, three, and eight o'clock. The eggs may be given raw or cooked soft in any form. Milk Diet.—Twelve ounces of AAdiole milk (375 c.c.) may be given every two hours; i. e., at six, eight, ten, tweh'e, tAvo, four, five, and eight o'clock, or the patient may sip it at her pleasure. The milk may be giA-en raAA', boiled, diluted Avith plain Avater, lime Avater, Vichy, seltzer, or Apollinaris to taste. The daily amount should include three quarts of AA'hole milk. Koumiss, buttermilk and milk soups are sometimes allowed. Note the exact amount taken, and give reasons for failure, Watch the stools for undigested milk. Liquid Diet.—Whole milk, buttermilk, koumiss, beef tea, or beef, chicken, mutton, oyster, or clam broth, in eight ounce portions, or tAvo ounces of beef juice, every two hours. Lemonade, orangeade, ice cream, or fruit ices, at intervals and amounts as desired. Ulcer Diet.—Whole milk and cream, equal parts, three ounces every tAvo hours. Sodium bicarbonate, thirty grains, in a small amount of water, to be given before and thirty minutes after feeding. Albumin Avater, soft boiled eggs, scraped beef, custard, and cream soups to be added later by direction of the physician. No seasoning except salt is alloAved. Prochownik Diet.—This diet is advised where some necessity exists for preventing a large child. It is ad- ministered in the last six Aveeks of pregnancy only. Breakfast.—Small cup of coffee, tAvo slices of toast (1 ounce). Lunch.—Small piece of meat, fish or an egg, a little sauce. A vegetable prepared Avith fat, lettuce, a small piece of cheese. Dinner.—Same as lunch with three slices of bread and butter, and a little milk. DIETS AND FORMULAE 333 A pint of Avater daily is alloAved; taken in sips it lasts longer. Soup, Avater, beer (all fluids) and sugar, pastry, and potatoes are forbidden. Skimmed Milk Diet (Karell).—Skimmed milk, to AA'hich a pinch of salt is added, 3 to 6 ounces, three or four' times daily, increasing the amount gradually, taken slowly to alloAV thorough mixture AA'ith saliA'a, Avarmed in Avinter, room temperature in summer. Acute Nephritis Diet.—Whole milk, 1000 c.c.; cream, 250 c.c; Avater, 150 c.c; stewed fruit, Avell SAveetened, 50 c.c. Bread, Avell buttered, may be toasted, 150 gm. (equal to three slices) 150 gm. Green salad of lettuce, celery, apple, pear or grape fruit, and served either Avith olrve oil, or Avith a mayon- naise dressing made from ohve oil, egg and lemon juice, Avith salt (but no pepper or condiments) may be given in tAvo small portions daily. Cooked cereals (cream of Avheat, etc.) with cream and sugar, one portion equal to about tAvo ounces, once daily. The above represents a daily fluid intake of about 1500 c.c. The diet is to be given in "three meals," at eight, one, and six o'clock, with fluid nourishment at eleven, three, and nine o'clock. RECTAL FEEDING Nutrient enemas should be given every six hours, un- less otherAvise ordered. It is necessary to cleanse the lower boAvel with a saline or soapsuds enema at least once a day. The cleansing enema should be given one hour before the nutrient enema is to be given. The proper quantity for the nutrient enema is four to six 334 OBSTETRICS FOR NURSES ounces for an adult, and one to three ounces for a child. Nutrient enemas should be given sloA\ly at Aery Ioav pressure, the level of the fluid in the can being not over eight to ten inches above the leA-el of the rectum. If the injected material is thick, a piston syringe may be re- quired. The patient should be placed upon the left side Avith the hips Avell eleA^ated and should be kept in that position for fifteen to tAventy minutes after the enema has been given. The tube should be oiled and not be inserted more than three or four inches. The tempera- ture of the enema should be about 98 degrees. If there is a strong tendency to evacuate the enema, pressure should be made against the rectum Avith a pad. The folloAving nutrient enemas may be ordered by name. Glucose Enema.—Glucose (dextrose, grape sugar) 1 ounce, normal salt solution 5 ounces. The glucose should first be dissolved in hot Avater. The amount of glucose may be increased, upon order, if no irritation is produced. Pancreatinized Milk Enema.—Add 1 tube of peptoniz- ing poAA-der, or 1 to 2 drams of "Pancreatic solution" to 1 pint of skimmed milk. Stir well and place in a Avarm Avater bath for one-half hour. Add 1 dram of salt. Milk and Egg Enema.—Thoroughly beat the whites of 2 eggs, add 1/3 dram of salt, and 6 ounces of skim- med milk. Add one tube of peptonizing powder, or 1 to 2 drams of "pancreatic solution," stir well, and place in a warm Avater bath for one-half hour. Milk, Egg, and Beef Juice Enema.—Mix the beaten Avhites of 2 eggs, 2 ounces of fresh beef juice, 6 ounces of skimmed milk, and 1/3 dram of salt. Add 1 tube of peptonizing poAvder, or 1 to 2 drams of "pancreatic solution," stir well, place in a Avarm Avater bath for one-half hour. DIETS AND FORMULAE 335 Milk and Glucose Enema.—Add 1 tube of peptonizing poAvder to 6 ounces of skimmed milk, stir well, place in a Avarm water bath for one-half hour. Add 3 drams of glucose and 1/3 dram of salt. ELIMINATIVE ENEMAS Impaction Enema.— Castor oil or olive oil, 1 ounce. Soapsuds (100° F.), 1 quart. Mix as thoroughly as possible, add one dram of spirits of turpentine beaten up Avith the yoke of one raAv egg. S. S. and G. Enema.— Soapsuds, 1 quart. Glycerine, 1 ounce. Asafcetida Enema.— Milk of asafcetida, 8 ounces. Water, 8 ounces. 1-2-3 Enema- Magnesium sulphate, 1 ounce. Glycerine, 2 ounces. Water, 3 ounces. Milk and Molasses Enema.— Milk, ordinary cooking molasses in equal parts, possibly 8 ounces of each. Heat, but do not boil. Turpentine Enema.— Soapsuds, 1 pint. Turpentine, 1 dram. It acts quickly and effectively. All enemas should be given through a colon tube. The patient should be on the left side and the tempera- ture of the injection should be about 100° F. 336 OBSTETRICS FOR NURSES DIET LIST Albumin Water.—Take Avhite of 1 egg, stir until separated. Add a little lemon juice and 1 pint of water. Ice and serve. Sugar or salt may be used. Barley Water.—Wash 2 ounces of barley Avith cold Avater. Boil for 5 minutes in fresh Avater. Strain. Then cover Avith 2 quarts of Avater and cook slowly down to 1 quart. FlaA^or Avith thinly cut lemon rind and sugar. Do not strain unless patient requests. Beef Juice.—Cut into cubes l]/2 inches each, 1 pound round steak. Place in a clean, ungreased pan, and fry one and one-half minutes on each side. Pour into hot meat press and apply pressure. In absence of a press, a potato ricer may be used. Season Avith salt and pep- per. May be served iced or heated by putting in double boiler and stirred all the time. Do not alloAv to curdle. Beef Tea.—Put 1 pound of finely chopped round steak into a quart glass jar, fill Avith cold Avater. Place jar in kettle of Avarm Avater. LeaA'e over sIoav fire for four hours. Strain, season Avith salt and pepper. Champagne Whey.—Boil 8 ounces milk for fifteen minutes. Strain through cheesecloth. Add iy2 ounces champagne. Chicken Broth.—Skin and chop in small pieces one small or one-half large foAvl. Boil bones and all with one blade of mace, a sprig of parsley, and 1 table- spoonful of rice, 1 crust of bread and 1 quart of Avater, for one hour. Skim from time to time. Strain through coarse colander and season to taste. Cinnamon Water.—One-half ounce stick cinnamon, 2 cups boiling Avater. Break sticks in small pieces. Add water, boil twenty minutes. Strain and seiwe hot or cold. DIETS AND FORMULAE 337 Clam Broth.—Wash thoroughly 6 large clams in shell. Put in kettle Avith 1 cup of cold Avater, bring sIoavIv to boil, and keep temperature for one minute. Pour off broth and serve hot. Add salt and pepper. Eggnog.—Beat an egg, Avhite and yolk separately. Add to the yolk 1 dram of Aanilla extract, a pinch of salt and 4 oz. fresh milk, and 1 dram of sugar. Add y2 dram of sugar to Avhite of egg, stir a portion into the glass and heap remainder upon top of glass. Egg Cordial.-—One egg Avhite, 1 teaspoon sugar, 1 tablespoon brandy, 2 grains salt, 2 tablespoons cream. Beat AA'hite until stiff. Add cream, continue beating, add other ingredients, and serve cold. Egg Lemonade.—Beat 1 egg and 1 teaspoonful of su- gar until very light, add y± cake of yeast dissolved in one-fourth cup of Avater, two tablespoonfuls of sugar, pour into bottles with patent stopper, fill bottles only tAvo-thirds full, cork tightly. Shake well. Allow to stand on ice tAventy-four hours. Flaxseed Tea.—One ounce of Avhole flaxseed, 1 ounce poAvdered sugar, ]/2 ounce licorice root, 1 ounce lemon juice. Pour over these materials 1 quart of boiling Avater and alloAV to stand four hours. Strain off liquor. Gum Arabic Water.—Dissolve 1 ounce of gum arabic in 1 pint boiling water. Add y2 ounce sugar, a wine- glassful of sherry, and juice of one lemon. Serve with ice. Junket.—Take ]/2 pint of fresh milk in a saucepan. Add 1 teaspoonful of essence of pepsin, stir just enough to mix. Pour into custard cups. Let stand until firmly curded. Serve plain or with grated nutmeg. Sherry may be added. Koumiss.—Heat four cups of milk, then cool; when lukewarm, add 14 eake of veast dissolved in one-fourth 338 OBSTETRICS FOR NURSES cup of Avater, two tablespoonfuls of sugar, pour into bottles Avith patent stopper, fill bottles only two-thirds full, cork tightly. Shake well, alloAv to stand on ice tAventy-four hours. Milk Shake.—White of 1 egg, 1 ounce sugar, 1 ounce chipped ice, 1 ounce cream. Shake in milk shaker tAvo minutes. Add milk to fill glass. Flavor AA'ith vanilla and lemon. Mutton Broth.—Boil sloAA'ly \y2 pounds of lean loin mutton, including the bone. Add a little salt and y2 onion. Pour broth into a basin. Skim off fat Avhen cool. Warm as used. Oatmeal Gruel.—One teacup oatmeal flakes, cover Avith 1 quart cold Avater. Place on sIoav fire and soak three hours. Strain, add 4 teaspoonfuls of sugar and 1 tea- spoonful of salt. Oatmeal Water.—Cover 1 teacupful oatmeal with 1 quart cold water. Let it stand tAvo hours. Stir often. Strain. Serve with salt, sugar and ice. Peptonized Milk. Warm Process.—Dissolve the con- tents of Fairchild's peptonizing tube in 4 tablespoonfuls cold water. Add to 1 pint of milk. Put in glass jar, and place jar in vessel of Avarm water. Heat slowly to 115° F. Stir slowly and allow it to remain thirty minutes. Place on ice at once to check further digestion. Peptonized Milk. Cold Process.—In a clean quart bottle, put one peptonizing powder (Fairchild). Add 1 teacupful of cold water. Shake. Add 1 pint fresh cold milk. Shake Avell. Place on ice. Do not heat before using. Rice Water.—Pick over and wash 2 tablespoonfuls of rice. Put in a saucepan with 1 quart of boiling water; simmer two hours. When rice is dissolved, strain. Add DIETS AND FORMULAE 339 teaspoonful salt. Serve warm or cold. Sherry may be added. Rum Punch.—Tayo teaspoonfuls poAvdered sugar, 1 egg Avell beaten, Avarm milk, 1 large Avineglassful; 4 ounces Jamaica rum. Flavor Avith nutmeg. Scraped Beef.—Place on breadboard a round steak. Scrape Avith tableknife but do not take any shreds of muscle. Salt and pepper. Spread on thin slices of bread. Place in toaster until seared. Toast Water.—Three slices of stale bread well browned, but do not burn. Put in a pitcher, pour over them 1 quart boiling Avater. Cover closely, and allow to stand until very cold. Strain. Wine and sugar may be added, to stimulate. Wine Whey.—Put 1 quart new milk in a saucepan and place over fire. Stir until nearly boiling. Add 2 ounces of sherry wine. Boil slowly for fifteen minutes. Skim off curds as they arise. Add 1 tablespoonful sherry. Skim again, then strain through gauze. CHAPTKPt XXV SOLUTIONS AND THERAPEUTIC INDEX Acid, Boric. 5 dr. in a pint of water makes a 4% solution, or 1:25. Acid, Carbolic. 15 at in a quart of water makes a 0.1% solu- tion, or 1:1000. 5 dr. to the quart makes a 2% solution; and l1^ oz. to the quart, a 5% solution. Chinosol. 15 gr. to the quart of water makes a solution of 1:1000. Formalin. 1 dr. to the quart of water makes a solution of about 1:500. Mercury Bichloride. 15 gr. to quart of water makes a 0.1 % solution, or 1:1000. 1% gr. to the quart makes a 0.01% solu- tion, or 1:10,000. Normal Salt Solution. 2 dr. of salt to the quart of water, or 0.9%. Physiological Salt' Solution. Take normal salt solution as given aboA'e and to every 3% oz. add 15 gr. of carbonate of soda. Potassium Permanganate. 2V2 dr. to the quart makes a 1% solution. 3 gr. to the quart makes a 1:5000 solution. Silver Nitrate. 4% gr. to the ounce of water or 1 gr. to 1-7/10 dr. makes a 1% solution. Ziratol. 21^% teaspoonfuls to a quart of water makes a 1% solution. For general reference the following valuable table is appended: 340 Quantity of solu- tion to be made Vi II. oz 1 fl. oz. 2 fl. oz. 3 II. oz. 4fl. cz. 5 fl. oz. 1.15 2.3 4.6 6.9 9.2 11.5 PERCENTAGE SOLUTION TABLE By Ai.fked I. COHN, PHAR. D.t in Merck's Report GRAINS OF SALT OR DRUG REQUIRED TO MAKE SOLUTIONS OF PERCENTAGE STRENGTH INDICATED 0.5% 1% 2% ' 3% '• 4% 5% 6% ! 8% \ 10% | 15% ; 20% | 25% ! 50% 1:500 1:1000 1:2000;1:300oj 1:4000 1:500() 1.6 6.9 9.3 11.7 j 14.1 19 24 | 36.8 50.2 1.2 , 13.9 18.6 \ 23.4 ! 28.2 ' 37.9 ' 47.9 j 73.5 100.3 56.4 j 75.8 95.8 |147 [200.6 84.6 113.7 143.7 ;220.5 301 2.3 4.6 9.2 18.4 j 27.8 37.2 13.8 27.6 i 41.7 | 55.8 36.8 I 55.6 74.4 18.4 23 46 69.5 I 93 46.8 70.2 93.6 117 112.8 141 151.6 189.5 191.6 294 401.2 239.5 367.5 501.5 65 1151. 2 0.46 0.228 012 0.075 006 0.05 130 '302.5 0.91 0.456 0.23 0.15 0.12 0.09 260 605 ; 1.8 I 0.91 j 0.46 i 0.3 0.23 018 390 907.5 i 2.7 137 0.68 0.46 0.34 0 27 520 1210 3.64 1.82 0.91 ! 0.61 0,46 0 36 650 ;1512.5 4.55 ! 2.28 1.14 0.76 ! 0.57 046 "~The~ table shews" the quantity of drug required to yield a given volume of solution of the percentage strength desired. Thus, to make one fluid ounce of a 5 per cent solution it is merely necessary to dissolve 23.4 grains ot the salt in suj- ficicnt ivatcr to make one fluid ounce. 342 OBSTETRICS FOR NURSES THERAPEUTIC INDEX Young's Rule for Dosage: The age of the child is di- vided by the age of the child plus 12, and the result is the appropriate dose for the child. The doses given beloAv are for the adult unless otherwise specified. Absorbent. A medicine or dressing that promotes absorption, such as potassium iodide, Tr. iodine, glycerine, or hot vaginal douches. Adrenalin. The blood-raising principle of the suprarenal glands. It is haemostatic and astringent. Acts somewhat like digitalis on the heart. Uses.—Vomiting of pregnancy, increased glandular activity, haemorrhage, inflammation of mucous membranes. Dose.—Internally, 5-10 m. of the 1:1000 solution. Extern- nally, the solution of 1:1000 or 1:10,000 may be applied. Albolene. An oily white substance obtained from petroleum. It is used on the nipples and skin of the mother and to remove the vernix caseosa from the skin of the child. Aloin, Strychnia, and Belladonna. A laxative pill which usually contains aloin 1/6 gr., strychnia sulph. 1/60 gr., and Bella- donna 1/12 gr. Ammonia Carbonate. Antispasmodic, stimulant, and expecto- rant. Uses.—Stimulant to heart. Stimulating expectorant in pneu- monia and bronchitis. Dose.—5-20 grains in mucilage or syrup. Anaesthone. A mixture of adrenalin chloride (0.1%) and chloro- tone (5%) in an ointment base of wool fat and petrolatum. Astringent, antiseptic, anesthetic and germicide. Useful ap- plication to swollen mucous membranes or in coryza. Argyrol (Silver Vitellin). Antiseptic and germicide. Uses.—Like Silver Nitrate, but less irritating to the tis- sues. 3-5% solution in water is an injection for gonorrhoea. 15% solution dropped in the eyes of the new-born may pre- vent ophthalmia. 25% solution may be used twice a day as a remedy for existing ophthalmia, but the strength should be reduced after three or four days. 10-15% solution is used as an injection in cystitis. An ounce or more of the solution may be left in the bladder until the next evacuation. Asafcetida. A fetid gum resin. Carminative, antispasmodic, mild stimulant, and expectorant. Uses.—Gas pains of adults and infants. Hysteria and in- digestion. Dose.—5-10 gr. t.i.d. For infantile colic, an emulsion called the mistura of asafoetida mav be used in 2-4 dram doses. For adults 1-2 tablespoonfuls. THERAPEUTIC INDEX 343 Belladonna. Nervine, mydriatic, sedative, narcotic, antispas- modic and anodyne. Makes the throat dry and dilates the pupils. Uses.—Night sweats, nervous cough, pain, incontinence of urine and to restrain glandular activity. Dose.—Fl. ext. 1-3 TIT.; dry ext. V2-l gr. Tincture 8-20 m.. Solid ext. Mi-Vi gr. All for adults. For infants, proportion- ately less. See Bide for Dosage. Benzoin. Antiseptic and externally a styptic and protective for sores. Uses.—Sore nipples and urticaria. Lard is also benzoin- ated for use in removing vernix caseosa. Compound Tr. of benzoin contains, benzoin, purified aloes, storax, balsam of Peru, and alcohol. Benzoinal, Albolene mixed with benzoin. Bismuth Subnitrate. A white heavy powder. Antiseptic and astringent. Uses.—Subacute gastritis, pyrosis, diarrhoea and vomiting of pregnancy. Particularly desirable in infancy because it is free from arsenic, lead and silver. Dose.—5-60 gr. in the adult. Boric Acid (Boracic Acid). A white crystalline powder. Anti- septic. Uses.—As a dressing and lotion for eyes, navel, mouth, nip- ples, and all mucous surfaces. In solution to preserve the sterility of rubber nipples until they are needed. Dose.—Internally, 5-15 gr. Solutions are usually about 4% or 5%. A saturated solution in water is about 6%. In hot water 25%. Boroglyceride. An antiseptic paste of boric acid and glycerine. When an excess of glycerine is present the preparation is called boroglyeerol. Uses.—An oxydizer in endometritis. It is applied to the cervix on cotton tampons. Calcium (Lime). Stomach sedative, soothes the irritated or burned skin, corrects hyperacidity, increases the clotting power of the blood (?). Lime water is a saturated solution of calcium hydrate and is used for nausea, to break up the curds of milk, and to increase its digestibility. It is mildly constipating. Calomel. See Mercury. Camphor. A solid volatile oil. Nerve sedative. Anaphrodisiac. Antispasmodic. Stimulant. Uses.—The monobromated camphor is given internally for hysteria, neuralgia, and as a hypnotic. Dose.—1-10 gr. Camphorated Oil. A solution of camphor in cottonseed oil. Eube- facient and stimulant. Uses.—Internally in collapse. Externally as an application to the child for colds of chest and nose. 344 OBSTETRICS FOR NURSES Do.se.—5-20 111 hypodermically in collapse. The injection should be made deep into the muscle. Carbolic Acid (Phenol). Derived from coal tar. Antiseptic, deodorant and local anaesthetic. Uses.—Vomiting of pregnancy, pruritus, eczema, steriliza- tion of instruments. Usual solution is 2%% to 5%. For sterilization of knives, scissors and other sharp instruments the 95% is used. In pruritus, the following wash will aid: carbolic acid, 12 dr., glycerine 2 dr., alcohol, 4 3 water q.s. 1 pt. Apply. Cascara Sagrada. Stimulant laxative, and cathartic. Useful in pregnancy, but after labor there is evidence that it may go over in the milk to the child. Dose.—Fl. ext. 10-20 Til. The Hinkle pill contains cascara. Castor Oil. Oil expressed from the seeds of the castor plant. A cathartic. Acts in four or five hours. Dose.—For adults, y2 oz. to 1 oz. For infants 10 to 60 drops given with a dropper—not with a spoon. Castor oil cocktail.—Einse out. the glass with lemon juice or whiskey. Pour in teaspoonful of lemon juice and a teaspoonful of whiskey, add castor oil in amount required, cover with whiskey and give. A paste is made from the mixture of castor oil and bismuth subnitrate in equal parts, which is an excellent prepara- tion for sore nipples. Cerium Oxalate (and Cerium Valerianate). Sedative and nerve tonic. The oxalate is a white crystalline powder, odorless and tasteless. Uses.—Vomiting of pregnancy, seasickness. Dose.—2-10 gr. several times daily. Charcoal. Administered in tablet form or as a powder between two slices of buttered bread. Uses.—Acid stomach. Vomiting of pregnancy. Chinosol. Nonpoisonous, nonirritating and odorless. Antiseptic deodorant, styptic and analgesic. Dissolves instead of coagu- lates secretions. Uses.—Antiseptic solutions for hands and sponges, deodoriz- ing wash for vagina post partum, intrauterine douche, wash for gonorrhoea and cystitis. Dose.—For douche or hand solution 1:1000 or 1:5000. For dusting powder, 1 part to 10 or 20 of starch, talcum, borie acid, or bismuth subnitrate. Chinosol will corrode unplated steel. It may be mixed with salt, but not with soap. Choral Hydrate. White crystal masses. Pungent in odor and taste. Hypnotic, antispasmodic, antiseptic and analgesic. Uses.—Insomnia, eclampsia, convulsions, and to restrain se- cretion of milk. Dose.—By mouth, 10-30 gr. By rectum, not to exceed 60 gr. In infants 1-2 gr. by rectum in an ounce of water. THERAPEUTIC INDEX 345 Chymogen. A preparation of rennin (10%) made by Armour & Company. Coagulen Ciba. A physiological nontoxic styptic, prepared from the natural coagulents of the blood. A 10% solution in water will hasten the beginning and end of coagulation. May be applied to bleeding surfaces directly, or given under the skin, into the muscle, or into a ATein. 3%% to 5% solu- tion in distilled water, should be sterilized by boiling 2-3 minutes. Do not filter. Inject. Cocaine Hydrochlorate. Anaesthetic, sedative, anodyne, anti- pruritic. Uses.—Vomiting of pregnancy, with caution. Dose.—Internally ^-l1/" gr. Externally a 4%-10% solution in water. Codeine. Alkaloid of opium. Less narcotic than morphine. Uses.—After-pains and pain of over-distended breasts. Dose.—i/i-l1/^ gr. by mouth. Vi-% gr. hypodermically. Compound Licorice Powder. See Senna. Condylomata. Use— B Acid. Salicyl. gr. x Acid Boric. gr. xxx Calomel. 3 i M. Sig.: Apply twice daily. Digitalis. Cardiac tonic. Diuretic. Stimulant. Uses.—Weak heart. Syncope. Collapse. Dose.—For adult: of the tincture, 5-15 Til, fl. ext. 1-3 TTL, ext. gr. %-%. Digipuratum. A preparation of digitalis from which the inac- tive substances have been removed. It is used in the same conditions as digitalis. Dose.—The tablets contain \y2 gr. and one is given four times daily until ten are taken. Then stop. Hypodermic- ally. Each viol contains 1 c.c. of fluid and equals 1% gr. of digipuratum. Each dose contains enough of the active principle of digitalis to kill a 30 gm. frog. Ergot (Fungus of Eye). Contracts unstriped muscle fiber. r.se.s.—To check haemorrhage after labor. To promote in- volution. Must not be given in labor until the uterus is empty. Dose'.—By mouth 15-60 m. of the fl. ext. Hypodermically, 10-20 ffl. Ergotole, Ergotine. Concentrated solutions of ergot, 2i/> times as strong as the fluid extract. They are sterilized and preserved in glass ampoules. Uses.—See Ergot. Dose.—30-60 TO.. Green Soap. A soap made of linseed or other oil, potash, alco- hol and water. 346 OBSTETRICS FOR NURSES "The adoption by the U. S. Pharmacopoeia of the term Sapo Viridis (green soap) is unfortunate, since soft soap even if made from green hempseed oil will become brown-yellow unless artificially colored."—U. S. Dispensatory. Haemophilia. A condition of the blood wherein its clotting power is diminished or absent. Coagulen, horse serum, or diphtheria antitoxin may be given hypodermically. Direct transfusion of blood from another is best. Hyoscine, Morphine, and Cactin. (H. S. & C. Tablets). A pro- prietary combination of drugs. The action is said to be similar to that of morphine and scopolamine. Iodine, Tincture. Uses.—To sterilize the skin before operation. In vomiting of pregnancy it is sometimes effective. Drop doses mav be given well diluted. Externally it is applied to ulcers, as in Bednar's disease, and sometimes as a dressing for the cord. In pruritus vulvae it is a valuable application. Iron. Tonic emmenagogue. Uses.—To increase the number of red blood corpuscles. To raise blood pressure and to increase the secretion of milk. Dose.—3-5 gr. Blaud's pill contains the carbonate in a form that is easily assimilated. Laxatives. Laxatives are unirritating and excite moderate peristalsis. Sulphur, magnesia, cassia, manna, cascara sagrada, the Hinkle pill, and the A, B & S pill are usually mild in action. Lysol. Disinfectant and antiseptic for hands and instruments. It is a brown syrupy fluid made from coal tar oil, which is distilled and mixed with fat, soap, etc. It has a creosote odor and contains 50% cresol. Eeadily soluble in water. Prepared in 1/>-4% solutions. Magnesia, Calcined. Antacid and cathartic. Comes in white cakes. Uses.—Acid stomach, vomiting of pregnancy, ".heartburn," and constipation. Dose.—30-120 gr. Magnesia, Milk of. A mixture of magnesia and water. Has the same properties as the above. Dose.—For adults, 2-3 teaspoonfuls. For infants, i,4-2 tea- spoonfuls. Magnesia Sulphate (Epsom Salts). Saline cathartic. Uses.—The profuse watery stools produced by magnesia are valuable aids to elimination when the kidneys are over- worked or defective. In congestion of the breasts and threatened eclampsia, or in any case where it is desirable to drain off waste or dehydrate the system. Dose.—1 teaspoonful daily in hot water before breakfast. V2-\ oz. as a single dose or 1 oz. by rectum, as in the 1-2-3 enema. THERAPEUTIC INDEX Oir o-ti Menthol (Mint Camphor, Japanese Peppermint). Analgesic, anti- septic, anaesthetic, and vascular stimulant. Uses.—In pruritus vulvae, vomiting of pregnancy, and haemor- rhoids. Dose.—By mouth 3-5 gr. In tampons, one part to five of oil. In ointments one part to sixteen. To the vulva for pruritus, use the spirits in 5% solution. Mercury (Hydrargyrum). Cathartic, alterative, antisyphilitic, antiseptic and disinfectant. Eeadily absorbed by the un- protected mucous surface and relatively inert when the membrane is covered by a discharge. Solutions of the bi- chloride when used as a lotion unite with the albumin of a mucous discharge and form an albuminate of mercury, which is inactive. Bichloride solutions have small place in obstetrics. They are hard on the hands and destructive to instruments. Other agents like lysol, ziratol and chinosol have satisfactory germicidal properties and in addition are nonpoisonous, lubricative and cleansing. Mercury should only be given to the infant in the form of calomel (the mild chloride). The dose is i/i2-% gr-> repeated if necessary. Morphine. Alkaloid of opium. Antispasmodic, hypnotic, analgesic and narcotic. Uses.—To relieve pain, produce sleep, check diarrhoea, and to control the pain, as well as the contractions of abortion. To relax a rigid os. Dose.—In "Twilight Sleep" and rigid os the first dose is Morph. sul. Yc-Vi gr. and scopolamine Hydrobromid 1/200- 1/150. The scopolamine to be repeated if required, in one- half or three-quarters of an hour. The usual dose of mor- phine hypodermically is yv>-V2 gr. Nitroglycerine (Glonoin). Vasomotor dilator, arterial stimulant. Uses.—For the prostration following haemorrhage. Dose.—1/200-1/50 gr. hypodermically. Novocaine. Local anaesthetic, similar to cocaine, but less toxic. For local anaesthesia in solutions of 0.25% to 2% usually in association with adrenalin (5-10 drops of the 1:1000 solu- tion to each 10 c.c. of novocaine solution). Nux Vomica. The plant from which strychnia is derived. Tonic, stomachic, and stimulant to muscle, nerve, and heart. jjses.—Bitter tonic and stimulant. Vomiting of pregnancy and agalactia. j)ose.—Ten drops of the tincture in water before meals. Opium. The concrete juice of the poppy. Believes pain. Con- stipates. Uses.—Haemorrhoids in adults, colic and diarrhoea in infants. Dose.—One grain in suppository night and morning for adult. For infant, as paragorie only. Two to five drops only, not repeated. Children bear opium badly. 348 OBSTETRICS FOR NURSES Pepsin. A ferment in the gastric juice that digests proteins. In commerce it is obtained from the pig. Uses.—Imperfect digestion. Dose.—For adult, 10-15 grs. For infant, 2 gr. Phenolphthalein. A nonofficial coal tar derivative. Mild laxa- tive. Dose.—2-3 gr. Phenolax and chocolax are preparations of the drug. Pituitary Extract (Pituitrin). A substance derived from the infundibular portion or the posterior lobe of the hypophysis cerebri. Nontoxic, stimulant to unstriped muscle. Uses.—Uterine inertia, post partum haemorrhage, Caesarean section and tympany. Will not produce abortion nor pre- mature labor. May be tried in acute anaemia to raise the blood pressure. Dose.—5-15 Tu_. Eepeated if necessary. Potassium (or Sodium) Bromide. White granular powder. Sol- uble, 1 to 5 in water. Sedative, hypnotic, antiepileptic. Uses.—Neurasthenia, convulsions, nymphomania, vomiting of pregnancy. Dose.—20-60 gr. In enema with chloral. Pot. bromide 40 gr. and chloral 20 gr. in several ounces of water or milk. Potassium Iodide. Alterative emmenagogue. Uric acid solvent. Uses.—Syphilis rheumatism, swellings, slow inflammations, excessive secretion of milk. Dose.—2-10 gr. increased as required. Potassium Permanganate. Dark purple opaque prisms. Soluble in water 1 to 16. Disinfectant, deodorant, antiseptic, astringent. Uses.—As an injection in leucorrhoea and gonorrhoea, 1:5000 solution. Purgatives. Simple purgatives produce free discharges from the bowels with some griping. Senna, aloes, rheubarb, castor oil, and calomel are examples. Saline purgatives are fol- lowed by profuse watery evacuations. Magnesia sulphate, and citrate, potassium and sodium tartrate, and sodium phosphate belong to this class. Drastic purgatives bring about a violent action of the bowels with much griping and tenesmus. Such are jalap, colocynth, elaterium, and croton oil. Hydrogogue purgatives combine the results of the salines and drastics. They have much griping with profuse watery stools. The hydrogogues are elaterium, gamboge, croton oil, and potassium bitartrate. Quinine Sulphate. (Derived from Cinchona bark.) Antipyretic, tonic, antiperiodic, antiseptic, emmenagogue and ecbolic. Uses.—Valuable stimulant in a slow first stage. It is com- bined with castor oil to bring on labor at term. Castor oil 1 oz. and quinine sulphate 10 gr. is given as the first dose, fol- lowed in an hour by another 10 gr. of quinine, and an hour later by another. Dose.—2-20 gr. THERAPEUTIC INDEX 349 Regulin. A mixture of agar-agar in dry form with extract of cascara sagrada. Uses.—A laxative in chronic constipation. Dose.—Teaspoonful to tablespoonful in stowed fruit or mashed potatoes, once daily. Russian Oil (Liquid Petrolatum). Laxative in pregnancy and puerperium. Acts mechanically and as a lubricant. Not unpleasant to take. Dose.—y2 oz. at bedtime, and, if necessary, before each meal. May be given to breast-fed babies in doses of gtts. xv three times daily. Senna. Laxative and purgative. Acts especially on the large intestine. Sometimes passes over in the milk to the child. Dose.—Fl. ext. 1-4 tcaspoonfuls. In compound licorice pow- der the dose is 30-80 gr. (about 10 gr. of senna to the dose). Silver Nitrate. Caustic, antiseptic, stimulant, irritant and anti- gonorrhceic. Table salt neutralizes it. Uses.—2% solution in water for pruritus vulvae. 1% solu- tion dropped into the eyes of the new-born to prevent oph- thalmia neonatorum. Do not neutralize the 1% solution. % gr. silver nitrate with 2 gr. of pepsin in capsule for pernici- ous vomiting of pregnancy. Sodium Bicarbonate (Baking powder). Antacid, antirheumatic. Uses.—Gout, dyspepsia, acid stomach, acidosis, vomiting of pregnancy. Soothes the skin when burned. Sodium Chloride. (Salt.) For normal saline use 10 gr. to 3V2 oz. of water. For phys- iological salt solution, add 15 gr. of Sod. Carb. to every 3y2 oz. of normal saline as made above. Sodium Citrate. A white odorless, granular powder with cool- ing salty taste. Uses.—Diuretic, antipyretic and refrigerant. Retards the coagulation of albumin in milk and aids the digestibility of proteins. May be indicated in gout and cystitis. Dose.—Internally, 15 to 60 gr. In the modification of cow's milk about two grains should be used for each ounce of the mixture. Spirits of Nitre, Sweet (Spirit Xitrous Ether). 4% solution of nitrous ether in alcohol. Diaphoretic, diuretic, antipyretic, stimulant, antispasmodic. Uses.—Fever, dropsy, vomiting of pregnancy, colic, anuria. Dose.—For adult, 20-60 gtts. For infants small doses often repeated. Stramonium (Jimson Weed). Hypnotic, narcotic, antispasmodic. jjses.—For haemorrhoids take Ung. Stramonii and Ung. Galli in equal amounts and apply. 350 OBSTETRICS FOR NURSES Urotropin. A white powder soluble in water. Urinary antiseptic, diuretic. Uses.—Cystitis, typhoid bacilli in urine, gout. It makes the urine irritatingly acid when given long. It does not act in alkaline media. Dose.—7%-10 gr. well diluted. Valerian. Anodyne, stimulant, antispasmodic and nervine. Uses.—Hysteria, hypochondriasis, headache. Dose.—30-60 m_ of the fl. ext. by mouth, or by rectum 2 oz. of the following mixture may be used P.E.N, for hysteria: Pot. Brom. 1 oz. Ext. Valerian fl. dr. vi. Normal saline q.s. oz xii. Veratrum Viride (Hellebore). Sedative, emetic, diaphoretic. diuretic. Eetards the heart's action without weakening it. Uses.—Eclampsia. Dose.—1 to 4 TTL of the fl. ext. is given hourly until the pulse comes down to 80. Veronal. Safe, reliable hypnotic. Uses.—Insomnia from hysteria, neurasthenia, and mental disturbance. Dose.—5 to 15 gr. dissolved in hot tea, milk, or Avater. May repeat. Zinc. Tonic, astringent, antispasmodic. £7ses.—Stearate of zinc is a valuable dressing in excoriations of buttocks and external genitals. Zinc Ointment. It is indicated for bedsores (decubitus) eczema, herpes, and intertrigo. Zinc ointment contains one part of zinc oxide to four parts of benzoinated lard. Ziratol. A mixture of phenols in soap, water, and glycerine. Antiseptic, deodorant and germicide. Eelatively odorless, easily soluble and does not injure hands, instruments, or rubber. It is said to be only 14 as toxic as carbolic acid. Used in solutions of 0.5% up to 5%. GLOSSARY [Adapted from Doiland Ab-nor'mal. Not normal; con- trary to the usual structure or condition. A-bor'tion. 1. The expulsion of the foetus before it is viable. 2. Premature stoppage of a morbid or a natural process. Ab-ra'sion. 1. A rubbing or scraping off. 2. A spot rub- bed bare of skin or mucous membrane. Ab'scess. A localized collection of pus in a cavity formed by the disintegration of tis- sues. Ac-couch' e-ment. Delivery in childbed; confinement. Ac'e-tone. 1. A colorless liquid found in pyro-acetic acid and in naphtha. 2. Any member of the series to which the nor- mal or typical acetone be- longs. A'ci-do"sis. Acid intoxication of the system from the elab- oration or too much acid by faulty metabolism or the imperfect disposition of nor- mal amounts of acid. A-ci'nus, pi. acini. One (acini, more than one) of the small- est lobules of a compound gland. Al'bo-lene. An oily white sub- stance derived from petro- leum. Al'bu-mi-nu"ri-a. The presence of albumin in the urine. Al'ka-line. Having the reaction of an alkali. Standard Dictionaries] A'men-or-rhce"a. Absence or abnormal stoppage of the menses. Am-mo'ni-a. A colorless alka- line gas, NH3, of penetrating odor, and soluble in water, forming ammonia-water. Am- moniacal urine contains am- monia, which is one form of nitrogen excretion. An-ae'mi-a. A condition in which the blood is deficient in quantity or in quality. An'aes-the"si-a. Loss of feel- ing or sensation, especially loss of tactile sensibility, though the term is used for loss of any of the other senses. An'aes-thefic. 1. Without the sense of touch or of pain. 2. A drug that produces anaes- thesia. An'al-ge"si-a. Absence of sen- sibility to pain. An-aph'ro-dis"i-ac. A drug that allays sexual desire. An'a-sar"ca. An accumulation of serum in the cellular tis- sues of the body. An'en-ceph"al-ous. Having no brain. An'ky-lo"sis. Abnormal rigid- ity or stiffness of a joint. An'o-dyne. A medicine that re- lieves pain. An'te par'tum. Latin for "be- fore delivery." An-te'ri-or. Situated in front of, or in the forward part of. 351 352 OBSTETRICS An'ti-pe'ri-od"ic. A drug that tends to pre\ent recurrent at- tacks of disease. An'ti-sep"tic. 1. Preventing de- cay or putrefaction. 2. A substance destructive to poi- sonous germs. A-pe'ri-ent. Mildly cathartic. Ap-nce'a. The absence of res- piration—especially that form which occurs in a child de- livered by the Caesarean oper- ation. A-re'o-la. The darkish ring around the nipple. As-ci'tes. Dropsy (an accumu- lation of fluid) in the ab- domen. A-sep'sis. Absence of septic matter, or freedom from in- fection. As-phyx'i-a. Suffocation. As-trin'gent. 1. Causing con- traction and arresting dis- charges. 2. An agent that arrests discharges. At'e-lec-ta"sis. Imperfect ex- pansion of the lungs at birth; partial collapse of the lung. At'on-y. Lack of normal tone or strength. A'tri-um. L., a hall.) The point of entrance of a bac- terial disease. At'ti-tude. A posture or posi- tion of the body. The rela- tion which the various parts of the child's body bears to its own long axis. The atti- tude of the foetus normally is complete flexion. Aus'cul-ta"tion. The act of lis- tening for sounds within the body. Bac-te'ri-a. The vegetable mi- croorganisms (Schizomycetes) especially the short-rod forms. Bal'an-i"tis. Inflammation of the glans penis. It is usual- ly associated with phimosis. FOR NURSES Bal-lotte'ment. The diagnosis of pregnancy by pushing up the uterus by a finger in- serted into the vagina so as to cause the embryo to rise and fall again like a heavy body in water. Bar'tho-lin glands. The vulvo- vaginal glands. Bleb. A skin vesicle filled with fluid. A blister. Breg'ma. The point on the sur- face of the skull at the junc- tion of the coronal and sagit- tal sutures. Cae-sa're-an sec'tion. (Named from Julius Caesar, who is said to have been thus born). Delivery of the foetus bv an incision through the abdom- inal and uterine walls. Ca'put. Any head, or head-like structure. Ca'put suc'ce-da"ne-um. A swelling formed on the pre- senting part of the foetus during labor. It is due to the effusion of fluid into the subcutaneous tissues, of the scalp and its retention there. Car-min'a-tive. Drugs that stimulate the circulation, the mental faculties, and intes- tinal peristalsis. Asafcetida, camphor, capsicum, cardamon, chloroform, ether, ginger, horseradish, mustard, and the oils of anise, cloves, spear- mint, nutmeg and valerian are carminatives. Car'ne-ous. Fleshy. Cath'e-ter, tra'che-al. A long slender tube designed for in- troduction into the babe's trachea as a means of suck- ing out mucus. Cath"e-ter-ize'. To introduce a tube and draw off fluid, as urine or mucus. GLOSSARY Caul. 1. The great omentum. 2. A piece of amnion which sometimes envelopes a child's head at birth. Cell. 1. Any one of the minute protoplasmic masses which make up organized tissue. Ceph-al'ic. 1. Pertaining to the head. 2. A medicine for the head. Ceph'al-hae-ma-to"ma. 1. A tu- mor or swelling filled with blood beneath the pericrani- um. Cer'vix. The neck or any neck- like part. Chlo-as'ma. The yellowish brown spots or patches that appear on the skin of pregnant wom- en. Cic'a-tri"cial. Pertaining to, or of the nature of, a cicatrix. Ci-ca'trix. A scar; the mark left by a sore or wound. Cil'i-a. 1. The eyelashes. 2. Minute lash-like processes that characterize certain cells. Cli'mac-ter"ic. A particular epoch of the ordinary term of life at which the body is be- lieved to undergo a radical change—especially applied to the menopause. Cli-ni'cians. Men who teach and explain diseases by show- ing actual cases. Clit'o-ris. The sensitive organ of the female, homologous with the penis in the male. Coc'cyx. The small bone situ- ated at the end of the sacrum. The very last portion of the spine. Col-lapse'. A state of extreme prostration and depression with failure of circulation. Col'les' mem'brane. A layer of tough sensitive fascia back of the perineum and on either side of the vagina. Co-los'trum. The first fluid se- creted by the mammary glands after functional ac- tivity begins. It contains casein and more albumen than milk, as well as numerous fatty globules. Col'peu-ryn"ter. A dilatable bag. used to distend the vagina. Co'ma. Profound stupor occur- ring in the course of a dis- ease or after severe injury. Co'ma-tose. Pertaining to, or affected with, coma. Com'pli-ca"tion. A disease or diseases concurrent with an- other disease. Con-cep'tion. The fecundation of the ovum. Con'dyl-o"ma. A wart-like ex- crescence near the anus or vulva. It may be as large as a cauliflower. Con-gen'i-tal. Born with a per- son ; existing at or before, birth. Con'ju-gate. The anteroposte- rior diameter of the pelvic inlet. Cor'o-nal. Pertaining to the crown of the head, as the coronal suture. Cra'dle cap. The dirty looking patch of epithelial scales and sebaceous material that de- velops over the anterior fon- tanelle of babies who haAre the exudative diathesis. Cra'ni-ot"o-my. The cutting in pieces of the foetal head to facilitate delivery. Cre-de Expression. The maneu- ver in which the uterus is grasped in the hollow of the hand and squeezed and pressed down upon to aid in the expulsion of the placenta. 354 OBSTETRICS FOR NURSES Cre-d6 Treatment. The instil- lation of a 1% solution of nitrate of silver into the eyes of the new-born to prevent ophthalmia. Curd. The coagulum of milk, consisting mainly of casein. Cy'an-o"sis. Blueness of the skin, often due to cardiac malformation causing insuf- ficient oxygenation of the blood. Cys-ti'tis. Inflammation of the bladder. De-cid'u-a. The membranous structure produced in the uterus during gestation and thrown off after parturition. D. reflexa, the part of decidua which is reflected upon and surrounds the ovum, D. sero- tina, the late decidua; the part of the decidua vera which becomes the maternal portion of the placenta. D. Vera, the true decidua; the portion of the decidua which linos the uterus. De-cu'bi-tus. 1. An act of ly- ing down. 2. A bed-sore. De-hy'drate. To remove the Mater. Di'a-be"tes. A disease marked by an habitual discharge of an excessive quantity of urine and the presence of sugar therein. Di"aph-o-re'sis. Perspiration, and especially profuse per- spiration. Di"aph-o-ret'ic. 1. Stimulating the secretion of sweat. 2. A medicine that increases the perspiration. Di-ath'e-sis. Natural or con- genital predisposition to a special disease. Dif'fer-en"tial. Pertaining to a difference, or differences. Dis-crete'. Separate lesions which do not blend or coalesce. Di'u-re"sis. Increased secretion of urine. Dor'sum. The back or any part corresponding to the back as the dorsum of the penis or foot. Duc'tus ve-no'sus. A total blood vessel connecting the umbilical vein with the post- cava. Dys-cra'si-a. A depraved state of the system, and especially of the blood, due to constitu- tional disease. Dysp-nce'a. Difficult or labored breathing. Dys-to'ci-a. Painful or slow- delivery or birth. Ec-bol'ic. An agent that accel- erates labor. E-clamp'si-a. A sudden attack of convulsions, especially one of a peripheral origin. Ec-top'ic. Out of the normal place. E-de'ma. Swelling due to ef- fusion of watery liquid into the connective tissue. Em'bo-lism. The plugging of an artery or vein b\r a clot or obstruction which has been brought to its place by the blood-current. Em'bry-o. The foetus in its earlier stages of development, especially before the end of the third month. Em-men'a-gogue. A drug that aids or stimulates menstrua- tion. E-mul'sion. An oily or resinous substance divided and held in suspension through the agency of an adhesive, muci- laginous, or other substance. En'do-me"tri-um. The mucous membrane that lines the cav- ity of the uterus. GLOSSARY 355 En-gage'ment. The head is said to be engaged when the larg- est diameters have passed the inlet. En'si-form. Shaped like a sword. Ep'i-si-ot"o-my. Surgical inci- sion of the vulvar orifice lat- erally for obstetric purposes. E-ro'sion. An eating or gnaw- ing away. Er'y-the"ma. A morbid redness of the skin due to congestion of the capillaries, of many varieties. E'ti-ol"o-gy. The study or theory of the causation of any disease. Ex-co"ri-a'tion. Any superficial loss of substance such as that produced on the skin by scratching. Ex'os-mo"sis (E.r-os-mose). Dif- fusion or osmosis from within outward. Ex-san'guin-a"tion. An exhaus- tion of the blood from a part or the whole of the body. Ex-trac'tion. The process or act of pulling or drawing out, particularly the removal of a child by pulling either with hands or forceps. Ex'tra-u"ter-ine. Situated or occurring outside of the uterus. Ex"u-da'tive di-ath'e-sls. A con- genital predisposition to ec- zema in various parts of the body, as well as to infections of the respiratory tract. Fae'ces (or fe'ees). The excre- ment or undigested residue of the food discharged from the bowels. Fen'es-tra-ted. (L., fenestrum, a window.) Pierced with one or more openings, like win- dows. Fer'ment. Any substance that causes fermentation in other substances with which it comes in contact. Fi'brin. A substance which, becoming solid in shed blood, plasma and lymph, causes the coagulation of these fluids. Fil'let. .1. A loop-shaped struc- ture. 2. A loop, as of cord or tape, for making traction. Fis'sure. A cleft or groove, normal or other. Fis'tu-la. A deep, sinuous ul- cer, often leading to an in- ternal hollow organ. Flu'id ex'tract. A concentrated solution of the active prin- ciple of a drug in such strength that 1 c.c. of the product equals 1 gr. of the crude drug. The fluid is a mixture of alcohol, water and glycerine in varying propor- tions. One mav be omitted. Fce'tus (or fc'tus). The unborn offspring of any animal that brings forth living progeny; the child in the womb after the third month. Fon'ta-nelle". Any one of the unossified spots on the crani- um of a young infant. It is so named because it rises and falls like a fountain. Fo-ra'men. A hole or perfora- tion, especially a hole in a bone. Four-chette'. The fold of mu- cous membrane at the poste- rior junction of the labia ma- jora. Frae'num (or fre'num). A fold of the integument or of the mucous membrane that checks, curbs, or limits the move- ments of an organ in part— as the framum of the tongue. Func'tion. The normal or proper action of an organ or set of organs. 35() OBSTETRICS Func'tion-al. Of or pertaining to a function. Fun'diis. The base or part of a hollow organ remotest from its mouth. Ga-lac'tor-rhce"a. Excessive se- cretion of milk. Ga-vage'. Feeding by the stom- ach tube; also the thera- peutic use of a very full diet. Gen'it-als. The reproductive or- gans. Ger"mi-cide'. An agent that de- stroys germs. Ges-ta'tion. Pregnancy. Glans cli-tor'i-dis. The distal or outside end of the clitoris. Glans pe'nis. The head, or terminal end, of the penis. Gon-or-rhce'a. A contagious catarrhal inflammation of the genital mucous membrane. Graaf'i-an fol'li-cle. Any one of the small spherical ovarian bodies, each of which con- tains an ovum. Hasm'o-phil"i-a. A condition of the system wherein bleeding occurs readily, and the blood clots slowly or not at all. Haem'or-rhage. A copious es- cape of blood from the ves- sels; bleeding. Accidental h., haemorrhage during pregnancy, due to premature detachment of the placenta. Post partum h., that which occurs soon af- ter labor, or childbirth. Unavoidable h., that which re- sults from the detachment of a placenta praevia. Hasm'or-rhoid. A pile, or vascu- lar tumor of the rectal mu- cous membrane. Hy-dat'id. An encysted vesicle containing an encysted fluid. From the Greek "Hydatis." meaning a drop of water. EOR NURSES Hy-dat'i-form. Ecsembling a hydatid in form. Hy-dram'ni-os. Dropsy of the amnion. Hy'dro-ceph"a-lous. A fluid ef- fusion within the cranium. This disease is marked by enlargement of the head, with prominence of the forehead, atrophy of the brain, mental weakness, and convulsions. Hy'giene. The science of health and of its preservation. Hy'men. The membranous fold which partially or wholly oc- cludes the external orifice of the vagina, at least during virginity. Hy'per-em"e-sis. Excessive vom- iting. H. gra-vi-da'rum, ex- cessive vomiting of prog- nancy. Hy'per-35"mi-a. Excess of blood in any part of the body. Hy-per'tro-phy. The morbid en- largement or overgrowth of a part. Hyp-not'ic. A drug that in- duces sleep. Hy'po-der-moc"ly-sis. The in- troduction, into (the subcu- taneous tissues, of fluid in large quantity. Hy'po-gas"tric. Of or pertain- ing to the lower anterior re- gion of the abdomen in the middle line of the body. The hypogastric arteries arise from the internal iliac in ad- dition to the branches given off from those vessels in the adult. Hy'po-phos"phite. Any salt of hypophosphorous acid. Ic'ter-us. Jaundice. Id'i-o-syn"cra-sy. An effect ab- normal to the one usually produced. An effect peculiar to the individual. GLOSSARY 357 Im-mu'ni-ty. The condition of being immune or exempt from disease, especially the condi- tion arising from inoculation, or from a peculiar resistance of the organism. Im'preg-na"tion. 1. The act of fecundation or of rendering pregnant. 2. The process or act of saturation, a saturated condition. In'farct. A mass of substance cxtravasated either into the substance of an organ or into a vessel due to the obstruc- tion to the circulation. In"fan-tile' pel'vis. A pelvis which has not responded to the developmental stimulation of the sexual glands at puberty, and therefore re- mains in its infantile shape. A masculine pelvis. In"fan-tile' u'ter-us. An unde- veloped uterus. In-fec'tion. The cummunica- tion of disease from one per- son to another, whether by effluvia or by contact, medi- ate or immediate; also the im- plantation of disease from without. In'fil-tra"tion. To cause a liquid or gas to penetrate or enter by pores or interstices. In'flam-ma"tion. A morbid con- tion characterized by pain, heat, redness and swelling. In-nom'in-ate. Not having a name, as the innominate bone. In-som'ni-a. Inability to sleep; abnormal wakefulness. In'ter-sti'tial. Pertaining to, or situated in, the interstices or interspaces of a tissue. In'ter-tri"go. A chafe, or chafed patch of the skin; also the erythema or eczema that mav result from a chafe of the skin. In-tro'i-tus. The entrance to any cavity or space. In-ver'sion. A turning inward, inside out, upside down, or other reversal of the normal relation of a part. In'vo-lu"tion. 1. A rolling or turning inward. 2. The re- turn of the uterus to its nor- mal size after parturition. 3. A retrograde change, the re- verse of evolution. Is-chu'ri-a par-a-dox'a. A con dition in which the bladder is over-distended with urine, al- though the patient continues to urinate, generally in drib- bles. Jaun'dice. Yellowness of the skin, eyes, and secretions, due to the presence of bile pig- ments in the blood. La'bi-a. Lip-shaped organs. The external folds of the vulva, labia majora, and the internal folds of the vulva, labia minora. Lac'e-ra"tion. 1. The act of tearing. 2. A wound made by tearing. Lac-ta'tion. 1. The secretion of milk. 2. The period of the secretion of milk. 3. Suckling. Lan-u'go. The fine hair on the body of the fetus. Lav-age'. The irrigation or washing out of an organ, such as the stomach or bowel. Le'sion. Any hurt, wound or local degeneration. Leu'cor-rhce"a. A whitish, vis- cid discharge from the vagina and uterine cavity. Light'en-ing. The sense of lightness and easier breath- ing that follows the descent of the head into the pelvis during the last three weeks of pregnancy. It is most likely to occur in primip- aras. 358 OBSTETRICS 1 Lo'chi-a. The vaginal discharge that takes place during the first week or two after child- birth. Lymph. A transparent slightly yellow liquid of alkaline re- action which fills the lym- phatic vessels. Mal-aise'. An uneasiness or in- disposition, discomfort or dis- tress. Mal'po-si"tion. Abnormal or anomalous position. Mam'ma. The mammary gland; the breast. Mam'ma-ry. Pertaining to the Mamma. Ma-ras'mus. Progressive wast- ing and emaciation, especial- ly such a wasting in young children when there is no obvious or ascertainable cause. Mas-sage'. The systematic, therapeutic friction, strok- ing and kneading of the body. Mas-ti'tis. Inflammation of the breast. Me-a'tus. A passage or open- ing, as the meatus urinarius. Me-lae'na ne-o-na-to'rum. The passage of dark pitchy stools containing blood pigments and blood that has been ex- travasated into the alimen- tary canal of the newborn babe. Mem'brane. A thin layer of tissue which covers a surface or divides a space or organ. Men'o-pause. The period when menstruation normally ceases; the change of life. Mis-car'riage. Abortion; pre- mature expulsion of the ftt'tus; birth of the fcrtus be- fore the twenty-eighth week. FOR NURSES Milk-leg (Phlegmasia Alba Do- lens). A condition developing ing in one, and rarely, in both, legs, after delivery. It is due to occlusion of the veins of the pelvis and leg by throm- bosis or to septic inflamma- tion of the pelvic connective tissue. Mole. 1. A fleshy mass or tu- mor formed in the uterus by the degeneration or abortive development of an ovum. 2. A nevus; also a brownish spot on the skin. Mons ven'er-is. A rounded prominence at the symphysis pubis of a woman. Mor-bid'i-ty. The condition of being diseased or morbid. Mor'cel-la"tion. Division and piecemeal removal. Mu'cus. The viscid watery se- cretion of the mucous glands. Mul-tip'ar-a. A woman Avho has borne more than one child. Mum'mi-fi-ca"tion. Dry gan- grene; also the drying up and shrivelling of the foetus. Myd'ri-at"ic. A drug that di- lates the pupil. Nau'se-a. Tendency to vomit; sickness at the stomach. Ne-cro'sis. Death of a tissue, especially of a bone. Ne-phri'tis. Inflammation of the kidney. Neu-rot'ic. 1. Pertaining to or affected with a neurosis. 2. Pertaining to the nerves. Neu'tra-lize. To render neutral or ineffective. Ni'tro-gen. A colorless gaseous element found free in air. Nod'u-lar. 1. Like a nodule or node. 2. Marked with nod- ules. GLOSSARY Nu'cle-us. 1. a spheroid body within a cell, forming the es- sential and vital part. 2. A mass of gray matter in the central nervous system. :*>. In chemistry, the central ele- ment in the molecule of a compound. Nu'tri-ent. Nourishing; afford- ing nutriment. Nym'phae. The labia minora. Ob-stet'rics. The art of man- aging childbirth cases; that branch of surgery which deals with the management of preg- nancy and labor. Ob-ste-tri'cian. One who prac- tices obstetrics. Oc'ci-put. The back part of the head. 01'i-go-hy-dram"ni-os. Scanti- ness of the liquor amnii. 01'i-gop-nce"a. A delay follow- ing the birth of a child be- fore the first respiration is established. Oph-thal'mi-a. Severe inflam- mation of the eye or of the conjunctiva. Or'gan. Any part of the body having a special function. Os. (L.. a mouth.) The orifice in the uterus or vagina. Os-mo'sis. The passage of a fluid through a membrane. O'va. Latin plural of ovum, ogg- 0'vii-la"tion. The formation and discharge of an unimpreg- nated ovum from the ovary. O'vule. 1. The ovum within the Graafian vesicle. 2. Any small egg-like structure. O'vum. 1. An egg. 2. The female reproductive cell which, after fertilization, de- velops into a new member of the same species. Ox'y-di"zer. Anything that combines with oxygen. Pal-pa'tion. The act of feeling with the hand: the applica- tion of the lingers with light pressure to the surface of the body for the purpose of de- termining the consistence of the parts beneath in physical diagnosis. Par-al'y-sis, Erb's. 1. Same as birth-palsy. 2. Partial paral- ysis of the brachial plexus af- fecting various muscles of the arm and chest-walls. It is revealed by an inability to lift the arm toward the head. Par-al'y-sis facial (Bell's). Paralysis of the face, due to lesion of the facial nerve or of its nucleus. Par'a-me-tri"tis. Inflammation of the parametrium, or cellu- lar tissue about the uterus. Par'a-phi-mo"sis. Eetraction of a narrow or inflamed fore- skin which can not be re- placed. Pa-ren'chy-ma. The essential or functional elements of an organ as distinguished from its stroma or framework. Pa-ri'e-tal. Of, or pertaining to, the walls of a cavity. Par'o-nych"i-a. Infection and suppuration about the junc- tion of nails and skin. Par'ox-ysm. A sudden recur- rence or sudden intensifica- tion of symptoms. Path-o-log'ic. Pertaining to pathology. Pa-thol'o-gy. That branch of medicine which treats of the essential nature of disease, especially of the structural and functional changes caused by disease. Pel-vim'e-ter. An instrument for measuring the various di- ameters of the pelvis. 3 GO OBSTETRICS FOR NURSES Pel-vim'e-try. The act of deter- mining the dimensions of the pelvis by means of a pelvim- eter. Per'i-ne-or"rha-phy. Suturation of the perineum, performed for the repair of a laceration. Per'i-ne"um. The space or area between the anus and the genital opening. Pe-riph'e-ry. The outward part or surface. Per'i-to-ne"um. The serous membrane which lines the ab- dominal walls. Per'i-to-ni"tis. Inflammation of the peritoneum. Per'i-stal"sis. A worm-like movement by which the ali- mentary canal propels its contents. Per-ni'cious. Tending to a fatal issue. Phe-nom'e-non. Any remark- able appearance; any sign or objective symptom. Phys'i-o-log"ic. Pertaining to physiology. Phys'i-ol"o-gy. Tlie science which treats of the functions of the living organism and its parts. Phi-mo'sis. Tightness of the foreskin such that it can not be drawn back over the glans. Phle-bi'tis. Inflammation of a vein. Pig'men-ta"tion. The deposition of coloring matter. Pla-cen'ta prae'vi-a. A placenta which intervenes between the infra-uterine cavity and the inner orifice of the cervical canal. Pla-cen'ta suc'cen-tur'i-a"ta. An accessory or subsidiary pla- centa. Pled'get. A small compress or tuft as of wool or lint. Pleth'o-ra. A condition marked by vascular turgescence, ex- cess of blood and fullness of pulse. Po-dal'ic. Pertaining to, or ac- complished bv means of, the feet. Pol'y-hy-dram"ni-os. Excess in the amount of the liquor amnii in pregnancy. Po-si'tion. 1. The attitude or posture of a patient. 2. The relation of the presenting part of the foetus to the quadrants of the maternal pelvis. Pos-te'ri-or. Situated behind or toward the rear. Post par'tum. After delivery. Pre'ma-ture. 1. Occurring be- fore the proper time. 2. An infant born before its proper term, but Ariable. Pre'ma-tu"ri-ty. The condition of a child that has been de- livered before term, and be- fore maturity or ripening has taken place. Pre-mon'i-tory. Serving as a warning. Pre'puce. The fold of skin covering the glans penis; the foreskin. Pres'en-ta"tion. 1. The appear- ance in labor of some particu- lar part of the foetal body at the os uteri. 2. That part of the fcetal body which first shows itself at the os in labor. Pri-mip'a-ra. A woman who has given birth, or who is giv- ing birth, to her first child. Prod'ro-mal. Premonitory. In- dicating the approach of an event, phenomenon, or dis- ease. Prog-no'sis. A forecast as to the probable result of an at- tack of disease; the prospect as to recovery from a disease afforded by the nature and symptoms of the case. GLOSSARY •;<;i Pro-jec'tion-al vom'i-ting. Sud- den violent emesis. Pro-lapae'. The falling down, or sinking, of a part or vis- cus. Pre-lep'sis. The anticipation and nullification of complica- tions before they arise. Prom"on-to'ry. A projecting eminence or process. Pro'phy-lax"is. The prevention of disease. Pro'te-in. Any one of a group of nitrogenized, noncrystal- lizable compounds similar to each other, widely distrib- uted in the animal and vege- table kingdoms, and forming the characteristic constitu- ents of the tissues and fluids of the animal body. They are formed by plants, the an- imal organism receiving them as food and transforming and assimilating them. They all contain carbon, hydrogen, nitrogen, oxygen and sulphur. Some of the most important are albumin, casein, legumin, fibrin, myosin and glutin. Psy'chic. Pertaining to the mind. Pu'bes. That part of the low- er central hypogastric region which, in the adult, is cov- ered with hair. The pubic region. Pu'Mc. Pertaining to the puhes, or os pubis. PuTier-ty. The age at which the reproductive organs be- come functionally operative. Pu'bi-ot"o-my. (lit--bos'te-ofo- my.) The operation of cutting through the pubic bone, lateral to the median line. Pu-er'pe-ral. Pertaining to childbirth. Pu'er-pe"ri-um. The period or state of confinement. The puerperium is the time suc- ceeding labor which is neces- sary for the restoration of the genitals to their condi- tion previous to pregnancy, or as near it as possible. It varies from 6 weeks to sev- eral months. Pll'ru-lent. Consisting of or containing pus. Py-as'mia. Blood-poison of mi- crobic origin. Py'e-li"tis. Inflammation of the pelvis of the kidney. Py'or-rhce"a. A discharge of pus, especially from infection around the roots of the teeth. Py-ro'sis. Heartburn. Acidity of the stomach. Eructations of acid. Re'flex-es. Reflected actions or movements. Impulses re- ceived and transmitted by the nervous system without con- scious volition. Involuntary responses to irritation. Auto- matic movements. Re-frig'e-rant. Relieving fever and thirst. A cooling remedy. Acidulous drinks and evapo- rating lotions are refrigerant. Re-gur'gi-ta"tion. 1. The cast- ing up of undigested food. 2. A backward flowing of the blood through the left auri- culo-ventricular opening, on account of imperfect closure of the mitral value. Re'lax-a"tion. I. A lessening of tension. 2. A mitigation of pain. Re'nal. Pertaining to the kid- ney. Res'ti-tu"tion. 1. An act or process of restoration. 2. The rotation of the present- ing part of the fret us outside of the vagina. 3(>2 OBSTETRICS FOR NURSES Re'tro-gres"sive. Going or moving backward. Passing from a better to a worse con- dition. Re'tro-ver"sion. The tipping of an entire organ backward. Rick'ets. (Ba-chi'tis.) A con- stitutional disease of childhood in which the bones become soft and flexible from retarded os- sification, due to deficiency of the earthy salts. Ro-ta'tion. The process of turn- ing around an axis. Rough'en-ing. Any rough, coarse food that gives bulk to the intestinal contents with- out much nutrition. Ru'be-fa"ci-ent. An agent that reddens the skin. Ru'gae. Wrinkles or folds. Rup'ture. 1. Forcible tearing or breaking of a part. 2. Hernia. Sa'crum. The triangular bone situated at the end of the spine. It is formed of five vertebrae, amalgamated and wedged in between the two innominate bones. Sag'it-tal. Shaped like, or re- sembling, an arrow. Sal'i-va"tion. An excessive dis- charge of saliva. Sal'pin-gi"tis. Inflammation of an oviduct or of the eustach- ian tube. Sal"var-san'. A compound in- vented by Ehrlich for the treatment of diseases caused by the Spirilla1, such as syphilis and recurrent fever. ft is popularly7 called 606. Sa-prae'mi-a. Poisoning of the blood by the absorption of toxins from localized infec- tions as from the uterus. Scap'u-la. The shoulder blade. Scro'tum. The pouch which contains the testicles and their accessory organs. Se-ba'ceous. 1. Pertaining to sebum or suet. 2. Secreting a greas\r lubricating substance. Se-cre'tion. 1. The process or function of separating vari- ous substances from the blood. 2. Any secreted substance. Sec'un-dines. All that remains in the uterus after the birth of the child is called secun- dines—placenta, membrane and cord. Se'men. 1. A seed or seed-like fruit. 2. The thick whitisli liquid fecundating secretion produced in coition. Shock. Sudden vital depres- sion, due to an injury or emo- tion which makes a sinister impression upon the nervous system. Show. The appearance of blood that foreruns a labor or men- struation. Sin'a-pism. A plaster or paste of' ground mustard-seed; a mustard plaster. Sin'ci-put. The portion of the head lying in front of tlie an- terior or large fontanelle. Si'nus. 1. A recess, cavity or hollow space. 2. A dilated channel for venous blood, found chiefly within the cra- nium and uterus during gesta- tion. 3. An air-cavity, in one of the cranial bones, especial- ly one communicating with the nose, such are the eth- moidal frontal maxillary and sphenoidal sinuses. 4. A sup- purating channel or fistula. Smeg'ma. A thick, cheesy, ill- smelling secretion found un- der the prepuce and around the labia minora. So-lu'tion. 1. The process of dissolving. 2. A liquid, con- taining dissolved matter. GLOSSARY 363 Sor'des. The dark brown mat- ter which collects on the lips and teeth in low fevers. Spas'mo-phil"ic di-ath'e-sis. Is a condition characterized by an increased elective irritabil- ity and a tendency to spasm, like contractions of one or more groups of muscles. (Grulee). Spe-cif'ic. 1. Pertaining to a species. 2. Produced by a single kind of microorganism. 3. A remedy^ specially indi- cated for any particular dis- ease. Sper'ma-to-zo"on. The motile generative element of the se- men which serves to impreg- nate the ovum. Spi'na bif'i-da. Congenital cleft of the vertebral column with meningeal protrusion. Spi'ro-chae"te. A genus or form of flexile spirobacteria. Sta'sis. A stoppage of the flow of fluid in any organ or any part of the body. Ste-no'sis. Narrowing or stric- ture of a duct or canal. Sterile. Nonfertile. Ster'il-i-za"tion. The act or process of rendering sterile. Still-birth. The birth of a dead foetus. Stim'u-lant. 1. Producing stim- ulation. 2. An agent or rem- edy that produces stimulation. Strep'to-coc"cus. A genus or form of bacterial organism, which grows in consecutive links, like a chain. Stri'a, pi. stria'. Streaks or lines. Stro'ma. The tissue which forms the ground substance, framework, or matrix of an organ. Styp'tic. Astringent, an agent for arresting haemorrhage. Sub'in-vo-lu"tion. Incomplete involution; failure of a part to return to its normal size and condition after enlarge- ment from functional activity. Sup-pos'i-to-ry. An easily fus- ible medicated mass to be in- troduced into the vagina, rec- tum, or urethra. Su'ture. 1. Surgical stitch or scam. 2. The line of junc- tion of adjacent cranial or facial bones. Sym'phys-e-ot"o-my. The divi- sion of the fibrocartilagc of the symphysis pubis in order to facilitate delivery by in- creasing the anteroposterior diameter of the pelvis. Sym'phy-sis. The line of junc- tion and fusion between bones originally distinct. The sym- physis pubis. Syn'chro-nous. Occurring at the same time. Syph'i-lis. A contagious ven- eral disease leading to many structural and cutaneous le- sions, due to a microorganism called the spirochaeta pallida. Tam'pon. A plug made of cot- ton, sponge, or oakum. Te-nac'u-lum. A hook-like in- strument for seizing and hold- ing tissues. Te-nes'mus. Straining, especi- ally ineffectual and painful straining. Throm'bus. A plug or clot in a vessel remaining at the point of its formation. Tinc'ture. The solution of me- dicinal substances in fluids other than water or glycer- ine. There is usually about one part of the drug to eight of alcohol. Tis'sue. An aggregation of cells, fibers and various cell- products forming a structural element. 364 OBSTETRICS FOR NIRSES Tox-ae'mi-a. Blood-poisoning. Tox'in. Any poisonous albumin produced by bacterial action. Trau'ma. A blow, wound, or other violent injury. Trau'ma-tism. A condition of the system due to injury. Tu'mor. 1. Swelling; morbid enlargement. 2. A neoplasm. A mass of new tissue which persists and grows independ- ently of its surrounding struc- tures, and which has no physi- ologic use. Tym'pa-ni"tis. Distention of the abdomen from gas. Um-bil'i-cal. Pertaining to the umbilicus. Um-bi-li'cus. The navel. U'ra-chus. A cord that extends from the apex of the blad- der to the navel. It repre- sents the remains of the canal in the fo-tus which joins the bladder with the allantois. U-re'a. A white crystallizablc substance from the urine, blood and lymph. U-re'ter. The fibro-muscular tube which conveys the urine from the kidnev to the blad- der. U-rae'mi-a. The presence of urinary constituents in the blood and the toxic condition produced thereby. U-re'thra. A membranous canal conveying urine from the bladder to the surface and in the male conveying the sem- inal ejaculations. U'rin-al"y-sis, The chemical analysis of urine. U'ter-us. The hollow muscular organ which provides lodge- ment for the fn'tus from con- ception to birth. The womb. U'ter-us hi-cor'nis. A womb wherein the two sides have been incompletely joined dur- ing development, and two horns, or protrusions, appear on the fundus. U'ter-us di-del'phys. A womb in which there has been sepa- rate development and incom- plete fusion of the.two sides. U'ter-us du'plex. A double uterus. U'ter-us sep'tate. A uterus that is divided by a partition or septum. Var'i-cose veins. Of the nature of, or pertaining to, a varix. The permanent dilatation of a vein. Ven'e-sec"tion. The opening of a vein for the purpose of let- ting blood. Ven'tral stalk. An embryonic process which is the rudimen- tal procusor of the umbilical cord, ft is known as the ven- tral stalk because somewhat later in tlie course of develop- ment it becomes attached to the ventral (abdominal) sur- face of the embryo. Ver'nix cas'e-o"sa. A fattv sub- stance that covers the skin of the fo'tus. Ver'sion. The act of turning. especially the manual turn- ing of the fictus in delivery. External V., that which is per- formed by outside manipula- tion. Internal v., version per- formed by the hand intro- duced into the uterus. Brax- ton Hicks' Version, a version done with tlie whole hand in the vagina and two fingers entering the uterus through the partially dilated os. Ves'i-cal. Pertaining to the bladder. GLOSSARY 365 Vi'a-bil"i-ty. Able to live af- ter birth. Vil'li. 1. The finger-like projec- tions that develop on the out- side of the egg and connect it vascularly and otherwise with the uterus; a vascular chori- onic tuft. 2. A minute club- shaped projection from the mucous membrane of the intestine. Vul-sel'lum. A forceps with teeth on the ends of the jaws. Walch'er's position. The pa- tient on the back with the hips at the edge of the table and the legs hanging down. Whar'ton's jelly. The soft pulpy connective tissue that constitutes the largest part of the umbilical cord. Womb. Same as uterus. INDEX A Abderhalden test for preg- nancy. 61 Abdomen: care of, 70 changes in pregnancy, 59 weakness of, $5 Abortion, 95 etiology, 207 management, 207 Accessory articles of diet, 319 Accidental haemorrhage, 22s After-birth, 11, 117 After pains, 151, 254 relief of, 154 Albuminuria, 77 (see Eclamp- sia) Amenorrhcea, 57 during lactation, 15S in the nonpregnant, 58 Amnion, 38 adhesions, S7 Anaesthetics, 103, 13S, 142 Anencephalus, 309 Anus, 23 Aphthae, 294 Areola, 31 Asepsis in delivery, 142 Aseptic care, 200 Asphyxia neonatorum, 278 methods of resuscitation, 279 Atelectasis, 283 Attitude of child, 165 B Baby: anencephalus, 309 aphthae, 294 asphyxia, 142, 278 balanitis, 306 bath, 266 bowels, 273 breasts, 293 care after delivery, 144 Baby—Cont 'd care at birth, 142 circumcision, 306 cleansing, 265 clothing, 270 colic, 299 constipation, 298 convulsions, 282 cradle cap, 295 diarrhoea, 298 exercise, 2S4 eyes, 268 furuncles, 3,05 flushings, 2S5 gavage, 285 genitals, 272 haemorrhage, 2S9 harelip and cleft palate, 287 heart, 278 hernia, 287 hydrocephalus, 308 icterus, 293 lavage, 286 marasmus, 303 menstruation, 293 mouth, 272 nails, 289 nursing periods, 273, 156 paraphimosis, 305 phimosis, 305 pneumonia, 304 prematurity, 301 priapism, 308 respiration, first, 142 routine for, 270 significant symptoms and conditions, 320 sleep, 272 snuffles, 304 spina bifida, 3,08 temperature, 276 thrush, 294 tongue-tie, 2S7 toilet basket, 271 3,67 3(kS INDEX Baby—Cont'd umbilicus, 267 urticaria, 294 vomiting, 300 weight, 271 Bag of waters, 39, 110 Balanitis, 306 Ballottement, 62 Barley water, 316 Baths, 69, 325 Bed, making, 133 Bed-linen, care of, 150 Bed-sores, 263 Bednar's disease, 294 Bichloride solution, 135 Birthmarks and deformities, 72, S7 Binder, 153 Bladder, 23 after delivery, 159 in pregnancy, 56, 58 Bleeders, 232, 290 Blood, in pregnancy, 55 Bowels, in pregnancy, 68 in puerperium, 157 Breast milk, quantity, 275 Breasts, 30 caked, .156, 243 care of, 71 changes due to marriage and pregnancy, 53, 59 inflow of milk, 53 massage, 156 nursing periods, 156 of puberty, 33 preparation for lactation,!55 removal of child, 252, 261 sensations in pregnancy, 59 supernumerary, 31 Breech presentation, 168 Brow presentation, 177, 179 Buttermilk, 314 C (icsarcan section, 195 Caput succedaneum, 127 Case record, nurse's, 131 Catheterization, after delivery, 159 before operations, 183 Caul, 114 Cepliallueniatoma, 12S Cervix, effacement, 110 repair, 144, 211 Child (see Baby) Chill in puerperium, 151 Chloasma, 55 Chloroform in labor, 103 Chorion, 3s Circumcision, 306 Clamp for cord, 26S Clitoris, 26 Coitus, 71 Colic, 300 Colostrum, 53 Conception, 36 Condylomata, 75 Confinement, estimating date, 58, 66 Constipation, 68, 298 Contraction of pelvis, 214 Contractions of Braxton Hicks, 53, 62, 109 Convulsions, of child, 282 of mother, 236 Cord, umbilical, 40 attachment to placenta, 42 cutting, 142 granulations of, 293 prolapse of, 220, 137 separation, 292 Cow's milk vs. breast milk, 311 Cradle cap, 295 Cramps, 56, 86 Cranioclasis, 194 Currettage of uterus, 206 in abortion, 207 Curve of Cams, 20 D Decapitation, 194 Delivery, asepsis during. 142 care of mother after, 144 on side, 140 Diabetes and pregnancy, 95 Diapers, 270, 273 bluing on, 270, 296 INDEX 369 Diarrhoea of child, 298 Diet in puerperium, 152. 155 Diets. 33,6 Doctor, 130 when to call, 131 what to report, 131. 319 Douche, vaginal, 202 aseptic. 200 in pregnancy, 71. 160 intrauterine, 205. 23,3 Dress in pregnancy, 69 Drugs affecting the milk, 275 Dry birth, 225 Ductus arteriosus, 49 venosus, 4S E Eclampsia, 78 blood pressure in, 55 svmptoms and management, 237 wet packs in, 231 Ectopic pregnancy, s»i Edema, 69 Enemas, eliminative, 3,55 nutrient, 334 Episiotomy, 211 Ergot. 143 after delivery, 150 in abortion, 207 in post partum haemorrhage, Eruptions on the skin, 55 Erythema, 290 Ether in labor, 103 Examination of patient, 134, 140 Excavation of pelvis, 19 Extrauterine pregnancy, 89 Exudative diathesis. 295 Eve symptoms in pregnancy, '69 F Face presentation, 174, 179 Fallopian tubes. 22 Fainting, 70 Fevers and pregnancy, 91 Flour ball, 316 Flushings. 285 Fetus, attitude, 44 circulation. 48 diameters of head. 46 fontanelles. 46 heart tones, 63. ISO movements, 44, 62 rate of growth, 46 rule for estimating length, 47 rule for estimating weight, 47 signs of danger to. ]s