A nurse's handbook of obstetrics, for use in training-schools

Front matter

Class M

Book „^_

Copyright N°

Preface To The Second Edition

The second edition of this work, coming as it does so soon after its initial publication, only serves to strengthen, in the mind of the author, his former belief that there was a place in the field of medical literature for a book of this character.

The entire text has been carefully revised for this edition and certain changes and additions have been made, but it has not been thought necessary to alter the general plan of the work to any material degree.

The author wishes to express his sincere thanks for the cordial reception which has been accorded to the book, and to assure its many friends of his appreciation of the hearty welcome with which it was greeted.

J. B. C.

t? j

240 West One Hundred and Thirty-eighth Street, New York. March 10, 1905.

Preface To The First Edition

This book was written to supply a need that has long been felt in the Training-School for Nurses with which the author is associated, and one which has doubtless been experienced in other institutions of the same character.

The trained nurse of to-day devotes not less than two, and usually three, years of her life to the study of her profession, a period of time which, until recently, was regarded as sufficient for the medical student to gain all the knowledge necessary for the acquisition of his diploma as a fully qualified physician and surgeon.

In spite of this, there are few if any strictly technical textbooks written expressly to meet the requirements of the pupil-nurse. She has, of course, her works on " Nursing," but when she takes up the purely medical or surgical side of her subject, as she must to a certain and not very limited extent if she is to perform her duties thoroughly and intelligently, she is obliged to turn for her information to books written solely for the use of physicians and medical students, and filled with incomprehensible technicalities and confusing statistics and discussions.

This makes the training of the pupil-nurse a problem of considerable difficulty not only to herself, but to her teachers and other instructors, and in the matter of obstetrics the condition of affairs seems to be especially marked.

The book-shops are filled with small volumes on " Maternity Nursing," " The Hygiene of Pregnancy," and similar subjects, but practically all of these works are written with a double pur-

8 PREFACE.

pose, and are so worded and arranged that they can be used by the prospective mother herself as well as by the nurse. Between these short, incomplete, and purposely " popular" books and the strictly medical work, there is nothing to which the nurse can appeal for information ; and the present volume is offered as a means of filling in the gap. It is intended to contain all of the science and art of obstetrics that a nurse need know in order to practise her profession in an intelligent manner consistent with her position as a scientifically educated woman, combined with a clear exposition of the principles and practice of maternity nursing. Statistics, discussions, and unsubstantiated theories have been entirely omitted, and an effort has been made to present the subject-matter in a way that will be perfectly clear to the beginner in the study of nursing.

It has been suggested to the author that a book written on the plan of the present volume would have a tendency to overeducate the nurse and make her feel that in point of knowledge she stood on an equal plane with the physician. The absurdity of this contention is based upon its inherent inconsistency, for

" A little learning is a dangerous thing,"

and education and intelligence are the best and surest safeguards against insubordination and usurpation of authority.

The lieutenant never questions the word nor criticises the action of his captain or colonel, yet both are educated on precisely the same lines ; but the private, who knows nothing of the science of war, and is required to work blindly and unquestioningly, is constantly ventilating his ideas and lamenting the ignorance of his superiors to any one who is foolish enough to listen.

Repetitions in the book are frequent and intentionally so. Details are treated with the utmost minuteness, and the Glossary

PREFACE. .9

contains many words not to be found in the text but included to facilitate collateral reading and the understanding of occasional remarks made by physicians.

The profusion of illustrations, of which seventy-six are original and were made especially for this work, adds greatly to the practical value of the book and has been rendered possible by the generosity of the publishers, whose unfailing courtesy and assistance at all times is most highly appreciated by the author.

The author wishes also to express his thanks and acknowledge his indebtedness to Miss Mary S. Gilmour and Miss Theodora H. LeFebvre, the Superintendent and Assistant Superintendent of the New York City Training-School for Nurses, who have most kindly read the manuscript and made a number of valuable corrections and suggestions, and to Dr. G. E. McCartney, who has aided him materially in various ways.

J. B. C.

240 West One Hundred and Thirty-eighth Street, New York. March 10, 1903.

Contents

CHAPTER PAGE

I. — Introduction 19

II. — The Pelvis 22

Introduction

In a paper read recently before one of the great medical societies of New York the gynaecologist was styled " that obstetrical camp-follower," and this characterization may well serve as a text for a dissertation on obstetric nursing.

Practically all women who consult the gynaecologist are married, have borne children, and date their troubles from the birth of one or another child, and it is safe to say that the comparatively few unmarried women who seek advice for the relief of pelvic disorders would be in infinitely worse condition than they are if they had passed through the ordeal of pregnancy and labor.

The amount of good for womankind that nurses can accomplish by the dissemination of judicious advice concerning the requirements of the pregnant state and by intelligent care of parturient and puerperal cases, probably exceeds in many ways the best efforts of the physician. Especially among primigravidae does this hold true, for women who have never borne children are often remarkably diffident in regard to their condition, and unless the early symptoms of pregnancy are exceptionally severe, they will neglect to place themselves under medical care until much mischief may have been done.

When nurses, as a class, will impress upon women who may come under their notice the importance, not only to themselves but to their infants, of consulting and implicitly following the directions of a skilful obstetrician as soon as they have reason to suspect that they are pregnant, they will save a large number of these patients many visits to the gynaecologist in after years.

A nurse can, with propriety, volunteer advice of this kind when a physician, taking the same stand, would often be unjustly suspected of ulterior motives, and her opportunities for doing so are greater than his in the exact proportion in which a woman will discuss a delicate subject with another woman more frequently and more freely than with a man.

Regarding nursing in the light of a noble profession, closely allied to that of medicine, no opportunity for aiding and permanently benefiting humanity will ever be overlooked, and scientific supervision of pregnancy, labor, and the puerperium can do more in this respect than all other branches of nursing combined.

As the writer has expressed in another place, let the pregnant woman be taken in hand at the very beginning of her pregnancy and put in condition to withstand the ordeal through which she has to pass, much as the athlete is " trained" for months before the encounter in which he is to figure.

No woman should die or even be seriously invalided as a result of pregnancy if she is under proper care from the beginning of gestation, and it rests with the nurses of modern times more than with the physicians to see that every woman is afforded such care and attention as will insure the successful outcome of her case.

The key-note of success in obstetric practice lies in a thorough knowledge of the patient's exact condition long before labor occurs and in ample preparation for delivery and after care, so that the labor may be conducted with every attention to aseptic detail and modern surgical method.

Twentieth century civilization has done much to retard the physical development of women in general, and, among those who are in a position to afford the services of a graduate nurse, very few have sufficiently robust constitutions and normally de-

INTRODUCTION. 21

veloped pelves and generative organs to make labor and its after effects anything but a matter of considerable moment.

Unless the physician has been afforded an opportunity to build up their general health and keep a watchful eye on the behavior of their bodily functions, and unless the nurse has made careful and judicious preparations for conducting their labors in a thoroughly aseptic manner, complications may arise at the last moment which may result in permanent invalidism, if not in the death, of the mother or child.

Obstetric nursing presents many unattractive features, for after labor there are two patients instead of one to be cared for, but it offers so many and so great opportunities for the advancement of " preventive medicine" that the writer cannot but look with considerable disfavor upon that large and constantly increasing class of hospital nurses who regard maternity cases as entirely beneath their dignity and who leave these unfortunate patients in the care of unskilled attendants, only to nurse them afterwards when they reach the operating-table of the gynaecologist.

II The Pelvis

The pelvis (Fig. i) is that portion of the skeleton which lies between the spinal column and the lower extremities. It is

Fig. i.— The normal female pelvis. (Garrigues.) A, sacrum; B, coccyx; C, crest of the ilium; D, acetabulum; E, spiue of the ischium; F, symphysis pubis ; G, spine of the pubis ; H, obturator foramen ; /, tuberosity of the ischium ; J, J, J, linea terminalis.

composed of four bones, — the sacrum and coccyx behind, and the innominate bones (ossa innominata) at the sides and in front. Each innominate bone (os innominatum) is divided by anatomists into three parts, — the ilium, the ischium, and the pubis.

The ilium, which is the largest portion of the bone, is broad, thin, concave on its inner aspect, and lies above the narrow constricted portion of the pelvis. Like its fellow of the opposite side, it is joined to the sacrum behind, and its upper flaring 22

THE PELVIS. 23

border forms the prominence of the hip, or crest of the ilium, commonly spoken of as the " hip bone."

The pubis joins directly in front, in the median line, with its opposite fellow, and closes, anteriorly, the cavity of the pelvis.

The ischium, which is that portion of the innominate bone lying beneath the ilium, is not of importance to the obstetric nurse, although it is of interest to know that it occasionally presents bony projections {exostoses) of sufficient size to obstruct the descent of the head during labor.

The sacrum is a triangular, wedge-shaped bone, consisting of five rudimentary vertebrae welded together, and lies at the back part of the pelvis, between the ilia (plural of ilium), closing in the cavity behind. Its upper surface, or base, is broad and flat, and supports the spinal column ("backbone") and with it the entire weight of the body. Its apex points downward and forward, and to it is attached

The coccyx, a very small triangular bone, resembling somewhat in appearance a miniature sacrum and being possibly the remains of a prehistoric caudal appendage, or tail.

Regarded as a whole, the pelvis may be described as a deep, bony basin resting on the upper extremities of the two femora (plural of femur), or thigh bones, and supporting the spinal column, which carries the weight of the trunk, the head, and the upper limbs. The flaring surfaces of the ilia make a sort of funnel to guide the foetus into this basin, which, having no bottom, forms a bony canal through which the child has to pass at the time of labor.

The most constricted portion of the pelvis is called the brim, or inlet (Fig. 2), and is, naturally, of the greatest obstetric importance ; for, as a chain is only as strong as its weakest link, so is a canal only as broad as its narrowest part, and, except in certain cases of deformity, any child that can pass safely through the brim can be delivered without any further difficulty.

The brim of the pelvis is bounded behind by that portion of the upper anterior surface of the sacrum, which projects farthest forward and is called the "promontory of the sacrum;" on the sides by the lower borders of the ilia; and in front by the two

A NURSE'S HANDBOOK OF OBSTETRICS.

pubic bones, which meet in the median line and form the "symphysis pubis/'

Fig. 2. — The pelvic inlet. (Garrigues.) A B, anteroposterior or true conjugate diameter; CD, left oblique diameter ; E F, right oblique diameter ; G H, transverse diameter ; A S, sacrocotyloid distance ; IK, crest of the ilium.

The contour of the inlet is more or less heart-shaped because of the jutting forward of the promontory of the sacrum, and the most important diameter of the pelvis is the distance between the promontory and the symphysis. If this is normal (ten centimetres, or about four and one-quarter inches), it is almost certain that the entire pelvis is normal, and that the child can be born without any serious difficulty.

The articulations (joints) of the pelvis, which possess obstetric importance, are four in number. Two are behind, between the sacrum and the ilia on either side, and are termed the sacro-iliac synchondroses (plural of synchondrosis) ; one is in front, between the two pubic bones, and is called the symphysis pubis; and the last, of little consequence, is that between the sacrum and coccyx, — the sacro-coccygeal articulation.

THE PELVIS.

All of these articular surfaces are lined with fibro-cartilage, which becomes thickened and softened during pregnancy, and a certain definite, though very limited, motion in the joints is essential to a normal labor. Even an ankylosis of the sacro-coccygeal articulation, preventing the tilting backward of the coccyx at the time of delivery, may necessitate the use of forceps, and, in the operation of symphyseotomy, which consists in cutting through the symphysis pubis and so separating the pubic bones, no increase in the capacity of the pelvis could be secured were it not for a very distinct hinge-like motion at the sacro-iliac synchondroses.

The pelvis is lined with muscular tissue, which provides a smooth slippery surface over which the fcetus has to pass during labor, and its bones are bound together by ligaments, which become softened and slightly lengthened as pregnancy advances.

Comparing the female with the male pelvis (Fig. 3), we find that the former is especially adapted to the uses for which

Fig. 3. — Male and female pelvis. A, male pelvis — narrow, heavy, compact; B, female pelvis— broad, light, capacious.

it is designed. It is shallow, but very capacious, lighter in structure and smoother than the male pelvis, which is deep, conical, rougher for muscular attachment, and more compact.

The entire problem in obstetrics consists in the safe passage of the fully developed foetus through the pelvis of the mother. Slight pelvic contractions, resulting in tedious or instrumental

A NURSE'S HANDBOOK OF OBSTETRICS.

deliveries, are comparatively common, while any such marked deformity as depicted in Fig. 4 would render labor by the natural

Fig. 4. — Female pelvis deformed by osteomalacia. (Garrigues.)

passages entirely out of the question. For these reasons the pelvis of every pregnant woman should be measured carefully at a sufficiently early date to enable the physician to determine definitely the proper course to pursue.

Fig. 5. — -Harris's pelvimeter.

The external pelvic measurements are taken with an instrument called a pelvimeter (Fig. 5), which acts on the principle

THE PELVIS.

of a carpenter's or plumber's calipers. The patient lies on her side or back, according to the diameters to be measured, with the abdomen exposed, as shown in Fig. 6. The internal pelvic measurements, for determining the actual diameters of the brim, are usually made by inserting two fingers into the vagina and up to the promontory of the sacrum and estimating the various dimensions in this manner (Fig. 7).

Fig. 7. — Internal pelvimetry. Measuring the distance between the promontory of the sacrum and the lower border of the symphysis pubis.

The importance of the knowledge gained through the skilful performance of external and internal pelvimetry cannot be overestimated, and it should never be neglected in the case of a woman pregnant for the first time nor in any case in which the patient has suffered previously from difficult or tedious labors.

In cases of slight contraction the induction of labor two or three weeks before term may be all that is necessary, while the existence of marked deformity may call for the performance of Csesarean section as the only alternative. It is to be kept in mind that the higher we ascend in the social scale the more frequently do we encounter pelvic deformities of varying degrees, due to faulty development superinduced by lives of luxury and indolence, and that the class of patients coming under the care of the graduate nurse presents a far greater proportion of such deformities than is found among women in the lower walks of life.

Ill

The Female Organs of Generation

The female organs of generation are divided into two groups, the external and the internal, which are connected by the vagina.

The external organs, taken as a whole (Fig. 8), constitute the vulva, and consist of —

Fig. 8.— External organs of generation. A, A, labia majora ; B, B, labia minora; C, meatus urinarius; D, clitoris; E, mons veneris; F, perineum ; G, anus; H, entrance to vagina.

The mons veneris, a firm, cushion-like formation covered with hair and lying directly over the symphysis pubis.

The labia majora, or greater lips, made up of adipose tissue

(fat) and covered externally with skin and hair and internally

with mucous membrane. They begin in the median line at the

lower border of the mons veneris and extend downward and

THE FEMALE ORGANS OF GENERATION.

backward, on either side, to meet at a point termed the fourchette, which is almost invariably torn at the first labor.

The labia minora, or lesser lips, lie entirely within the vulva, except in the case of infants and of women who have borne children or are much emaciated. They are covered entirely with mucous membrane, and their upper extremities are divided into two parts, one passing above and one below (and so forming a hood for)

The clitoris. This is a small reddish tubercle situated about half an inch behind the upper and anterior junction of the labia majora.

The meatus urinarins, commonly spoken of as the " meatus/' is the external opening of the urethra, which is the canal (about one and one-half inches in length) leading to the bladder. The meatus lies directly back of the clitoris and about three-quarters of an inch from it. When the labia are separated it appears as a small dimple in the median line under the symphysis.

The vagina is a musculo-membranous canal, five to six inches in length, leading from the vulva to the uterus and lying wholly within the true pelvis. It is lined with mucous membrane, the secretion of which possesses marked germicidal properties. In consequence of this fact the vagina is always aseptic except in the presence of disease or very soon after direct infection from without, and for this reason a vaginal douche should never be given before labor unless it is specially ordered by the physician. Under ordinary circumstances such a douche can do no good, and it is certain to do actual harm by removing the natural and aseptic lubricant of the vagina, even if it does not, through carelessness of preparation or administration, introduce infection where none had existed previously.

The internal organs of generation (Figs. 9 and 10) consist of the uterus, the Fallopian tubes, and the ovaries.

The uterus, or womb (Fig. 11), is a hollow, pear-shaped organ about three inches in length in the non-pregnant state. It is composed of muscular tissue, covered externally almost wholly with peritoneum and internally with mucous membrane, and is suspended in the pelvis by means of a number of ligaments

A NURSE'S HANDBOOK OF OBSTETRICS.

arranged in pairs and stretching across from the uterus to the sides of the pelvis or to other pelvic organs. This arrangement of the ligaments is such that the uterus is allowed considerable freedom of motion, and its position varies slightly with respiration, with the posture of the woman, and with the condition of the bowels and bladder. In other words, the uterus has no

Fig. 9. — Internal organs of generation. (Keating and Coe.) Showing the uterus in its normal position between the bladder and the rectum. The vagina lies between the lower border of the bladder and the meatus urinarius above and the rectum and anus below, separated from the latter by the perineum.

intimate attachment to any fixed point, but hangs in the pelvis in a way to permit of its enormous enlargement during pregnancy, — from about the size of an tgg before conception has occurred to that of a fairly large pumpkin at the time of labor. The uterus lies in about the centre of the pelvis, below the brim, with the bladder in front and the rectum behind, so that, of

THE FEMALE ORGANS OF GENERATION.

Fig. 10. — The internal organs of generation, seen from above. (Keating and Coe.)

Fig. 11.— The uterus and its appendages. (Keating and Coe.) The ovaries are the almondshaped bodies lying between the uterus and the extremities of the Fallopian tubes.

A NURSE'S HANDBOOK OF OBSTETRICS.

necessity, a full rectum will force it forward and a distended bladder will tilt it backward. Its upper, rounded border is called the fundus, and its lower, narrowed portion the cervix, while that part between the fundus and the cervix is termed the body of the uterus. The cervix projects into the vagina for a distance of about half an inch, much as a cork projects into the neck of a bottle.

Fig. 12. — The cavity of the uterus. (Garrigues.) c, vagina; e, external os; d, internal os ; f, fundus, the letter being placed over the entrance of the Fallopian tube.

The spaces between the sides of that part of the cervix which extends into the vagina and the vaginal walls are termed fornices (plural of fornix), and are divided into four parts. The anterior fornix is between the anterior wall of the cervix and the anterior vaginal wall ; the posterior fornix is between the posterior vaginal wall and the posterior wall of the cervix; the lateral fornices are the spaces between the cervix and the vaginal walls on either side.

The cavity of the uterus (Fig. 12) is lined with mucous membrane, and is divided into two parts, — the cavity of the body and the cavity of the cervix. The cavity of the body is tri-

THE FEMALE ORGANS OF GENERATION. 33

angular in shape, with its apex pointing downward, while that of the cervix is spindle-shaped.

There are three openings into the cavity of the uterus. The external opening, called the external os (Latin for mouth), is in the centre of the cervix as it projects into the vagina. It is very small in the non-pregnant state, barely admitting a probe, but at the time of labor it dilates to a size sufficient to permit the passage of the foetus. The other openings are at the upper angles of the triangular cavity of the body and lead into the Fallopian tubes, which will be described later. As the Fallopian tubes open directly into the peritoneal cavity, it will be seen that there is a direct avenue from the peritoneum to the outer world, through the Fallopian tubes, the uterus, and the vagina.

The cavity of the cervix is slightly distended above the external os, to become contracted again at its junction with that of the body. This second contraction is termed the internal os, and it is because of these two points of contraction that the cavity of the cervix acquires its spindle shape.

The Fallopian tubes (see Fig. 11) are two trumpet-shaped tubes, from four to five inches in length, extending from the upper angles of the uterus, just below the fundus, towards the sides of the pelvis. Between their outer extremities and the uterus, on either side, are found

The ovaries (Fig. 13), which are the germ-producing organs of the woman and about the size and shape of an English walnut. Each ovary contains in its substance at birth a vast number of germs or ovules (from Latin, meaning "little eggs"), and, beginning at about the time of puberty and occurring at or about every menstrual period, one or possibly two of these ovules enlarges, approaches the surface of the ovary, escapes into the Fallopian tube, and so passes on into the uterus.

The ovule which has " matured" in this way is the only one that can be impregnated by the male germ, and if there is no male element present in the Fallopian tube, where impregnation usually occurs, nothing results beyond the usual menstrual phenomena.

The perineum (see Fig. 9) can hardly be considered as belonging to the organs of generation, but it may best be described in this chapter. Briefly, and as far as the nurse is concerned, it is the triangular mass of tissue which separates the vagina from the rectum. Its upper surface is covered by the

LC/'

b *

Fig. 13.— Ovary and tube of a girl twenty-four years old. (Waldeyer.) U, uterus ; T, tube; LO, ovarian ligament; 0, ovary; x, limit of peritoneum ; &, cicatrices of ruptured Graafian follicles.

lower wall of the vagina, its posterior surface is in contact with the rectum, and its external surface is covered with skin and lies between the lower angle of the vulva and the anus. The perineum forms the floor of the genital canal, and in certain difficult labors it is torn, when the head is born, to an extent varying all the way from a slight nick in the skin to a deep laceration extending through the anus into the rectum itself.

The mammae {mammary glands or breasts) are two highly specialized sebaceous glands located on either side of the anterior wall of the chest between the third and seventh ribs. They secrete the milk which serves as the sole nourishment of the infant during the early months of its life, and they are abundantly supplied with nerves and blood-vessels and intimately connected, by means of the sympathetic system, with the uterus and other generative organs. This sympathetic relation is especially noticeable when the infant nurses immediately after birth

THE BREASTS.

and reflex uterine contractions result from the irritation of the nipple caused by the suckling.

The breasts of a woman who has never borne a child are conical or hemispherical in form, but their size and shape vary greatly in women who have nursed one or more infants.

The breasts are made up of glandular tissue and fat, and each organ is divided into fifteen or twenty lobes, which are separated from each other by fibrous and fatty walls and subdivided into numerous lobules (little lobes) (Fig. 14). The

Fig. 14. — Mammary gland of a woman during lactation, with lactiferous ducts and sinuses.

(Luschka.)

lobules are composed of acini (plural of acinus), in which the milk is formed, and as the ducts approach the nipple they are dilated to form little reservoirs in which the milk is stored, but contract again as they pass into the nipple.

The external surface of the breast is divided into three portions, as follows: (a) The white, smooth, and soft area of skin extending from the circumference of the gland to the areola, (b) The areola, which surrounds the nipple and is of a delicate pinkish hue in blondes and a darker rose-color in brunettes. Under the influence of gestation the areola becomes darker in shade, and this pigmentation which is more marked in brunettes than in blondes, constitutes, in many cases, a valuable sign of pregnancy (see Figs. 31 and 36). (c) The nipple, a large conical papilla projecting from the centre of the areola and having at its summit the openings of the milk ducts.