Obstetrical nursing : a manual for nurses and students and practitioners of medicine

Front matter

Qass.

Book

COPYRIGHT DEPOSIT

CHAPTER II. Pelvis . 32

External Genitals 36

Mons Veneris, Labia Major a and Minora 36

Clitoris 37

Vestibule, Hymen, Vulvovaginal Glands, Perineum . . 38

Internal Genitals 38

Vagina 39

Uterus 41

Menstruation 46

Fallopian Tubes 47

Ovaries 48

Urinary Organs 49

Intestines 51

Peritoneum 52

Breasts 52

Embryology 54

Ovum 54

Spermatozoon 55

Fertilization 56

Segmentation, Embryo and Fetus ....... 57

Chorion 61

Amnion, Yolk, AUantois 62

Umbilical Cord 63

Migration and Nidation of Egg, Decidua 63

Placenta 64

Relation of Mother to Fetus 65 viii CONTENTS

CHAPTER III. Physiological Changes 67

Changes in Uterus 67

Changes in Genital Organs and Breasts 70

Pathological Changes 71

Nausea and Vomiting 71

Dental Caries, Nephritis 77

Toxemia 78

Frequent Micturition, Edema 85

Varicosities 86

Signs of Pregnancy 86

Abortion 86

Extra-uterine Pregnancy 88

Placenta Previa 90

Separation of Normally Seated Placenta 95

Cancer of the Cervix 96

Hydatid Mole 96

Management of Pregnancy 98

Diet 98

Bathing 99

Dress 100

Exercise 103

Care of the Breasts 104

CHAPTER IV. Eutocia and Dystocia 105

Causes of Labor 105

Forces of Labor 106

Labor Pains 106

Stages of Labor 107

Fnst Stage 107

Effacement of Cervix 109

Formation of Bag of Waters 109

Rupture of Membranes Ill

Second Stage Ill

Third Stage 112

After-pains 112

Mechanism of Labor 113

Posture 113

Position, Presentation, Station 115

Descent 116

Rotation 121

Exit of Head 121

Exit of Body 124

Expulsion of Placenta 125

CONTENTS IX

^lanagement of Labor 127

Nurse's Outfit, Patient's Outfit 128

Preparation of Nurse 130

Method of Cleaning Hands 132

Preparation of Patient 134

Enema 134

Closet, Bath 135

Dress, Bed 136

Disinfection of Genitalia, Shaving 140

Solutions 142

Examination of Patient , 145

Abdominal Examination 146

Inspection, Palpation 146

Auscultation 152

Inspection of Genital Region 155

Palpation of Perineum 155

Internal Examination 156

Care of Bladder and Catheterization 160

Nourishment 161

Moral Support 161

Analgesia and Anesthesia 162

Ether and Chloroform 163

Support of Back 164

Pulling . 165

Supporting Perineum 165

Position of Patient 168

Delivery of Body 168

Ligation of Cord 169

Management of Third Stage 170

Causes 172

Atonic Hemorrhage 173

Hemorrhage from Partial Detachment of Placenta 175

Traumatic Hemorrhage 175

Hemorrhage from Deficient Coagulability of Blood . 176

Inversion of Uterus 176

Prevention of 176

Removal of Partly Adherent Placenta 177

Expression of Placenta 178

Manual Removal 179

Management of Atonic Hemorrhage 180

Massage 180

Hot Douche 181

Ergot 183

Summary 183

Combating After-effects of Hemorrhage . . . . . 184

Hypodermoclysis 185

From Abnormal Forces 188

From Abnormal Passages 188

X CONTENTS

From Abnormalities in Passenger 189

Twins 189

Short Cord 189

Prolapse of Cord 190

From Abnormal Mechanism , 190

From Accidents . 190

Rupture of Uterus 191

Vulvar and Perineal Lacerations 191

Frequency 191

Classification 192

Preparation 192

Induction of Abortion 194

Induction of Labor 196

Dilatation of the Cervix 199

Symphysiotomy 200

Hebosteotomy 201

Version 202

Changing Face to Vertex 203

Expression of Fetus 205

Expressing Head from Vagina 206

Manual Extraction 207

Forceps 208

Cesarean Section 211

Porro-Cesarean Section 216

Extraperitoneal Cesarean Section 216

Postmortem Cesarean Section 217

Vaginal Cesarean Section 217

Embryotomy 219

Decapitation 221

Removal of Placenta 221

Repair Operations 222

Vaginal Douche, Intra-uterine Douche 224

Intra-uterine Tamponade . 224

Hypodermoclysis 225

Chapter V. Puekpeeium 226

Duration 226

Lochia _ 227

Care of Bed, Cleaning of Patient 228

Symptoms 233

Treatment 237

Puerperal Tetanus 239

Puerperal Insanity 239

Difficult Micturition 240

CONTENTS XI

Diet 246

Breasts, Lactation 251

Colostrum 251

Distention 252

Pumping 253

Bandage 254

Ice-bags 258

Massage 259

Infection 262

Galactorrhea 270

Hypertrophy of Axillary Sweat Glands 270

Care of Room 270

Rest 272

ToHet 274

Posture ^ 274

^lassage and Passive Movements 275

Bed Exercise 276

Getting Up • 279

CHAPTER VI. First Care 282

Treatment 284

Slapping 284

Removal of Mucus 285

Hot and Cold Baths 286

Laborde Method 287

Byrd Method 288

Sylvester Method 290

Schultze Method 291

Insufflation 294

Protecting Child Before Separation 294

Fu-st Care of Eyes 295

Tying Cord .296

Condition of Newborn 297

Malformation 299

Molding of Head 300

Caput Succedaneum 300

Cephalhematoma 300

Birth Injuries 301

The Skin 302

Jaundice 303

Bath 303

Cleaning Perineal Region 306

Care of Navel 308

Umbilical Hernia 310

Care of Genitalia 310

Menstruation in Infancy 311 xil CONTENTS

Adherent Foreskin 311

Cii'cumcision 312

Undescended Testicles 312

Care of Breasts 313

Care of Mouth 313

Thrush 313

Tongue-tie 314

Care of Nose 314

Vomiting 314

Diarrhea 315

CoKc 317

Care of Ears 318

Care of Eyes 318

Ophthahnia Neonatorum 318

Subconjunctival Hemorrhage 320

Sleep 323

Premature Children 334

Dangers 334

House or Incubator Station . . . 334

Warm Room 336

Incubator 336

Oxygen 339

Dressing and Bathing 339

Subsequent History 340

Incubation for Other Debihtated Conditions 340

OBSTETRICAL NURSING.

Chapter I. Introductory

A nurse's success or failure depends not only upon her knowledge of disease and its complications and the proper way to manage them, but quite as much upon her common-sense and tact in dealing with people and her ability to adapt herself to circumstances. When a nurse leaves the hospital and enters upon private nursing she finds the conditions quite different from those in which she has been trained. Sometimes her patient is not tractable. When a patient goes to a hospital she assumes that she must adapt herself to the regime already instituted and acquiesces in all the nurse's directions. In her own home she does not so easily lay aside her authority and the nurse finds it necessary to adopt other measures in carrying out the directions of the physician than those she is accustomed to use in the hospital. Moreover, the household arrangements must be taken into consideration. She has to deal with one or more servants and must be careful not to cause any disturbance. She frequently has to manage not only her patient, but also her patient's relatives who may have more or less authority in the house. Often she has to put up with unsatisfactory facilities for doing her work as she has been accustomed to perform it. In short, she finds private nursing and hospital nursing so different that she is often discouraged over her difficulties and mistakes. 2

If she has the will and tact she will soon overcome these difficulties, provided she has the proper foundation of a good training in the work she is called upon to do. It is the object of this introductory chapter to call attention to certain obligations or duties which a nurse owes to herself, to her patient, and to the attending physician, which, when duly appreciated and regarded will smooth over many of the difficulties and bring her a quicker and greater measure of success.

The rules of conduct based upon these duties apply more or less to all nursing. Obstetrical nursing differs from other nursing in the fact that the obstetrical nurse has to care for two patients, the mother and the child. Her patients, while helpless, are generally not sick. Her duty is to preserve the health of her patients instead of to cure them. She is generally engaged beforehand, and is the choice of her patient or her physician. If she gives satisfaction she is the recipient of much gratitude, and her success in her calling is assured. It not infrequently occurs that a nurse fails to satisfy her patient or her physician, and yet she is quite unconscious of the reasons for her failure. It is not uncommon for her in such cases to assume that her patient or the physician, or both, dislike her or fail to appreciate her because of some whim or unjust prejudice against her. A careful study of some of the following suggestions may lead her to clear up her ideas and discover where she can improve if she be anxious to improve.

Duties to Self. — ^The nurse's chief duty to herself is the care of her health. Without health she not only suffers and risks her future career, but she is unable properly to care for her patient. No one who is not strong and free from all constitutional or local disease should attempt nursing as a calling. If a nurse contracts a chronic disease after she has begun her work the question of giving up her profession becomes a very important one and must be decided by careful study in each individual case. Certain diseases are absolutely prohibitive. No nurse

NURSE'S DUTIES TO SELF 19

who has consumption, for example, has a right to continue her work. Syphihs and epilepsy are also examples of chronic diseases which absolutely disqualify a nurse. Certain pelvic diseases may greatly limit a nurse's usefulness. If a nurse has very painful menstruation, so that she is hardly able to be out of bed for tw^o or three days, she is certainly not in a condition to properly care for her patient. Acute infectious diseases disqualify a nurse, of course, until she has recovered. An obstetrical nurse, in particular, must avoid all infection both on account of the mother and the child. No nurse should think of going to an obstetrical case until she has entirely recovered from scarlet fever, measles, erysipelas, etc. The greatest difficulty in deciding what to do arises in such affections as sore throat, colds, and attacks of influenza or grip. Should a nurse assume charge of a case of obstetrics or remain with a case if she has an ordinary tonsillitis or bronchitis ? Ordinarily there is here much too great laxness of judgment. In every such case the nurse should consult the attending physician and be guided by his advice. If she remain in attendance she should at least take all possible care to avoid infecting her patients.

As a means tow^ard the preservation of her health, she must attend to the regulation of her food and drink, care of her person, her clothing, sleep, and exercise.

The kind of food and its preparation will of course vary in different houses. Generally she will have no difficulty in obtaining a sufficient amount of good, wholesome food. A nurse has no right to be whimsical in her diet, and should not cause any unusual disturbance in the kitchen by asking for uncommon dishes. If she needs, during the day or night, an extra lunch, it is perfectly proper that she should ask for it in case it is not provided. A cup of hot milk is one of the best lunches that can be taken, as it is both a stimulant and a food. Sometimes, in emergencies, w^hich often occur during the labor, meal times are very irregular. At such times a cup of hot milk is also very valuable.

Intimately connected with the question of eating is the proper care of the mouth, stomach, and bowels. Good teeth and a good stomach are specially valuable when there is a lack of good food. A decaj^ed tooth is not only a source of suffering but also a cause of improper nourishment and ill health. Bad teeth and a disordered stomach also cause a bad breath, which is a very serious failing in a nurse. It is, indeed, so important that it practically prevents a nurse from caring for a sensitive or well-bred patient. A nurse should always keep her teeth in good condition. Upon the slightest sign of trouble she should consult her dentist. Even if she has no toothache it is well for her to consult her dentist every year at least to be certain that no decay is developing insidiously. She should, of course, use her brush and powder morning and night, and wash out the mouth with some mild antiseptic wash after each meal.

If a coated tongue, eructation of gas, or regurgitation of food or pressure over the stomach after eating indicate a disease of that organ, she should make a vigorous effort to improve her digestion. Care of her diet, avoidance of indigestible foods, like salads, pickles, fried dishes, etc., will be the first measures to suggest themselves. A cup of hot water taken before meals will often improve the digestion. A regulation of constipated bowels is often important. If this care is not sufficient a nurse should consult her physician.

Constipation is a frequent cause of ill health in women, and many nurses suffer more or less from this trouble. Very frequently it is due to carelessness or ignorance. If a girl is taught to secure a regular movement of the bowels at a certain time every day she will grow up with regular habits. If she is allowed to neglect this important function, to attend to the bowels sometimes at one hour and sometimes another, and frequently omit caring for herself an entire day, she will probably be more or less constipated. Every nurse should learn the extreme importance of a regular daily evacuation of the bowels, and if she

XURSE'S DUTIES TO SELF 21

has not been taught the proper care of herself while a child she should make e^'e^y eft'ort to correct this mistake. In case a regular routine is not sufficient she may need a laxative diet and medicines and perhaps injections. A glass of water taken fifteen to twenty minutes before meals is sometimes sufficient as an aid. Frequently fruit is quite a help. Coarse foods, including bran and agar-agar, are often necessary. Sometimes a laxative mineral water or small amount of salts taken in the morning for some time will help toward a cure. Any nurse who has had any trouble with constipation is advised to cure herself before she begins private nursing. The circumstances which surround her in a private house make it very desirable that she should have no trouble of this kind. If she is accustomed to regular habits she will have no special difficulty in caring for herself properly.

The care of the digestive tract suggests the care of the skin. It may be impossible to carry out the habit of daily bathing, i. e., in a tub. Such a habit is very useful to a nurse and should be practised whenever possible. A free use of, cold water over the neck and chest is a substitute to be recommended. Perfect cleanliness to prevent all odors of perspiration or exhalation is a matter of course. It is hardly necessary to say that the use of perfumes about the person is vulgar and disagreeable to the patient.

The care of the hands will be spoken of when we come to consider the subject of disinfection in the preparation for labor. It will then appear that clean hands, without cracks, hangnails, or any abrasions, unadorned by rings, are the most important possessions of a nurse.

The care of the skin is closely connected with the subject of clothing. Loose, comfortable clothes should always be worn. They should be warm in winter and afford the proper protection at other seasons of the year. Wool of the proper weight or wool and cotton or wool and silk are the best materials except in the summer. The feet especially should be well protected. The shoes should have reasonably thick soles and be of sensible shape and size with rubber heels. A corset which compresses the waist just below the ribs is unhygienic and absurd for any woman, but especially for a nurse. Her skirts should be light. She should rely more for the protection of the skin upon the undergarments than upon the skirt. The waist and outside skirts are of course of washable material.

A word should be said concerning the night clothing. Since an obstetrical nurse is almost certainly called upon during the night, when the temperature of the room is lower than in the daytime, she must be prepared with the proper night clothes. Not only should she have a long, warm night-gown with the proper robe, but the feet and lower extremities must be protected For this purpose pajamas with feet are well adapted. Warm slippers are absolutely necessary. A little extra care or expense will pay for itself many times over if it preserves to the nurse her chief capital, her health.

x\n obstetrical nurse is often disturbed very much in her sleep, especially during the first week. Unless she is able to get along twenty-four hours without sleep she should not undertake this branch of nursing. The possibility that such a demand will be made upon her at the beginning of her engagement makes it important that she should always go to a case quite fresh and thoroughly rested. In the subsequent weeks she generall}^ will be able to make up her lost sleep.

In order to be in the best possible condition she should take a brisk walk in the open air of an hour or half an hour every day. It may often happen that in the beginning of a case this is impossible, but, as a rule, it can be carried out. The shorter the time that can be devoted to the walk the more wisely should it be employed. Breathing deeply with the shoulders thrown back with an energetic w^alk of even fifteen minutes will be of value for the entire day.

Duties to Doctor. — In a broad sense of the term the nurse is the doctor's assistant. The doctor alone is

NURSE'S DUTIES TO DOCTOR 23

responsible to the patient for the management and outcome of a case. It is not possible or desirable to have a divided responsibility. Being responsible it is necessary that the doctor should have complete authority. He is responsible for the nurse and she is responsible to him. From this it follows that it is the duty of the nurse to work entirely under the doctor's directions. She should assume no responsibility on her own account further than may be necessary to meet emergencies during the absence of the physician. She should under no circumstances institute treatment in opposition to that laid down by him. If it should be necessary to do something not ordered by the physician, she should report to him fully as soon as possible her action and the reasons for it. Only in this way can she secure and retain his confidence and properly perform her duty as his assistant.

It is never her duty to make, unasked, suggestions to the doctor. As a rule only ignorant or superficial nurses think to increase their importance and impress the physician with their knowledge by making suggestions concerning the treatment of the case.

If a nurse should make any mistakes, as anyone may do, she should report these mistakes to the physician at their next meeting. She will find that he will appreciate her situation and think more of her for her frankness and honesty. Nothing is more calculated to shake the confidence of a physician in a nurse than to find out later, from other sources, of mistakes which she has not reported.

As the physician's assistant the nurse has to assist or wait on him during his attendance at the confinement, and his subsequent visits and to carry out his orders in his absence. She must also watch her patient and report symptoms. In order to carry out the physicians' orders it follows, as a matter of course, that the nurse must understand him. If she has any doubts as to the meaning of any direction she should ask that it be thoroughly explained to her. The excuse that she did not understand what the doctor meant is no excuse at all.

In order to report properly on the progress of a case it is necessary for the nurse to keep a record. The report or record of the nurse is of great importance to the physician, the patient, and to herself. The patient's welfare and sometimes her life depend upon the care with which her symptoms are watched and recorded. A mistake in the temperature or pulse will often deceive the physician and cause him to overlook an important feature of the patient's condition. Failure of the nurse to observe some unusual temporary symptom may have the same result. Of course a false record is the worst of all. If a nurse should forget to take the temperature or pulse, and in order to cover up her mistake make a record which she thinks is about right, she is guilty of a crime against the patient which, at times, might have the most serious consequences.

The nurse's record is of great importance to the physician, for it enables him to see in a moment the events of the day. If a nurse could know what satisfaction a physician takes in a properly kept record, complete yet not diffuse, neat and easily read, she would feel herself repaid for a little extra care.

For the nurse herself the record is of importance because by it her education, ability, and character are often judged. Poor spelling and poor writing stamp a nurse as ignorant and careless. A diffuse, mixed-up report shows her to be illogical and poorly trained. A neatly written report that contains only essential matters marks her as one possessed of good mental qualities and proper training.

It is always desirable that she should form the habit of recording each item as soon as observed. Unless this habit of making a prompt record is formed she will become accustomed to delaying writing for several hours, when some things will be forgotten and the record will lose its accuracy. If possible the records should be kept in ink, being thus permanent and neater.

Of course the record should be preserved until the case is terminated. It is often necessary to refer back to it

NURSE'S DUTIES TO DOCTOR for the history of the beginning of the case. When the nnrse leaves to whom does the record belong? If the physician does not care for it the nnrse may preserve it if she chooses. It is not good policy, however, for her to preserve a number of records in one book. When she carries such a case-book from one patient to another she exposes the history of a former case to the eyes of strangers. The nurse cannot know but what the patient or the patient's friends or the physician may take up her casebook to look at the record of the patient and almost involuntarily notice reports of former cases. A great majority of patients would object to this publication of the history of their sickness; therefore, if a nurse preserves her reports she should keep each case separately. Sometimes a physician furnishes the blanks for the records, as he wishes to preserve them for future reference. The accompanying charts show a form which will perhaps serve as a model for childbed and infant records. They are kept on cards 10x15 centimeters in size, to file away with pregnancy and labor cards.

Name.

Baby Record.

When born. Birth weight

Page

Hour. P.

T.

Bowels.

Urine.

Navel.

Eyes.

Puerperal Record.

Name of patient. Date of confinement. Name of nurse. Page.

Hour.

P. T.

Bowels. Urine.

Lochia.

Breasts.

Medicine.

t i !

In a system like this as much space can be used as is needed. One or two pages or more may be used in a day or one page may serve as a record for two or three days. A heavy hne drawn across the card separates the report of one day from another. The date is placed in heavy figures in the hour column. The ordinary method of indicating the time in the hour column for each separate entry is, of course, known to all. Any necessary remark concerning the bowel movement is placed in the proper column. The quantity of urine as well as its character is to be recorded if possible. During the first two or three days the amount and character of the lochia is reported in some detail. Later a general observation of the entire day may sufiice. The condition of the breasts should also be noted with some detail. In the last column the facts concerning sleep, food, and bathing can be entered. General observations that might be assumed should be omitted. For example, patient washed, patient rubbed, or dressing changed are unnecessary items. More explanations for the use of the puerperal and baby records will be given in subsequent chapters.

It is often necessary to advise a young nurse upon leaving the hospital to engage upon private nursing that she should be loyal to the doctor in charge of the case. She finds that his practice differs, perhaps in important details, from that which she has been taught in her training course. She should never comment on this fact to the patient or to the patient's friends and compare a physician in attendance with some other physician with whom she has been associated. Such a course is very unwise and will generally react against her. If she, by this course, should create a lack of confidence in the physician on the part of the patient she may be doing a great deal of harm to both parties. She should carry out any directions which seem to her useless. It is not her business to judge. Loyalty to her physician should be her constant motto. If a case should ever arise where she is unjustly accused by the physician, she had

NURSE'S DUTIES TO PATIENT 27

better suffer quietly than to bring the matter before the patient. In extreme cases where she feels that great injustice has been done her, she would better ask the advice of the superintendent of her training-school.

Duties to Patient.— As assistant to the doctor it is the. duty of the nurse to her patient to carry out his orders. This subject has been sufficiently discussed. There are, however, duties devolved upon the nurse which are not directly comprised in the explicit directions given by the physician. These assumed duties may be comprehended in the statement that a nurse should secure for her patient the best possible physical and mental condition. Both are promoted by the proper and skilful care of the patient's toilet, care of her room and surroundings, and the general conduct of the case so as to prevent worry, anxiety, or annoyance.

In brushing the hair, giving a sponge bath, a douche, or an enema a nurse displays not only her training but also her habits of attentive tidiness. A nurse who leaves her patient or her patient's bed wet or soiled after washing the genitals or caring for the bowels cannot expect the best recommendations from the most desirable class of patients. It is impossible to give explicit directions to a nurse who is careless in these respects. Tidiness and cleanliness should be part of a nurse's nature. A nurse who makes such mistakes after a hospital training of three years is hopeless. She may satisfy a slovenly patient and even be a favorite in certain classes because of other good traits. A first-class nurse will attend to the personal wants properly because she herself knows what good breeding desires and demands. She knows that if she were in the patient's place she would like to have her food, however simple, served properly. She would like to have her nurse bring her occasionally fresh water without being reminded. If she were to ask for a drink of water she would not like her nurse to give her a glass of stale, lukewarm water that has stood some time in the room. She would not like to be obliged to ask for a mouth wash or a tooth-brush.

Knowing what she herself desires she will have no difficulty in satisfying any patient.

The same golden rule that applies to the toilet applies also to the room and the surroundings. A refined nurse will imagine herself the patient and picture her satisfaction w^ith a tidy and well- ventilated room. She would appreciate the nurse who knows how to dust the room, not by brushing into the air a cloud of dust to settle back on the furniture or floor. She would not like to lie and look for hours at her dresser in disorder, neither would she like to ask her nurse to care for it. She Avould become quite impatient with a nurse who did not know enough to care for her flowers at night. The sensitive patient regards these things often much more than a knowledge of anatomy or medicines.

A nurse cares for the mental condition of her patient more by what she does than by what she does not do. x\ cheerful and quiet manner is appreciated by everyone. Some ability to entertain is not to be despised. A gossipy nurse is, however, somewhat dangerous. Above all things a nurse must avoid speaking of other patients or of the affairs of families in w^hich she has lived. Whatever she learns of a patient or a patient's family should be held strictly confidential. Should a patient be so indiscreet as to ask a nurse about such matters she is in duty bound to avoid giving answers to such questions.

A nurse should also avoid the introduction of disagreeable subjects. Conversation about diseases in general is undesirable. A nurse will soon learn the temperament of her patient and subjects that should be introduced.

A nurse should not ask unnecessary questions. Whatever pertains to her work let her find out for herself or from servants or other members of the family if possible. In an obstetrical case it is always well for a nurse to go to the house before the time of the expected confinement to learn the arrangements of the house in order that she may not need to annoy the patient after the labor begins.

A nurse should also leave her patient alone at times.

XURSE'S DUTIES TO PATIENT 29

Often a patient wishes rest of which she is deprived by the presence and perhaps the conversation of the nurse. Let the nurse occasionaUy withdraw from the room, remaining within calL

It would seem almost absurd to say that a nurse should not use the sick-room for her own toilet, if it were not for the fact that this mistake is often made. Trained nurses have even been known to use the toilet articles of their patients.