A nurse's handbook of obstetrics

Front matter

Class Book

Mssj

TO fopyrightN

Preface To The Seventh Edition

In revising this book for the seventh edition, it was thought best to present the subject matter in a somewhat different grouping. The text has been considerably changed and much new material added upon current nursing subjects, as well as fifty new illustrations and a number of colored plates.

It is hoped this book will still prove to be a guide and stimulus to all who follow the traditions and highest ideals of the nursing profession. Since 1903 its text has been a model which has found much favor. The revision was made possible through the courtesy of Honorable John A. Kingsbury, Commissioner of Charities, and the co-operation of the officials, doctors and nurses of City Hospital, and various maternity hospitals in New York City.

September, 191 5. C. E. Gray, R.N.

M. A. Baker, R.N.

Contents

CHAPTER PAGE

I. — Introduction 19

II. — Anatomy 28

Introduction

The art of nursing the obstetrical patient is practised by various classes of people. We are very prone to consider only the doctor and the trained nurse. Statistics, however, demand consideration of other factors. Taking any city or town in the United States, we find that a woman about to present her most valuable gift to the world, a healthy child, if not provided with hospital care away from the family, may be cared for:

i. By the doctor, in his out-patient and country practice.

2. The nurse midwife.

3. The graduate nurse in private, hospital, visiting nurse and rural Red Cross work.

4. Various orders of nursing sisterhoods.

5. A trained midwife from schools of midwifery abroad.

6. The midwife trained in American schools of midwifery, such as Bellevue.

7. The correspondence school graduate.

8. The untrained nurse.

9. The licensed midwife.

10. The unlicensed midwife occasionally.

11. Relatives of the patient.

12. Neighbors.

The dominant issue of the present-day teaching is prevention of waste. All civilization is striving, by every means possible, to conserve and add to the vital resources of the nation. A few daring bacteriologists have done research work which has given us perhaps our greatest influence and inspiration to this end, in preventive and curative medicine.

This knowledge is in a large measure rendered ineffective by the dense amount of deep ignorance concerning the facts of life.

Tradition, prejudice, and social customs all tend to surround the practice of obstetrics with conditions which are largely responsible for the following figures which are inserted as an example of some of the results of the care given at childbirth. The figures are by Doctor Haven Emerson, Deputy Commissioner of the Department of Health of the City of Xew York.

IN NEW YORK CITY FOR THE YEAR I9I4

Number of births reported by physicians 87,650

Number of births reported by midwives 52,997

Number of infant deaths under ten days reported by physicians. . 3,683

Number of infant deaths under one year 13,312

Number of cases of ophthalmia neonatorum reported by physicians 14

Number of cases of ophthalmia reported by midwives 12

Number of deaths in 19 14 from puerperal sepsis 1 407

Number of midwives practising in New York City 1,448

These figures and facts are not dull, but force the logical conclusion that the most essential fact of obstetrics is a knowledge and a following of a high standard of asepsis. This fact cannot be brought before the public too emphatically, too clearly, or too often.

It is the definite duty of every nurse to follow the medical profession closely, and by utilizing every opportunity that sympathy and tact may devise, to teach unceasingly the doctrine of prenatal care and the need of the best obstetrical assistance.

Nature makes lavish efforts to protect the expectant mother from infection. This is interfered with by contact infection

thirty-five per cent, of these deaths were in women who had fceetratt ended by midwives prior to the development of the sepsis, which ended in their deaths. It is approximately estimated that between six and seven thousand deaths from puerperal sepsis occurred in the United States in the same year.

INTRODUCTION. 21

from the family, from visitors, from the patient herself, and from the nurse or doctor.

Aside from the natural immunity possessed by healthy tissues against infection, there is the vaginal secretion, which is usually spoken of as being a natural antiseptic. What is meant is, that while swarming with bacteria, these bacteria manufacture lactic acid, and no pus organism can survive in an acid medium.

Normally the changes in the soft parts of the reproductive organs during pregnancy and labor are accompanied by an increased amount of vaginal secretion. Beyond this there is the closed door to infection of the uterus itself, by means of a mucous mass or plug, called the operculum.

At the end of the first stage of labor the membranes rupture, the liquor amnii carries with it the vaginal contents and a large percentage of the bacteria.

The vaginal walls enlarge during the actual passage of the child; this is followed by the remaining liquor amnii, and, finally, by the delivery of the placenta ; so that there is left but little chance for bacteria to survive.

The whole object of asepsis is to prevent infection of the uterus from the outside. Obviously this resolves itself into a principle of prevention of infection during labor, and the practice of rigid asepsis and faultless technic on the part of the doctor and nurse.

Every case of puerperal sepsis, with rare exception, proves that infection has been introduced from the outside by septic hands, septic instruments, or septic matter from the vulva or vagina carried by douches or instruments into the uterus. The septic infection comes from anything not sterile. This is occasionally unavoidable, owing to complicated instrumental or operative delivery, but a pyogenic infection has no more place in obstetrics than in surgery, and it can be almost as certainly prevented.

Septic infection from the hands may be prevented by proper cleansing, wearing of gloves, and then by using the hands only when imperatively demanded.

A NURSE'S HANDBOOK OF OBSTETRICS.

Septic infection from instruments may be prevented by proper cleansing and boiling; then proper technic in the treatments or douching will prevent the carrying of infection from the vulva or vagina.

Whether the infection is mild and results in invalidism, or whether it is virulent and causes death, the nurse who is intelligent and conscientious will feel strongly her responsibility.

POINTS FOR THE OBSTETRICAL NURSE

Pasteur said : " It is within the power of man to cause all parasitic diseases to disappear from the world." Fatal cases of puerperal sepsis in a hospital are almost unknown. They should be equally rare in the home; and if proper care is exercised this will be the case.

The purpose of this elementary review is to lessen the total of 6000 deaths per year in the United States. It is hoped that all who read it will consider it seriously, whether they are graduates, undergraduates, midwives or lay helpers.

Bacteria are vegetable organisms.

Pathogenic bacteria are those organisms which cause morbid or diseased changes in human tissues.

Infection is the communication of disease from one person to another. The term is also used to denote the agent by which disease is conveyed.

Septic infection is infection caused by septic organisms.

Sepsis is infection by bacteria.

Asepsis means without sepsis ; that is surgical cleanliness or freedom from infection.

Aseptic means in a surgically clean manner.

Pyogenic relating to pus-forming organisms.

Sterile means entire absence of living organisms of any kind. Sterilization is the process of rendering an object free from germs.

Antiseptic means preventing sepsis or pus formation or putrefaction.

(1) No one should undertake obstetrical nursing who has

INTRODUCTION. 23

any pus infection whatever, or who has been recently exposed to a communicable disease. In such a case, report the exact condition to the obstetrician and act under his orders. Carry out thoroughly a system of disinfection.

(2) Articles for emergency use, packings, dressings, treatments, etc., should be sterile and in readiness; neglect to provide these is criminal. Wisdom lies in the prevention of infection and in preparation for emergencies.

(3) Prepare all essentials for doctor (see list). Prepare all essentials for nurse (see list). Prepare all essentials for mother (see list). Prepare all essentials for infant (see list).

(4) Hands must be thoroughly scrubbed under running water for five minutes with any good soap and a clean nail brush ; use particular care between the fingers and around the nails. Cut the nails close and manicure often. Soak in biniodide of mercury 1 : 1000, or sponge with alcohol 95 per cent. Wear rubber gloves, previously sterilized by washing and boiling for five minutes.

(5) Fingers must never be used where an applicator or forceps can be made to serve. These are to be kept in a jar filled with 2 per cent, solution of lysol or 95 per cent, alcohol.

(6) Use sterilized soap.

(7) Never use grease as a lubricant. It is always dirty, and it destroys rubber. Use lysol, 2 per cent., or a sterile emulsion made from soap. ,

(8) Never catheterize a patient unless all possible means to avoid it have been tried ; and then only by express order of the doctor, and with exact technic.

(9) A nurse should not renew a vulva pad after removing a bed-pan from her patient until she has made her hands surgically clean.

( 10) Especial care is essential to prevent infection of vulva, bladder, and breasts.

(11) A cord dressing will not be reinforced or renewed until the nurse has surgically clean hands.

(12) She will never leave a patient's breast exposed, but will protect it by a sterile dressing, and use sterile cotton swabs when cleansing the nipple, at all times treating both breast and nipple as open wounds.

(13) So long as she is with her patient she will keep a complete daily record of patient and infant, charting all physician's visits and treatments.

(14) She may use a fountain syringe for enemata, but an agate irrigator with cover and separate tubing carefully boiled is essential for infusions and for sterile uses.

(15) She will tactfully instruct her patient not to infect herself or infant, and will strive to prevent the baby from developing bad habits. Failure to do this is inexcusable.

(16) She will handle conditions so that the equipment the home affords may be utilized to the advantage of the patient, and by her resourcefulness and adaptability render the economic drain upon the family income as small as possible, without sacrificing a single principle of asepsis.

(17) The nurse should prove a continuous exponent of personal hygiene, in person, uniform, and habits.

(18) She must never relax in vigilance, duty, judgment, or loyalty.

The feminist movement is strongly pushing forward a demand from women themselves for better obstetrics, for better training and judgment on the part of both doctors and nurses. They are less willing to accept inferior service, and demand that the best help available be given them.

Operations are often attempted at home that should in justice to the mother and child be performed in hospitals. Lack of adequate assistance or equipment and improper surroundings not infrequently render recovery problematical. The patients and families must be taught that this is highly improper and that the obstetrician must have adequate assistance and remuneration. Good judgment, swift decisions, and quick action are in demand from the obstetrician. He should have assistants and a nurse worthy this need. Only with a large intelligence and sympathy, trained in technic, plus experience, can a nurse fulfil her opportunity. Private nursing lays greater responsibility upon her than does her hospital work. She must

INTRODUCTION. 25

have a sufficient knowledge of psychology to follow the mental processes of her patient. Thus, the nurse should secure her patient's confidence, and persuade her to place herself in the care of a physician as soon as possible ; she should help her to live a normal life, induce her to eat proper food, take sufficient exercise, secure enough rest, and happily to await her baby's coming. She should ward off dread of suffering by being able to promise that a good obstetrician will not let her suffer too much actual anguish. She should make real to her that the care of her infant begins nine months before it is born ; that the baby requires only a few articles of a very special kind and that these should be in readiness ; that her own return to normal health and comfort, as well as her child's best chance for life, lies in her preparing to nurse it, and that all the earth does her honor.

When on the case, dignity, efficiency, cleanliness and quiet are most essential. Too many objectionable traits, such as gossiping, relating personal details, reciting history of cases, disturbing domestic regime, discourtesy, etc., when placed in the balance beside skill, are found to outweigh efficiency, and the nurse becomes a menace to the well-being of her patient.

The strength and force of character possessed by a nurse will enable her to become a tower of strength to the expectant mother, and by proper suggestion and direction of her mind the actual realization of her sufferings may be much lessened. If the nurse is unintelligent or unobservant of her patient's attitude of mind, she may undo all the efforts of the physician to encourage and assist. It should be a part of her training, and it is her duty, to help her patient mentally as well as physically.

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.

It may be stated, as a general rule, that no woman should die

INTRODUCTION. 27

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 developed 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; i?, coccyx; C, crest of the ilium; D, acetabulum; £, spine 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 28 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.

ANATOMY.

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 sacrococcygeal 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 foetus 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

Fig. 6. — Measuring the distance, iliac crests.

ANATOMY.

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 ringers 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 over-estimated, 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 Caesarean 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. 3

Ill

Anatomy (continued)

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 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 urinarius, 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 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 egg 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