Obstetric and gynecologic nursing

Front matter

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Preface To The Fifth Edition

The fifth edition of this book has been enlarged and thoroughly revised. Appreciating the value of good nursing in hospital and private work, the author hopes that this book will be of interest and value to trained nurses. The writer is indebted to Miss Martin of the Jefferson Maternity for many suggestions of practical value. Acknowledgments are also made to Miss L. S. Clayton, Chief Nurse of the Philadelphia Hospital; and Miss Walker, Superintendent of Nurses at the Pennsylvania Hospital, for information concerning details of treatment.

250 South Twenty-first Street,

Part I.— Obstetric Nursing Page

Introduction ■ I]t

CHAPTER I Definition of Pregnancy; The Growth of the Ovum 13

The Fetus, 14 — Physiology of Pregnancy, 16 — The Placenta, 19 — Anatomy of Pregnancy, 20 — Medical Care During Pregnancy, 22 — The Breasts, 22 — Prenatal Care, 2$.

Chapter II

Diet, 25 — Clothing, 26 — Exercise, 28 — Motoring, 29 — Fresh Air, 29 — Quiet, 30 — Baths, 30 — Sea Bathing, 30 — Growth of the Uterus, 31 — Descent of Child, 31 — Uterine Contractions, 32 — Fetal Movements, 33 — Excessive Fetal Movements, 34 — The Breasts, 34 — Sunken Nipples, 36 — Morning Sickness, 37 — Constipation, 37 — Irritability of the Bladder, 39 — Faintness, 40 — Swelling of the Legs, 40 — Care of the Skin, 41.

CHAPTER III Nursing in the Complications of Pregnancy 42

Impaction of Feces and Displacements of the Womb, 42 — Toxemia of Pregnancy, 45 — Pernicious Nausea, 45 — General Condition of the Patient, 54.

CHAPTER IV Labor, Description of and Preparations for 59

Pains, 60 — Recognition of Labor, 61 — First Stage, 61 — Second Stage, 62 — Third Stage, 65 — Preparations for Labor, 65 — Dressings, 66 — Medicines, 71 — List, 71 — Room for Confinement, 73 — Bed, 74 — Basins and Clothing, 74 — Ligatures, 74 Baby-clothes, 76 — Crib, 76.

Chapter V Page

The Duties of the Nurse During the Patient's Labor. ..... 78

The First Stage, 78 — The Second Stage, 81 — Nitrous Oxid and Oxygen Anesthesia, 82 — The Third Stage, 84 — Lacerations, 85 — Douches, 85 — The Binder, 87 — Labor without the Doctor, 88 — Labor with Breech Presentation, 92 — Twin Labor, 92 — Prolapse of Hand or Cord, 93.

Chapter VI

Duration, 94 — Involution, 94 — Lochia and Bowels, 94 — Rest, 95 — Soiled Linen, 95 — The Newborn Child, 96 — Cleanliness for the Mother, 96 — Massage and Posture, 97 — Light and Air, 99 — Mother and Child, 100 — Warmth, 100 — Bowel Movements, 100 — Diet, 101 — Asepsis and Drainage, 102 — The Breasts, 104 — Catheter, 105 — Asepsis, 105 — Visitors, 106 — Getting Up, 107 — Physician's Examination, 108 — The Mother's Figure, 108.

CHAPTER VII The Newborn Child and Its Care no

Physiology of the Infant, no — Its First Food, in — Mother's Milk, 112 — The Child's Stomach, 113 — Nursing, 113 — Water, 114 — Warmth for the Child, 115 — Sleep, 115 — Clothing, 115 — Bathing, 116 — Massage, 118 — Dressing the Umbilicus, 118 — The Mouth, 119 — The Eyes, 119 — Habits and Nerves, 120 — The First Discharges from the Bladder and Bowels, 121.

CHAPTER VIII The Accidents of Pregnancy 122

Abortion, 122 — Rest, 123 — Asepsis, 123 — Consequences of Abortion, 123 — Bleeding, 124 — Enlarged Veins, 125 — Rupture of Membranes, 126 — Convulsions (Eclampsia), 127 — Syncope, 128.

Chapter IX

Hemorrhage During and After Labor, 130 — What the Nurse Must Do, 132 — To Prevent Return of Bleeding, 133 — Transfusion, 134 — Tamponade, 134 — Convalescence, 135 — Prolapse of the Umbilical Cord, 135 — Asphyxia of the Child, 136 — Cleansing of the Mouth, 137 — The Pulmotor, 137 — Artificial Breathing, 137 — Stimulation, 141 — Favorable and Unfavorable Signs, 142.

Chapter X

In Private Houses, 143 — Sterilizing Utensils, 145 — Clothing, 146 — Light, 142 — Preparation of Patient, 148 — Anesthesia, 149 — Anesthesia by the Nurse, 149 — Instruments, 152 — Delivery

PAGE

by Forceps, 153— Walcher's Position, 160— Version or Turning, 161— Symphysiotomy; Pubiotomy, 162 — Embryotomy (Craniotomy), 165 — Delivery by Abdominal Section (Cesarean Section), 167— Extraperitoneal Section, 174— Vaginal Cesarean Section, 174 — The Induction of Labor, 179 — The Immediate or Primary Repair of Lacerations, 181 — Obstetric Operations in Septic Cases, 185— Plastic Surgery, 189— Late or Secondary Operations for Laceration of the Vagina, Pelvic Floor, and Perineum, 194.

Chapter XI

Symptoms, 201 — Cleansing the Birth-canal, 202— Purgatives; Counter-irritation, 203 — Treatment of Fever, 203 — Fresh Air Treatment, 204 — Nourishment, 204 — Stimulation, 205 — Operations, 206 — Bed-sores, 206 — The Nurse, 207 — Nursing the Child, 208.

CHAPTER XII Complications of the Lying-in Period 210

Complications with the Breasts, 210 — Excess of Milk, 210 — Lack of Milk, 210 — Distention of the Breasts, 212 — Medicines, 215 — Drying Up Milk, 216 — Abnormal Nipples, 217 — Cracks and Fissures in the Nipples, 219 — Ulcers on the Nipples, 220 Abnormal Milk, 220 — Breast-abscess, 220 — Puerperal Thrombosis of the Lower Extremities, 223 — After-pains, 225.

CHAPTER XIII Puerperal Mania 227

Treatment, 227 — Precautions, 228.

Chapter XIV

Partial or Mixed Feeding; Weaning; Artificial Feeding. ... 229 Advantages of Nursing, 229 — Diet and General Care to Promote Nursing, 2 29^Feeding and Nursing, 231 — Prescription of Food for Infants, 232 — Dilution of Cows' Milk, 232 — Cleanliness with Milk, 232 — Preparation of Milk, 233 — Bottles, 234 — Nipples, 234 — Weaning, 235 — Composition and Care of Cows' Milk, 236 — Mixing and Pasteurizing or Sterilizing Milk, 237 — Emergency Feeding, 240 — Gruels, 242 — Beef -juice, 242 — Medicines and Proprietary Foods, 242 — Feeding Without the Bottle, 243 — Colic, 243 — Record of Feeding, 244 — Infant's Stools, 243 — Indigestion, 244 — The Child's Habits, 244 — Constipation or Diarrhea, 245.

CHAPTER XV Care of Prematurely Born Children 246

Incubation, 246 — Fresh Air, 249 — Dressing the Child, 249 — Feeding, 250 — Stimulation and General Care, 250 — Inunctions and Massage, 252.

Chapter XVI Page

Constipation, 253 — Disorders of the Mouth and Gums, 255 — Diseases of the Lungs in Infants, 257 — Septic Infection in Infants, 260 — Wounds and Injuries of Infants, 261 — Bleeding from the Umbilicus; Protruding Umbilicus, 262 — Eruptions in Infants, 263.

CHAPTER XVII Disorders of Infancy {Continued) 265

Ophthalmia Neonatorum, 265 — Earache, 270 — Foreign Bodies in the Eye, Nose, and Throat, 271 — Intussusception, 272 — Malformations, 273 — Retention of Urine, 274 — Circumcision, 274 — Dilatation, 275 — Hare-lip and Cleft Palate, 276.

CHAPTER XVIII Disorders of Infancy {Concluded) 279

Hernia, 279 — Cyanosis, 279 — Tongue-tie, 280 — Constitutional Disorders, 280 — Rickets, 280 — Tuberculosis, 281 — Hydrocephalus, 281 — Marasmus, 282 — Parasites, 282 — The Itch Insect, 283 — Intestinal Parasites, 283 — Jaundice, 284 — Enlargement of the Breasts, 285 — Suppression of Urine, 285 — Persistence of Meconium, 286 — Eczema, 286 — Scalp-crusts, 287 — Convulsions, 288 — Vaccination, 289 — Poliomyelitis, 291.

Chapter XIX

Weight, 293 — Length, 295 — General Development, 295 — The Nervous System, 295 — The Care of the Nerves, 297 — Motion, 297 — Periods of Development, 299 — Dentition, 300 — To Promote Development, 301 — Care During Teething, 302 — Exercise and Air, 302 — Sleeping Porches and Sun Parlors, 303.

PART II.— GYNECOLOGIC NURSING Introduction 304

Definition, 304 — Causes of Disease, 304 — Peculiarities of Patients, 305 — The Management of Patients, 305.

CHAPTER I The Examination of Patients 307

Preparation for Examination, 307 — An Office Examination, 307 — Instruments, 308 — Antiseptic Solutions, 309 — Cotton or Gauze, 309 — Light, 309 — Examination in Private Houses, 310 — Description of Instruments for Examination, 311 — Specula, 311 — Examination under Ether, 313 — Duties of Office Nurse, 314.

Chapter II Page

Postures of the Patient for Examination and Operation. . . 316 Dorsal or Lithotomy Position, 316 — Sims' Position, 317 — Knee-chest Position, 319 — Trendelenburg Position, 319 — Standing Position, 322 — Squatting Position, 322 — Position Bending Forward, 323.

CHAPTER III Local Treatment; Pessaries 324

Local Treatment, 324 — Posture, 325 — Tampon, 325 — Carded- wool Tampons, 326 — Vaginal Capsules, 326 — Pessaries, 327 — Introduction of the Pessary, 328 — Caution to Patients, 328 — Removal and Readjustment of the Pessary, 329.

Chapter IV

Vaginal Douches, 330 — The Hot Vaginal Douche, 330 — Astringent Vaginal Douches, 330 — Antiseptic Vaginal Douches, 331 — Preparations of Iodin — Lugol's Solution, 334— The Temperature and Quantity of Douches, 334 — Syringes and Douche-tubes, 334 — Posture of Patient, 335 — Douche-pans, 335 — Method of Giving Douches, 337 — Cautions and Dangers in the Use of Douches, 338 — Douches after Plastic Operations, 339 — Intestinal Douches, 340 — Solutions, 340 — Tubes for Intestinal Douches, 340 — Posture of the Patient, 340 — Method of Giving, 341 — Vesical Douches, 341 — Fluid Employed, 342 — Posture and Preparation of the Patient, 342— Method of Giving the Douche, 343 — Care of the Apparatus Employed, 345.

Chapter V

Rest, 346 — Food, 347 — Forced Feeding in the Insane, 347 — Rectal Feeding, 348 — Water, 348 — The Care of the Eyes, 349 — The Care of the Skin, 349 — Manicuring and Pedicuring, 349 — Care of the Mouth and Teeth, 350 — General Massage, 350 — Intestinal Massage, 350 — Intestinal Massage with Salines, 351 — Pelvic Massage, 351 — Postural Gymnastics, 352 — Electrical Treatment, 332 — Electric Cabinet, 353 — Electric Baths, Mud Baths, Carbonic Acid Baths, 353 — Intravenous Medication and Vaccines, 354 — Direct Transfusion, 355 — The Care of the Intestines, 356.

CHAPTER VI Gynecologic Operations 357

Operations in which the Peritoneal Cavity is Not Opened, 357 — Preparation of the Patient, 358 — Preparation of Room in Private House, 359 — Sterilizer and Instruments, 360 — Needles and Sutures, 360 — Solutions and Stimulants, 360 — Operations of This Sort in Hospitals, 361 — The After-care of These Patients. 362.

Chapter VII Page

Operations in which the Peritoneal Cavity is Opened 363

Nature's Safeguards, 363 — Preparatory Treatment, 364 — The Dangers of Celiotomy, Abdominal or Vaginal, 364 — Preliminary Treatment, 365 — Operating-rooms, 368 — Anesthetizing room, 369 — Sterilizing-room, 370 — Store-room, 370 — Recovery-room, 370 — Doctor's dressing-room, 372 — Apparatus, 372 — Preparation of Operating-room and Furniture, 379 — Improvised Operating-room in Private House, 379 — Improvised Apparatus, 380 — Dressings and Solutions for Cases in Private Houses, 381 — Emergencies in Private Houses, 381.

Chapter VIII

Sterilization of the Hands of Physicians and Nurses, 383 — Gloves, 386 — Antiseptic Covers for Jars and Tables, 386 — Preliminary Preparation of the Abdomen and Vagina, 387 — Final Preparation, 389 — The Anesthetizer, 392 — Physician's Clothing, 392 — Dress for Nurses, 393 — Discipline of the Operating-room, 393 — Training of Nurses in Operative Work, 394.

Chapter IX

Arrangement of the Patient's Room, 396 — Vomiting, 397 — Hemorrhage and Shock, 398 — Septic Infection, 401 — Restlessness and Thirst, 405 — Abdominal Distention, 406 — Food and Stimulants, 407 — The First Movement of the Bowels, 408 — The Murphy Method, 410— The Fowler Position, 410 — The Use of the Catheter, 411— Increased Diet, 411— Stimulation by the Mouth, 412 — Changes of Posture, 412 — The Care of the Skin, 413— The Care of the Drainage-tube, 413— When is a Patient Convalescent after Abdominal Section? 415 — The Nurse, 415.

Chapter X

Redressing, 418— The Removal of the Stitches, 419 — Stitch-hole Abscess, 420 — Changes in Diet, 421 — Sitting Up, 421 — Getting Up Comfortably, 422— Ventral Hernia^ 422 — Sudden Death during Recovery from Abdominal Operation, 424.

CHAPTER XI Vaginal Celiotomy 425

Preparations for Vaginal Celiotomy, 425 — Posture, 425 — Instruments and Appliances, 426 — Hemorrhage and Shock, 426 — After-treatment, 426— Dressings, 427— Convalescence, 427.

Chapter XII

Suspicious Symptoms, 428 — Cancer of the Pelvic Organs, 428 — Cancer of the Breast, 430 — Non-operative Treatment of Cancer, 432 — Cancer of the Bladder or Bowel, 433 — Radium and jc-Ray in Treatment of Cancer, 435 — Bed-sores, 435 — Pain, 436 — Death from Cancer, 437 — Dangers of Infection, 437 — Dangers to the Nurse, 438.

CHAPTER XIII Mental Diseases Complicating Pelvic Disorders 439

Melancholia, 439 — Perversions, 439 — Mania, 440 — General Care, 440 — The Menopause, 441.

Chapter XIV

Gonorrhea, 443 — The Effects of Gonorrhea, 443 — The Conveyance of Gonorrhea, 444— Treatment, 444 — Care of the Nurse, 445 — Syphilis, 445 — Treatment, 445 — The Results of Syphilis, 447 — The Treatment of Hereditary Syphilis, 447 — Precautions for Nurses in Dealing with These Cases, 448.

Appendix

Other Methods for the Preparation of Surgical Supplies and Aseptic Precautions 473

Index 481

PART f.

Obstetric Nursing

Introduction

Obstetric nursing is that branch of the art of caring for the sick which includes the nursing of the mother during pregnancy, parturition, and the puerperal state, and also the care of her child.

It demands some knowledge of natural pregnancy and of the signs of accidents and diseases which may occur during pregnancy. It also requires knowledge and experience in the care of the patient during the labor and during her complete recovery, with the needs of her child. The obstetric nurse must also know how to help patient and doctor in the accidents and complications of labor, and has an important part to play in caring for mother and child in the diseases which occasionally attack them during the puerperal period. As wounds occur during labor, and as operations must often be performed during or immediately after labor, a thorough knowledge and drill in asepsis and antisepsis are absolutely indispensable.

The field of obstetric nursing is thus a wide one. Some of the most remarkable physiologic changes known in the human body accompany pregnancy and parturition ; while few patients are so absolutely healthy

1 2 INTR OD UCTION.

that pregnancy and childbirth proceed in a perfectly natural way.

The personal relations of the obstetric nurse with her patients are peculiarly interesting. The coming of the child is usually an occasion of joyful anticipation, while the accidents and diseases occurring at this time may become very rapidly serious and be followed by a tragic termination. No nurse who gives good and faithful service is more thoroughly appreciated by her patients and the physician in charge. The affection given so freely to the child is often extended to the nurse, and firm and lasting attachments of a most interesting nature often develop.

To nurses gifted with good health and strength, who have opportunities for proper training and experience, and who are naturally fond of young children, obstetric nursing offers an exceedingly interesting and very lucrative branch of medical work.

Chapter I

DEFINITION OF PREGNANCY.— THE GROWTH OF THE OVUM.— THE FETUS.— THE ANATOMIC STUDY OF PREGNANCY.

Pregnancy. — By the term "pregnancy" is understood the presence of the impregnated ovum within the body of the mother. The ova are formed in the ovaries, from which they are discharged by the bursting of the sacs in which they are contained, and from which they pass through the oviducts, or Fallopian tubes, into the uterus, or womb. Impregnation may occur in the Fallopian tubes, and very rarely in the burst sac of the ovary. When the impregnated ovum has lodged in the womb and develops there to maturity, the pregnancy is said to be normal, intra-uterine, or entopic. When the impregnated ovum remains in the Fallopian tube or escapes thence into the abdomen or into the pelvis, the pregnancy is said to be abnormal, extra-uterine, or ectopic.

Growth of the Embryo. — When the impregnated ovum reaches the womb, it usually lodges in the upper portion of the uterus near the openings of the Fallopian tubes. It fastens itself to the lining membrane of the womb, and gradually forms membranes of its own which surround it. For the first few months of its development it is called an embryo. It resembles a small bladder, or cyst, covered on its outer surface with white shaggy projec-

H

PREGNANCY.

tions which look like fringes of moss or like a soft and white chestnut burr (Fig. i). These projections are upon the outer membrane covering the embryo, called the chorion, and are the tendrils by means of which the embryo clings to the wall of the womb. Within the chorion and next the embryo is a very thin and delicate membrane, called the amnion, which forms a fluid, called the amniotic fluid, in which the growing embryo moves during its development.

The characteristic form of the human being is seen in very early embryos. The limbs are soon developed ; the

Fig. i. — Human ovum of about twelve days (Reichert) : A, side view; B, front view.

eyes appear in primitive form ; the body is bent slightly forward, while the embryo moves in the amniotic liquid. It obtains its nourishment through a vesicle, or bladder, which contains rudimentary blood-vessels which afterward enter into the umbilical cord. During the first three months of pregnancy this description of the embryo would apply, and the chorion can usually be recognized by its pale and shaggy appearance, in cases in which the embryo is expelled, when the specimen is floated on cold water in a white vessel.

The Fetus. — At about the fourth month of gesta-

THE FETUS. 1 5

tion the after-birth, or placenta, begins to be formed, while the membranes rapidly grow larger to give greater space for the growing embryo. The name " fetus " is now applied to the young being, and the umbilical cord gradually develops, connecting the placenta to the umbilicus of the fetus. The form of the fetus is distinct and characteristic of the human being, the fingers and toes gradually become separated from each other, the eyes develop completely, and gradually the usual appearances of a newborn child are present in varying degree.

At twenty-six weeks of gestation the fetus has grown so large that it is possible for it to live outside the body of the mother. It is exceedingly unlikely, however, that such would be the case with most infants. At twentyeight weeks, or seven months, children have often survived, and from this time on to the usual termination of pregnancy children are frequently born and live.

Position and Presentation. — During this time the child has assumed its position in the mother's womb, which in most cases is with the head lowermost, the back of the child turned toward the mother's left side, and the feet and knees upon her right side, just above the middle of the womb. The placenta grows in proportion to the weight and vigor of the child. The cord is sufficiently long to permit free movement on the part of the child, while the amniotic liquid provides a useful protective against injury and also a suitable medium in which fetal movements can occur. In some cases the head of the fetus is lowest and the back is turned to the mother's right side. In other cases the breech and thighs of the child are lowest, while the , head is uppermost in the womb. Occasionally the child' lies transversely in the uterus, with its head upon one side and its feet and limbs upon the other.

Full-term Pregnancy. — Pregnancy usually lasts in normal cases two hundred and eighty days. It cannot be said to be abnormal if it continues three hundred days, nor if it terminates at two hundred and seventy days. The average child at full term is twenty inches (fifty centimeters) long, weighs from six and one-half to seven and one-half pounds, is strong enough to cry vigorously and to suck the nipple of the mother, and is fully capable of living outside the mother's womb. Its placenta, or after-birth, weighs about a pound, and the umbilical cord is usually from fifteen to twenty-five inches in length. While the bones of the child are fairly developed, those of the skull are not tightly knit together, but can be moved at the edges, and in some instances can be made slightly to overlap. There are several membranous spaces along the central line of the fetal skull, the largest of which is called the anterior fontanel. This name was given because the beating of the blood in the brain can be seen at this point in the rise and fall of the membranes covering the brain. As this movement resembles that of a fountain, the space has been called a fontanel.

The Physiology of Pregnancy.— During pregnancy the healthy mother grows in all portions of the body. To feed herself and the child, the blood becomes abnormally rich, the muscle of the heart is larger and stronger than usual, the various organs of nutrition are increased in size and activity,- and the skeleton becomes larger and heavier. The increase in blood is often evident in the darker color of the lips and other mucous membranes. In many patients the appetite is increased, the patient feels stronger and better than before, and is capable of considerable exertion. In healthy women the

PLATE I.

THE PHYSIOLOGY OF PREGNANCY. I?

excretions are increased and an additional quantity of oxygen is required to purify the blood. A vaginal discharge of whitish mucus is commonly observed during pregnancy and is a natural thing. The normal vaginal discharge in a healthy pregnant patient is capable of destroying bacteria, and is thus of value in protecting the mother. It should not be removed by douches in healthful cases, hence a nurse should not give a vaginal douche to a pregnant patient, not even if labor is beginning, without the distinct order of the physician in charge.

As pregnancy progresses, the size of the womb varies at different periods.

At four months the womb can be distinctly felt in the abdomen above the pubes, at five months it is midway between the pubes and the umbilicus, at six months the top of the womb is at the umbilicus, at seven months it is two fingers' breadth above, at eight months it is a hand's breadth above the umbilicus, and at nine months it is distending the tissues at the tip of the breast-bone or sternum (Plate 2).

After the ninth month, in patients who are pregnant for the first time, the child usually descends into the pelvic brim, and the uterus is lower down. In patients who have had several pregnancies the child remains above the pelvis until labor begins.

The child in the womb is usually situated with the head lowest at the brim of the mother's pelvis (Fig. 2). In most cases the back of the child is on the left side of the mother, and the heart-sounds of the child are heard on the mother's left side between the crest of the pelvis and the umbilicus. Occasionally the child has the head uppermost and the breech lowest in the womb, and, very i8

PREGNANCY.

rarely, the child is turned transversely in the uterus. Occasionally the face instead of the vertex of the head is situated at the upper part of the pelvis. That part of the child which is lowest in the womb is said to present, and various situations of the child's body, with reference to the mother, are said to be its positions.

When more than one child is in the womb at the same time they fit into the uterus as best they can, usually the head of one being lowest and the head of the other being above.

The after-birth is usually attached to the posterior wall of the womb some distance above the opening at the mouth.

The child while within the uterus has lived through oxygen obtained from the mother's blood. The blood of the child passing through the umbilical cord into the placenta comes there so close to the blood of the mother that oxygen passes from the maternal into the fetal blood. Thus the child has had no need to breathe. Its lungs have required but very little blood. For this reason the circulation of blood in the unborn child differs from that in the child after birth. Before birth there is an opening in the partition between the two sides of the child's heart, and, as blood is not needed in large quantity in the lungs, it passes from the right side of the fetal heart into the left side, instead of going from the right side of the heart into the lungs. So soon as the child is born and the umbilical cord has been tied and cut, it ceases to

Fig. 2. — Adaptation between the uterus and the fetus at term in vertex presentation (American Text-Book of Obstetrics).

THE PLACENTA. 19

obtain oxygen from its mother. It begins to breathe. Its lungs unfold and admit air and the opening between the two sides of the heart closes. To help this the child should be laid upon the right side for the first day or so after birth. Several days are required to unfold fully the lungs and to seal perfectly the opening in the heart. If this does not completely shut, the blood of the child remains without its proper quantity of oxygen, the child is blue in the face, and is often called a " blue baby."

Not only does the child within the womb obtain oxygen from the blood of the mother, but some nutritious matter passes into the fetal blood, while the fetus discharges into the blood of the mother some of the waste matter from its own body. As the fetus during its development lives entirely upon the mother, it is evident that she requires abundant food of an easily digestible character ; that she should have the greatest possible supply of fresh, pure air ; and that she should discharge freely the waste from her own body through the kidneys, intestines, skin, lungs, and liver, because she is burdened with her own waste and that of the fetus as well.

The Placenta. — The placenta, or after-birth, is a most important organ for mother and child. By means of this the oxygen in the mother's blood is conveyed to the blood of the child , and the waste products from the child's blood are consumed in the blood of the mother. The placenta also stops the passage of bacteria from mother to child, and thus protects the child against infection. When the mother is infected by serious disease, like syphilis, the placenta may become extensively changed and the child will die as a result. Should the placenta become separated from its attachment to the wall of the uterus, the child will die and the mother's condition will be serious through hemorrhage. The placenta is usually formed about the fourth month, and if the mother is healthy her general condition improves at this time. At this period the product of conception ceases to be called the "embryo" and is named the "fetus." In common language the placenta is called the "after-birth."

The Anatomy of Pregnancy.— The womb, or uterus, in which the child is developed is a hollow muscular organ which increases in size with the growth of the child. Its muscular tissue is so interwoven that when it contracts it exerts great expulsive force. Although the womb before pregnancy is only two and a half to three inches in length, it becomes many times larger, extending with the child almost the entire length of the abdomen nearly to the diaphragm. As the womb grows it draws up, somewhat the ovary and the Fallopian tube upon each side. As pregnancy proceeds the womb lies a little obliquely across the abdomen, its upper portion being a little to the right of the median line, and its lower portion inclined a little to the left. It pushes the intestines to each side, often compressing them to such an extent that constipation results.

The Fallopian tubes are composed of muscular tissue, elastic tissue, and mucous membrane, resembling the uterus in structure. They are capable of slight contractions, and, should the impregnated ovum remain in the tube, it can develop to a certain point. The ovaries during pregnancy are usually quiescent, and menstruation does not, as a rule, continue during pregnancy.

The Birth-canal. — The Fallopian tubes, the uterus, the vagina, and the muscular floor of the pelvis comprise what is known as the birth-canal. This is contained in the pelvis, or bony basin. When the child has fully developed, labor must come on to secure the ex-

THE ANATOMY OF PREGNANCY. 21

pulsion of the fetus from the mother's womb. The child is pressed out from the body of the mother by the contraction of the uterine muscle aided by the diaphragm and the abdominal muscles. The lower part of the womb, called the neck, or cervix, dilates or stretches, while the vagina and pelvic floor dilate and relax to allow the passage of the child. If the child be large, and if the tissues do not dilate readily, then lacerations, or tears, may result. If such tears be not closed by sutures, some portion of the birth-canal will sag downward or prolapse, and the supports of the womb being weakened, the uterus may assume abnormal positions, and the patient suffer as a consequence. The muscular and elastic tissues described form a continuous canal or muscular tube.

The Bony Pelvis. — The bony pelvis of the mother comprises the sacrum, which forms the posterior wall of the pelvis, and two large, irregularly shaped bones one upon each side, called the innominate bones. The two side bones of the pelvis have different names in their different portions. Thus in front the two halves are termed the pubic bones, while at the lowest point near the rectum we have the ischia. The thigh-bones, or femora, fit into sockets at each side of the pelvis. These bones are bound together by ligaments, and the whole forms an irregularly shaped bony cavity which may undergo some change in form and contour during pregnancy and labor. The shape of the normal pelvis is caused by the healthy development of the mother, not only through inherited good health, but also through exercise. When, however, the mother has a disease of the skeleton like rickets, or when during early life she is prevented from walking and from exercising as she naturally would, deformity of the pelvis results. Body tumors occasionally grow upon the walls of the pelvis and obstruct its cavity.