■ " A TEXT-BOOK 
OF 
OBSTETRICAL NURSING 
BY 
ALICE WELD TALLANT, A.B., M.D. 
"i, 
PROFESSOR OF OBSTETRICS, WOMAN S MEDICAL COLLEGE OF PENNSYLVANIA; 
OBSTETRICIAN-IN-CHIEF TO THE HOSPITAL OF THE WOMAN'S MEDICAL 
COLLEGE OF PENNSYLVANIA; GYNECOLOGIST AND OBSTETRICIAN ON 
THE VISITING STAFF OF THE PHILADELPHIA GENERAL HOSPITAL; 
CONSULTING PHYSICIAN TO THE GIRLS' DEPARTMENT OF 
THE GLEN MILLS SCHOOLS 
ILLUSTRATED*WITH 116 ENGRAVINGS 
LEA & FEBIGER 
PHILADELPHIA AND NEW YORK 
1922 ■_ Copyright 
LEA & FEBIGER ' 
1922 
PRINTED IN U. S. A. TO 
ALL THE NURSES WHO HAVE WORKED WITH ME 
FOR THE WELFARE OF OUR PATIENTS IN THE MATERNITY 
OF THE WOMAN'S MEDICAL COLLEGE OF PENNSYLVANIA 
THIS BOOK IS DEDICATED 
AS AN EXPRESSION OF MY SINCERE APPRECIATION PREFACE 
Tins book is the outcome of several years' teaching of 
the nurses in the Hospital of the Woman's Medical College 
of Pennsylvania. I have intentionally given considerable 
space to the discussion of the general subject of obstetrics, 
because I have found from the questions of my classes that 
it was of interest and of value to them as a background for 
the more practical part of their training. I hope that I have 
also placed enough emphasis on the human side of obstet- 
rical nursing to convince any nurse who may read this book 
that here as in all her professional work the watch-word is 
service. 
A. W. T. 
Philadelphia, 1922. CONTENTS. 
CHAPTER I. 
Obstetrics 17 
CHAPTER IL 
Physiology of Pregnancy 52 
CHAPTER III. 
Physiology of Labor and the Puerperium 74 
CHAPTER IV. 
Management of Pregnancy 86 
CHAPTER V. 
Management of Labor 109 
CHAPTER VI. 
Complications of Pregnancy 145 
CHAPTER VII. 
Complications of Labor 166 
CHAPTER VIII. 
The Puerperium 186 VIII 
CONTENTS 
CHAPTER IX. 
Obstetrical Operations 205 
CHAPTER X. 
The Newborn Baby and its Care 236 
Appendix 275 
Index 277 OBSTETRICAL NURSING. 
CHAPTER I. 
OBSTETRICS. 
Obstetrics is the art of assisting women in childbirth, 
according to the usual definition, but the obstetrical care of 
a patient really concerns itself with the three parts of the 
process: pregnancy, labor and the puerperium. 
Pregnancy covers the period of the growth of the child 
in the uterus from its beginning, and normally lasts, about 
two hundred and eighty days. A woman who is pregnant 
for the first time is called a primipara or primigravida; one 
who has passed through one or more pregnancies is a mul- 
tipara. These terms are often abbreviated to i-para and 
x-para. 
Labor or parturition is the process by which the child is 
expelled from the uterus. Its duration is usually several 
hours, but varies according to conditions which will be 
detailed later. The term parturient is sometimes used to 
denote a woman in labor. 
The puerperium is the period after the birth of the child, 
during which the woman's whole system is resuming its nor- 
mal condition, after the changes incident to pregnancy and 
labor. Puerpera is the technical term applied to the patient 
during this period. 18 
OBSTETRICS 
Obstetrical Nursing.-In the average case the nurse's 
services are desired for the labor and two to four weeks of 
the puerperium. She is not needed during pregnancy unless 
complications arise, although many women prefer to have 
the nurse in attendance during the last few days, rather 
than to wait for the onset of labor before calling her. If 
the patient is to be confined in a private house, she will prob- 
ably wish the nurse to make a visit or two, to help her in 
planning the necessary arrangements and getting together 
the supplies. 
The nurse who is connected with a modern obstetrical 
clinic or out-patient service will find that much of her work 
has to do with the prenatal care of expectant mothers. Not 
only will she see them as they come to the clinic for exami- 
nation but she will probably be called upon to visit them 
in their homes and give them instructions as to their mode 
of living and the preparations for the advent of the baby. 
After the birth of the child there will be not only the care 
of mother and baby during the puerperium but also the 
follow-up work involved in a postnatal clinic, in which both 
are kept under observation, with especial attention to the 
care and feeding of the child until it has passed the danger- 
ous first months of life in which so many infants slip away 
for want of proper supervision. 
The obstetrical nurse, trained in a hospital and accustomed 
to its routine, finds entirely new problems to face when she 
takes up private nursing. The hospital supplies and appli- 
ances which she has come to look upon as a matter of course, 
do not exist in the home, and she must exercise forethought 
and ingenuity in providing substitutes. The patient is no 
longer one of a large number, an incident in the day's work, 
but the center of attention in the family, to whom no detail 
of her comfort is too small to be of importance. The nurse's OBSTETRICAL ANATOMY AND PHYSIOLOGY 
19 
position is one which requires special judgment and tact 
in her dealings with the family, and she comes of necessity 
into particularly intimate relation with her patient. 
Obstetrical work is too often looked upon as an uninter- 
esting routine, exacting in its hours and not demanding the 
display of the highest skill. The nurse who undertakes it 
will find, however, that the greatest responsibility is laid 
upon her, for on her ability to meet an emergency with skill 
and prompt action will depend not one life alone but two. 
Even though the case be "only a normal one/' she has the 
opportunity to illustrate the true meaning of the word 
obstetrics in standing by her patient in her hour of need. 
And truly " to stand helpfully by a soul on earth whose body 
is in pain ... is one of the highest privileges as well 
as the most sacred duty."1 
OBSTETRICAL ANATOMY AND PHYSIOLOGY. 
Pelvis.-The pelvis is the bony girdle of the lower part of 
the trunk, and has in general the function of supporting the 
body-weight and transmitting it to the lower limbs. It has 
also a special obstetrical importance, because in it lie the 
reproductive organs of the woman and through its cavity 
the child passes at the time of birth. 
The pelvis consists of four bones: the sacrum, the coccyx 
and the two hip bones. It has also three joints: the sym- 
physis pubis, where the hip bones meet anteriorly, and the 
two sacro-iliac articulations or synchrondroses, where they 
meet the sacrum. There is so little movement at these 
points that it is hard to think of them as actual joints, but 
at least they prevent the pelvis from being an absolutely 
1 Worcester: Nurses for our Neighbors, 20 
OBSTETRICS 
rigid bony ring, especially during pregnancy, when the soften- 
ing of the tissues and the more abundant blood supply allow 
a slight increase in the amount of motion. 
The entrance to the pelvis from above is called the inlet 
or superior strait, and the opening below, bounded on each 
side by the ischial tuberosities, the outlet or inferior strait. 
The cavity is narrower below than above, as the distance 
Fig. 1.-Median sagittal section of pelvis. (Gray 
between the tuberosities is only 11 cm., while the widest 
measurement of the inlet, from side to side, is 13.5 cm. (a 
difference of about one inch). In other words, the pelvis is 
slightly funnel-shaped. This shape is more marked in an 
infant. Since the sacrum and coccyx, forming the posterior 
wall of the pelvis, have a length of about 10 to 11 cm., while 
the symphysis, forming the anterior wall, is on the average 
only about 4 cm. deep, it is easy to see that the pelvis is much OBSTETRICAL ANATOMY AND PHYSIOLOGY 
21 
Fig. 2.-Female pelvis. (Cragin.) 
Fig. 3.-Male pelvis. (Cragin.) 22 
OBSTETRICS 
deeper posteriorly than anteriorly. This fact affects some- 
what the way in which the child passes out of the pelvis. 
There are various anatomical differences between the pelvis 
of a man and that of a woman. The most important of these 
are as follows: 
1. The woman's pelvis is wider above. 
2. Its cavity is shallower. 
3. Its outlet is wider. 
Fig. 4.-Pseudo-osteomalacic pelvis. (Naegele.) 
These differences all show that the female pelvis is more 
adapted for child-bearing, since the child can more easily 
enter a wide inlet, pass through a short canal and emerge 
from a wide outlet. In some cases in which a woman's 
pelvis is more like the male type, or those in which through 
lack of development it still keeps the shape of the child's 
pelvis, labor is bound to be more difficult. If a child or a 
young girl does much hard work, especially heavy lifting, 
while the bones are still comparatively soft, various changes 
in the shape and size of the pelvis may be brought about, 
which will also add to the difficulties of childbirth. Similar 
results are seen when lack of nourishment has prevented OBSTETRICAL ANATOMY AND PHYSIOLOGY 
23 
proper development of the bones. The softening of the 
bones due to rickets, a common disease of children, or osteo- 
malacia, an adult disease very uncommon in this country, 
may be a cause of very serious deformities. Hip disease, 
lameness and spinal curvature may also distort the shape, 
making the pelvis irregular or asymmetrical. 
Fig. 5.-Osteomalacic pelvis. (Bumm.) 
Muscles.-The muscles of the pelvis serve in part as a soft 
pad or lining, which protects the child from injury by the 
hard bony surface. Others, especially the levator ani, go to 
make up the so-called floor of the pelvis, and still others 
enter into the formation of the perineum. 
Reproductive Organs.-The female reproductive organs are 
classified as internal and external organs. The vagina, 
which makes a passage for the child from the uterus to the 
outside world, will be described under the first heading. 24 
OBSTETRICS 
External Organs.- Mons Veneris.-The mons Veneris is a 
pad of fatty tissue, covered with skin and hairs, which lies 
over the symphysis. 
Clitoris 
Vestibule 
External urethral 
orifice 
Vaginal orifice 
Hymen 
Fig. 6.--External genital organs of female. The labia minora have been 
drawn apart. (Gray.) 
Vulva,-The vulva is the name given to the external 
structures lying posterior to the mons Veneris. First among 
these are the labia majora, two folds of skin which run 
backward on either side from the mons to the perineum. OBSTETRICAL ANATOMY AND PHYSIOLOGY 
25 
The pubic hairs of the mons are continued down over their 
outer surfaces. Beneath the skin there is fatty and connec- 
tive tissue and also an abundant plexus of veins, which not 
infrequently become large and varicose during pregnancy 
and may even rupture with the strain of labor. 
Labia Minora.-The labia minora are smaller folds of 
skin, which lie to the inner side of the labia majora and 
parallel to them, often quite hidden between them. They 
join anteriorly and spread apart posteriorly, leaving a 
somewhat triangular or almond-shaped space between them. 
Clitoris.-At the junction of the labia minora, which form 
its prepuce, is a small, sensitive structure called the clitoris. 
Its tip or glans, which is about the size of a small pea, pro- 
trudes from between the folds of the labia. 
Vestibule.-The vestibule is the triangular area enclosed 
by the labia minora. In it are found the openings of the 
urethra and vagina, and at either side of the vaginal orifice, 
the ducts of the vestibular glands of Bartholin. 
Bartholin's Glands.-These glands, located just outside the 
vagina, empty a slight secretion which helps to keep the 
parts moist. In case of infection, especially by the gono- 
coccus, abscesses may form in them, and after the infection 
has apparently disappeared, the organisms may still remain 
hidden deep in the glands, waiting their chance to make 
further trouble. 
Vagina and Hymen.-The vagina serves as the canal of 
entrance to the uterus and also as a passage through which 
any cast-off material from the uterus, like the menstrual dis- 
charge, can make its way out. During labor it forms a 
canal inside the bony pelvis, through which the child is born. 
The entrance to the vagina is encircled by a fold of skin 
and mucous membrane, the hymen. The opening thus left 
is usually so small that unless the hymen happens to be 26 
OBSTETRICS 
Fig. 7.-The crescentic hymen. (Cragin.) 
Fig. 8.-The annular hymen. (Cragin.) OBSTETRICAL ANATOMY AND PHYSIOLOGY 
27 
extremely soft and elastic, it is ruptured at the first sexual 
intercourse. During childbirth the edges are still farther 
stretched and torn, so that there remain afterward but a 
few tags of tissue, the carunculae myrtiformes. 
The vagina itself is a canal into which the lower end of 
the uterus dips. It is somewhat curved, with its longer 
wall posteriorly, like the pelvis, and its length is from 6 to 
Fig. 9.-Carunculae myrtiformes. (Cragin.) 
10 cm. (2| to 4 inches). When the woman is lying on her 
back, the direction of the vagina is not horizontal but 
obliquely downward. These facts have a very practical 
bearing and should be kept in mind during such procedures 
as a vaginal examination, the introduction of a speculum or 
the giving of a douche. It is also important to remember 
the position of the vagina in the pelvis, with the urethra and 
bladder lying in front of it and the rectum behind, since this 28 
OBSTETRICS 
explains how its canal may be obstructed by pressure from a 
full bladder or rectum. 
The vaginal wall consists of muscle and connective tissue, 
including many elastic fibers, and has a lining of mucous 
Fig. 10.-Internal genital organs, with bladder, urethra and rectum, seen 
from the side. (Bacon.) 
membrane, containing many layers of flattened epithelial 
cells, something like the skin. The anterior and posterior 
walls lie in loose folds which seem almost to close the open- 
ing, but they are easily stretched apart, so that the canal 
which seemed barely large enough to admit the examining OBSTETRICAL ANATOMY AND PHYSIOLOGY 
29 
finger can make room for an eight- or ten-pound baby with 
little difficulty. 
There are no glands in the vagina, but a so-called secretion 
of white, curd-like material is present, especially during 
pregnancy. Although the studies of different investigators 
show varying results, it is probable that this acts as a pro- 
tection by destroying or at least rendering harmless any pus 
organisms which may enter the vagina during pregnancy. 
Unfortunately it has no effect on the gonococcus. 
Internal Organs.- Uterus.- The uterus is sometimes called 
the organ of menstruation, but its more special obstetrical 
functions are to hold and nourish the fetus during pregnancy 
and to expel it after labor sets in. It is a somewhat pear- 
shaped organ, barely three inches long, which lies in the 
pelvis, in front of the rectum and behind the bladder, against 
which it tips forward, when in the normal position. It is 
so movable that its position is easily changed by pressure 
from the surrounding organs, especially when it is heavy or 
congested. Except for its lower end, the cervix, which dips 
down into the vagina, the uterus is covered with a part of 
the peritoneum which lines the abdominal cavity. Its walls 
are made of strong smooth muscle fibers, which grow tre- 
mendously during pregnancy and set up powerful contrac- 
tions during labor. Its cavity is lined by mucous mem- 
brane or endometrium, in which lie quantities of glands. The 
cells of the endometrium are provided with cilia, fine hair- 
like processes, w'hich by their motion create a current down- 
ward toward the vagina. 
The uterus is usually described as consisting of two parts, 
the body and the neck or cervix. The body may be further 
divided into two parts: the upper segment or fundus, which 
has especially thick muscular walls, and the lower segment, 30 
OBSTETRICS 
whose walls contain more connective tissue and are therefore 
more easily stretched. 
The cervix is really a narrow canal, about an inch long, 
with an opening at each end; the internal os passing into the 
cavity of the uterus above, and the external os into the 
vagina below. In a woman who has not borne children it 
is a round or oval opening, too small to admit more than 
Ligament of ovary 
Epobphoron 
Ostium 
abdominale 
Ovarian fimbria 
Ovarian 
vessels 
External uterine orifice 
Fig. 11.-Uterus and right broad ligament, seen from behind. The broad 
ligament has been spread out and the ovary drawn downward. (Gray.) 
a finger-tip, but in the course of labor the canal is stretched 
wide open to let the child pass through. It is often slightly 
torn at childbirth, and afterward looks like a transverse slit. 
The os is usually filled with the mucus secreted by the cervical 
glands, which is particularly thick and abundant during 
pregnancy. Besides this opening below, through the cervix 
into the vagina, the uterus has two others above, into the OBSTETRICAL ANATOMY AND PHYSIOLOGY 
31 
uterine or Fallopian tubes, which branch off from each 
side of the fundus. 
The uterus has three pairs of ligaments: the broad liga- 
ments, folds of peritoneum which pass from the sides of the 
uterus toward the pelvic walls; the round ligaments, thin 
muscular cords running forward to the inguinal canals; and 
the utero-sacral ligaments, extending backward on either side 
of the rectum to the sacrum. These all help to keep the 
uterus in position, but they may become so stretched in 
pregnancy from the strain of the heavy uterus that they no 
longer succeed in holding it in its proper place. 
The blood supply of the uterus comes from the uterine 
and ovarian arteries, which run along its lateral edges, send- 
ing branches across its anterior and posterior surfaces, and 
forming a complicated network. Its nerves come from the 
sympathetic nervous system. 
Fallopian Tubes.-The Fallopian tubes are about four or 
five inches long and run in the folds of the broad ligament 
toward the sides of the pelvis. They are also called the 
oviducts because they are the ducts which carry the ova or 
eggs from the ovaries to the uterus. The uterine end of the 
tube is so narrow that it will barely admit a fine probe, but 
the farther end, or fimbriated extremity, is a little wider and 
shaped somewhat like a funnel or trumpet. Like the uterus, 
the tubes are covered by peritoneum and lined with mucous 
membrane, and their walls are composed of smooth muscle. 
The cells of the mucous membrane are furnished with cilia 
which set up a current down toward the uterus and thus 
suck in the ovum when it has been cast out from the ovary, 
and send it toward the uterine cavity. 
Ovaries and Ovulation.-The ovaries lie behind the tubes, 
attached to the broad ligaments, but not between their folds. 
They are about one and a half inches long and almond- 32 
OBSTETRICS 
shaped, and are largely made up of a firm connective tissue 
called stroma, in which are crowded thousands of tiny ova, 
each surrounded by a thin capsule. An ovum is simply a 
single round cell, too small to be seen without a microscope. 
With its capsule it is called a Graafian follicle. Although the 
ova are present at birth, it is not until the age of puberty 
that they are discharged regularly from the ovary, to be 
carried into the uterus by the tubes. This process, ovula- 
tion, occurs every four weeks during the sexual life of a 
woman. 
Before the ovum can break through the surface of the 
ovary, the follicle swells considerably, and after it has been 
discharged, the cavity which it leaves behind is filled in by 
a growth of cells containing a yellow pigment called lutein. 
This gives to the mass of cells a yellow color and also the 
name of corpus luteum (yellow body). The cells continue 
to increase until the corpus luteum at its highest development 
is about one-third the size of the entire ovary; from that 
point it begins to be absorbed and finally disappears. The 
whole process takes something over a month, if the ovum is 
not fertilized; if, however, conception occurs, the corpus 
luteum grows larger, and remains in the ovary throughout 
pregnancy. 
Other Pelvic Organs. - Bladder.-Besides the reproductive 
organs the pelvis contains the bladder with its canal, the 
urethra. As has already been stated, the bladder lies just 
in front of the uterus, and the two organs can thus act upon 
each other by pressure. A full bladder may push the uterus 
backward or even obstruct the passage of the child. The 
heavy pregnant uterus, crowding against the bladder, may 
cause irritation, with frequent voiding of urine, or in more 
extreme'cases may even interfere with the emptying of the 
bladder. OBSTETRICAL ANATOMY AND PHYSIOLOGY 
33 
Rectum.-The rectum lies in the pelvis behind the uterus, 
and is separated from the vagina by a comparatively thin 
septum of muscle and connective tissue, which is sometimes 
torn through in the course of a very difficult labor. The 
pressure of the uterus is likely to cause constipation during 
pregnancy and sometimes hemorrhoids as well. 
Fig. 12.-Breast, showing lobes, lobules and lactiferous ducts. (Cragin.) 
Breasts, or Mammary Glands.-The function of the breasts 
is to secrete the milk which serves as food for the child for 
many months after its birth. The glandular substance of 
the breast is divided by strands of connective tissue into 
fifteen or twenty lobes, which are subdivided into lobules 
and again into still smaller areas called acini. The milk is 
secreted by the cells of the acini. Each lobe has its own duct 34 
OBSTETRICS 
to carry the milk to the nipple, from which the fluid can be 
easily pressed out. True milk is not usually secreted until 
the third day after delivery, but the milk-sugar and other 
substances needed are being stored up in the glands through- 
out pregnancy, and after the second month the breasts 
contain a watery fluid called colostrum. 
Menstruation.-Menstruation is the name given to the 
periodic discharge of blood from the uterus, usually at 
intervals of four weeks, from the time of puberty to the 
menopause. -By a cycle of changes occurring every month, 
the mucous membrane becomes swollen, softened and 
engorged with blood, which finally escapes in the menstrual 
flow. The exact cause of menstruation is still under dis- 
cussion. The process is certainly dependent on the -func- 
tioning of the ovaries, since it ceases when those organs are 
removed by operation. According to the latest investiga- 
tors, the corpus luteum and its secretion play an important 
part in bringing it about. Whatever the cause, the practical 
result of the menstrual changes in the endometrium is to 
provide a place in which the fertilized ovum can be received 
and nourished by the mother's blood. If conception does 
not take place, the ovum does not remain in the uterine 
cavity, and the excess of blood passes out, as already stated. 
If, on the other hand, the ovum is fertilized and becomes 
imbedded in the mucous membrane, this blood is needed 
for its nourishment and is not discharged from the uterus. 
It thus comes about that the cessation of menstruation is 
likely to be the first sign of the beginning of pregnancy. 
The flow does not reappear until after the birth of the 
child and often not until the end of lactation. 
Fertilization of the Ovum.-Although the process of ovula- 
tion occurs at regular intervals, the ovum which is dis- 
charged cannot develop into a living being unless it has OBSTETRICAL ANATOMY AND PHYSIOLOGY 
35 
first been fertilized. The male elements, or spermatozoa, 
after being introduced into the vagina, make their way up 
through the uterus and into the tubes by their own power 
of motion. The meeting of the ovum and spermatozoon 
takes place while the ovum is still in the tube, and fertiliza- 
tion is accomplished by the entrance of the head of the sper- 
matozoon (which represents its nucleus) into the ovum to 
unite with its nucleus. 
I*- Head-» / » 
E * Body ■* 
*Tail •> 
Fig. 13.-Spermatozoa (greatly magnified): A, front view; B, 
profile view. (Bacon.) 
Sometimes the ovum after conception remains in the 
tube, caught in the folds of its mucous membrane, and begins 
to develop there. The resulting pregnancy is called extra- 
uterine or tubal. It is an abnormal and dangerous condi- 
tion, because the tube is far too small to accommodate the 
ovum as it grows larger and develops into a child, and con- 
sequently it finally ruptures or pushes its contents out 
through the fimbriated extremity, with serious or even fatal 
hemorrhage. 36 
OBSTETRICS 
As soon as fertilization is accomplished, the ovum begins 
to grow by dividing into two cells, each of which divides 
again, and this process continues until a mass is formed, 
called the morula or mulberry mass. Probably it is at about 
this stage that it enters the uterine cavity. 
Implantation of the Ovum in the Uterus.-It has already 
been pointed out that the changes in the uterine mucous 
membrane leading up to menstruation serve to prepare 
a place for the impregnated ovum. These changes become 
so marked after conception has occurred that the endo- 
metrium receives another name, the decidua, during preg- 
nancy. The next question is, how does the ovum become 
attached to the uterine wall? This is the work of the cells 
on its outer surface, which are already busily engaged in 
developing a sac to hold the future fetus. These cells have a 
special power to eat into other tissue, and when the morula 
comes in contact with the softened vascular decidua, it bur- 
rows down into it by their action. As the ovum at this 
time is not as large as the head of a small pin, it needs only 
a very minute hollow, and after it has slipped into its place, 
the decidua easily and quickly grows over it, so that it is 
enclosed on all sides. Meanwhile the sac has been formed 
and now consists of two membranes, one within the other; 
the inner one is the amnion and the outer the chorion. 
Amnion.-The amnion, or inner lining of the sac, is a thin, 
smooth, transparent membrane, filled with a pale yellowish, 
watery fluid. The uses of this fluid during pregnancy are 
many. It provides a medium of constant temperature for 
the fetus to live in, protects it from injury in case of any 
blow or shock to the mother, and makes motion easy. It also 
prevents the amnion from adhering to the fetus. Its most 
unexpected function is that of supplying fluid to the tissues 
of the fetus, and possibly even a slight amount of nourish- OBSTETRICAL ANATOMY AND PHYSIOLOGY 
37 
ment as well, since the fetus actually swallows it during 
intra-uterine life. At the time of labor the amniotic fluid 
has other uses which will be discussed later. It finally 
escapes toward the end of labor, when, as the common say- 
ing is, "the waters break" or, in obstetrical language, the 
membranes rupture. The amount of fluid at term is about 
one pint. 
Fig. 14.-Fetus in amniotic sac. 
Chorion.-The chorion, which lies outside the amnion, 
begins as a smooth membrane also, but soon changes its 
character, sending out a quantity of fine, thread-like processes 
called villi, until the ovum in its membranes looks like a 
miniature chestnut burr. Later these villi grow longer and 
branch like very delicate seaweed. They grow into the 
decidua, eroding its tissues and breaking through the walls 
of its capillaries, so that the blood flows out around them. 
They thus accomplish two things, for besides holding the 
fetal mass firmly attached to the uterine wall, they draw 38 
OBSTETRICS 
nourishment from the mother's blood which they can pass 
on to the fetus through a band of tissue which connects the 
embryo and the chorion. 
Placenta, Membranes and Umbilical Cord.-The decidua 
which closes over the ovum is only a narrow layer to start 
Decidua 
Decidua 
Uterine cavity 
Decidua serotina 
combining with 
chorion frondo- 
sum to form 
placenta 
Chorion 
Amniotic cavity 
Decidua 
Decidua 
Decidua 
Internal os 
Cervix 
External os 
Fig. 15.-Uterus at end of second month showing fetus and formation 
of placenta. (Bumm.) 
with, and as the fetus grows and pushes out into the cavity 
of the uterus, it is stretched out into a thin membrane. 
The villi which come in contact with it gradually disappear, 
until the chorion on that side also becomes a thin membrane 
called the smooth chorion and the tw'o finally fuse into one. 
Meanwhile quite different things are going on in the OBSTETRICAL ANATOMY AND PHYSIOLOGY 
39 
decidua serotina, directly beneath the ovum, and the villi on 
that side. The decidua becomes thicker and more abundantly 
Fig. 16.-Mature placenta, seen from the maternal side, showing the 
umbilical cord and the placental lobes or cotyledons. (Cragin.) 
supplied with bloodvessels, and the villi continue to grow down 
into it, branching as they go, until the decidua and chorion 40 
OBSTETRICS 
(called frondosum on account of its branching structure) are 
welded together into a solid-looking mass called the placenta. 
Fig. 17.-Mature placenta, seen from the fetal side. (Cragin.) 
The band of tissue which joined the embryo and the chorion 
has now stretched out into a cord, running from the placenta OBSTETRICAL ANATOMY AND PHYSIOLOGY 
41 
to the umbilicus of the fetus and carrying vessels which 
connect those in the placenta with the child's circulation. 
The placenta at term is a flat, somewhat circular mass, 
dark red in color, about an inch thick and six or seven inches 
in diameter. The outer or maternal side toward the uterine 
wall is divided by deep grooves into irregular-shaped sec- 
tions called cotyledons; the inner or fetal side is smooth and 
shows just beneath its surface large bloodvessels entering 
the umbilical cord, which is usually inserted a little to one 
side of the center of the placenta. 
The cord is about twenty to twenty-five inches long and 
a little less than an inch thick. It is made of a soft, whitish, 
mucoid material called Wharton's jelly, in which the umbilical 
vessels are so imbedded that they are protected from pres- 
sure or injury. The protection of these vessels is of more 
vital importance to the fetus than might at first be realized, 
for while it is easy enough to see that if they were torn, the 
child would bleed to death through them, the serious effect 
of a few minutes' pressure is harder to understand. The 
point is, that since the umbilical vein carries not only nourish- 
ment but oxygen, pressure on it will deprive the fetus of its 
supply of oxygen, and the child will die from asphyxiation 
just as any of us would die if we had no air to breathe. It 
has been found that pressure lasting more than eight minutes 
is usually fatal. 
Development of the Ovum.-Three stages are recognized in 
the development of the ovum in the uterus: 
1. The ovum, a microscopic structure, without definite 
form; the first two weeks. 
2. The embryo, with definite shape but nothing to dis- 
tinguish it from the embryos of other animals; the third to 
the fifth week inclusive. 42 
OBSTETRICS 
3. The fetus, showing signs of human form; from the end 
of the fifth week to the end of pregnancy. 
After the formation of the morula, fluid appears in its 
interior, pushing the cells toward the surface and making a 
cavity at the center. At this stage it is called the blasto- 
dermic vesicle. Next there is a thickening of the cells at 
one point on the surface, and here changes go on rapidly. 
The cells increase in number, change their shape, arrange 
themselves in layers and send off branches and folds to form 
the limbs and the various organs, until with the end of the 
second week the embryo stage is reached. 
During the next three weeks all the organs and systems 
are being laid down. The spinal canal starts as a groove, 
closing in by the end of the fourth week. The digestive 
system appears as two depressions, one at either end of the 
embryo, which later deepen and push inside the body until 
they meet, forming a tube from which develop the com- 
plicated coils of the intestines. A rudimentary heart, with 
four tiny chambers, is ready to begin its functions by the 
fifth week. The primitive kidneys, liver and other organs 
also appear. Externally, the limb buds push out and there 
are even the rudiments of features, although the eyes are 
placed at the sides of the head, giving the face a grotesque 
appearance. The embryo at the end of the fifth week is so 
curved on itself that the head and tail ends are close together. 
It is barely 1 cm. in length. 
During the rest of intra-uterine life the fetus is going 
through the changes which result in the development of the 
child as we see it at birth. At first the head is very large in 
proportion to the body, on account of the rapid growth of 
the brain. The face closes in during the second month. 
Sometimes the closure is not perfect and the child is born 
with the well-known deformity of hare-lip or cleft palate, OBSTETRICAL ANATOMY AND PHYSIOLOGY 
43 
Heart 
Hyoid arch\ 
Mandibular 
Maxillary process 
Eue^ 
L Fore-limb 
Hind-limb 
Fig. 18.-Human embryo (magnified) thirty-one to thirty-four days old. 
(His.) 
Auricula 
Eye - 
Nose 
Fore-limb 
Digits < 
Hind-limb 
Umbilical cord 
Fig. 19.-Human embryo (magnified) of about six weeks. (His.) 44 
OBSTETRICS 
which is caused simply by some arrest in the development 
at this early stage and not by a fright or any so-called 
"maternal impression." During this month a layer of skin 
appears, so thin that the muscles and bloodvessels can be 
plainly seen through it. The intestines are now well-devel- 
oped, but the abdominal wall does not close over them until 
the third month. Cases are sometimes seen in which the 
child when born has a pouch of intestines still protruding 
from the umbilicus. The genitalia are present early, but it 
Fig. 20.-Child with double cleft palate and protrusion of abdominal 
contents. 
is not until the fourth month that the external organs are 
sufficiently developed to indicate clearly the sex of the child. 
In the fifth month the movements of the child become strong 
enough for the mother to feel them and the fetal heart 
sounds can be heard through her abdominal wall by a skilled 
ear. In this month fine downy hairs, the so-called lanugo, 
begin to grow all over the skin. They usually disappear by 
the time the child is born, and their presence therefore sug- 
gests that it is premature. The glands of the skin also SIZE OF FETUS AT DIFFERENT MONTHS 
45 
become active in this month, secreting a whitish, oily sort of 
substance which is often seen smeared over the body of a 
newborn baby, especially on its back and in the creases of 
the skin. This is called vernix caseosa. Fat is one of the 
last tissues to appear, and the fat layer grows so slowly that 
even at the seventh or eighth month the fetus is so thin and 
its skin so wrinkled that it looks strangely old. 
SIZE OF THE FETUS AT THE DIFFERENT MONTHS. 
Many elaborate tables have been calculated, showing the 
average length of the fetus at each month, but for practical 
purposes that of Haase, which is simple and easy to remem- 
ber, is more satisfactory. According to this, during the 
first five months the length of the fetus in centimeters equals 
the square of the number of the month. 
1 month (1x1) 1 cm. 
2 months (2x2) . 4 " 
3 " (3x3) 9 " 
4 " (4x4) 16 " 
5 " (5x5) 25 " 
To find the length during the last five months, multiply 
the number of the month by five. 
6 months (6x5) 30 cm. 
7 " (7x5) 35 " 
8 " (8x5) 40 " 
9 " (9x5) . . . • 45 " 
10 " (10x5) 50 " 
The weight varies so much that it is not a reliable guide. 
The following table is only approximate. 
4 months s 3 to 4 oz. 
5 " 9 to 10 " 
6 1| lbs. 
7 2| " 
8 3J " 
9 " 4| to 5| " 
10 " 7 to 7| " 46 
OBSTETRICS 
The Fetus at Full Term. -The general appearance of a new- 
born baby is too familiar to need much description, but a 
few points in its anatomy are worth mentioning. The child 
is not simply a grown person in miniature. Its body is 
long, its limbs relatively short and its head disproportion- 
ately large; indeed, the circumference of the head is actually 
greater than that of the chest. 
Internally we find as a characteristic fetal structure the 
thymus gland, which disappears in later life, but is sometimes 
so large in the infant that it causes death from pressure on 
the throat. The digestive system has already been func- 
tioning during intra-uterine life and the intestines are filled 
with waste matter, the meconium, a greenish-black, sticky 
material, which is sometimes passed during labor if there 
is much pressure on the fetus. The stomach is smaller than 
might be supposed, and at birth it cannot comfortably hold 
more than an ounce-a practical point to remember in feed- 
ing a young baby-but the liver is large. The rectum is 
relatively large and straight, a fact which makes an enema 
or a colon lavage a rather easy procedure. The kidneys 
are secreting urine, which may or may not have reached the 
bladder by the time the child is born. 
Since the fetus does not breathe in the uterus, the lungs 
are solid and contain no air until the child expands them 
after its birth. There is thus no reason for the blood to pass 
through the lungs to be aerated, especially as it has already 
received the necessary oxygen from the placenta. It is 
accordingly sent directly from one side of the heart to the 
other through the foramen ovale, a hole between the auricles, 
and from the pulmonary artery to the aorta through a special 
communicating vessel, the ductus arteriosus. These struc- 
tures are characteristic of the fetal circulation and normally 
close in early infancy. If they remain open, serious heart SIZE OF FETUS AT DIFFERENT MONTHS 
47 
trouble results. The child's circulation is so interfered with 
that its face becomes a dusky, bluish color on the slightest 
exertion, and early death is the usual end. This is what is 
commonly meant when a child is said to be a blue baby 
or to have congenital heart disease. 
The Head of the Fetus.-In the process of labor the head 
is the most important part of the fetus, and it is mention- 
ed so often in all the descriptions that one might suppose 
it to be the only part concerned. This is because in the 
great majority of cases (about 96 per cent) the child lies 
with its head down, so that the head enters the pelvis first 
and is born first. As the head is also the largest part of the 
fetus, the management of labor almost resolves itself into a 
matter of the management of the birth of the head. 
The bones of the fetal skull are not welded together, as in 
the adult, but are loose and movable. Between them are 
the sutures, narrow spaces covered only by membrane and 
scalp. The wider spaces formed by the meeting of the 
sutures are the fontanelles. The main part of the skull is 
made up of four bones: the two parietal bones, coming from 
either side to meet in the median line at the sagittal suture; 
the occipital bone, at the back, separated from them by the 
lambdoid suture; and anteriorly the frontal bone, which 
forms the forehead. The other bones of the cranium are of 
less importance from the obstetrical point of view. The 
frontal bone is divided into two parts by the frontal suture 
and is separated from the parietal bones by a transverse 
suture, the coronal. The fontanelle at the junction of these 
sutures with the sagittal suture is four-sided and diamond- 
shaped; it is called the anterior or large fontanelle. A 
smaller triangular space formed by the meeting of the 
sagittal and lambdoid sutures is known as the posterior or 
small fontanelle. In obstetrical terminology the part of the 48 
OBSTETRICS 
Fig. 21.-The posterior fontanelle. (Cragin.) 
Fig. 22.-The anterior fontanelle. (Cragin.) PHYSIOLOGY OF THE FETUS 
49 
head which lies in front of the large fontanelle is the sinciput; 
the part directly over the fontanelle is the bregma; that 
between the two fontanelles is the vertex; and that over the 
occipital bone is the occiput. 
The sagittal suture and one or both of the fontanelles can 
usually be felt if the cervix is at all dilated when an internal 
examination is made, and they thus serve as useful land- 
marks to the obstetrician in the diagnosis of the position of 
the head. The loose structure of the head and the softness 
of the bones also serve a good purpose in making the head 
so easily compressible that it can change its shape according 
to the pressure of the birth canal. If pregnancy continues 
beyond the allotted ten months, not only does the head 
grow larger but the bones become harder and less movable, 
so that labor is more difficult. 
The head of the fetus moves with great freedom. Extremes 
of flexion and extension are easy for it and in rotating, it can 
turn so far that the face looks obliquely over the shoulder. 
In this way it can still further accommodate itself to the birth 
canal. The measurements of the head show that it is longer 
antero-posteriorly than transversely, and that its smallest 
circumference is presented in the position of extreme flexion. 
PHYSIOLOGY OF THE FETUS. 
There is no doubt that the fetus is very favorably sit- 
uated in intra-uterine life, for it obtains everything with- 
out any effort. It does not need to use its lungs or digestive 
system, because oxygen and nutritious substances are 
brought from the placenta after they have been absorbed 
from the mother's blood. The impurities which the blood 
collects while circulating through the child's body are carried 
out to the placenta and pass through the villi to be absorbed 50 
OBSTETRICS 
back into the mother's blood. Thus the mother not only 
supplies nourishment for the child but also disposes of its 
waste products, and the placenta may in a way be considered 
as a filter between the blood systems of the two, or even, as 
it is sometimes called, as the lungs and digestive tract of 
the fetus. Thanks to the amniotic fluid, the child loses no 
bodily heat, and motion is made so easy that it wastes but 
little energy. It has been well said that the balance sheet 
of the fetus shows large receipts and small expenditures. 
We have already seen how the amniotic fluid protects the 
fetus from injury. The placenta, too, has its part to play in 
protecting it as far as possible from any disease which the 
mother may have. Since it keeps the mother's blood from 
mingling with that of-the child, it is able for the most part 
to prevent any bacteria in her system from entering the fetal 
circulation. In this it succeeds better than was once sup- 
posed. The widespread idea that tuberculosis was almost 
sure to be inherited received a rude blow when the bacteri- 
ologists took hold of the problem, for they soon proved that 
it was rare to find tubercle bacilli or tuberculous lesions in 
either the child or the placenta. Typhoid bacilli seem better 
able to make their way through to the fetus, but other 
bacterial diseases are seldom communicated. Smallpox is 
transmissible, but occurs so rarely now that it can be omitted 
as a danger. 
The one striking exception to the rule against the trans- 
mission of disease from the mother is in the case of 
syphilis. This disease not only infects the fetus but also 
deprives it of its proper blood supply by obliterating the 
bloodvessels in the placenta, and the result is often the death 
of the fetus while it is still in the uterus, even before full 
term. Fortunately the drugs which are used in the treat- 
ment of syphilis, if given to the mother, are absorbed through PHYSIOLOGY OF THE FETUS 
51 
the placenta into the child's system, so that the disease can 
frequently be prevented or cured if the treatment is started 
early enough. In this connection it is as well to mention 
that many drugs are thus passed on through the placenta 
to the fetus, and that their possible effect must always be 
considered. This is a particularly practical point to bear in 
mind when an anesthetic is being given to the mother, as 
prolonged anesthesia may result in asphyxia of the fetus. CHAPTER II. 
PHYSIOLOGY OF PREGNANCY. 
DURATION OF PREGNANCY. 
The duration of pregnancy is probably about two hundred 
and seventy to two hundred and seventy-three days. It 
cannot be calculated exactly even in the cases where we know 
the date of the sexual intercourse which preceded it, becausfe 
we have no way of telling how long a time elapsed before the 
ovum was fertilized. According to obstetrical custom it is 
considered as two hundred and eighty days or ten lunar 
months from the last menstrual period. The obstetrical month 
always means the lunar month of four weeks. In order to 
find the expected date of confinement, which is usually the 
first thing that a patient wishes to know, we calculate as 
best we may on this basis, and by counting ahead two 
hundred and eighty days (nine calendar months and one 
week) from the last menstruation we arrive at a date which is 
not absolutely correct but is near enough to go by. Accord- 
ing to this reckoning, if the last period began February 10, 
the expected date of the confinement would be November 
17. The quickest method of calculating is first to add the 
week (making February 17) and then count back three 
months instead of counting ahead nine. 
The end of the allotted ten months is called full term or 
simply term; labor which comes on at or about this time is 
called full-term labor and the child is a mature or full-term 
child. When the birth takes place much before term, labor 53 
CHANGES DURING PREGNANCY 
and child are premature. If the child has reached such a 
stage of development that it can live outside the uterus, it 
is said to be viable. In the average case this point is not 
reached until the end of the seventh obstetrical month or 
the twenty-eighth week, and it is therefore the rule to con- 
sider the fetus not viable if it is born before this time, 
even though there have been occasional exceptions. An 
interruption of pregnancy earlier than seven months is a 
miscarriage, or an abortion if we are using obstetrical lan- 
guage. Since this term has come to have the meaning of 
criminal abortion associated with it in every-day speech, we 
do not use it in speaking to patients, but call all cases mis- 
carriages. The birth of a dead child is a still-birth. If the 
still-born child has been dead in the uterus long enough 
for decomposition of its tissues to have begun, it is called a 
macerated fetus. 
CHANGES DURING PREGNANCY. 
Conception gives rise to a series of changes in the woman's 
body which are not localized in the uterus or even in the 
pelvic organs but affect her entire system. Some of these 
changes are important from the point of view of diagnosis 
of pregnancy; others produce symptoms which may need 
special treatment. 
Changes in the Uterus.-Size.-The change most easily 
noticed is the steady growth of the uterus, making it possible 
for an organ but three inches long to hold the child, placenta 
and amniotic fluid. This is accomplished by: 
1. An increase in the size of each muscle fiber to about 
ten times its normal size. 
2. A slight increase in the number of fibers. 54 
PHYSIOLOGY OF PREGNANCY 
3. Stretching of the uterine wall, in the last months, when 
it can no longer keep pace with the growth of the fetus. 
For the first three months the uterus is still in the pelvis 
and cannot be felt from outside, but after that time the 
fundus rises above the pelvic brim and can be easily pal- 
9 months 
10 months 
8 months 
7 months 
6 months 
5 months 
4 months 
Fig. 23.-Height of the fundus at the different months of pregnancy. 
(Bumm.) 
pated through the abdominal wall. The height of the fun- 
dus gives us a fairly satisfactory method of estimating the 
duration of pregnancy. At the different months it is as 
follows: 
Four months. Two or three fingers' breadth above the 
symphysis. CHANGES DURING PREGNANCY 
55 
Five months. Half way between the symphysis and the 
umbilicus. 
Six months. At the level of the umbilicus. 
Seven months. Three fingers' breadth above the umbili- 
cus. 
Eight months. Six fingers above the umbilicus. 
Nine months. Nine fingers above the umbilicus, or just 
below the ensiform cartilage at the tip of the sternum. 
Ten months, or at term. During the last month the 
fundus sinks almost to the level of the eighth month. 
Roughly speaking, therefore, we may say that the fundus 
rises at the rate of about three fingers' breadth a month. 
These figures apply to primiparse, that is, women who have 
not born children and whose abdominal walls, are therefore 
strong enough to hold the uterus up in normal position. In 
multiparse, especially those whose muscles have become 
stretched and lax, the fundus is likely to tip forward and be 
felt at a lower level. The sinking of the fundus in the last 
month is caused by a settling of the child's head into the 
pelvis, called engagement. In multiparee this often does not 
occur until the beginning of labor. 
Shape.-The uterus in the early months of pregnancy 
becomes more spherical and later on more oval. The shape, 
like the size, depends upon its contents, and varies with the 
position of the child and placenta and the amount of amniotic 
fluid. 
Position.-As the uterus grows larger and heavier, it pulls 
on its ligaments, and tips farther forward in the pelvis. In 
the first three months this change in its position can be made 
out only by an internal examination, but the result is plain 
enough. As the uterus crowds forward against the bladder, 
the pressure causes a desire to void the urine and so relieve 
the irritation by keeping the bladder empty. Frequent 56 
PHYSIOLOGY OF PREGNANCY 
micturition is therefore an early symptom of pregnancy, 
disappearing in the fourth month as the uterus rises out 
of the pelvis. After this time the uterus is held up by the 
abdominal wall, but if the muscles are not strong enough, 
the fundus may sag far forward. 
Consistency and Blood Supply.-The uterus needs a par- 
ticularly abundant blood supply during pregnancy for two 
reasons: (1) Because it has grown so much larger that 
its blood supply must increase accordingly; and (2) because 
more blood is needed for the fetus. It is no surprise then to 
learn that its bloodvessels increase in size. The change is 
most marked in the veins, the largest of which become almost 
the size of the little finger. Remembering this, it is easy 
to understand how even a comparatively slight injury to 
the uterine wall may mean a profuse hemorrhage. 
The tissues of the uterus being thus engorged with blood, 
it becomes softer in consistency, especially in the cervix. 
The congestion also shows itself in the purplish color of the 
cervix, which can be seen by using a speculum. 
Cessation of Menstruation.-It is an almost universal rule 
that menstruation ceases during pregnancy. A woman who 
misses a period after intercourse has good reason to believe 
that conception has occurred. 
Changes in Other Pelvic Organs.-The other pelvic organs, 
like the uterus, have an increased blood-supply, and the 
vagina and vulva show the same bluish-purple discoloration 
as the cervix. Even the pelvic joints receive their share, 
and allow a little more motion of the bones, on account of 
the softening of their tissues. The curdy secretion of the 
vagina is increased. The corpus luteum of pregnancy 
occupies a large part of the ovary and there is usually no 
ovulation. CHANGES DURING PREGNANCY 
57 
Breasts.-In the first weeks of pregnancy the woman 
notices a sense of fulness and tingling and perhaps tender- 
ness in the breasts, which is followed by an increase in their 
size. The areola about the nipple changes color, becoming 
pinker in blonde women and dark brown in brunettes. 
Sometimes the color spreads in a circle outside the areola, 
forming a secondary areola. The so-called Montgomery's 
Fig. 24.-Primary areola in a brunette, showing tubercles of Montgomery. 
(Cragin.) 
glands appear as small elevations around the nipples and the 
nipples themselves grow more prominent. By the third 
month a watery fluid, the colostrum, can be pressed from 
the nipples. Sometimes the skin is marked with striae, 
lines like pink scars, which radiate out from the nipple. 
Skin.-The skin of the abdominal wall is more likely to 
show the presence of striae than are the breasts, and the 58 
PHYSIOLOGY OF PREGNANCY 
scar-like stripes are longer and wider and deeper in color 
when they first appear. Occasionally one of them will even 
suggest an operation scar. The color gradually fades and 
old striae from a previous pregnancy are silvery in appearance. 
Fig. 25.-Pigmentation along median line of abdomen; also abdominal 
striae. (Cragin.) 
There is often a line of brown pigmentation running down 
the midline of the abdomen, especially in dark-skinned 
women. Brownish patches of pigment called chloasma may 
also appear on other parts of the body. When on the face 
they are rather disfiguring, but fortunately they tend to 
fade after pregnancy is over. 
Circulatory System.-As the heart has so much more work 
to do during pregnancy, some observers have stated that it CHANGES DURING PREGNANCY 
59 
grows temporarily larger. On account of the pressure of 
the uterus upon the large veins which come from the lower 
part of the body, the circulation is somewhat interfered with, 
and it is not at all uncommon for a woman to be troubled 
with swelling of her feet at the end of the day or after stand- 
ing a long time. This swelling must not be confused with 
that due to kidney disease. Varicose veins also result from 
the interference with the circulation. 
Respiratory System.-Like many of the other organs the 
lungs feel the pressure of the growing uterus, consequently 
the breathing may be embarrassed in the last months. 
This is, of course, particularly the case when the uterus is 
more than normally distended, as by an unusually large fetus, 
twins or an excess of amniotic fluid. LTnder such circum- 
stances the sinking of the fundus in the tenth month is often 
a great relief, and perhaps for that reason is commonly 
called "lightening." A change in the voice occasionally 
results from pregnancy and is therefore dreaded by singers. 
Digestive System.-The stomach is one of the first organs 
outside the pelvis to be affected by pregnancy and to make 
its sensations felt. Often by the end of the first month, 
rarely even within the first week, the patient is troubled by 
nausea, with or without vomiting, which comes on the first 
thing in the morning when she gets up, but usually passes 
off in the course of the day. This troublesome symptom is 
familiarly known as "morning sickness." ITsually it stops 
by the end of the third month, but it may grow worse, pass- 
ing into the serious form of pernicious vomiting. Many 
women are so fortunate as to escape it altogether. By a 
wholly unexplained freak of nature, in rare cases it is the 
husband who suffers from the morning sickness. 
As the uterus rises in the abdomen, the intestines are 
pushed upward and to the sides, and on account of the long- 60 
PHYSIOLOGY OF PREGNANCY 
continued pressure their muscular walls lose their tone. 
This, added to the interference with defecation which results 
from the pressure of the uterus on the rectum, makes con- 
stipation so common a symptom among pregnant women 
that it may fairly be included in the list of the normal changes. 
General Metabolism and Urinary System.-Since the mother 
must provide suitable nourishment for the child and elimi- 
nate its waste products as well as her own, her bodily pro- 
cesses must be even more than normally active. Various 
interesting studies have been made to show how she stores 
up in her tissues the materials which are needed for the 
growth of the fetus, even preparing a supply of milk sugar 
to be used in her milk after the child is born. Because of 
the increased work which is thus going on in all parts of her 
system, her metabolism is more easily disturbed during 
pregnancy. 
Kidneys.-The kidneys, which have so much to do with 
the elimination of waste products, are particularly likely to 
be affected by the strain, and the resulting condition is 
recognized under the term "kidney of pregnancy." While 
this is not necessarily serious in itself, it is often only a part 
of a general disturbance which may develop into grave tox- 
emia, ending in convulsions (the condition called eclampsia), 
if not treated in time. For this reason the examination of 
the urine at frequent intervals during pregnancy has come 
to be a routine procedure, and the findings have often served 
as a danger signal, so that further trouble has been averted 
by proper treatment. 
The frequent voiding of the urine which is caused by the 
irritation from the pressure on the bladder in the early 
months of pregnancy has already been mentioned. This 
symptom may recur in the last month when the head settles 
into the pelvis and presses against the bladder. 61 
DIAGNOSIS OF PREGNANCY 
Blood-pressure.-There is no characteristic change in the 
blood-pressure during pregnancy, but in the presence of 
even a beginning toxemia it begins to rise. By taking the 
blood-pressure at regular intervals the physician may be 
warned at the onset of this trouble. 
Bones and Teeth.-It is generally accepted that the mother 
builds up the child's bony framework at the expense of the 
calcium in her bones and teeth. While the bones are almost 
never affected to any marked degree, the teeth often decay. 
Nervous System.-Much mention has been made of a 
certain nervous irritability and depression of pregnancy as 
showing an upset nervous equilibrium. Such feelings are 
in great part only the rather natural result of the discomfort 
extending over many months and the apprehensions aroused 
by the lurid obstetrical tales of friends and family. One 
curious mental twist must, however, be considered char- 
acteristic of pregnancy-the craving for strange and often 
most undesirable articles of food, as for example, chalk or 
laundry starch. 
DIAGNOSIS OF PREGNANCY. 
There are many abdominal enlargements that have been 
confused with pregnancy, sometimes with disastrous results 
to the patient. Moreover it must be remembered that the 
matter of diagnosis may concern not only the woman's 
physical welfare but also her character and reputation. An 
absolutely sure diagnosis cannot be made without demon- 
strating the presence of the fetus by one of the following 
positive signs. 
1. Feeling the fetal movements. 
2. Outlining the fetal parts. 
3. Hearing the fetal heart. 62 
PHYSIOLOGY OF PREGNANCY 
Fetal Movements.-In an internal examination the obstet- 
rician can sometimes bring out what are called the passive 
movements of the fetus, by pushing it about, as it floats in 
the amniotic fluid. The active movements are a more reli- 
able sign, however. It has already been stated that by the 
fifth month of pregnancy the mother is usually able to feel 
the fetus, and to this sensation the name "quickening" has 
been given. It is nevertheless quite possible for her to be 
mistaken, and the sign is therefore considered as positive 
only when the examiner recognizes the movements. In the 
latter part of pregnancy, especially if the abdominal wall is 
thin, movements can be easily seen through it or felt by 
putting a hand on the abdomen. Earlier, and in cases where 
the movements are only slight, it is possible to perceive them 
by listening through the abdominal wall, when a sudden 
light tap or fluttering can often be made out. 
Outlining the Fetal Parts.-The methods of mapping out 
the fetus will be taken up in describing the examination of 
the pregnant woman. It is enough to say now that it is 
quite possible not only to obtain proof of the presence of the 
fetus but also to discover its exact position in the uterus. 
Fetal Heart.-Auscultation of the fetal heart through the 
abdomen of the mother is now practised so universally that 
it is hard to realize that it was only a century ago that 
the sounds were first heard by Mayor, of Geneva, in 1818. 
The child's heart-rate usually runs from 120 to 160, and 
is therefore likely to be so much faster than the mother's 
that there is no trouble in distinguishing between the fetal 
heart and the pulsation of the large vessels in the mother's 
abdomen. Moreover, the fetal heart has a double beat like 
the ticking of a watch. The heart can be heard any time 
after the end of the fifth month, and even earlier by a skilled 
ear. Some obstetricians claim that the sex of the child can POSITION OF THE FETUS IN THE UTERUS 
63 
be determined by the rate of the heart beat, which should 
be more rapid in a girl, but no reliance can be placed on this 
sign. Indeed, it is quite futile to prophesy as to the sex, 
since no method has yet been discovered by which it can be 
ascertained. 
Although these positive signs may be required to establish 
the diagnosis of pregnancy in a doubtful or medico-legal 
case, the physician is usually called upon to make a diagnosis 
in the early months, before they are available. This he is 
able to do in the average case, by observing the various 
signs and symptoms which have already been described 
among the changes occurring in pregnancy. Most import- 
ant, from the point of view of diagnosis, are the changes 
noted in the uterus, which can be made out only by a vaginal 
examination; but the changes in the breasts, the morning 
sickness, cessation of menstruation, bladder symptoms, 
quickening and pigmentation, all aid in completing the 
clinical picture. If a sufficient number of these signs and 
symptoms are present, the diagnosis can be made with a 
fair degree of certainty. 
Various tests have been devised, using the mother's blood 
serum, to prove that pregnancy exists, but they are com- 
plicated and not always to be relied upon, and for the present 
they are not practical aids to diagnosis. The best known 
among them is that of Abderhalden. The or-ray has also 
been called in to do its part, but the pictures are not satis- 
factory in the early months. 
POSITION OF THE FETUS IN THE UTERUS. 
It was once thought that the position of the child in the 
uterus was merely a matter of chance, and the old books 
show pictures of all sorts of fantastic poses. The fact of 64 
PHYSIOLOGY OF PREGNANCY 
Fig. 26.-Vertex. Hight occipito-anterior position. (Jewett.) 
Fig. 27.-Vertex. Left occipito-posterior position. (Jewett.) POSITION OF THE FETUS IN THE UTERUS 
65 
Fig. 28.-Vertex. Left occipito-anterior position. (Jewett.) 
Fig. 29.-Vertex. Right occipito-posterior position. (Jewett.) 
5 66 
PHYSIOLOGY OF PREGNANCY 
Fig. 30.-Face. Left mento-anterior position. (Jewett.) 
Fig. 31.-Face. Right mento-anterior position. (Jewett.) POSITION OF THE FETUS IN THE UTERUS 
67 
Fig. 32.-Face. Right mento-posterior position. (Jewett.) 
Fig. 33.-Face. Left mentoposterior position. (Jewett.) 68 
PHYSIOLOGY OF PREGNANCY 
Fig. 34.-Breech. Right sacro-anterior position. (Jewett.) 
Fig. 35.-Breech. Left sacro-anterior position. (Jewett.) POSITION OF THE FETUS IN THE UTERUS 
69 
Fig. 36.-Breech. Right sacro-posterior position. (Jewett;) 
Fig. 37.-Breech. Left sacro-posterior position. (Jewett.) 70 
PHYSIOLOGY OF PREGNANCY 
the matter is that the fetus adapts itself to the shape of the 
uterine cavity, and the position which it assumes depends 
Fig. 38.-Shoulder. Right scapulo-anterior position. (Jewett.) 
Fig. 39.-Shoulder. Left scapulo-anterior position. (Jewett.) POSITION OF THE FETUS IN THE UTERUS 
71 
largely on that. Since the uterus, after the first months of 
pregnancy, becomes distinctly oval in shape, we should 
expect to find that the fetus is trying to make an oval mass 
Fig. 40.-Shoulder. Right scapulo-posterior position. (Jewett.) 
Fig. 41.-Shoulder. Left scapulo-posterior position. (Jewett.) 72 
PHYSIOLOGY OF PREGNANCY 
of itself, and that is what actually happens. In doing 
this it takes a position which has been described as one of 
universal flexion. The thighs are flexed on the abdomen, 
and the knees on the thighs; the arms are crossed on the 
chest and the head is bowed over them. The result is what 
the text-books call the "fetal ovoid," which fits very neatly 
into the cavity of the uterus. The less amniotic fluid there 
is in the sac, the closer the uterine walls press against the 
fetus and the more ovoid becomes the fetal mass; on the 
other hand, if the fluid is plentiful, the fetus has more free- 
dom of movement, and its legs and arms are not held so close 
to the body. 
As the child's head is less bulky than the buttocks and 
thighs, and as the lower part of the uterus is a little less 
roomy than the fundus, it naturally follows that the fetus, 
in the majority of cases, lies with its head down, as if it were 
standing on its head. The head will thus be the part of the 
child which enters the pelvis first, or in obstetrical language, 
it is the presenting part. The flexion of the head on the 
chest makes the occiput or vertex the lowest part, and con- 
sequently the first to enter the pelvis, and it is therefore cus- 
tomary to call these cases vertex presentations; when, on 
the other hand, as sometimes happens, the head is above 
and the buttocks or breech below, the presentation is called 
a breech. Vertex presentations occur in about 96 per cent 
of all cases and breech in only about 3 per cent. Rarely 
the head enters the pelvis without becoming well flexed, so 
that the brow or face is born first, and these cases are, of 
course, called brow or face presentation. 
In order to describe more definitely how the child lies, 
we also note how it is turned toward the mother's right or 
left side, her anterior abdominal wall or her back. It is the 
presenting part which determines the given position. For POSITION OF THE FETUS IN THE UTERUS 
73 
example, if the occiput is turned anteriorly and to the 
mother's left side, the position is more quickly described 
by using the obstetrical name, left occipito-anterior, or as 
it is commonly abbreviated, L. O. A. The other positions 
of the occiput will, -of course, be right occipito-anterior, 
left occipito-posterior and right occipito-posterior (R. O. A., 
L. O. P. and R. 0. P.). When the breech presents, the 
positions are named according to the position of the sacrum, 
left sacro-anterior, etc., abbreviated L. S. A., etc. In face 
presentations the chin is the determining point and we have 
right mento-anterior, etc. The left anterior positions are 
the most frequent and also the most favorable; with the left 
occipito-anterior heading the list. 
In all these presentations the fetus is fitting its ovoid to 
the oval uterine cavity, and the two have their longest 
diameters parallel. In about 1 out of every 200 cases, how- 
ever, the fetus lies in a transverse presentation, that is, 
horizontally, with its long diameter across the abdomen. 
This is particularly likely to happen when the uterus is 
stretched out of its natural shape, perhaps because the woman 
has born many children, perhaps because there is more 
than the usual amount of amniotic fluid, so that the fetus 
floats into a horizontal position. The child is often so 
movable that we can hardly describe any portion of its 
anatomy as the presenting part, until labor begins, when the 
shoulder is gradually pushed down into the pelvis, making 
a shoulder presentation. It needs little imagination to see 
that when the child is lying transversely, it cannot pass 
through the pelvis until the position has been changed in 
some way by the obstetrician, and that this so-called " cross- 
birth" always means an operative delivery. CHAPTER III. 
PHYSIOLOGY OF LABOR AND THE PUERPERIUM. 
STAGES OF LABOR. 
Since the object of the process of labor is to expel the 
contents of the uterus, it stands to reason that the first step 
will be to open the cervix wide enough to let the child pass 
through. It might be supposed that the entire contents- 
fetus, placenta, membranes and fluid-wrould come away 
together in one mass, and this is actually the case in some 
abortions, but in full-term labors the child is born first, 
through a rent in the membranes by which the fluid has 
escaped, and the placenta and membranes follow shortly 
afterward. Labor is thus divided into three stages: 
First stage: Dilatation of the cervix. 
Second stage: Expulsion of the child. 
Third stage: Delivery of the placenta. 
These stages may overlap a little, but for practical pur- 
poses they may be described separately. 
Onset of Labor.-During the last two weeks of pregnancy 
the woman often has vague, irregular, premonitory pains, 
which may be severe enough to be misleading, and occasion- 
ally the doctor is called on account of these pains or others 
w'hich prove to be only the result of some digestive dis- 
turbance. The onset of true labor is characterized by the 
regularity of the pains and the contractions of the uterus 
which accompany them. If the abdomen is palpated, the 
uterus can be felt to grow hard beneath the hand and also STAGES OF LABOR 
75 
to press forward a little with each pain. Another sign of 
the beginning of labor, familiarly known as the '"show," is a 
discharge of blood-stained mucus from the cervix. 
First Stage.-The first pains come at long intervals, per- 
haps half an hour apart, but the intervals soon become 
shorter, and when the first stage is well under way, the pains 
are coming every three to five minutes. It is usually stated 
that the first pains are felt in the back, and that they gradu- 
ally radiate around to the abdomen, running along the 
sides and down the thighs, but there is no real rule in this 
matter, and the pains are often felt in the back throughout 
the first stage, while at other times they are only in the 
abdomen. 
As the uterus contracts, its walls press against the sac of 
amniotic fluid (the bag of waters, as it is often called), 
which becomes tense, bulging into the cervical canal with 
each pain and helping to stretch it open. The contractions 
also push the presenting part down against the internal os, 
and this reinforces the pressure of the fluid. Since all this 
pressure is from above, the upper part of the cervix is natur- 
ally the first to be dilated, and in a primipara the external 
os dilates hardly at all until the canal has been stretched 
open from above-obliterated, as we say. In a multip- 
ara the obliteration of the canal and the dilatation of the 
external os go on more or less together. The process con- 
tinues until the cervix is completely dilated and rolls back 
from the presenting part, so that the fetus can be pushed out 
of the uterus. At this point the membranes usually rupture 
and the fluid escapes, for the bag of waters has done its 
work in aiding the dilatation and is only in the way during 
the descent of the child through the vagina. If the mem- 
branes rupture early in labor, or, as sometimes happens, 
even before the pains have started, the labor is much pro- 76 
PHYSIOLOGY OF LABOR AND PUERPERIUM 
longed, because the head alone does not dilate the parts as 
well as when combined with the fluid. This is called dry- 
labor. 
Fig. 42.-Sagittal section through the pelvis and uterus near the end of the 
first stage of labor, showing the posture of the child and also the bag of 
water intact (A). (Bumm.) 
The duration of the first stage varies within rather wide 
limits. It is naturally much longer for a primipara, whose 
cervix is being stretched for the first time, than for a mul- 
tipara in whom the parts have already been stretched by 
child-bearing. Dry labor also prolongs the process. Dila- 
tation will proceed more slowly when the presenting part STAGES OF LABOR 
77 
is not far enough down to add to the pressure against the 
internal os. The length of the first stage averages from six 
to eight hours in a multipara and from twelve to fifteen in a 
primipara. 
Second Stage.-With the second stage of labor come the 
bearing-down pains, in which strong voluntary efforts of 
Fig. 43.-Beginning of the exit of the head. The perineum is distended 
and the head visible. (Bumm.) 
the abdominal muscles are added to the involuntary uterine 
contractions to bring about the birth of the child. If the 
membranes have not already ruptured at the end of the first 
stage, when dilatation was complete, the physician ruptures 
the sac, as the expulsion of the child is quicker after the 
fluid has drained off. The presenting part is driven down 78 
PHYSIOLOGY OF LABOR AND PUERPERIUM 
into the vagina with each pain, receding a little after the 
pain is over, so that the vagina and vulva are gradually 
stretched to allow the passage of the child. Just as the 
cervix was dilated until its edge was thinned and there was 
space enough for the head to pass through, so the vagina 
is spread open and the perineum is thinned by the pressure. 
Fig. 44.-The head is about to pass through the vulvar ring in the sub- 
occipito-frontal circumference. (Bumm.) 
Presently the scalp of the child can be seen through the 
vaginal opening at the height of a pain, and little by little 
the head pushes through, followed by the shoulders and 
the rest of the body. The pains meanwhile grow more and 
more severe, often with shorter intervals between them, until 
they are almost unbearable during the birth of the child 
through the vaginal outlet. STAGES OF LABOR 
79 
The second stage of labor, like the first, varies greatly in 
length. It averages almost two hours in a primipara, while 
in a multipara with a roomy, lax vagina, three or four strong 
pains may suffice to complete the birth. 
Mechanism of Labor.-The expulsion of the child in the 
second stage of labor amounts to something more than simply 
pushing it straight down the vagina in whatever position 
it happens to be lying. In almost every case the fetus 
turns in different ways to accommodate itself to the shape 
of the birth canal. These movements constitute what is 
known as the mechanism of labor. 
In describing the mechanism of labor the left occipito- 
anterior position, being by far the most frequent, can be 
taken as the type of normal labor. In these cases the head 
engages in the superior strait with the occiput to the left and 
anterior and the brow to the right and posterior, and the 
sagittal suture thus lies in the right oblique diameter of the 
pelvis. It remains in this position while the fetus is descend- 
ing through the birth canal, but just before it has reached 
the pelvic outlet the occiput begins to turn anteriorly until 
it is directly under the symphysis and the face in the hollow 
of the sacrum, making the suture lie antero-posteriorly. 
This movement is called internal rotation because the rota- 
tion occurs within the birth canal. If the head is not well 
flexed when it enters the pelvis, the flexion gradually 
increases with its descent until its smallest circumference 
(the suboccipito-bregmatic) is passing down the vagina. 
The head thus reaches the pelvic floor well flexed and 
ready to be expelled. On account of the upward turn of 
the vagina the head, if driven horizontally, would tear its 
way through the perineum into the rectum in its effort to 
emerge. This is avoided by a movement of extension which 
sends the occiput upward through the vaginal opening, and 
the head is therefore said to be born by extension. 80 
PHYSIOLOGY OF LABOR AND PUERPERIUM 
During all this time the shoulders are still lying obliquely 
in the pelvis, for it is only the head that has been concerned 
in the movements which have just been described. It is 
now their turn to rotate so that one of them comes under 
the symphysis and the other into the hollow of the sacrum. 
The head helps them by turning itself until the occiput points 
directly to the left side and the face to the right. This move- 
ment is external rotation, because the head is now outside 
the canal. The shoulders are thus given a start, and while 
the anterior remains wedged at the symphysis, the posterior 
slips down along the curve of the sacrum until it is born. 
The anterior shoulder then comes out and the rest of the 
body follows. 
The different steps of the mechanism of labor are thus 
seen to be: 
1. Descent. 
2. Flexion. 
3. Internal rotation. 
4. Extension. 
5. External rotation. 
Engagement may be added aS a preliminary step, since 
it may form a part of the process of labor, although it has 
often occurred before labor began. 
Moulding of the Head.-In the average case the child's head 
cannot make its way through the birth canal without receiv- 
ing more or less pressure from the bony pelvis and the mus- 
cular walls of the vagina. Since the bones of the skull have 
not yet grown together at all and are still soft enough to be 
easily compressed, they respond to the pressure by slipping 
over one another in whatever way will make the head best 
fit the space through which it must travel. This process is 
called the moulding or configuration of the head. 
Usually it is enough if one parietal bone overrides the other STAGES OF LABOR 
81 
at the sagittal suture, narrowing the head from side to side, 
but if there is much disproportion between the head and the 
pelvis, the head can be made still smaller by the pushing of 
the frontal and occipital bones under the parietals. The 
head thus becomes much distorted in its shape, growing long 
and narrow and sometimes even one-sided, but it can always 
recover its natural shape after the child is born. 
Fig. 45.-Fetal skull, showing displacement of bones in moulding as in 
Fig. 47. The right parietal bone projects over the left and both over the 
occipital. (Bumm.) 
When there is much pressure, a soft swelling often appears 
in the scalp on the part of the head which is lowest in the 
birth canal, usually just above the occiput, so that the head 
looks even longer.. This is the caput succedaneum, usually 
called simply the caput. It is especially likely to develop 
when the membranes rupture too early and the head is 
pressed close against the cervix during its dilatation. In 
such a case the caput serves a useful purpose in acting as a 
substitute for the bag of waters and aiding in the dilatation 
of the cervix. Indeed, a marked caput has sometimes been 
mistaken for tense membranes. PHYSIOLOGY OF LABOR AND PUERPER1UM 
82 
Fig. 46.-Fetal skull, showing displacement of bones in moulding, as in 
Fig. 48. The parietal bones project over both the frontal and occipital. 
(Bumm.) 
| Caput succedaneum 
Fig. 47.-Moulding of fetal head during labor. Bone displacements shown 
in Fig. 45. Caput succedaneum also shown. (Bumm.) STAGES OF LABOR 
83 
Third Stage of Labor. - Detachment and Expulsion of the 
Placenta.-The third stage of labor may be considered as 
having two parts: (1) The detachment of the placenta and 
(2) its expulsion. Immediately after the birth of the child 
the walls of the uterus, which have been stretched for so 
many months, retract and thicken, just as any elastic 
material would do when released from the strain of long 
stretching. Retraction is thus quite different from the 
Fig. 48.-Moulding of fetal head during labor. (Bumm.) 
active contraction of the uterine muscle, and the two must 
not be confused. As a result of the retraction of its walls, 
combined with the muscular contractions, which still con- 
tinue, the uterus, which perhaps reached nearly to the tip 
of the sternum, is now found below the umbilicus, and its 
cavity becomes correspondingly smaller. This sudden 
change in the surface to which it has been attached causes 
the placenta to begin to peel away from the uterine wall, 
and within a half hour, often in but a few minutes, it is 
entirely separated and ready to be expelled. 84 
PHYSIOLOGY OF LABOR AND PUERPERIUM 
The detachment of the placenta may start at the edge 
(Duncan mechanism) or at the center (Schultze mechanism); 
either method is normal. In the former case blood is seen 
escaping from the vagina throughout the process of separa- 
tion and -the placenta slips out edgewise. In the latter there 
is little or no bleeding to be seen, because the blood is held 
back in the cup-like depression of the placenta; and the 
placenta emerges with the flat fetal surface first and its edges 
folded back, looking not unlike an umbrella which has been 
turned inside out. The blood which has been kept back in 
the uterus follows with a sudden gush. 
In the absolutely normal case the expulsion of the placenta 
is accomplished by an additional bearing-down movement 
on the part of the woman, but practically this often fails, 
and it is necessary for the physician or nurse to lend aid by 
making pressure on the fundus. 
The cavity of the uterus is now empty, and its walls 
retract and contract still further. The muscle fibers com- 
press the vessels which run among them, and in this way 
prevent any great flow of blood from the open surface left 
by the detachment of the placenta. The escape of blood is 
further controlled by the formation of clots which very 
effectually plug the mouths of the vessels. If there is any 
interference with the contraction and retraction of the 
uterus or the coagulation of the blood, serious or even fatal 
hemorrhage may result. 
The Puerperium.-This is the period of reconstruction and 
return to normal. The muscle fibers of the uterus, which 
underwent such marked hypertrophy during pregnancy, now 
begin to degenerate and shrink down until the uterus is 
once more a pelvic organ. The raw surface left by the 
separation of the placenta and membranes must heal over 
and a new endometrium must form. First, however, any STAGES OF LABOR 
85 
shreds of dead tissue and bits of blood clot which would 
delay the healing process, are discharged from the uterus 
until there is a clean surface from which to regenerate the 
new mucous membrane. Any lacerations and injuries of 
the birth canal will also be undergoing repair as far as 
possible. 
Involution, the process by which the uterus returns to 
its normal condition, requires about six weeks for its com- 
pletion. For a time the decrease in the size of the organ 
can be easily followed by palpating the abdomen from day 
to day and noting the height of the fundus. By the end of 
the tenth day in the average case, this has come down to 
the level of the symphysis and after that it can no longer 
be felt by external palpation alone. 
Lochia.-During the early part of the puerperium there 
is a discharge from the uterus called the lochia, which 
consists of debris and waste material. For the first two or 
three days this is made up largely of blood which oozes out 
from the inner surface of the uterus, and therefore receives 
the name of lochia rubra, or red lochia. This presently gives 
way to a pinkish or blood-streaked discharge, the lochia 
serosa, which is in turn replaced by a whitish, mucous 
discharge, the lochia alba. These three stages are not clear- 
cut and are likely to overlap more or less. In the average 
case the lochia rubra and serosa together cover a period of 
about a week, while the lochia alba lasts for a week or ten 
days. 
Lactation.-A very different process, which might be called 
constructive, begins in the puerperium. This is lactation, 
the establishment of the milk secretion. By the second or 
third day after delivery the colostrum which has been in 
the breasts during pregnancy changes to the milk which is 
needed for the nourishment of the child. CHAPTER IV. 
MANAGEMENT OF PREGNANCY. 
EXAMINATION OF THE PREGNANT WOMAN. 
Pelvic Measurements.-As it is of the greatest importance 
to the obstetrician to know whether his patient has a pelvis 
of normal size and shape, certain measurements have been 
devised, which are taken with the pelvimeter, an instrument 
not unlike a pair of calipers, and these measurements are 
now a part of every routine examination. While it is not 
to be expected that every nurse will perfect herself in the 
exact technic of taking them, she should at least know 
what they are, in order to have an intelligent understanding 
of her cases, and how they are taken, in order to prepare a 
patient for the examination. 
The measurements in common use are: 
1. Interspinous, the distance between the anterior-superior 
iliac spines, 25 to 26 cm. (10 to 10^ inches). 
2. Intercristal, between the iliac crests, 28 to 29 cm. (11 
to 11| inches). 
3. Intertrochanteric, between the great trochanters, 30 to 
32 cm. (121 inches). 
4. Transverse diameter of the outlet, between the ischial 
tuberosities, 10 to 11 cm. (4 inches). 
5. External conjugate or Baudelocque's diameter, from 
the spine of the last lumbar vertebra to the symphysis, 20 
to 21 cm. (8 inches). 
From the first two measurements we get information as EXAMINATION OF THE PREGNANT WOMAN 
87 
to the width of the pelvic inlet; from the next two, as to the 
width of the pelvic outlet; from the last, as to the antero- 
posterior measurement of the inlet. These are all external 
measurements. The patient is prepared by having her 
clothing drawn away from the hips and lower abdomen. 
For the first three measurements she lies on her back, with 
Fig. 49.-Measuring the iliac spines. (Bumm ) 
her legs extended or flexed, as the physician may prefer; 
for the fourth, in the dorsal or lithotomy position, with the 
thighs well flexed; for the fifth, she lies on her side or stands. 
If these measurements are normal, no internal measure- 
ment is necessary in most cases. If, however, Baudelocque's 
diameter is much below normal, a more accurate internal 88 
MANAGEMENT OF PREGNANCY 
measurement, the diagonal conjugate, is added to the list. 
This runs from the lower border of the symphysis to the 
promontory of the sacrum and should measure 13 cm. (5 
inches). The patient lies in the dorsal position and is pre- 
pared as for any vaginal examination. The physician takes 
the measurement with the finger, and the length is then 
measured on the finger with the pelvimeter. 
Fig. 50.-Measuring the external conjugate (Baudelocque's 
diameter.) (Bumm.) 
Some obstetricians include in their routine the oblique 
diameters, taken externally from the anterior superior spine 
on one side to the posterior superior spine on the other. 
These should normally be the same length (21 cm.) and any 
marked difference between them is a sign of an asymmetrical EXAMINATION OF THE PREGNANT WOMAN 
89 
pelvis. The patient lies on her side or stands during the 
procedure. 
Supposing the diagnosis of pregnancy to have been made 
and the measurements taken, there still remain many points 
of importance to be brought out by external examination. 
Chief among them are: 
Fig. 51.-Palpating the fundus. (Bumm.) 
1. The probable duration of pregnancy. 
2. The size of the child. 
3. The presentation and position. 
4. The engagement of the presenting part. 
5. Whether the child is alive. 90 
MANAGEMENT OF PREGNANCY 
We rely on palpation of the uterus through the abdominal 
wall to give us most of this information. 
By palpating the fundus we determine first its height with 
reference to the symphysis, the umbilicus or the ensiform, in 
order to get an idea of the approximate duration of the 
pregnancy. By deeper palpation we find out what part of 
Fig. 52.-Palpating the back and small parts. (Bumm.) 
the fetus is occupying the fundus, and thus gain a point in 
the diagnosis of the presentation. The head is distinguished 
from the breech by being less bulky, harder and more mov- 
able, and its rounded shape is especially characteristic. 
Next comes the palpation of the two sides of the abdomen. 
On one side will be felt the smooth, firm plane of the child's 
back, while on the other the small parts, as the limbs are EXAMINATION OF THE PREGNANT WOMAN 
91 
called in obstetrical language, make the outline more irregu- 
lar, and the shape of a leg or arm can often be felt. In the 
rare transverse presentations the head will be found at one 
side and the breech at the other. 
Fig. 53.-Palpating the presenting part. (Bumm.) 
In the lower part of the uterus, just above the symphysis, 
we locate the presenting part, which will be freely movable 
unless the examination is made in the last month of preg- 
nancy, when it may have descended into the pelvis and 
become firmly engaged. 
There still remains to be established the very important 
point, whether the child is alive-or "quick," in the quaint 92 
MAN AGEMEN T OF PREGNANCY 
term of former days, which is preserved in law terms 
even now. The movement of the fetus or the sound of 
its heart beats is a sure sign. The fetus is often so active 
in the last months that mere inspection of the abdomen is 
enough to prove the presence of a living child, and the 
movements may also be felt by palpation; but in a large pro- 
Figs. 54 and 55.-Auscultation for fetal heart sounds in vertex and face 
presentations. (Bumm.) 
Fig. 54 
Fig. 55 
portion of the cases we resort to auscultation of the fetal 
heart, using either the ear or a stethoscope. Contrary to 
what might be supposed, except in face presentations the 
child's heart is heard best on the side of the mother's abdo- 
men toward which its back, not its chest, is turned, for the 
very good reason that the arms folded over the chest and 
the flexed head usually obstruct the sound on that side. EXAMINATION OF THE PREGNANT WOMAN 
93 
In vertex presentations the heart is heard in the lower 
part of the abdomen; in breech presentations, at about 
the level of the umbilicus or even above it. In anterior 
positions it is heard through the anterior abdominal wall; 
in posterior positions, toward the flank of the mother. For 
Fig. 56.-Illustrating the points of maximum intensity of fetal heart 
sounds in vertex and breech presentation. (Bumm.) 
example, in a case of right occipito-posterior (R. O. P.) we 
should listen for the heart in the right flank; in left sacro- 
anterior (L. S. A.), a little to the left of the umbilicus. The 
location of the heart may thus be an aid to the diagnosis of 
the position of the fetus when the other findings have been 
obscure. 94 
MANAGEMENT OF PREGNANCY 
Sometimes while listening for the fetal heart we hear a 
soft blowing or whistling sound instead of clear-cut pulsa- 
tions. This sound, which is called a souffle, is caused by the 
blood in the vessels of the uterus or the umbilical cord. In 
the former case it will have the same rate as the mother's 
pulse and is therefore known as the maternal souffle. In the 
latter, its rate will be that of the fetal heart, and the sound is 
called the fetal or funic souffle. 
As an example of a diagnosis made by external examina- 
tion, let us take the findings in a given case. The fundus 
is three fingers' breadth above the umbilicus; the breech is 
in the fundus, the back to the left side, the small parts to 
the right; the head is below, not engaged; the fetal heart is 
heard in the left lower quadrant of the abdomen. The diag- 
nosis here would be seven months' pregnancy, vertex pre- 
sentation, left occipito-anterior (L. O. A.). 
Most physicians will not expect the nurse to be proficient 
in obstetrical diagnosis and its technic, except in one point, 
the auscultation of the fetal heart. As we shall see later, it 
is often necessary to watch the heart very closely during 
labor, as a guide to the condition of the child, and the nurse 
will often be relied upon to do this. She should, therefore, 
take advantage of every possible opportunity to listen to a 
fetal heart. In this way alone can she become familiar 
with the sounds and learn to count accurately, so that she 
will at once notice any change in its rate, regularity or char- 
acter. While many physicians prefer to use a stethoscope, 
it is absolutely necessary to become skilled in detecting the 
heart sounds with the ear, and especially so for the nurse, 
w'ho does not usually carry a stethoscope. When listening, 
if there is any doubt whether sounds are fetal or maternal, 
the point may be cleared up by taking the mother's pulse 
and comparing the rate. Indeed, this is a wise precaution EXAMINATION OF THE PREGNANT WOMAN 
95 
in any case, as the mother's heart is sometimes unexpectedly 
rapid. 
During the examination the patient lies on her back, with 
her clothes drawn away from her abdomen. A sheet may 
be draped over the pubis and hips and a towel used to cover 
her clothes above. This is particularly desirable for clinic 
patients, whose clothing is not always clean. If the ear is 
to be used in listening to the fetal heart, another towel or a 
piece of gauze should be provided to lay on the abdomen 
during auscultation. The towel must not be too thick or it 
will interfere with hearing the sounds. 
The examiner stands beside the patient, facing toward 
her head, using two hands while palpating the fundus and 
the sides of the abdomen, and one hand, with the fingers 
and thumb spread wide apart, to grasp the head in palpating 
above the symphysis. When the head is engaged or far 
back in the abdominal cavity, it is more easily felt if the 
examiner faces toward the patient's feet and uses both hands, 
pressing in deeply but always gently from the two sides. 
Internal Examinations in Pregnancy.-Internal examinations 
are made for the purpose of establishing the diagnosis of 
pregnancy or confirming the diagnosis of the presentation 
of the fetus in a doubtful case. They also give the physician 
information about the shape and size -of the birth canal and 
the condition of its tissues. If the external measurements 
are small, the diagonal conjugate is taken by means of a 
vaginal examination. The value of internal examinations 
during labor, will be explained later. 
Preparation of the Patient.-The patient lies on her back 
with the thighs and knees flexed and the knees widely sepa- 
rated. If she is on an examining table, her hips are brought 
to the edge of the table and her feet supported by stirrups. 
In a private home she may lie across the bed, with her hips 96 
MANAGEMENT OF PREGNANCY 
close to the edge and her feet resting on chairs or held by 
the nurse or other attendant. The doctor can often make 
a sufficiently satisfactory examination without having her 
thus turned across the bed. 
A clean sheet is draped over the legs and lower abdomen, 
leaving the vulva exposed. The vulva is then cleansed 
thoroughly but gently, as the tissues are sensitive and easily 
irritated. Cotton balls or pieces of gauze are substituted 
Fig. 57.-Patient draped with sheet ready for examination. (Cragin.) 
for the brush. The routine procedure is soap and water, 
followed by bichloride, lysol or other antiseptic solution. 
The washing is done from above downward, and a piece of 
cotton which has come in contact with the anal region must 
not touch the vulva. After the vulva has been cleansed 
externally, the labia are separated carefully with the fingers 
of one hand, and the parts between are washed with fresh 
gauze and irrigated with sterile water and the antiseptic EXAMINATION OF THE PREGNANT WOMAN 
97 
solution. If the physician is not ready to make the examina- 
tion, a sterile pad or towel is laid over the vulva. On no 
account must the draping sheet, which is not sterile, come in 
contact with the vulva, as this would simply undo the whole 
work. 
Iland Disinfection.-Disinfection of the hands is quite 
as important in obstetrics as in surgery. Various methods 
have been described, but all are founded on one basic prin- 
ciple, thorough scrubbing at the start. A nurse will make 
it a point to find out the technic used by the physician, so 
as to have in readiness his chosen solutions. 
The hands are first scrubbed with soap and water and a 
brush for from five to ten minutes. For making a single 
vaginal examination at a clinic it will be enough to scrub 
well above the wrists, but in preparing for a delivery the 
obstetrician scrubs up to the elbows. Special care is taken 
to remove all material from under and about the nails, and 
for this a nail-cleaner or an orange-stick will be needed. 
Brushes are sterilized by boiling for at least ten minutes and 
the nail-cleaners can be kept in an antiseptic solution. 
Green soap has long been the standard for surgical use. If 
a liquid is preferred, the tincture of green soap or any of the 
good liquid soaps made by reliable surgical supply houses 
can be used; enough for a single scrubbing is poured into a 
flat dish into which the brush can be easily dipped. It is 
against all rules of aseptic technic to handle a bottle or other 
container while cleansing the hands. If no other soap is 
available, as in an emergency call, a new cake of Ivory soap 
will answer the purpose. On no account should one rely on 
a piece which has been used by the family or lying about, 
collecting dirt and germs. 
After thorough cleansing the hands and arms are soaked 
in an antiseptic solution for at least two minutes. Bichlo- 98 
MANAGEMENT OF PREGNANCY 
ride of mercury 1:1000 is as safe as any, but is so irritating 
to the skin of many people that lysol solution or alcohol is 
often preferred. The latter is now so difficult to procure that 
it is no longer found as a matter of course in the average home. 
Rubber gloves are a routine part of the process of preparing 
for an obstetrical examination. They protect patient and 
physician alike. In a hospital they are best dry-sterilized, 
powdered and placed in a sterile wrapper. The cuff should 
be turned back so that the gloves can be easily drawn on. 
In the home, unless the doctor brings his gloves ready-steri- 
lized, they are prepared by boiling for ten minutes. If they 
must be reboiled after using, the nurse will first carefully 
wash off any traces of blood or mucus which may be left 
from the previous examination, as boiling will only coagulate 
such material and make it stick to the rubber. 
HYGIENE OF PREGNANCY. 
The care of a pregnant woman should always include clear 
directions as to her mode of living. In general it may be 
said that if she has been leading a healthy, well-ordered life, 
without too much heavy work or over-vigorous exercise, 
the nearer she can keep to her accustomed habits the better. 
Nothing is worse than for her suddenly to give up her usual 
activities and sit down at home with only thoughts of her 
condition to occupy her. Her life should be as healthy and 
normal as possible, from both the physical and the mental 
point of view. 
Diet.-Since the mother is providing the nourishment for 
the child as well as for herself, she must keep herself well- 
nourished, but that does not mean that she must "eat for 
two," in the familiar phrase, since overloading her stomach 
and overtaxing her kidneys and digestive system may have HYGIENE OF PREGNANCY 
99 
serious effects. Various diets have been suggested, with the 
idea of limiting the size of the child or its bony development, 
so that the birth will be easier. Unfortunately these ideas 
have not been borne out by the facts, and the woman who 
diets herself with this mistaken notion only weakens herself 
quite unnecessarily, as the child will get what it needs for 
its development, except in cases of extreme malnutrition of 
the mother. 
As to the choice of foods, their chief requisites are that 
they shall be nourishing and easily digested. In spite of the 
old idea that an expectant mother should eat much rich 
food, simpler things are better for her, provided they con- 
tain the necessary nourishment. She should avoid rich 
pastry and greasy, fried things, and she should limit her 
ration of meat, as that also taxes the digestion and the 
kidneys during pregnancy. If a patient is showing the 
slightest signs of toxemia, almost the first order is to cut out 
meat from her dietary, and even if conditions are normal, 
she will do well to take it only once a day. As proper 
elimination is especially important for a pregnant woman, 
she should take fruit, green vegetables and cereals in plenty, 
and avoid constipating foods. Tea or coffee once a day will 
do no harm, but their use should be restricted. Milk is one 
of the simplest and best of foods, and if the patient likes it, 
she may take a quart a day. If she does not care for it or 
thinks that it makes her "bilious," it can be used freely on 
cereals or served up as junket or soup, or in cocoa. Water 
is an excellent diuretic, and six to eight glasses a day are 
none too much. Alcohol in any form is better omitted 
during pregnancy. 
Dress.-The clothing must be comfortable and sightly. 
Fortunately the days of the wasp-waist have gone by and 
women can wear the rather loose garments of the modern 100 
MANAGEMENT OF PREGNANCY 
styles without exciting attention, even when fairly advanced 
in pregnancy. Most women feel the need of some sort of 
support of the abdomen, and will do well to wear a corset, 
provided it does not press on the uterus in such a way as to 
force it or the fetus into a bad position. An ordinary corset 
may be worn, but the various types of maternity corset 
which are on the market are usually more satisfactory. A 
woman whose abdominal wall is loose and stretched by pre- 
vious pregnancies will sometimes need to wear a special 
abdominal supporter. It is a mistake to suppose that a 
tight corset will "preserve the figure," as the saying is. By 
its pressure the muscles of the abdomen, which need special 
strength at the time of labor, are so weakened that they are 
far more likely to be lax and flabby after the confinement. 
Clothing which hangs heavily on the hips should be avoided, 
as also tight bands. Round garters interfere with the circu- 
lation in the legs and predispose to varicose veins. The 
modern high-heeled shoes are particularly pernicious for the 
pregnant woman, as they throw the weight farther forward 
and increase the strain on the abdominal walls. 
Exercise and Bathing.-A moderate amount of exercise is 
needed to keep up the woman's muscle tone, but preg- 
nancy is not the time to try to work up muscular strength, 
and she should not overtire herself. Walking is the easiest 
form of exercise, and the fresh air adds to the benefit from it. 
If she must stay in the house, she should cultivate the habit 
of open windows and deep-breathing exercises. Any vio- 
lent exercise or work which involves straining, heavy lifting 
or long hours of standing is to be avoided. Many women 
are so situated that they must do their own housework, and 
if the heavier part can be avoided, this does no harm, espe- 
cially if it is done with the windows open as much as possible. 
Automobile riding over rough roads has often brought on a HYGIENE OF PREGNANCY 
101 
miscarriage, and trolley-cars, with their jolting and crowd- 
ing and the frequent necessity of hanging to a strap during 
a large part of the way, are not much better. The woman 
should try not to ride at the rush hours, and should always 
"watch her step," as a sudden start might give her a bad 
fall. 
Bathing every day keeps the skin in good condition and 
helps elimination through that channel. Cold showers and 
sprays are better omitted. In the early months sea-bath- 
ing in calm water may be permitted, but not if the water or 
the day be cold, as the chilling of the body may be danger- 
ous. Surf bathing should be absolutely prohibited at all 
times. 
Bowels and Kidneys.-On account of the pressure of the uterus 
on the intestines constipation is so common during pregnancy 
that special attention must be paid to the care of the bowels, 
the more so because of the danger of toxemia when they are 
inactive. Although diet and plenty of water to drink will 
help, it is often necessary to supplement hygiene by drugs. 
A pregnant woman should never take cathartic pills because 
they are advertised at the drug store or prescribed by inter- 
ested friends, as they may contain drugs which are too drastic 
and lead to straining and hemorrhoids, or even to miscarriage. 
Cascara, milk of magnesia and phenolphthalein are all safe 
enough and the various forms of mineral oils are often effec- 
tive. The simpler saline laxatives, like sodium phosphate 
and the laxative mineral waters are helpful, chiefly because 
they make the patient drink a full quota of water, which is 
of benefit to the kidneys as well. 
Free elimination of urine is a necessity, if toxemia is to be 
avoided. The pregnant woman should pass at least three 
pints of urine in the twenty-four hours. If the output is 
scanty, extra fluids should be ordered. If the result is not 102 
MANAGEMENT OF PREGNANCY 
satisfactory, diuretic drugs are prescribed; among the com- 
monest are potassium citrate and Basham's mixture. The 
urine should be brought to the physician for examination at 
intervals varying from one to four weeks, according to the 
time in pregnancy. 
Care of the Breasts.-The breasts require special care 
during pregnancy to prepare them for the nursing period. 
There should be no pressure on them from the clothing, 
and if they are large or heavy, a support must be worn. 
The nipples may be anointed with any bland ointment 
or oil to soften them; if the skin over them is very 
sensitive, applications of a mildly astringent lotion will 
harden it. A mixture of boric acid and 50 per cent alcohol 
may be used, and glycerite of tannin in weak solution and 
witch-hazel are also advised. While it may be necessary 
to draw out flat or inverted nipples, manipulation should be 
avoided as far as possible, as tending to cause irritation. 
Prevention of Miscarriage.-The patient should be warned 
of the dangers of miscarriage and cautioned against over- 
work, straining efforts, jolting rides and sudden jars, and 
anything which might cause uterine congestion, especially 
in the first three months of pregnancy before the placenta 
is fully formed and firmly attached to the wall of the uterus. 
For this reason intercourse,, with its resulting congestion, 
may be a danger in the early months, apart from other 
considerations; in the last month it should be prohibited on 
account of the danger of infection, in case labor should come 
on soon afterward. The woman should also be told to report 
at once to her physician in case of unusual pain, bleeding or 
discharge of any kind, as these may be the symptoms of a 
beginning miscarriage. 
Toxemia.-Since toxemia is so grave a complication, the 
patient must also be urged to report any symptoms which HYGIENE OF PREGNANCY 
103 
may be connected with it; headache or blurred vision, dizzi- 
ness, epigastric pain, nausea or vomiting (if more than the 
slight "morning sickness" and particularly in the later 
months after that symptom should have passed), scanty 
urination or edema. 
Maternal Impressions.-One of the things which causes the 
greatest anxiety to some women at the time of pregnancy 
is the fear that the child will be "marked" or malformed in 
some way, on account of some experience through which 
they have passed, especially if it has been a sudden shock or 
fright. There is practically no basis for such a belief, and 
the nurse should always do her best to allay such fears and 
show the mother that they are groundless. 
Prenatal Care.-Just as in every branch of medicine the 
stress is now being laid on the preventive side, so in obstet- 
rics within late years a great effort has been made to develop 
that side of the work by giving the prospective mother every 
care throughout her pregnancy. As cases have been more 
carefully studied, it has been more and more clearly shown 
that many of the difficulties and dangers of obstetrics can 
be avoided or at least decidedly lessened, if they are recog- 
nized early enough to receive the right treatment at the 
right time. 
Without going into the details of all the possible compli- 
cations, it may be stated that the chief conditions which 
threaten the welfare of mother and child are somewhat as 
follows: 
1. Interruption of pregnancy before full term; miscarriage 
or premature labor. 
2. Disproportion between the child and the pelvis, due to 
the small size or deformity of the pelvis or the large size of 
the child. 
3. Abnormal positions of the child in the uterus. 104 
MANAGEMENT OF PREGNANCY 
4. Toxemia, convulsions and kidney disease. 
5. Venereal disease. 
6. Hemorrhage. 
7. General poor physical condition of the mother, as from 
malnutrition, overwork, tuberculosis, heart trouble, etc. 
It is most interesting to see how many of these dangers 
can be controlled when the patient is kept under observation 
and given intelligent prenatal care. If she consults a physi- 
cian at the beginning of her pregnancy and receives careful 
directions as to her mode of living, with special emphasis 
on the possible causes of miscarriage, she is far more likely 
to avoid such an accident. If she has a small pelvis, this 
will be discovered when her measurements are taken, and 
while nothing can be done to change the condition of her 
pelvis, the physician, being "forewarned, forearmed," is 
prepared to treat the case as may be wisest, sometimes by 
inducing labor before term, sometimes by performing Caesa- 
rean section at term. Moreover, by seeing the patient regu- 
larly throughout her pregnancy he can watch the growth of 
the fetus and thus know wrhat to expect at the time of the 
delivery. If a malposition is found, in many cases it can be 
corrected by external manipulation. The examination of the 
urine and the estimation of the blood-pressure give valuable 
information as to a beginning toxemia or the presence of 
any disease of the kidneys. Syphilis is detected by the 
Wassermann test and gonorrhea by the microscopical exami- 
nation of a smear taken from the cervix. When found, they 
can be treated, and in the case of syphilis, if the treatment 
is started early enough, it affects not only the mother but the 
fetus as well and may actually prevent it from acquiring the 
disease. Tuberculosis and heart disease are found w'hen a 
physical examination is made; they can be treated and the 
influence of pregnancy on their progress carefully noted. HYGIENE OF PREGNANCY 
105 
Women suffering from malnutrition can be built up physi- 
cally. Overwork is harder to remedy, especially among the 
poor, but the social-service worker will often find a solution 
of the problem. In short, there remains only hemorrhage 
which cannot be influenced by prenatal care, and even that 
will be far better treated if taken in time. 
Organization of a Prenatal Clinic.-Prenatal work is fast 
becoming a specialty for nurses, particularly for those whose 
interests lie along the lines of social service. An outline of 
the organization of a prenatal clinic and its work therefore 
deserves a place in a book on obstetrical nursing. 
It is taken for granted that any patient who applies at 
the clinic for care will be questioned by the social-service 
worker as to such matters as her home conditions, family 
and finances. In the more strictly medical part of the record 
the aim is to get information which will be of value in the 
management of her case. If the woman has had other preg- 
nancies, inquiries should be made as to complications during 
pregnancy, labor or the puerperium, the size of the children, 
and their condition at birth, difficult or operative deliveries 
and if possible the cause of the difficulty. Miscarriages and 
stillbirths should be carefully noted. It is important to 
know whether the mother has been able to nurse her babies 
and whether she has ever had breast abscesses. It is also of 
interest to note whether in her previous pregnancies she was 
under the care of a clinic, a private physician or a midwife. 
All these data will help the doctor to judge what may be 
expected in the case. 
The first point in the history of the present pregnancy is 
the date of the last menstruation, in order to get an idea of 
of the expected date of confinement. If quickening has 
occurred, the time when it was first noticed may help in the 
calculation, especially if the menstrual history is unsatis- 106 
MANAGEMENT OF PREGNANCY 
factory. Nausea, vomiting and constipation should be noted 
and particular inquiries should be made into any symptoms 
pointing to any beginning toxemia, such as headache, blurred 
vision, edema of the feet, hands and face and scanty urine. 
The examination of the patient will include the usual 
physical examination of the heart and lungs; an examination 
to establish the diagnosis of pregnancy, if that be necessary; 
the measurement of the pelvis; palpation to determine the 
position of the fetus and the probable duration of the preg- 
nancy; an examination of the vulva to discover the presence 
of edema, varicosities and former perineal lacerations; a 
vaginal examination if the case requires closer investigation. 
A smear of any discharge from the cervix should be made 
as a routine at a clinic patient's1 first visit, and the blood 
taken for a Wassermann test. At every visit the blood- 
pressure should be taken and a specimen of urine obtained 
for examination. 
The nurse's share in the examinations will depend on the 
doctor in charge of the clinic. In any case she must have 
in readiness the instruments and supplies which are likely 
to be needed, including a pelvimeter for the pelvic measure- 
ments, a speculum, dressing forceps, applicators and sterile 
glass slides for taking the cervical smear, the blood-pressure 
apparatus, the necessary sheets and towels for draping the 
patient during-the examination, a stethoscope, sterile hand 
brushes, green soap (or whatever liquid soap the physician 
may prefer), an antiseptic solution (bichloride, lysol, alcohol, 
or whatever the physician is in the habit of using) and 
sterile gloves for the internal examination, cotton balls, etc., 
for washing up the patient and the necessary syringes, needles 
and tubes for the Wassermann outfit. 
If possible,- three rooms should be devoted to the clinic: 
a waiting-room, a room for the history-taking and an exam- HYGIENE OF PREGNANCY 
107 
ining-room. It is most undesirable for the waiting patients 
to hear one another's symptoms or see others being exam- 
ined. If the clinic is a large one, two or more examining- 
tables can be arranged, according to the number of patients, 
and separated by sheets hung from screens so that the tables 
are contained in cubicles. Each patient thus has a certain 
amount of privacy and can dress and undress in her cubicle 
without the need of an extra dressing-room. 
The examining-room should contain a sink or basin with 
hot and cold water, where the physician can scrub his hands, 
and a place for boiling gloves and instruments, in case the 
sterile supplies run short. 
As it is probable that the physician in charge will want 
someone to help in taking the blood-pressure and getting 
the blood for the Wassermann tests, the nurse will do well to 
learn the technic. In many clinics the nurse also makes the 
routine examinations of the urine, except perhaps the micro- 
scopical examination. If she is wide-awake and helpful, she 
can train herself to be a valuable assistant. 
It is of the greatest importance that the patients should 
visit the clinic at regular intervals, so that their progress 
can be carefully followed. The frequency of the visits is 
set by the head of the clinic and will naturally vary accord- 
ing to the individual opinions. One visit a month is usually 
enough up to the end of the fifth month; after that twice a 
month or every two weeks, increasing to once a week in the 
last two months, when symptoms of toxemia are especially 
apt to arise. At some clinics a uniform interval of two weeks 
throughout pregnancy is the rule. The patient is directed to 
report at once any untoward symptoms, especially any which 
would point to a beginning toxemia or miscarriage. 
Since most of the women who attend such clinics are too 
busy with their household cares to make the frequent visits 108 
MANAGEMENT OF PREGNANCY 
as above outlined, and find it hard to see the need of coming 
so often when they are feeling well, one of the duties of the 
prenatal nurse will be to pursue them to their homes and 
persuade them to visit the clinic. If it is really impossible 
for them to attend regularly, she will visit them herself at 
the stated intervals, bringing away a specimen of urine and 
taking the blood-pressure each time, inquiring into their 
general condition and making any examination which the 
doctor may direct. If she finds anything out of the normal, 
she must insist on their consulting the clinic physician. 
Postnatal Clinics.-It sounds rather like an Irish bull to 
say that one of the important parts of a prenatal clinic is 
postnatal work, but such is nevertheless the case. All the 
obstetrical skill in the world has been of little avail in 
saving a child's life, if it is left to the care of an ignorant 
mother after its birth and no attempt made to keep it well. 
Patients who have received prenatal care and have been 
carried safely through confinement should be urged to report 
back to the clinic with their babies a month after delivery, 
so that directions can be given them as to the care of the 
babies and themselves. After that they should be kept 
under observation by visits to the clinic at stated intervals, 
so that the babies can be weighed, their progress observed 
and their feeding and general care supervised. 
Such a well-babies' clinic is of the greatest value in teach- 
ing the mothers how to care for their children and is another 
step in preventive medicine in obstetrics. At the first visit 
and probably the second as well the mother should also 
receive an examination, and if there remains any condition 
which needs treatment, that should receive attention at the 
proper clinic. Infant welfare is receiving great emphasis at 
the present time, and rightly enough, but maternal welfare 
deserves its share too. CHAPTER V. 
MANAGEMENT OF LABOR. 
Preparations for Confinement in a Private House.-Arrange- 
ments for a confinement in a private house are of neces- 
sity distinctly different from those in a well-equipped hos- 
pital, and the nurse's ingenuity and powers of organiza- 
tion will often be put to the test. This is particularly true 
in such work as an out-patient obstetrical service, since the 
homes of the patients are often devoid of all conveniences. 
Nevertheless, the prenatal nurse can accomplish wonders by 
looking over the ground beforehand and making the most 
of what can be obtained. 
The nurse who is to take charge of a private case of this 
sort should make a point of visiting the home before the 
appointed time, since in this way she can familiarize herself 
with the arrangements of the house and the location of the 
kitchen, bath-room, etc. She may also be able to give help- 
ful suggestions as to the choice of the room in which the 
patient is to be confined, the best way of arranging the furni- 
ture and the various other preparations which the patient 
will wish to make. More than this, she makes the acquaint- 
ance of her prospective patient, so that she does not enter 
the house as an utter stranger at the time of the confinement, 
a point which counts for much. 
The room in which the patient is to be confined and in 
which she will spend the first weeks of the puerperium, 
should be the brightest and most cheerful in the house, well 110 
MANAGEMENT OF LABOR 
lighted by artificial light and conveniently near a bath-room. 
It is neither necessary nor desirable to transform it into a 
hospital operating-room, with bare walls and white enameled 
furniture; on the contrary, it should be as home-like and 
pretty as possible, since surroundings have more effect on 
patients than we always realize. Nevertheless, the nurse 
must see to it that anything that might be spoiled by the 
spilling and spattering which necessarily occurs at the time 
of the delivery is temporarily removed. People are prone to 
resent damage done to their property, and the remembrance 
of the faithful and devoted service of a nurse in a time of 
great emergency suffers, if it is called to mind by spots on 
the carpet or wall-paper, ruined varnish and the like. For 
the time of the confinement rugs should be taken up; if there 
is a carpet on the floor, this must be covered in the region 
of the bed by laying down a piece of oilcloth (newspapers 
will serve, if nothing else is at hand). Any bureau or table 
on which obstetrical supplies, medicines or solutions are to 
be placed, must be protected with enamel-cloth, oil-cloth or 
the ever-to-be-depended-on newspapers. Poor families can 
be instructed to save old papers for the event, so that there 
will be a goodly supply on hand. We must not forget that 
in even the poorest home there will be treasures which must 
be kept from harm, although they may look like the veriest 
rubbish to us. 
The bed must not be tucked into a corner, if this can 
possibly be avoided, but should have only the head against 
the wall, thus allowing access to both sides of it and free 
passage around it. It should be the highest bed in the 
house, for the sake of the doctor and nurse, who will work 
at a disadvantage, if they are continually stooping in the 
course of their care of the patient; moreover, a high bed 
makes an operative procedure much easier. If there is no PREPARATIONS FOR CONFINEMENT 
111 
high bed available, a strong, steady table, such as an ordinary 
kitchen table, should be provided in case of any operation. 
A defect common to most beds is th ad they are too soft, so 
that the woman soon slips down into a hollow, from which 
it is impossible to drain off any fluid or discharge and in 
which it is difficult for the obstetrician to do his work. It is 
usually possible to support the mattress by firm boards 
placed underneath it; an ironing-board will answer the 
purpose satisfactorily. The boards must, of course, be 
removed after the delivery, as they will make the bed too 
hard and uncomfortable to lie on for any length of time. 
The arrangement of the bed is familiar to most nurses. 
First, the mattress is covered with a piece of rubber sheet- 
ing or oil-cloth, which is large enough to hang well over the 
edge or even to be tucked under it. Over this is spread a 
full-length sheet, carefully tucked in all around. A second 
piece of rubber sheeting, about half the length of the mat- 
tress, is covered with a draw-sheet and laid over the middle 
of the bed, where it will be beneath the patient during the 
delivery; it can be removed afterward, leaving the clean 
permanent-bed arrangement underneath. In addition to 
these, bed-pads should be provided, which can be changed 
as they become soiled during the labor. These can be made 
of the quilted padding which can be bought at any shop, or 
a home-made variety may be devised with layers of brown 
paper or newspapers covered with old muslin. They can 
be eked out with "clean rags" which dispensary patients 
should be urged to save for the occasion. In a hospital a 
Kelly pad, covered with a sterile sheet or towel, is usually 
placed under the patient at the time of the actual delivery. 
This is not as satisfactory for home use, because it is so 
hard to clean and sterilize the rubber pad. A similar con- 
trivance can be made out of newspapers, rolled like the 112 
MANAGEMENT OF LABOR 
edges of the Kelly pad, and covered with muslin. A clean 
pail is placed beside the bed, so that it receives the water and 
other material which drains away from the field of operation. 
As already stated, the floor beside the bed must be protected 
with oil-cloth or paper. The bed is made up so that it opens 
at the right side, since the obstetrician will take up his posi- 
tion at this side. A chair is placed beside the bed for his 
use, as he will not wish to stand all the time. 
At the head of the bed, and better at the left side, where 
it will not interfere with the obstetrician, is a table with 
the outfit for the anesthetist. Two other tables will be 
needed, one for the solutions for the doctor and the other 
for the sterile supplies, cord instruments, etc. The bureau 
or dresser will serve in place of the latter, if need be, but it 
is usually occupied by the extra supplies, medicines, hypo- 
dermic outfit and such things, which must be at hand in 
case of need, but are not necessarily required in a normal 
delivery. Another part of the room is reserved for the 
baby's basket. A baby's bath-tub and a large basin (a 
dish-pan is about the right size) should be ready to hold the 
hot and cold water, in case the child needs to be resuscitated. 
In a hospital two small tubs are provided for this purpose. 
The outfit for giving an intra-uterine douche, ready sterilized, 
must be near at hand for use in case of hemorrhage. Plenty 
of sterile water, both hot and cold, is indispensable. 
The Hospital Delivery-room.-The appointments of the 
delivery-room in a well-conducted hospital are in general 
the same as those of the operating-room, and the same 
rules of rigid aseptic technic hold sway. The room should 
be always prepared to receive any sort of emergency case. 
The sterile hand-brushes and soap are in covered containers 
on the sink. The antiseptic solution and sterile water for 
soaking the hands and arms after scrubbing are best kept THE HOSPITAL DELIVERY-ROOM 
113 
not in basins but in deep jars of glass or agate in which the 
arms can be easily immersed as far as the elbows; these are 
covered when not in use. A movable stand with two basins 
is also provided. At the time of the delivery they are filled 
with fresh sterile solutions and the stand is wheeled near 
the bed within easy reach of the obstetrician. The solutions 
for washing off the patient (liquid soap, sterile water and 
the antiseptic of choice) are ready in well-stoppered flasks. 
The catheterizing-tray must not be forgotten. 
Fig. 58.-Hospital delivery-room showing anesthetist's table, intra-uterine 
douche outfit, baby's crib and tray for treating eyes. At the extreme left 
may be seen tables with sterile supplies and stand with basins. 
The supplies required for a normal delivery may be 
wrapped in a sheet and the whole bundle sterilized; it is 
then placed unopened on a table. This sterile pack will 
contain two surgeon's gowns, head-gauze or cap, mask, two 
pairs of gloves, two sheets, one pair of leglets, at least six 
towels, plenty of gauze squares or sponges, the cord instru- 
ments, tape and dressing. Ready sterilized in separate 114 
MANAGEMENT OF LABOR 
packages are the instruments for repair of lacerations (both 
cervical and perineal) and two pairs of obstetrical forceps 
(high and low). On a small table beside the baby's crib 
are the solutions, eye-droppers and other things for treat- 
ing the child's eyes. Reference has already been made to 
the small tubs used in the resuscitation of the infant. The 
anesthetist's table should be well stocked with the necessary 
articles. An oxygen tank, easily accessible and surely full, 
is essential. 
Since hemorrhage is so grave an obstetrical complication 
and since, moreover, it may come on without the least warn- 
ing, it is vitally important to have at hand, ready for use 
without a minute's delay, whatever may be needed to meet 
this emergency. The outfit for the intra-uterine douche 
(container, tubing and nozzle) is hanging from its standard, 
sterilized and carefully covered. Several rolls of uterine 
packing of various widths (mostly from four to six inches) 
are close at hand. It may even be thought wise to include 
a few rolls in the sterile pack. A rectal tube and a hypo- 
dermoclysis outfit are conveniently accessible and sterile 
normal salt solution must be kept in stock. An absolutely 
necessary part of the equipment of every delivery-room is 
the hypodermic tray, which should contain two tested 
syringes and half a dozen needles (also tested). Besides the 
usual collection of drugs for hypodermic administration 
ergot and pituitary extract in sterile ampoules are all-import- 
ant. 
Internal Examinations during Labor.-As a general rule the 
physician is the one to make internal examinations during 
labor, but as some doctors wish the nurse to be trained to 
aid in this way and as certain emergencies may require it, 
the nurse will do well to learn how such an examination is 
made and what is to be learned from it. INTERNAL EXAMINATIONS DURING LABOR 
115 
Internal examinations are either vaginal or rectal. Since 
the former are in far more common use and offer the easier 
Fig. 59.-Method of making a vaginal examination. (Cragin.) 
method of determining the conditions present, they will be 
described here. It is claimed that the use of rectal exami- 
nations will greatly reduce the danger of puerperal infection, 116 
MANAGEMENT OF LABOR 
since they afford no possible opportunity of carrying infec- 
tion into the uterus. The preliminary cleansing of the hands 
and parts is thus unnecessary, and a glove is worn only for 
the protection of the hand from contamination by the con- 
tents of the rectum. It must be remembered, however, that 
extra care must be taken in sterilizing the gloves afterward, 
as the colon bacilli which live in the rectum seem to be 
particularly resistant organisms. In point of fact, infection 
from vaginal examinations is little to be feared if aseptic 
technic is scrupulously observed. 
Hand disinfection and the preparation of the patient for 
a vaginal examination have already been described. It 
must be borne in mind that the vulva can never be rendered 
as sterile as the hand and that in making an examination we 
must as far as possible avoid touching the vulva with the 
hand which is to be introduced into the vagina. For this 
reason the labia are separated and the vaginal introitus 
spread wide open with the fingers of the left hand while two 
fingers (the index and middle fingers) of the right hand are 
gently slipped into the canal. If the patient is not yet past 
the first stage of labor, the fingers must be carried obliquely 
downward and far back to reach the cervix. If the head 
has begun to descend, the fingers may come in contact with 
it if introduced horizontally. 
The chief points to be noted in a routine examination are 
as follows: 
1. The cervix; its consistency and the amount of dilatation. 
2. The membranes; whether intact or ruptured. 
3. The presenting part; whether head, breech or small 
part; whether movable above the superior strait or firmly 
fixed and descending through the birth canal; whether turned 
anteriorly or posteriorly. 
The dilatation of the cervix is usually measured in fingers' MANAGEMENT OF THE FIRST STAGE OF LABOR 
117 
breadths. The examiner inserts the two fingers into the 
external os and by separating them, estimates how many 
fingers could be introduced. Some prefer to compare the 
amount of dilatation to the size of a coin, as a quarter or a 
dollar. As the dilatation proceeds, the cervix rolls back 
from the presenting part until the edge can barely be felt, 
and the dilatation is then complete. 
The membranes can be felt like a tense sac bulging through 
the os, when the patient has a pain; between the pains they 
are more difficult to identify. In a doubtful case it is better 
to examine during a pain. If the membrane is applied very 
closely to the presenting part, it is hard to tell whether the 
sac has ruptured or not. If the head is the presenting part, 
the hair can be felt after the membranes have ruptured. 
Sometimes the fluid, with flakes of vernix, can be seen oozing 
from the vagina. 
The head is distinguished from the breech by its rounded 
shape and its hard consistency. It may be possible to feel 
the sutures and fontanelles, if there is sufficient dilatation 
and the head is not too high. After the rupture of the 
membranes the difference is more easily made out; if the 
breech is presenting, the anus can then be felt, and the 
meconium escaping from it confirms the diagnosis. 
Various abnormal conditions are revealed by a vaginal 
examination. The most important of these are a prolapsed 
cord and placenta previa. The cord is recognized by its 
pulsation; the placenta is felt as a soft mass protruding into 
the cervix and perhaps covering the presenting part. The 
early discovery of these complications may mean the saving 
of life. 
Management of the First Stage of Labor.-As soon as it is 
decided that labor is definitely under way, it is routine to 
give the patient an enema and a bath. The former procedure 118 
MANAGEMENT OF LABOR 
should be carried out in practically every case, unless the 
patient is too far advanced in labor when first seen. If a 
woman is allowed to go through labor without having her 
lower bowel thoroughly emptied, one of two things is likely 
to happen, if not both. Either the mass of fecal matter will 
obstruct the full stretching of the vagina, or some of it will 
be squeezed out with each pain during the descent of the 
head through the lower vagina, soiling the obstetrical field 
of action and perhaps bringing infection. It is, moreover, 
extremely disagreeable to the patient to have the additional 
discomfort of feeling the bowels move during the birth of 
the child. 
The bath is often omitted in the case of private patients, 
but it may be sadly needed in hospital and out-patient prac- 
tice. In any case the vulva, thighs, buttocks and lower 
abdomen should be thoroughly cleansed with soap and water, 
and the vulva further cleansed with an antiseptic solution 
such as bichloride of mercury (1:2000) or lysol (1 per cent 
solution). If a bath is given, the greatest care should be 
taken to prevent the water from entering the vagina, since 
it may carry infection. It is therefore better not to let the 
patient sit in the water. A gentle shower may be used, water 
may be poured over the patient as she stands in the tub, or a 
simple sponge bath may serve all purposes. 
Hospital routine usually includes the shaving of the pubic 
hairs, especially where they run back along the sides of the 
vulva, since it is quite impossible to make the hairs aseptic- 
ally clean, and moreover, blood, vaginal discharge or fecal 
matter may cling to them and serve as the starting-point 
for an infection. In country or dispensary practice it is not 
always practicable to have the parts shaved, but at least 
the hairs about the vulvar opening can be clipped short with 
scissors. MANAGEMENT OF SECOND STAGE OF LABOR 
119 
It was at one time the custom to give an antiseptic vaginal 
douche as part of the preparation for labor, with the idea that 
the solution would destroy any bacteria which might have 
entered the vagina. While some physicians may still follow 
this routine, the general consensus of opinion now is that a 
douche should not be used, as it probably does more harm 
than good by washing out the vaginal secretion which is 
the natural protection against bacteria, as well as possibly 
carrying organisms in from the vulva on the douche nozzle. 
The only exception to this rule is in the case of a gonorrheal 
discharge.' Since the vaginal secretion has no effect on the 
gonococcus, no harm is done by removing it, and the douche, 
by washing out the discharge and cleansing the vagina, may 
prevent the child's eyes from being infected during the birth. 
A nurse should never give a douche without a doctor's order. 
After the patient has been prepared, she should put on 
clean underclothes and a loose and comfortable dressing- 
gown, and try to occupy herself in some way so as to take 
her mind off herself. It is a great mistake to put a patient 
to bed at the beginning of the first stage of labor, for the 
pains are not as effective when she is lying down and she 
grows tired of the bed before the second stage, when she 
should be kept there. Patients who have been put to bed 
too early often become restless and insist on getting up 
during the bearing-down pains. Toward the end of the 
first stage the woman is usually more comfortable in bed. 
Before she goes to bed her hair should be braided in two 
braids; this can be done as a part of the preparation, if 
desired. 
Management of the Second Stage of Labor.-As soon as the 
second stage of labor has begun, the patient is put to bed, 
and not allowed to get up again for fear that the child may 
be expelled unexpectedly. Even though she wishes to get up 120 
MANAGEMENT OF LABOR 
only for the purpose of going to the toilet, this must not be 
permitted and a bed-pan must be used instead, as the some- 
what squatting position and the straining efforts of moving 
the bowels may push the child out before she realizes what 
is happening. Many cases are on record in which the baby 
was born in this way, through sheer accident, and not a few 
in which the mother has attempted to conceal the birth of 
the child or destroy its life by letting it be born in a privy or 
water-closet. It may be necessary to watch very carefully 
a woman who is illegitimately pregnant, although it is only 
fair to say that in most cases she is ready to go through the 
ordeal bravely enough, however hard the circumstances may 
be. 
It is usual to have the patient lie on her back throughout 
the second stage of labor, although some obstetricians prefer 
to have her turned on her side at the time of the actual 
delivery. This means that she will be kept in one position 
from one to three hours in many cases, and it is not to be 
wondered at that she becomes cramped and uncomfortable 
and suffers from backache which may annoy her almost 
more than the pains themselves. It is true that the dorsal 
position makes it easier for the woman to use her abdominal 
muscles in bearing down, but she may certainly be allowed to 
take other positions, turning from side to side between the 
pains, and while she is on her side the nurse has a chance to 
make her more comfortable by rubbing her back. If the 
patient lies for a long time with her knees flexed, she may be 
troubled with agonizing cramps in her legs; these also are 
relieved by a change of position and rubbing. She is likely 
to become very weary from the repeated straining, and if 
the room is warm, as it is so often the case in a hospital, she 
may be almost bathed in perspiration, while her mouth 
and lips become dry and parched. A thoughtful nurse will MANAGEMENT OF SECOND STAGE OF LABOR 
121 
watch her patient and see that her face is sponged off with 
cool water. If it is not practicable to give her something 
to drink, because an anesthetic is to be used, she can at least 
moisten her lips and rinse out her mouth. Any little atten- 
tions like these make a great difference in the comfort of the 
patient and help her in going through the strain of labor. 
When the pains come, the patient should be encouraged to 
make the best use of them in every way. Some women, 
particularly if it is their first experience, actually do not know 
how to bear down in the most effective way, and must be 
shown or aided. It is often a help to have something to 
pull on, and the first instinct of the patient is to grasp the 
hand of the nurse or any other person who may be at the 
bedside, but as this is fatiguing to all concerned, it is better 
to arrange some mechanical contrivance. Straps with 
handles are used in most hospitals, but where these are not 
available, a very satisfactory substitute can be made with 
a twisted sheet passed around the foot of the bed. It must 
be carefully explained to the patient that she must bear down 
only during the pains, as she will sometimes keep on strain- 
ing after the pain is over, accomplishing nothing and only 
wearying herself needlessly. As the head begins to emerge 
from the vagina she should be told to take short breaths and 
not push hard, for a strong bearing-down pain at this point 
may send the head out so suddenly and with such force that 
a bad laceration is the result. The use of an anesthetic, to 
relax the patient as well as to save her the last severe pains, 
is well worth while. 
Posture.-The position of the patient during this stage 
deserves special consideration. When the head is slow to 
engage or pass through the superior strait, a posture is used 
which makes more room for it by opening the pelvic inlet a 
little farther. This is the Walcher position, in which the 122 
MANAGEMENT OF LABOR 
woman's hips are brought to the edge of the bed and the 
legs allowed to hang over it. It has the disadvantage of 
being so uncomfortable that the patient cannot long remain 
in it, but it can be repeated at intervals. 
Fig. 60.-Walcher position. (Bumm.) 
Among primitive peoples the woman squats on the ground 
during the second stage of labor, because in that position 
the abdominal muscles can be used to the best advantage, 
with the knees pressed against them and reinforcing their 123 
MANAGEMENT OF SECOND STAGE OF LABOR 
action. We have long since adopted the idea that a woman 
should be in bed at the time of her delivery, yet we must 
try to utilize the principle of the squatting position to make 
the pains more effectual. This we do by placing her on 
her back with her knees flexed, when she is having the 
expulsive pains. When the head has reached the pelvic floor, 
its expulsion is made easier if she takes the lithotomy posi- 
tion, with the thighs flexed on the abdomen. This corre- 
sponds more nearly to the squatting position, and moreover 
it increases the size of the pelvic outlet a little, just as the 
Walcher position increased the inlet. 
During the actual delivery the patient lies either on her 
back or on her side, according to the preference of the 
obstetrician. When she is on her side she cannot bear down 
as well as in the dorsal position, and this is sometimes an 
advantage, when there is danger that the head will be expelled 
too rapidly. It is routine with some physicians to deliver 
primiparae in the lateral and multiparse in the dorsal position. 
As the head pushes down lower in the pelvis, it makes 
pressure on both the urethra and the rectum, through the 
vagina. Sometimes the pressure prevents the emptying of 
the bladder, which may become so full that it bulges above 
the symphysis like a tumor and in neglected cases reaches 
almost to the umbilicus. There is always danger in such 
overdistention of the bladder, but in an obstetrical case 
there is the special difficulty that it will act as an obstruc- 
tion to the passage of the child's head. If the patient can- 
not void her urine, she must be catheterized, and the result 
is often to shorten what seemed like a serious delay in the 
second stage of labor. The nurse should be on the lookout 
for this complication and report to the physician when it 
occurs. If a patient must be catheterized during labor, a 
rubber catheter should be used, because a glass one may be 
broken in the attempt to push it past the head. 124 
MANAGEMENT OF LABOR 
If the patient has not had an enema, feces may be squeezed 
out of the rectum at this stage-of the process. If this hap- 
pens, the material must be carefully wiped away and sterile 
gauze or a sterile towel laid over the anus. In any case the 
opening will bulge until the mucous membrane is easily seen, 
as in a case of prolapse of the rectum. If the pressure 
continues too long, hemorrhoids sometimes result. 
In the average case the doctor is called as soon as the 
second stage begins. It is, therefore, a matter of import- 
ance for the nurse to learn to recognize the change in the 
character of the pains which ushers in this stage. It is not 
enough to wait for the rupture of the membranes, for while 
in many cases this does occur at the end of the first stage, it 
may also be delayed until just before the child is born or, as is 
well known, the baby may even be born in the unruptured 
membranes or caul. 
The physician should always be informed of the rupture 
of the membranes, however, whether this comes early or 
late, since the cord may slip down with the gush of fluid, 
giving rise to one of the most serious accidents of labor. If 
the physician is at hand, he will usually examine after the 
escape of the fluid, to assure himself that this has not hap- 
pened. If he is not within reach, the nurse will do well to 
listen frequently to the fetal heart, since pressure on the 
cord is shown by failing heart tones. The treatment of this 
complication will be described later. 
If the nurse is left in charge of the case in the doctor's 
absence, with instructions to report to him, she should ask 
for most explicit directions concerning what she is to report 
and when. In every case it will be her duty to watch the 
condition of both mother and child, and to notify the obstet- 
rician if things are not going well. It is equally important 
to report slow, nagging, ineffectual pains and those which MANAGEMENT OF SECOND STAGE OF LABOR 
125 
are too violent, since both types are exhausting to the 
patient. The character and rate of the mother's pulse are 
a reliable guide to her condition; a pulse of over 100 between 
the pains is too rapid. Danger to the fetus is shown by weak, 
irregular heart beats, growing either fast or slow. The 
passage of meconium must always be reported at once, since 
it means either a breech presentation, which the nurse 
should not be expected to handle alone, or beginning asphyxia 
of the child. 
When the physician is in the house, especially if the case 
is lasting into the night, he will often ask the nurse to watch 
the patient while he rests, and to call him in time for the 
delivery. Under these circumstances it is customary to 
wait until the descent of the head is shown by the separation 
of the labia and the opening of the introitus with a pain, the 
bulging of the perineum and the protrusion of the rectum. 
The advance of the head can also be ascertained by palpation 
through the perineum, with the patient in the dorsal position. 
As soon as the nurse has notified the obstetrician, she will 
get everything in readiness for the delivery. The patient 
is placed in the dorsal or left lateral position, according to the 
doctor's order. The vulva is once more carefully cleansed, 
the sterile leglets are drawn on, a sterile sheet or towel is 
laid beneath her and another across her abdomen. Sterile 
sponges or squares of gauze and sterile towels are laid within 
the reach of the obstetrician, also the cord instruments, the 
bobbin and the cord dressing. Meanwhile the physician has 
been scrubbing up, and will be ready to put on the sterile 
gown, cap and gloves with the nurse's assistance. As soon 
as he has assumed charge of the patient, the nurse will be 
free to see that everything is ready for use at a moment's 
notice. These last preparations will include the arrange- 
ment of the baby's basket, with a hot-water bottle; the 126 
MANAGEMENT OF LABOR 
outfit for the intra-uterine douche; a sterile hypodermic 
syringe; the droppers and solutions for the eyes; and what- 
ever might be needed for the resuscitation of the child. 
Management of the Delivery of a Normal Case.-There are 
so many chances of an unexpectedly sudden delivery before 
the arrival of the physician that a nurse who intends to take 
many obstetrical cases should make herself familiar with the 
management of a normal delivery, in order to be able to act 
in an emergency. 
When the head reaches the pelvic floor, it will be noticed 
that the labia begin to separate a little at the height of each 
pain and that there is slight bulging of the perineum. This 
separation becomes more marked and the vagina then begins 
to gape open with the pains, until little by little the head 
appears, only to recede as the pain subsides. After arrang- 
ing the patient for delivery as has been already described, 
the nurse disinfects her hands and puts on a sterile gown and 
sterile gloves. She then takes her place at the right side of 
the bed, with sterile towels and gauze and the cord instru- 
ments within easy reach. 
There are two points to be remembered in the manage- 
ment of the delivery: (1) That the head must be prevented 
from passing through the vaginal opening too fast, in order 
to guard against perineal tears; and (2) that the birth must 
not be so delayed as to endanger the life of the child. The 
simplest method of protecting the perineum from laceration 
is to hold the left hand firmly over the vaginal orifice and 
press against the head as the pain drives it down, letting it 
advance only enough to dilate the vulva a little each time 
until the opening is large enough to let it come through. 
With the right hand pressure is made through the perineum, 
to help the extension of the head. While the head is actu- 
ally emerging, the patient must not be allowed to bear down MANAGEMENT OF DELIVERY OF NORMAL CASE 
127 
too hard, lest a sudden expulsive movement send the head 
out before it can be controlled. If no anesthetic is avail- 
able, the patient should be directed to take short, panting 
breaths, so that she cannot strain with so much force. ' 
Fig. 61-Head under control. Patient deeply anesthetized for a few 
moments. The towel in the photograph has been allowed to slip back 
to show the position of the anus. In practice the lower gloved hand should 
be covered with a sterile towel. (Cragin.) 
As soon as the head is born, the nurse will feel for the cord, 
as it is not at all uncommon to find it around the child's 128 
MANAGEMENT OF LABOR 
neck. If there, it should be slipped over the head, so that 
there will be no danger of its being drawn tight about the 
neck while the birth is being completed. Sometimes there 
are two or three coils, or even more. When the cord is so close 
about the neck that it cannot be brought over the head, it 
may be necessary to clamp it in two places and cut between 
the clamps, if it is interfering with the delivery. When the 
head begins to swing around so that the occiput is turned to 
the side, it is a sign that the shoulders are about to rotate, 
and that they can be extracted. The patient may be allowed 
to bear down gently to bring the shoulders to the vulvar 
opening, but if she cannot control her movements, it may be 
better to extract them between the pains, to avoid tearing 
the perineum. The child's head is grasped by the chin and 
the occiput, and drawn downward, to bring the anterior 
shoulder close under the symphysis, and the posterior 
shoulder is then guided out over the perineum. When this 
has emerged, the anterior is allowed to slip out, and the 
whole body will follow easily. Occasionally the shoulders 
are so firmly wedged (impacted, is the obstetrical term) 
that considerable force is necessary to dislodge them, and it 
may even be necessary to make traction in the axilla in a 
difficult case, but this should be avoided, because of the 
danger of causing paralysis of the arm from pressure on the 
nerves. 
Anesthesia in Labor.-There are still people who hold to 
the old idea that a woman must bring forth her children 
in sorrow, and that no effort should be made to assuage 
her sufferings, and occasionally women will refuse the relief 
afforded by an anesthetic on account of their religious beliefs; 
but the general practice of our modern days is to use an 
anesthetic as a routine, at least in the second stage, unless 
the labor is short or the pains not severe. It has already ANESTHESIA IN LABOR 
129 
been stated that its use not only spares the woman much 
suffering but also shortens the process of labor and lessens 
the danger of lacerations by relaxing the muscles and other 
tissues. 
In the first stage of labor, when the pain is intense and 
the dilatation slow, other means are used for this purpose. 
Opium, either as a suppository (| to 1 gr.) or in the form of 
morphine by hypodermic (| to | gr.), is in common use, 
and chloral, 15 to 20 gr. (given in milk, by rectum, on account 
of its irritating qualities) is an old and tried remedy. The 
anesthetics in use at the present time are: 
1. Chloroform. 
2. Ether. 
3. Nitrous oxide and oxygen. 
4. Scopolamin and morphine. 
Chloroform.-Chloroform as an anesthetic in labor was 
introduced by the English obstetrician, Simpson, and because 
he used it when in attendance on Queen Victoria, this method 
of relieving the pain of labor has been called confinement 
" a la reine." For some reason it is a more popular anesthetic 
abroad than in the United States, and in this country it is 
more often used in the south than in the east and north. It 
is true that as a general anesthetic chloroform has certain 
dangers, but as administered in obstetrical cases it is safe 
enough, because the patient is kept under its influence for 
so short a time and gets enough air for safety. The method, 
of administration is to pour a few drops on an Esmarch 
inhaler (or on a piece of folded gauze) just at the beginning 
of a pain and let the patient breathe it in until the pain is 
over. With the suffering dulled in this way the woman 
bears down more effectively and the parts become relaxed. 
Between the pains she receives none of the anesthetic until 
just as the head is passing over the perineum, when the 130 
MANAGEMENT OF LABOR 
anesthesia may be deepened so that she is unconscious at 
the moment of the delivery. It is seldom advisable to give 
chloroform before the second stage. 
Ether.-Ether is administered in much the same manner 
as chloroform, but its action is not as rapid and more is 
needed to bring about the desired result. If too much is 
given, the contractions may be interfered with and the 
patient cannot bear down as well. The danger of having 
ether near an open flame must never be forgotten. Ether 
is probably the most commonly used of the above anesthetics, 
at all events, in this country, and it is the anesthetic of choice 
for obstetrical operations. In such cases the patient is 
anesthetized as for any other operation. Although the 
anesthesia must be deep enough to relax the patient thor- 
oughly, it is a common experience to find that less ether is 
needed for obstetrical operations, probably because the 
woman is tired from the strain of labor and is therefore more 
easily brought under the influence of the anesthetic. 
Nitrous Oxide.-Nitrous oxide, the familiar "laughing 
gas" of the dentists, is not a satisfactory anesthetic unless 
mixed with oxygen. This combination has been suggested 
as effective and safe in obstetrical cases and excellent results 
have been reported. It is not widely used on account of 
the somewhat cumbersome apparatus, which cannot be 
easily carried outside of a hospital, and its expense. Like 
ether and chloroform, the gas is given with the pains, to 
relieve the patient's suffering without rendering her 
unconscious; unlike them, it can safely be begun during the 
first stage. It should be administered only by a trained 
anesthetist. 
Scopolamin-morphine.-The scopolamin-morphine method 
is better known by its popular name of "twilight sleep." It is 
also called the Freiburg method, because its technic was ANESTHESIA IN LABOR 
131 
perfected at the hospital there by Kronig and Gauss. In 
spite of the widespread publicity which it received a few 
years ago, it is not regarded with favor by most obstetricians 
in this country, although it has some enthusiastic and firm 
adherents. It should really be called amnesia rather than 
anesthesia, because the result of the treatment is loss of 
memory of the pain suffered and not actual abolition of the 
pain, although this is somewhat lessened. The patient often 
has all the appearance of great suffering, perhaps becoming 
very restless or even violent or delirious, and it is hard to 
believe that the experience is not being impressed upon her 
mind. 
While the success of the method depends largely on its 
adaptation to each individual case, according to the condi- 
tions which may arise, the technic in general may be described 
as follows. After the first stage of labor is well established, 
with the pains coming not more than five minutes apart, the 
patient receives a hypodermic injection of morphine (gr. |) 
and scopolamin (gr. Three-quarters of an hour to an 
hour later a second dose is given, but this time the morphine 
is omitted and only gr. of scopolamin is used. This is 
repeated in about an hour. After this the dosage is regu- 
lated by the patient's condition. The idea is to keep her 
sufficiently under the influence of the drugs to be oblivious 
to what is going on about her, without becoming actually 
unconscious. Certain tests of her memory are tried from 
time to time, so that the physician may know when it is 
necessary to repeat the injections. In order to heighten the 
effect of the drugs, the room is darkened and kept absolutely 
quiet and the patient's eyes may be covered. The obstet- 
rician must be almost constantly in attendance. 
It can be easily understood that this method is one which 
requires the greatest care in the administration of the drugs 132 
MANAGEMENT OF LABOR 
and the most watchful observation of the patient. As an 
overdosage is likely to cause asphyxiation of the child, the 
fetal heart must be frequently counted and all preparations 
must be ready for an operative delivery, should signs of 
danger arise. The baby is often born in a condition called 
oligopnea, in which it makes no effort to breathe, although 
it is not in a state of true asphyxia. The method must be 
set down as dangerous except in the hands of those specially 
trained in its technic. 
The nurse's part in obstetrical anesthesia may be an 
important one, as she is often asked to give the chloroform 
or ether. Unless she is a trained anesthetist she will not be 
expected to administer nitrous oxide, and "twilight sleep" 
is always directed by the obstetrician. 
Care of the Newborn Child.-As soon as the baby is born, 
if it is breathing well, it is laid on its right side between 
the mother's feet, to wait until the pulsation in the cord 
has stopped. If there seems to be much mucus in its throat, 
the head may be lowered to let it run out more easily. As 
long as the cord continues to pulsate, we know that blood is 
passing from the placenta to the child's circulation, and as 
the quantity of blood may amount to an ounce or two, it is 
better to let the child have the benefit of this additional 
nourishment. When the pulsation ceases, the cord is tied 
and cut. 
The umbilical tape or bobbin which is used for tying the 
cord can be obtained ready-sterilized in envelopes or small 
glass containers from any surgical-supply house, or narrow 
tape can be cut into lengths of ten to twelve inches, and 
sterilized by the nurse beforehand. In an emergency a 
piece of narrow tape or a strong twisted thread can be 
used after boiling it or soaking it in an antiseptic solution. 
The tie is placed one-half inch beyond the skin of the umbil- CARE OF THE NEWBORN CHILD 
133 
icus, and the knot, which must be a square knot, is drawn as 
tight as possible, to make pressure on the vessels through 
the soft Wharton's jelly. As someone has said, "Tie it as 
tight as you can, and then a little tighter." To make 
assurance doubly sure, the ends of the tape should be carried 
to the other side of the cord and tied a second time. Great 
care should be taken not to pull on the cord, and in tying it 
the thumbs should be held close to the knot, to avoid a jerk, 
if the child should move. Another tie or a clamp is placed 
about an inch further away from the child's body and the 
cord is cut between them. Ordinary straight scissors can 
be used, but special scissors are made for the purpose. Their 
blades are curved so that they fit around the cord and their 
points are blunt for greater safety. In any case the child 
should be protected from any possible injury by laying the 
back of the hand on the abdomen and letting the cord come 
through between two of the fingers while it is being cut. 
The next step is to scrub off the stump of the cord two or 
three times with a piece of sterile gauze, watching carefully 
to see whether there is any oozing from the vessels. If none 
is seen, the stump is swabbed with alcohol and a sterile 
gauze dressing applied, with a sterile abdominal band out- 
side of it. The dressing consists of a few layers of square 
gauze, slit to the center on one side, so that it can be folded 
about the umbilical stump. Sometimes the cord is passed 
through a hole in the center of the dressing. 
Eyes.-The treatment of the eyes is an important part 
of the routine care of a newborn baby, because it prevents 
the development of any infection which may have been 
acquired from organisms in the mother's vagina. Ophthal- 
mia neonatorum, or gonorrheal ophthalmia, the inflammatory 
condition of the eyes caused by the gonococcus, is the most 
dangerous of these infections, and is responsible for so many 134 
MANAGEMENT OF LABOR 
cases of blindness that preventive treatment is required by 
law in some places. An efficacious method now in common 
use was introduced by Crede, of Leipzig, in 1884. 
Fig. 62.-Treating the baby's eyes. The cotton pledgets are omitted to 
make the picture clearer. 
The Crede treatment consists in dropping 1 drop of a 1 
per cent solution of silver nitrate into the baby's eyes, fol- 
lowing it with free flushing with boric acid solution. The 
child's head is turned to one side, so that the fluid used in 
one eye cannot possibly run into the other. The eyelids 
are held apart with pledgets of sterile cotton, and 1 drop of 
the silver nitrate solution is dropped into the eye. On 
account of the possible irritation from the silver solution the 
eye must be flushed with normal salt solution or boric acid 
immediately afterward. If the silver nitrate solution is too 
strong, if too much of it is used, or if the eye is not well 
flushed afterward, an inflammatory reaction known as CARE OF THE NEWBORN CHILD 
135 
"silver catarrh" is likely to follow. After one eye has been 
thus treated, the baby's head is turned to the other side and 
the other eye treated in the same manner, fresh pledgets 
being used to hold it open. In some clinics one of the 
so-called organic compounds of silver, such as argyrol (20 
per cent) or protargol (10 per cent) is used in place of the 
silver nitrate. They are less irritating and need not be 
followed by the free flushing; they are also more expensive. 
After the eyes and cord have been treated, the child is 
wrapped in a blanket and laid in a crib or basket or some 
safe spot, where it cannot roll off and nothing will be laid 
on it. The mother's bed is a poor place. A hot-water bottle 
is put under the baby. This must not be too hot and must 
not come in contact with the child's skin, and the blanket 
between it and the child must not be wet. The bottle must 
be tested for possible leaks before using, and its cap screwed 
in tightly. Too much emphasis cannot be laid on these 
points. Failure to observe them has been the cause of serious 
burns. 
As an active infant may become uncovered by moving 
about, the child should be inspected frequently. In some 
hospitals the baby is put into a flannel bag before being 
wrapped in the blanket. As the warmth of the crib some- 
times starts an oozing from the cord, the dressing should 
also be inspected at frequent intervals. The child's color 
and respiration should also be watched, especially if measures 
of resuscitation were required. As soon as the mother has 
received all the necessary attention, and can safely be left 
alone, the nurse takes charge of the baby again, and oils 
its body thoroughly to remove the vernix caseosa before 
bathing it. It goes without saying that every newborn 
infant should be examined carefully for any malformations 
or birth injuries. 136 
MANAGEMENT OF LABOR 
Management of the Third Stage of Labor.-If the hand is 
placed on the uterus as soon as the child is born, it will be 
found that the fundus has sunk below the umbilicus, where 
it remains while the placenta is separating. If the separa- 
tion is according to the Duncan mechanism, there will be a 
slight steady flow of blood from the vagina, which is normal 
Fig. 63.-Crede or Dublin method of expressing the placenta. (Bumm.) 
and should give no cause for alarm as long as no great amount 
is lost. When the placenta has become detached, the fundus 
rises to the umbilicus or even above it, and the cord may 
slip down through the vulvar opening. If the woman has 
a very thin abdominal wall, a slight bulging above the sym- 
physis may be seen as a sign that the placenta has descended MANAGEMENT OF THE THIRD STAGE OF LABOR 
137 
into the lower uterine segment. It is important to learn to 
recognize when the separation has taken place, because 
although the expulsion should be accomplished spontane- 
ously, experience has shown that it frequently requires 
assistance. If there is no result from the bearing-down 
efforts of the patient, the fundus should be kneaded a little 
to insure its firm contraction, and then grasped with the 
thumb in front and the four fingers behind it; firm pressure 
is then made obliquely downward in the direction of the 
pelvic cavity, until the placenta is pushed out of the vagina. 
This method is commonly called by the name of Crede, 
but should really be known as the Dublin method, since it 
was first practised at the Rotunda Maternity Hospital in 
that city. It must be clearly understood that this pro- 
cedure is used to express the placenta after it has separated, 
and not as a means of detaching it. 
Whether the placenta is expelled spontaneously or thus 
aided, a hand must be ready to receive it as it emerges from 
the vagina, as otherwise it may be pushed out too fast, and 
by falling suddenly it may tear through the membranes and 
leave a piece of them behind in the uterus. If, as sometimes 
happens, the membranes or a part of them remain adherent 
to the uterine wrall or are caught in the cervix, it may be 
necessary to make slight traction to release them. This is 
best done by twisting them into a cord, to prevent their 
tearing when the traction is made. Sometimes gentle tap- 
ping on the lower segment of the uterus just above the 
symphysis will help. The placenta and membranes should 
always be carefully examined to see that no portion of them 
has been left behind. They are then placed in the pan or 
other receptacle which the nurse has ready at hand. 
Once the placenta is completely expelled, the uterus will 
in normal cases contract still further, until the fundus is 138 
MANAGEMENT OF LABOR 
three or four fingers' breadth below the umbilicus, and the 
bleeding is then comparatively slight. If, however, there 
is any tendency to relaxation, massage is used to stimulate 
contraction and a dose of ergot (1 dr. of the fluidextract, 
by mouth) is given. As a further measure an ice cap may be 
placed over the fundus. The use of ergot is routine with 
many obstetricians, while others give it only if the bleeding 
is too free. If the patient is to be left with only her family 
to look after her, as must often be the case in a hospital 
out-patient service, it is safer to give the medicine and even 
to leave an additional dose to be taken an hour or two later. 
The nurse should inquire beforehand as to the routine of 
the physician. It is a safe rule to remain with the patient 
at least an hour after the delivery of the placenta, to guard 
against possible hemorrhage. During this time the fundus 
should be palpated from time to time to assure its firm con- 
traction, and the discharge from the uterus should be 
observed. The pulse-rate should also be noted, as a rapid 
pulse sometimes gives warning of concealed bleeding. 
Care after Delivery.-As soon as the placenta has been 
expelled, if there are no sutures to be taken and the baby does 
not require special attention, the mother is made comfort- 
able. Even though she may be feeling no more pain, she 
is often cramped from keeping one position for so long a time, 
sore from the straining efforts, and wet, cold and thor- 
oughly uncomfortable from lying on a wet pad or, as is 
sometimes the case, in a pool of fluid. 
All the soiled dressings, sheets and towels are now removed 
with the draw-sheet, and the patient's thighs, buttocks 
and vulva thoroughly cleansed and carefully dried. A clean 
bed-pad is placed beneath her and a sterile pad is laid over 
the vulva, held in place by a T-binder. If the physician's 
practice is to use an abdominal binder, this is applied and the ASPHYXIA OF THE CHILD 
139 
pad pinned to it. A fresh night-dress is put on, which has 
been warmed if the weather is cold. In any case the patient 
should be well covered and a hot-water bottle placed at 
her feet, as there is often a reaction after the delivery and 
the woman may even have a postpartum chill. A hot drink 
is often very comforting, unless she has been deeply anes- 
thetized. The use of an opium suppository by rectum is 
part of the routine after-care with some physicians, as it 
quiets the patient and gives her a good chance of getting to 
sleep. Whether it is used or not, rest is what she needs, 
and the nurse should see to it that the members of the family 
do not disturb her after the first congratulations are over. 
Meanwhile there are three things to be watched during the 
first few hours after delivery-the pulse, the fundus and the 
amount of bleeding. If any of these presents signs of hemor- 
rhage, the nurse must report at once to the doctor. Some 
obstetricians order a routine dose of ergot, to be given in an 
hour or two, especially if the woman has a tendency to more 
than a normal amount of bleeding. The puerperium chart 
is begun as soon as the patient is comfortably arranged, with 
the temperature, pulse and respiration and the amount of 
discharge as the first items. 
Asphyxia of the Child. Resuscitation Measures.-Asphyxia 
of the child is to be looked for in any case in which during 
labor there is prolonged pressure on the child, pressure of 
even short duration on the cord, separation of the placenta, 
or long anesthesia. The condition shows itself before the 
baby is born, by marked irregularity or weakness of the 
heart beat and changes in its rate between the pains. It 
must be remembered that it is normal for the rate to change 
during the pains. The passage of meconium is also a sign 
of asphyxia in a head presentation, as it means that the 
sphincter of the anus is becoming relaxed. In a breech Fig. 64.-Byrd-Dew method. Flexion. 
Fig. 65.-Byrd-Dew method. Extension. ASPHYXIA OF THE CHILD 
141 
presentation meconium is often squeezed out by the pressure 
of the birth canal, as the breech descends, and its passage 
does not necessarily mean asphyxia. 
There are two types or, we might better say, two degrees 
of asphyxia, since in the more serious variety the condition 
has simply progressed further. In the first stage, asphyxia 
livida, the child looks purple and congested and the muscles 
are stiff. It may not be breathing at all, but is perhaps 
giving an occasional gasp. In the second stage, asphyxia 
pallida, the baby is white and limp, it makes no effort to 
breathe, and the heart is beating only faintly. This is a 
grave condition. 
Treatment.-The treatment of asphyxia depends on the 
stage which it has reached. In asphyxia livida it may be 
enough to hold the child up by the feet to let the secretions 
or mucus run out of its mouth, and then stimulate the 
respiration by rubbing the body or giving a few light slaps 
across the buttocks. If there is much mucus in the mouth, 
it may be wiped out with a bit of gauze wrapped around the 
little finger, but this must be done gently, as the mucous 
membrane of the mouth is easily injured. If the air-pas- 
sages are seriously blocked, the tracheal catheter or aspira- 
tor is used to draw the fluid out. A splash of cold water 
or a little ether poured on the chest will sometimes start 
the respiration. A common method of treatment is to place 
the baby alternately in a hot and cold bath, but this is too 
much of a shock for a deeply asphyxiated child, and in such a 
case a better method is to keep it in the warm bath and rub 
its chest with a piece of ice or splash the cold water on it. 
If these simple measures are not effective, some kind of 
artificial respiration must be used. The Sylvester method, 
so commonly used for adults, is not as satisfactory for a new- 
born infant. The Byrd-Dew method, or one of its modi- 142 
MANAGEMENT OF LABOR 
fications, is as effective as any. In this the baby's head is 
supported by putting the thumb and forefinger of one hand 
around its neck, while the other three fingers are under its 
back; the other hand holds the child's knees. The knees 
and chest are then brought together by flexing the body, to 
give the motion of expiration, and full extension of the 
body expands the chest and acts as inspiration. This alter- 
nate flexion and extension are repeated at regular intervals, 
about twelve times a minute. Too much force should not 
be used, as the child may be injured. In order to avoid 
chilling the child's body the manipulation may be performed 
with the baby in the hot bath or wrapped in a warm blanket. 
Prochownik's method is to hold the child inverted, with 
its head just touching the bed or table so that it is slightly 
extended, and then to compress the chest lightly at regular 
intervals. This also favors the escape of fluids from the 
air passages. The Schultze swinging method is compara- 
tively little used, because of the danger of hurting the child 
during this vigorous maneuver. 
A simple method is rhythmical traction on the tongue 
with a hemostat or suture, while the child lies with its head 
hanging over the edge of a table; this can also be done in the 
warm bath. 
The pulmotor or lung motor is used by some physicians, 
but is not, as a rule, found outside of a hospital. 
Oxygen may work wonders. It is given through a funnel 
held over the baby's face. Unfortunately it is seldom 
available in the home. In an emergency, the respiration 
has often been started by direct insufflation-breathing into 
the child's mouth to expand the lungs and compressing the 
chest to force out the air. Care must be taken not to inflate 
the stomach. 
If the child is in a state of pallid asphyxia, the measures ASPHYXIA OF THE CHILD 
143 
of resuscitation must be of the gentlest, as the more vigor- 
ous methods may even turn the scale against it. The baby 
must be kept as warm as possible in the warm bath or in hot 
blankets, and the application of cold is absolutely contra- 
indicated. The air passages should be cleared and artificial 
respiration, by the Byrd-Dew method or mouth-to-mouth 
insufflation, begun at once. Oxygen is particularly valuable 
in these cases. If the heart action is very weak, the doctor 
Fig. 66.-Administration of oxygen. 
may order a small dose of some heart stimulant, such as 
strychnine, ether, brandy or camphorated oil, to be given 
by hypodermic. The efforts at resuscitation must not be 
relaxed as long as there is even the faintest flicker of a heart 
beat, as the most desperate cases will sometimes respond 
after all hope has been abandoned. 
After the respiration has been established, if the case has 
been one of pallid asphyxia, the baby must be carefully 144 
MANAGEMENT OF LABOR 
watched for some hours, as the respiration may grow weaker 
and fail, if no additional care is given. The child must be kept 
especially warm, and the hot-water bottles in its crib renewed 
as fast as they become cool. Oxygen should be at hand, 
to be administered if the infant becomes at all cyanosed. 
The bath must be postponed until there is no danger to be 
feared from cooling the body surface, and the baby should 
be gently rubbed with warm oil instead. 
If the child is premature, the measures of resuscitation to 
be employed are those suited to a case of asphyxia pallida, 
since the baby is often-too weak to stand much handling. CHAPTER VI. 
COMPLICATIONS OF PREGNANCY. 
Vomiting of Pregnancy.-Nausea and vomiting are so com- 
mon in early pregnancy as to be considered among its diag- 
nostic signs. The familiar name of "morning sickness" 
gives the clinical picture, since it is in the morning that the 
patient is thus troubled. If she remains in bed until after 
her first meal and takes but a light breakfast, she may be 
able to keep it down. One of the most important points 
in the treatment is rest after taking food. Laxatives and 
digestive mixtures may be helpful and cerium oxalate has 
long had a partially deserved reputation in the treatment. 
The patient should be encouraged by the assurance that the 
condition will not last long. 
Indigestion.-As the uterus rises in the abdomen and 
crowds against the stomach and intestines, symptoms of 
indigestion are likely to result. The greater the distention 
of the uterus, as by twins or hydramnios, the more trouble- 
some are the symptoms. The patient's most frequent com- 
plaint is "heart-burn." Sometimes a simple remedy like 
bicarbonate of soda or aromatic spirits of ammonia relieves 
the worst of the distress. 
Toxemia.-Toxemia has already been mentioned as one 
of the dangers of pregnancy*which can be largely controlled 
by prenatal care. It is due to a heaping up in the mother's 
system of waste products and perhaps actual toxins from the 
fetus, which are not carried off by her eliminative organs. 146 
COMPLICATIONS OF PREGNANCY 
Both the kidneys and the liver may be so affected by toxemia 
that serious degenerative processes set in. The signs and 
symptoms of a beginning toxemia are, as before stated, 
eye symptoms, headache, dizziness, constipation, scanty 
urine (showing albumin and often casts as well), edema and 
high blood-pressure. If the condition is neglected, the 
patient may become more and more drowsy and lethargic 
and finally die in coma. More often toxemia develops into 
eclampsia, a condition marked by severe convulsions. A 
grave type of vomiting is a less common phase of toxemia. 
Treatment.- The treatment of an early case of toxemia is 
largely hygienic. By restricting the diet and stimulating 
elimination the danger can often be warded off. The food 
must be light and easily digested, and plenty of fluid must 
be taken; it may be necessary to prescribe a milk diet. 
The bowels are kept moving freely and the output of urine 
is increased by diuretic drugs as well as by the fluids. Sweat- 
ing by hot baths or packs helps the action of the skin. 
Hyperemesis Gravidarum. Pernicious Vomiting.-Hyper- 
emesis is an exaggeration of the nausea and vomiting which 
are so common in pregnancy. It may be caused by some 
local trouble, such as a uterine displacement, or more often, 
is a manifestation of toxemia. A large number of cases must 
be set down to some nervous condition. The toxemic cases 
are the most serious. 
As the condition progresses, the nausea and vomiting, 
instead of passing off in the course of the morning, persist 
throughout the day. Soon there is vomiting when any sort 
of food or even liquid is taken, and finally the retching 
comes on at the slightest movement, or when the patient is 
lying perfectly still. She becomes emaciated and exhausted 
from the straining and vomiting and the loss of sleep; her 
mouth is dry and cracked, and thirst becomes agonizing; HYPEREMESIS GRAVIDARUM 
147 
jaundice may appear; the temperature and pulse-rate 
increase; blood or "coffee-ground" material are brought 
up in the vomitus. If not controlled, the condition results 
fatally. 
Treatment.-The time for treatment is early, before the 
vomiting has become pernicious. Diet is restricted to 
liquids, and very small amounts are given, perhaps only a 
teaspoonful at a time, until the stomach can tolerate more. 
Milk, albumen water, or Vichy, taken with ice, or just the 
opposite, hot water, milk or bouillon, should be tried. Some- 
times the most unlikely sort of food, such as meat, bacon 
or salty things, meet with unexpected success. The patient 
herself may suggest something for which she has a special 
craving. In cases with a marked nervous element the nurse 
can do a great deal by making an attractive-looking tray. 
If no nourishment is retained, the physician will stop the 
attempt to give food by mouth and will resort to rectal 
feeding or the use of saline or glucose solution by rectum or 
saline by hypodermoclvsis, to relieve the distressing thirst. 
Absolute quiet is essential in a serious case, and the patient 
may have to be kept in a darkened room. 
The list of drugs which have been suggested includes a 
large part of the pharmacopoeia, and although some may 
help, none can be counted on. Extract of corpus luteum is 
one of the newest remedies. Blood serum from a healthy 
pregnant woman has been used experimentally. Lavage 
of the stomach is worth trying. Gynecological procedures 
are occasionally successful. Finally there are cases in which, 
without any explainable reason, the trouble suddenly stops 
and never recurs. These are probably neurotic in origin. 
If the condition goes on from bad to worse in spite of all 
treatment, the physician will reluctantly decide to interrupt 
the pregnancy by performing what is called a therapeutic 148 
COMPLICATIONS OF PREGNANCY 
abortion. This is undertaken only when all other measures 
fail, and usually only after consultation with another obstet- 
rician, since the responsibility of destroying the life of the 
fetus is a grave one. 
Eclampsia.-By eclampsia we understand the occurrence 
of convulsions due to toxemia. These may come on during 
pregnancy, labor or the puerperium. In most cases the 
attack has been preceded by symptoms pointing to toxemia, 
but occasionally the convulsions begin so suddenly and 
unexpectedly that they fully justify the name eclampsia, 
which means a shining or flashing forth. 
The convulsive movements begin with a slight twitching 
of the face which spreads to other muscles until the whole 
body is thrown into violent spasms. The jaw becomes set 
and the tongue and lips may be badly bitten; blood-stained 
froth appears at the lips; the face becomes purple as the 
breathing is stopped by the spasm of the respiratory muscles. 
An eclamptic convulsion is so distressing to witness that it 
seems to be lasting a long time, but in reality the average 
duration is only about a minute. The spasm at last relaxes, 
and for a little while the woman lies unconscious, breathing 
heavily. After the first convulsion she soon regains con- 
sciousness and is apparently unmindful of what has happened, 
but if the convulsions recur, the periods of unconsciousness 
grow longer until she is in a state of coma from which she 
cannot be roused. Her face becomes so swollen and dis- 
colored that she may be actually unrecognizable. The pulse 
runs up and the blood-pressure is high, often around 200. 
The temperature may also rise. If the disease cannot be 
controlled by treatment, the patient finally dies in a con- 
vulsion or in deep coma. In some cases death is due to edema 
of the lungs. Even if the treatment is successful, the con- 
vulsions may be followed by a period of mental confusion, ECLAMPSIA 
149 
during which the patient screams and struggles and becomes 
quite unmanageable. This condition gradually clears up, 
but the woman is usually left without any memory of what 
has passed, and may not even remember the birth of the 
child. 
Treatment.-Since eclampsia is simply a late manifestation 
of toxemia, the preventive treatment is that already cov- 
ered under the heading of toxemia. It is summed up in the 
one word elimination. If the body can get rid of the poisons 
circulating through it before they have done too much 
damage, the toxemia will be controlled and there will be no 
eclampsia. 
Even after the convulsions have come on, elimination will 
still play a large part in the treatment. The lower bowel 
is emptied by a thorough flushing and vigorous purgation 
is started. Croton oil is a favorite prescription. It must 
be remembered that this is so powerful a drug that its dose 
is only 1 to 3 drops, and also that on account of its irritant, 
almost corrosive action, it must be well diluted and mixed 
with a full dram of olive oil. If this is introduced far back 
on the tongue, it will usually be swallowed, even though the 
patient seems to be unconscious. Castor oil and Epsom salts 
are also used. Lavage of the stomach is recommended. 
If this is done, the salts, dissolved in a glass of water, can be 
introduced directly into the stomach through the tube. 
The bladder is emptied by catheterization, the amount of 
urine measured and the specimen saved for examination. If 
the patient is sufficiently conscious to swallow easily, diuretic 
drugs are given. For more rapid action and for unconscious 
patients warm salt solution by rectum is more efficacious. 
The action of the kidneys may be further stimulated by the 
use of hot poultices over the loins or by cupping. Hot packs 
aid the elimination through the skin, but on account of their 150 
COMPLICATIONS OF PREGNANCY 
depressing effect they should not be continued for more than 
twenty or at most thirty minutes, and the patient must be 
closely watched and her pulse noted at short intervals. 
Every care must be taken to keep the patient from injuring 
herself during the convulsions, and some contrivance to pre- 
vent her biting her tongue and lips is absolutely necessary. 
A well-padded tongue depressor, mouth gag or clothes pin, 
or even a folded towel, will serve this purpose. 
Chloroform and ether were formerly used as a routine 
to control the convulsions, but have been largely abandoned 
because of their effect on the already damaged kidneys and 
their depressing action on the heart. Oxygen is given to 
relieve the cyanosis. 
Quiet is an essential part of the treatment. The neces- 
sary manipulations must be performed with the least possible 
disturbance to the patient, since a sudden noise or move- 
ment often brings on a fresh convulsion. 
Venesection may be performed by the physician to lower 
the blood-pressure and remove at least a small part of the 
poison in the circulation. The vein at the bend of the 
elbow is chosen. It may be punctured with a hollow needle 
or scalpel, or if small, must be dissected out first. As much 
as 1 pint (500 cc) of blood can be removed with benefit to 
the patient, but the amount is gauged by observing her pulse, 
blood-pressure and general condition during the process. 
The blood is often thick and dark and clots so quickly that 
the results are not satisfactory. To dilute the toxins in the 
system saline solution is introduced by hypodermoclysis or 
even intravenously, as well as by the rectum. 
There is great difference of opinion as to the wisdom of 
using sedative drugs, such as morphine, chloral, etc. . Vera- 
trum viride was once popular. 
Unless the patient responds promptly to treatment, the 151 
CONDITIONS IN THE UTERUS 
physician will go on to perform immediate delivery, by 
whatever operative means may be best suited to the par- 
ticular case. Even Caesarean section is used. 
It will thus be seen that the duty of the nurse, as soon as 
she has notified the obstetrician of the onset of the convul- 
sions, is to prepare for any of the above measures which 
he may order and have everything in readiness for an opera- 
tive delivery. If unable to reach a doctor, she can at least 
protect the patient from injury during the convulsions, 
give an enema and apply external heat. In keeping the 
patient's chart she should carefully record the time and 
duration of the convulsions, the pulse and temperature, and 
the quantity of urine passed, saving the specimen for the 
doctor to see. 
CONDITIONS IN THE UTERUS. 
Displacements.-Posterior displacements of the uterus give 
troublesome pressure symptoms during the first three months 
while the uterus is still a pelvic organ. In most cases a 
retroverted uterus will right itself as it rises out of the pelvis, 
but especially if it is bound down by adhesions, it may be 
held in the pelvis, crowded down under the promontory of 
the sacrum (incarcerated is the technical term) until abor- 
tion takes place. If recognized in time by the physician, 
the condition can usually be corrected so that the preg- 
nancy goes on to term. In neglected cases serious symp- 
toms may arise. Once more the moral is to avoid trouble 
by consulting the doctor early. 
After the uterus has risen up into the abdomen, it may be 
displaced anteriorly, if the abdominal walls are too weak to 
hold it up in good position. This state of things is often 152 
COMPLICATIONS OF PREGNANCY 
seen in women who have had a long succession of preg- 
nancies at short intervals. The uterus may sag forward 
Fig. 67.-Pendulous abdomen with misdirected force causing inertia. 
(Cragin.) 
for want of support, until the fundus is even lower than the 
cervix. Such a condition is a cause of malpresentations and CONDITIONS IN THE UTERUS 
153 
makes labor difficult. It is greatly relieved by wearing an 
abdominal binder or belt of some sort. 
Hydramnios and Oligohydramnios.-An excessive accumu- 
lation of amniotic fluid is called hydramnios. In extreme 
cases the quantity may run up to two or three gallons. The 
overdistention of the uterus adds to the discomfort of the 
woman during pregnancy, partly on account of the added 
weight but more because of the pressure symptoms, par- 
ticularly a distressing shortness of breath which results 
from the pressure against the diaphragm. Hydramnios pre- 
disposes to malpresentations and prevents early engagement 
of the head by letting the fetus float about so easily that it 
does not remain long in one position. It is a frequent 
complication of twin pregnancy. When the membranes are 
ruptured the nurse should have a basin of some sort to 
catch the fluid, otherwise the bed will be drenched. 
Oligohydramnios is just the opposite condition. The 
amniotic fluid may be so scanty that the fetus is deformed 
by the pressure of the uterine wall. 
Hydatidiform Mole.-This is a degeneration which attacks 
the chorionic villi, changing them into little sacs full of fluid, 
until the whole placental mass has the appearance of a 
bunch of small grapes. The fetus soon dies from lack of 
nourishment. The mole may burrow down into the uterine 
wall, causing hemorrhage; if left too long in the uterus, it 
has a tendency to cause a malignant growth. Miscarriage 
is the usual end of the process. If the diagnosis is made 
before this happens, the physician will empty the uterus 
at once. 
Chorio-epithelioma.-Chorio-epithelioma is the malignant 
growth which results from a hydatidiform mole. It may 
also follow cases of abortion and normal full-term labor. 
Fortunately it is a rare complication, for it is the most 154 
COMPLICATIONS OF PREGNANCY 
rapidly-growing and fatal of all forms of cancer. Uterine 
hemorrhage is its chief symptom. The treatment is imme- 
diate hysterectomy. 
Fig. 68.-Hydatidiform mole perforating the uterine wall. (Bumm.) 
Hemorrhage. - Hemorrhage during pregnancy is practi- 
cally always from the uterus and means but one thing, the 
separation of the placenta (or before the formation of the 
placenta, the separation of the chorion) from its place of 
attachment to the uterine wall. Bleeding in the early 
months is usually a sign of a beginning abortion. In the CONDITIONS IN THE UTERUS 
155 
last few months the separation is often caused by a malpo- 
sition of the placenta, which is implanted so low in the 
uterus that it encroaches upon the internal os-the condi- 
tion known as placenta previa. Detachment of a normally 
implanted placenta in the late months is really the same 
process as that which occurs in an abortion, but it is attended 
with far graver danger, because the uterine vessels are so 
much larger at this time that the hemorrhage may be rapidly 
fatal, before the fetus can be extracted. Fortunately it is 
rare. 
In any case of hemorrhage, at whatever time in pregnancy 
and from whatever cause, the doctor must be notified at 
once. The patient must be put to bed and kept absolutely 
quiet, with her head low. If there is much bleeding, the 
nurse will busy herself, while waiting for the physician, in 
making all possible preparations for the physician's examin- 
ations, the treatment of hemorrhage and even an operation. 
If the hemorrhage becomes dangerously profuse before his 
arrival, she may have to take the responsibility of packing 
the vagina tightly with sterile gauze or cotton, to make 
pressure on the cervix, and giving the patient such stimula- 
tion as may be needed. The foot of the bed may be raised, 
if the patient shows signs of faintness. 
Abortion. Miscarriage.-Abortion is technically the inter- 
ruption of pregnancy at any time before the fetus is viable, 
in other words, before the twenty-eighth week. It is com- 
mon usage to call it a miscarriage after the fourth month, 
and in speaking to the "laity" that term is used for all 
cases which have come about spontaneously. 
An induced abortion is one which is brought on by arti- 
ficial means. When induced by a physician on account of 
some condition which menaces the mother's life, it is called 
a therapeutic abortion, because it is a necessary therapeutic 156 
COMPLICATIONS OF PREGNANCY 
measure to cure or relieve the condition. Since it must 
mean the destruction of the life of the unborn child, it is 
undertaken only when there is grave danger for the mother 
in the continuance of the pregnancy, and no reputable 
physician would countenance its performance under other 
circumstances. Unfortunately there are unscrupulous doc- 
tors and midwives who are little more than professional 
abortionists, and to them turn many women who wish to 
be relieved of the burden of pregnancy for merely personal 
reasons. More than this, it has become a commoner prac- 
tice than most people dream for women to undertake certain 
procedures on themselves, without a thought of the moral 
or legal wrong of the act and the danger of it. Not only 
are abortions thus induced very properly considered criminal 
abortions and made punishable by law, but they are respon- 
sible for invalidism and the loss of many lives from hemor- 
rhage and infection. The nurse cannot set her face too 
strongly against such practices, and since she often comes 
into more confidential relations with her patients than the 
doctor can, she has an opportunity to wield a powerful 
influence for good which she should never neglect. 
Abortions are classified according to the stage which the 
process has reached. A threatened abortion is only begin- 
ning and there is good hope of preventing it from going 
any farther, while an inevitable abortion has progressed so 
far that treatment is of no avail to stop it. An abortion 
is incomplete when only a part of the contents has been 
expelled; it is complete if everything has come away and the 
uterus is empty. 
The causes of abortion include: (1) Conditions in the 
uterus, such as endometritis, displacements, defective 
implantation of the placenta on the uterine wall; (2) disease 
in the mother, especially various fevers, influenza and CONDITIONS IN THE UTERUS 
157 
syphilis; (3) external causes, such as heavy work, blows and 
falls, rough rides, etc. Certain drugs might also be classed 
among the external causes. Experience has shown that the 
chemicals used in some industries affect the pregnant woman 
and predispose to abortion. 
Treatment.-The preventive treatment of abortion has 
already been outlined under the hygiene of pregnancy. The 
treatment after the process has actually begun will depend on 
the stage which it has reached. A threatened abortion may be 
averted in many cases by absolute rest in bed and sedative 
drugs. An inevitable or incomplete abortion will require 
the emptying of the uterus, either with the hand or the 
curette. As already stated, packing may be necessary as a 
temporary measure to control hemorrhage; sometimes it 
stimulates the uterus to contract and expel its contents. If 
the abortion is complete, all that is needed is to keep the 
woman in bed, like a puerperal case, until the pelvic condi- 
tions are sufficiently normal. 
Extra-uterine Pregnancy.-In this condition, which is also 
known as ectopic or tubal pregnancy, the ovum becomes 
implanted and begins to develop outside of the uterus in the 
Fallopian tube. It is easy to see that there will be scant 
room in the tube for the fetus to grow, and it is therefore not 
surprising that in the majority of cases the fetal mass either 
squeezes its way out through the fimbriated end of the tube 
(tubal abortion) or breaks through its wall (tubal rupture). 
In either event there is likely to be profuse hemorrhage and 
the woman may die unless prompt measures are taken. If 
the mass ruptures through the tube between the layers of 
the broad ligament, a hematoma may form and become so 
walled off that the hemorrhage is stopped. In some rare 
cases the fetus passes out into the abdominal cavity without 
dangerous hemorrhage and continues its growth there. This 158 
COMPLICATIONS OF PREGNANCY 
condition is called abdominal pregnancy. If it is recognized 
in time, the child can be removed by an abdominal operation. 
More often it is overlooked and spurious labor with so-called 
false pains comes on at term, followed by the death of the 
child. The fetus may then be carried in the abdomen for 
years as a mummified fetus or a calcified mass called a litho- 
pedion or stone child, but it may also decompose or become 
infected, setting up serious symptoms. 
Fig. 69.-Tubal abortion. (Cragin.) 
The diagnosis of extra-uterine pregnancy can usually be 
made if the physician sees the patient early enough and 
makes an internal examination, when the mass can be felt 
in the tube, at one side of the uterus. This is another argu- 
ment for consulting the doctor at the beginning of pregnancy. 
Since rupture may take place at any time from the fourth 
week on, it is plain that many cases will escape notice until 
the alarming symptoms of rupture and hemorrhage appear. 
Occasionally the patient has had premonitory symptoms of CONDITIONS IN THE UTERUS 
159 
pain and irregular bleeding, with the discharge of bits of 
membrane. If the diagnosis is made, the treatment will 
be immediate operation to remove the tube and its contents 
before it has had a chance to rupture. 
The diagnosis of a ruptured tubal pregnancy is usually not 
difficult. In a typical case, after a fall or even the merest 
slip or jar, which often is enough to bring about the rupture, 
the patient is suddenly seized with severe pain and all the 
symptoms of internal hemorrhage, shock and collapse. The 
obstetrician must be notified at once and a laparotomy per- 
formed without delay if the woman's life is to be saved. If 
the rupture is between the layers of the broad ligament, the 
mass may be emptied out through the vagina, without the 
necessity of an abdominal operation. The nurse will make 
the usual preparations for operation and also have in readi- 
ness everything which may be needed for the treatment of 
hemorrhage and shock. 
Cardiac Conditions.-Pregnancy throws additional work on 
the heart, and labor adds the strain of fatigue and pain, 
variations in blood-pressure and most of all, the muscular 
efforts of the second stage. The normal heart is strong 
enough to overcome these difficulties, but one with weak- 
ened muscle or valve lesions may give way under the strain. 
A patient with cardiac trouble should be warned of the 
possible effect of over-exertion during pregnancy. She must 
follow with the greatest care any directions which the physi- 
cian lays down with regard to rest, diet and elimination, 
since a comparatively slight attack of indigestion or consti- 
pation may have serious consequences. The nurse should 
report such signs as weak, irregular or rapid pulse, dyspnea, 
dizziness or faintness. She will do well to ask for explicit 
directions as to the treatment to be used in a heart attack. 
An emergency may call for immediate stimulation of the 160 
COMPLICATIONS OF PREGNANCY 
heart by such drugs as strychnine, caffeine, digitalis or 
camphorated oil, given hypodermically. 
The obstetrician will make labor as easy as possible for 
the patient. Perhaps he will shorten the second stage by 
applying forceps, since even the combination of the opera- 
tive procedure and the anesthetic involves less strain on the 
heart than the muscular exertion of the bearing-down pains. 
Perhaps he will induce labor a little before term. A grave 
heart condition, not yielding to other treatment, may even 
require the induction of abortion to save the mother's life. 
Varicose Veins.-As pregnancy progresses, the pressure of 
the growing uterus interferes with the return flow of the 
blood from the lower limbs and varicose veins may result. 
These more often develop in the legs, but are not uncommonly 
seen on the vulva as well. If the varicosities are large, there 
is danger of their rupturing. 
An abdominal binder may relieve the pressure by giving 
support to the uterus, but a well-fitting elastic stocking is 
almost a necessity in some cases. A less expensive appliance 
is supplied by strips of adhesive plaster, placed below the 
most prominent veins. 
Diseases of the Urinary Tract.-Examination of the urine 
during pregnancy occasionally shows the presence o(f sugar. 
This is often connected with some upset in the general 
metabolism. True diabetes is rare. Albumin and casts 
suggest toxemia but are also present in chronic nephritis 
which has been aggravated by pregnancy. Pus in the urine 
means cystitis or pyelitis. The latter condition is char- 
acterized by attacks of severe pain, with fever or chills. 
It usually yields to simple treatment with diet, diuretics and 
some urinary disinfectant like hexamethylenamin, and local 
application of heat to relieve the pain. Cystitis and pye- 
litis are also complications of the puerperium. The cause CONDITIONS IN THE UTERUS 
161 
has sometimes been traced to careless technic in catheter- 
ization. 
Acute Infectious Diseases.-The acute infections as compli- 
cations of pregnancy carry with them a double danger, since 
they may affect both mother and child. The effect on the 
fetus may be due to the high temperature or to the poison 
of the disease itself, which may be transmitted in the form 
of the organisms or more often as their toxins. In either 
case the fetus may die and miscarriage will then follow. 
These infections run a more serious course in the pregnant 
woman, who must moreover face the chance of miscarriage 
or premature labor to make things worse. Especially 
dreaded are the streptococcus infections, including erysipe- 
las and scarlet fever, and now influenza has been added to 
the list as the most deadly of all. In the severe pandemic of 
1918 one pregnant woman after another sickened, miscarried 
and died, in spite of her physician's best efforts. 
The only special directions to a nurse in charge of such a 
case are therefore to be on the watch for symptoms of 
beginning abortion and to report at once to the doctor if 
any arise. 
Tuberculosis.-There was an old idea that pregnancy had 
a beneficial effect on tuberculosis, but in point of fact the 
tuberculous process is often hastened by pregnancy, although 
with proper care an incipient pulmonary case can sometimes 
be carried safely through. During labor the straining 
muscular efforts with the increased blood-pressure may bring 
on an attack of dyspnea followed by collapse. Even after 
the delivery the danger is not over, for the disease may 
suddenly flare into activity during the puerperium and 
progress rapidly to its end like the old-fashioned "galloping 
consumption." 
The treatment of tuberculosis is attended by certain diffi- 162 
COMPLICATIONS OF PREGNANCY 
culties during pregnancy. The high protein diet and 
abundant nourishment, with even forced feeding, are not 
well suited to the pregnant woman, whose metabolism is 
easily disturbed and for whom proteins must be limited on 
account of the effect on the kidneys. Rest is hard to secure 
for her heart while pregnancy is continually throwing extra 
work on it. Moreover the pressure of the growing uterus 
against the diaphragm may seriously embarrass the respira- 
tion. The patient must be kept under the closest surveil- 
lance, and rise of temperature or pulse-rate, cough and loss 
of weight carefully noted. If she is found to be losing ground, 
it will be necessary to interrupt the pregnancy. In laryngeal 
tuberculosis treatment is so unavailing and the prognosis 
so bad that the obstetrician may induce abortion without 
more ado. A patient who goes on to term must be guarded 
as far as possible against the straining of the second stage 
of labor. The irritating effects of anesthetics on the lungs 
must always be borne in mind. It has already been men- 
tioned in a previous chapter that tuberculosis is rarely 
transmitted to the fetus. The babies of tuberculous women 
are often strong and well-developed, with no sign of the 
disease. The mother must not be allowed to nurse her child 
because of the drain on her strength and the danger of infect- 
ing the baby through the close contact. 
Venereal Disease. -Gonorrhea and syphilis are dreaded as 
obstetrical complications, and rightly so. Their disastrous 
effects do not stop short with the mother but extend to the 
child as well. 
Gonorrhea.-Pregnancy has no marked effect on the course 
of the disease, except that on account of the increased blood 
supply to the parts, the so-called venereal warts are more 
likely to develop. Sometimes the discharge grows more 
profuse. 163 
CONDITIONS IN THE UTERUS 
The effects of gonorrhea on the mother are: 
1. Inflammation of the uterine mucous membrane (endo- 
metritis) leading to abortion. 
2. Puerperal infection. 
3. Later pelvic inflammatory trouble, especially in the 
tubes, often going on to abscess formation (pus tubes) and 
necessitating serious operations. 
4. Sterility, following the inflammation in the tubes. 
The results to be feared for the child are: 
1. Death of the fetus, in the cases of abortion. 
2. Ophthalmia neonatorum, a dangerous infection of the 
eyes, which is a frequent cause of blindness. 
3. Vulvo-vaginitis, in girl babies, especially if born by the 
breech. 
The disease should be treated as thoroughly as possible 
during pregnancy, to prevent its extension by puerperal 
infection and to guard the child from infection of its eyes 
at the time of birth. Douches given during labor may 
cleanse the vagina and so lessen the chance of such infection, 
but on account of the danger the routine prophylactic treat- 
ment of the eyes by the Crede method should be given as 
soon as the baby is born. The nurse cannot be too careful 
in the precautions which she takes to prevent the spread of 
the disease. All pads and dressings from the mother must 
be burned at once. The nurse must wear gloves when caring 
for the patient and must moreover disinfect her hands most 
thoroughly afterward. On no account should she touch her 
face or eyes if there is the slightest chance that her hands 
have been in contact with infectious material. If the solu- 
tion should spatter in her face while she is giving a douche, 
she must at once wash her face carefully and use the proper 
prophylactic treatment for her eyes. 
The symptoms and treatment of gonorrheal puerperal 164 
COMPLICATIONS OF PREGNANCY 
infection and ophthalmia will be taken up elsewhere (pages 
199 and 240). 
Syphilis.-Syphilis is like gonorrhea in running its usual 
course during pregnancy, but unlike it in seldom compli- 
cating the puerperium, although syphilitic fever at that time 
is not unknown. It is still more unlike it in not causing 
sterility, since the records show that syphilitic women often 
give a history of many pregnancies. It is, however, far 
more disastrous than gonorrhea in its effect on the child. 
Syphilis acts on pregnancy chiefly by interrupting it before 
term. Premature labor is common and late abortions rather 
than early ones are the rule. If a woman has a record of 
recurrent premature labors, syphilis is always to be con- 
sidered as a possible cause. 
Still more characteristic is death of the fetus in the uterus 
and its retention there until the body is badly macerated by 
the time labor sets in. While there are other causes of intra- 
uterine death, such as nephritis, hospital statistics hold 
syphilis responsible in from two-thirds to four-fifths of the 
cases. A macerated fetus is a most unsightly object, limp 
and discolored, with the skin peeling off over large areas of 
its body. Its head is collapsed and the bones give the impres- 
sion of floating about in fluid; this makes the birth of the 
child often unexpectedly quick. Sometimes the amniotic 
fluid is a dirty reddish brown or green in color. The diag- 
nosis of syphilis may be inferred if the mother has a positive 
Wassermann test. In a doubtful case a postmortem examin- 
ation will show other syphilitic changes in the organs and 
the presence of the spirochetes, usually in the much-enlarged 
liver. 
Even when the infection is not severe enough to kill the 
fetus, it is likely to show itself sooner or later. Sometimes 
the child is born with the disease in a more or less advanced CONDITIONS IN THE UTERUS 
165 
stage; sometimes the symptoms do not come on for a few 
weeks after its birth; and finally there are the . cases of 
so-called late hereditary syphilis, in which the manifestations 
of the disease are delayed until the sixth year or even until 
puberty. 
On account of this danger of transmission of syphilis to 
the child in the uterus, it is of the greatest importance to 
detect the presence of the disease in the mother. Since she 
may infect the fetus even when she has no discoverable 
lesions herself and gives no history which suggests any 
previous trouble, recourse must be had to the Wassermann 
test, which should be a routine procedure in every clinic. 
If this is positive, treatment must be started at once, with the 
hope of saving the child as well as curing the mother. If it 
is not practicable to give the Wassermann test in every case, 
it should at least be done whenever a woman gives a history 
of miscarriages, premature labors or dead fetuses. The 
symptoms of syphilis in the child will be discussed under 
diseases of the newborn. 
It is probably unnecessary to warn the nurse of the 
extremely infectious nature of syphilis, but the need of care 
cannot be emphasized too often. Any abrasion of the skin 
may be a portal of entry for the infection. CHAPTER VIL 
COMPLICATIONS OF LABOR. 
DYSTOCIA. 
Dystocia means difficult labor. It is the result of some 
abnormality in the forces of labor, the passages through which 
the child must pass, or the passenger, as the fetus itself is 
often called. Various accidents of labor will also add to the 
difficulty. 
Abnormality of the Forces. Maternal Dystocia.-The com- 
monest abnormality of the forces is uterine inertia, in which 
the contractions become weak and irregular or even cease 
altogether. In the old days, when ergot was used to 
strengthen the pains, inertia was often replaced by quite 
the opposite condition, a continuous tetanic contraction of 
the uterus resulting from the stimulation of the drug. If 
the delivery could not be effected soon, the outcome was 
all too often a dead baby, on account of the continued 
pressure, or even rupture of the uterus. 
Inertia is to be looked for in women whose uterine muscle 
is weakened by a rapid succession of pregnancies or stretched 
by twin pregnancy or hydramnios. In most cases it results 
from the fatigue of a long labor. 
The nurse can do a great deal to prevent inertia by con- 
serving her patient's strength and keeping up her courage. 
If it occurs, the physician's treatment will vary according to 
the conditions present. Some patients need only rest to 
enable them to go on with fresh vigor, and will respond DYSTOCIA 
167 
wonderfully to an opiate. Others require stimulation of 
the muscle, which may be secured by the long-tried quinine 
and strychnine or the newer preparation, pituitary extract. 
Abnormality of the Passages. Maternal Dystocia.-Abnor- 
mality of the passages may be in either the bony pelvis or 
the soft parts of the birth canal. If the pelvis is small (or 
contracted, to use the technical term), labor may be only 
prolonged while the extra resistance is being overcome, but it 
is sometimes so obstructed that the child cannot be born by 
the natural passages and Caesarean section is necessary. 
The commonest types of contracted pelvis are the flat 
pelvis, in which only the antero-posterior diameter of the 
pelvic inlet is shortened, and the generally contracted pelvis, 
in which all the pelvic measurements are below normal. 
Rachitis (rickets) is often a cause of such deformities. 
Another common type is the funnel pelvis, in which only the 
pelvic outlet is decreased in size. 
Obstruction by the soft parts, as for instance a rigid cervix, 
may be remedied by stretching or even by cutting the tis- 
sues. The physician will often dilate the cervix manually, 
asking the nurse to give the patient a few whiffs of ether or 
chloroform during the process. 
Abnormality of the Passenger. Fetal Dystocia.-Dystocia 
due to the fetus may be on account of its size, particularly 
if the mother has gone beyond full term, so that not only is 
the child's head large but the bones are so hard that it cannot 
be easily moulded. Malpresentations of the fetus are a 
frequent cause of dystocia and deserve to be taken up in some 
detail. 
Malpresentations. - Posterior Positions of the Occiput.- 
Normal labor has been described for the anterior positions of 
the occiput, L. O. A. and R. O. A. The occiput may also 
be turned posteriorly in the positions R. 0. P. and L. O. P. 168 
COMPLICATIONS OF LABOR 
The former is far more common. Labor is longer in 
the posterior positions because at the time of internal rota- 
Fig. 70.-Diagram showing outline of brim of normal and of flat rachitic 
pelvis. Black line, normal; dotted line, fiat. (Jewett.) 
Fig. 71.-Funnel-shaped pelvis. (Jewett.) 
Fig. 72.-Diagram showing outline of brim of normal and of justominor 
pelvis. Black line, normal; dotted line, justominor pelvis. (Jewett.) 
tion the head must turn through a longer distance to bring 
the occiput under the symphysis; but unless the patient DYSTOCIA 
169 
becomes fatigued, the birth is usually spontaneous if this 
anterior rotation takes place. In a small proportion of the 
cases, however, the head, instead of rotating anteriorly, turns 
posteriorly so that the occiput lies in the hollow of the sacrum. 
Even then we may hope for spontaneous labor, but the proc- 
ess is still further prolonged because in this position the 
head does not fit so well in the birth canal. Not infrequently 
it becomes wedged in an unfavorable position, especially if 
it is large, and labor comes to a standstill. In such cases 
forceps must be used. 
Fig. 73.-Moulding of head in face presentation 
Face and Brow Presentations.-If the head is not well 
flexed when it enters the superior strait, the brow will pre- 
sent or, if the extension is still greater, the face will be the 
presenting part. These cases are rare, especially the former. 
In face presentations, if the chin is directed anteriorly, the 
labor will probably be spontaneous but long; if posteriorly, 
the chin may rotate into the hollow of the sacrum, in which 
case it is not able to stretch down to the vulvar opening and 170 
COMPLICATIONS OF LABOR 
an operative delivery is necessary. In face presentations the 
caput forms over the face and the child when born is a dis- 
tressing sight, with its features distorted by the swelling 
and edema. The parents must be warned what to expect, 
but they may also be assured that the condition will clear 
up. 
Breech Presentations.-Breech presentations occur in about 
3 per cent of all cases; they are more frequent in premature 
births than at term, and quite common in twin pregnancy. 
If the breech alone presents, the case is one of frank breech; 
if one or both of the feet slip down in advance of the breech, 
it is a footling. 
Labor is likely to be longer than in vertex presentations, 
because the breech does not dilate the parts as effectively as 
the firm, round head. Although spontaneous delivery results 
in many cases, the obstetrician must be ready to interfere 
at a moment's notice if there is any delay, as there is more 
chance of pressure on the child and particularly on the cord 
during the birth. Sometimes the cord prolapses and is 
caught between the child's body and the pelvis. The nurse 
must watch the fetal heart even more carefully than usual 
and report at once if it shows signs of failing. 
The mechanism of labor is naturally just the reverse of that 
in the ordinary vertex presentation. The breech enters the 
pelvis lying obliquely, but as it descends it rotates until it 
is lying antero-posteriorly, with one hip under the symphysis 
and the other against the sacrum. The posterior hip is 
born first, followed by the anterior. The body is then forced 
down until the shoulders appear, and while the anterior one 
is wedged under the symphysis, the posterior slips out over 
the perineum. After the anterior shoulder is born, the head 
turns so that the occiput is anterior and then emerges from 
under the symphysis. DYSTOCIA 
171 
It must be borne in mind that as soon as the umbilicus 
has passed out from the vagina, there is usually pressure on 
the cord. Since this means shutting off the child's oxygen 
supply and since, as we have already learned, the fetus cannot 
live more than eight minutes without oxygen, it naturally 
follows that not more than eight minutes at the most can 
be allowed to elapse between the appearance of the umbilicus 
and the birth of the head. If the shoulders or head should 
be caught, the physician must at once complete the delivery. 
Fig. 74.-The Mauriceau or Smellie-Veit method of extracting the 
after-coming head. 
In any case of breech presentation the patient should be 
brought to the edge of the bed for the delivery, since the 
doctor can work to much better advantage. In case of delay 
he will reach in to bring out the arms and then extract the 
head, by what is called the Mauriceau or Smellie-Veit 
method, steadying and flexing it by putting one finger 172 
COMPLICATIONS OF LABOR 
in the child's mouth, while he makes traction on the shoul- 
ders or pressure on the fundus with the other hand. 
The nurse can help by making the pressure over the fundus, 
obliquely downward, as in the Dublin method of expressing 
the placenta. If the head is too firmly wedged to be 
extracted in this way, forceps may have to be applied. 
They should be at hand, ready sterilized, in every case, so 
that no precious time will be lost in an emergency. All 
preparations should be made for resuscitating the baby. As 
the perineum is often lacerated during the rapid extraction 
of the head, the instruments for repair are likely to be needed. 
In the absence of the doctor the nurse must be ready to 
act to save the life of the child, and if pressure on the uterus 
does not serve to bring about the delivery within the time 
limit, she must try to extract the head as above described. 
Prompt action should be her watchword, after the body is 
born. 
Transverse Presentation.-A transverse presentation, also 
known as a shoulder presentation, is always a serious com- 
plication, since the child cannot be born if it remains lying 
across the pelvis. If there is no one at hand to give the 
proper treatment, the child will die from the pressure and 
the uterus will probably rupture in the effort to expel it, with 
a fatal result for the mother as well. Even the "laity" 
know the dangers of a "cross birth." 
If the presentation is recognized during pregnancy, it is 
often possible to change it by external manipulation. If the 
woman goes into labor with the fetus lying transversely, the 
obstetrician must perform version, reaching up into the 
uterus with one hand until the child's feet can be grasped, 
turning the child and then extracting it as in a breech 
presentation. The patient must, of course, be anesthetized 
for the operation. MULTIPLE PREGNANCY 
173 
MULTIPLE PREGNANCY. 
In about 1 out of every 100 cases conception results in 
the development of more than one child. This is brought 
about by the fertilization of more than one ovum or an ovum 
with more than one nucleus or by other more complicated 
conditions which need not be discussed here. Heredity 
seems to play its part as a factor, for multiple pregnancy 
Fig. 75.-Placenta in double ovum twins. Two cords, two sets of 
membranes, placentas fused. 
often runs in a family. The children are called twins, trip- 
lets or quadruplets, according as there are two, three or 
four of them, but it is so rare for more than two to be born 
(triplets occur only once in 7000 or 8000 cases) that for 
practical purposes multiple pregnancy is represented by 
twin pregnancy. 
If two ova have been fertilized, the twins are called double- 
ovum twins and each fetus has its own separate placenta and 
set of membranes, although the placentas may be so nearly 174 
COMPLICATIONS OF LABOR 
united as to have the appearance of a single large one. 
Single ovum twins, resulting from the fertilization of one 
ovum, have but one placenta between them, and their 
respective circulations may so overlap that one fetus is able 
to get more than its fair share of nourishment from the 
placental blood and thus develops at the expense of the 
other. Single ovum twins are always of the same sex, while 
double ovum twins-may.be of different sexes. 
The diagnosis of twin pregnancy is suggested by the 
large size of the abdomen, but must be confirmed by mapping 
out more parts than could belong to one fetus or hearing two 
fetal hearts of different rates. This last is by far the surest 
sign. The two fetuses may take various positions, but most 
commonly they lie longitudinally, both presenting by the 
head, or one vertex and the other breech; more rarely both 
are breech presentations. The diagnosis is not very easy 
and in a large proportion of the cases jt is not made until 
after the birth of the first child. 
Because the uterus is overdistended by its contents, labor 
is likely to come on somewhat prematurely, and the babies 
are often below the average size, even when born at full 
term. For this reason labor may be comparatively quick 
and easy, although more often the first stage is long, because 
the uterine muscle has been so stretched throughout preg- 
nancy that it cannot contract well. Even when there are 
two separate placentas, that of the first child remains in 
the uterus until after the second twin is born, when both 
placentas come away in the third stage. Operative inter- 
ference may be necessary on account of uterine inertia, 
especially after the birth of the first child. Other com- 
plications of multiple pregnancy are hydramnios, pressure 
symptoms, varicose veins and a greater liability to toxemia. 
The weak contractions of the uterine muscle may be a cause PROLAPSE OF THE CORD 
175 
of postpartum hemorrhage, and the loss of its tone predis- 
poses to subinvolution in the puerperium. 
If the diagnosis of multiple pregnancy has been made early, 
the nurse should be prepared to be called to the case before 
the calculated date for a full-term confinement. At the 
time of the delivery she should have everything ready for 
an operative delivery, in case of inertia or malpresentation, 
and should also make the necessary preparations for the 
treatment of hemorrhage. The babies will require the usual 
care for premature infants, if they are not fully developed, 
and extra feeding, if they are large and strong and are not 
getting enough from their mother. 
PROLAPSE OF THE CORD. 
In the course of labor it sometimes happens that the 
umbilical cord slips down in advance of the presenting part. 
This is particularly likely to occur when the membranes 
rupture at the height of a pain and the fluid comes away with 
great force, as in a case of excessive amount of amniotic 
fluid; and also in malpresentations, such as breech and 
transverse, in which the presenting part does not fill in the 
pelvis well and so leaves room for a loop of cord to descend. 
Prolapse of the cord means death to the child from the 
shutting off of its oxygen supply, as the cord is compressed 
more closely between the pelvis and the presenting part. 
On account of this grave danger the nurse must notify 
the physician immediately and while waiting for his arrival 
she must do what she can to prevent pressure on the cord. 
This is best accomplished with the patient in the knee-chest 
position, since in this position the fetus falls forward and is 
raised out of the pelvis. Having placed the patient thus, 
the nurse will disinfect her hands and replace the cord, push- 176 
COMPLICATIONS OF LABOR 
ing it up into the uterus past the presenting part, if possible. 
If the loop has prolapsed far enough to come in contact with 
vulva or any unsterile material, it should be wiped off with 
an antiseptic solution before replacing it. It should always 
be noted whether the cord is still pulsating, and if so, the 
rate should be counted. Successful reposition of the cord 
is not always possible, and even if the loop is replaced, it 
may be pushed down again by the uterine contractions. The 
patient should be kept in the knee-chest position as long as 
she can endure the discomfort of it, so that the cord will 
receive the least possible pressure. The Trendelenburg 
position also acts to relieve the pressure, and in an emergency 
a chair can be placed on the bed and the patient's hips 
elevated by lifting them upon it. The Sims position with the 
pelvis elevated by pillows is more comfortable than either of 
these, if the woman must be kept in it for any length of 
time. 
The nurse may have noticed and reported changes in the 
fetal heart-rate which were the result of the pressure on the 
cord, but unless she has been instructed by the physician to 
make an internal examination, she has no way of knowing 
that prolapse has occurred until the loop has slipped down 
far enough to be seen protruding from the vagina. Inter- 
nally the diagnosis is made by feeling a soft, pulsating mass 
beside or below the presenting part. Externally there is, 
of course, no difficulty in recognizing a loop of cord. 
In any event the nurse should make all preparations for 
an operative delivery, since it is probable that the physi- 
cian on his arrival will hasten the birth of the child by the 
use of forceps, breech extraction or version and extraction, 
as the case may require. 
Placenta Previa.-In this condition the placenta, instead 
of being implanted in the upper part of the uterus, is in the PROLAPSE OF THE CORD 
177 
lower uterine segment, in the region of the cervix. In 
marginal placenta previa it reaches just to the edge of the 
internal os; in central or complete placenta previa it entirely 
covers the os. The latter type is far more serious. 
Fig. 76.-Central placenta previa. Placenta between the head 
and the partly dilated os. (Hunter.) 
Usually there has been slight bleeding or some blood- 
streaked discharge to give warning of the trouble, but a 
profuse hemorrhage may be the first sign. The bleeding 
comes on suddenly, painlessly and without any apparent 178 
COMPLICATIONS OF LABOR 
cause; the woman may even wake in the night and find her- 
self lying in a pool of blood. 
In cases of placenta previa the obstetrician is confronted 
with a double problem; the control of the hemorrhage and 
Fig. 77.-Complete or central placenta previa. (Bumm.) 
the prompt delivery of the patient. If the implantation is 
marginal and the bleeding only moderate, rupturing the 
membranes may accomplish the double purpose, provided 
that labor has already begun. A rubber bag may be intro- PROLAPSE OF THE CORD 
179 
duced into the cervix, to make pressure on the bleeding area 
while dilating the cervix. Braxton-Hicks' method is to 
draw one of the child's legs through the os and let it make 
the pressure. Most cases will require an operative delivery, 
Fig. 78.-Partial placenta previa. (Bumm.) 
whether by forceps, version or breech extraction. Caesarean 
section may be the safest method, especially in central 
placenta previa. 
The dangers of this condition are not over when the 180 
COMPLICATIONS OF LABOR 
delivery is finished, as postpartum hemorrhage is a frequent 
sequel. Sometimes the blood seems to have lost its power 
to clot. Placenta previa is one of the gravest obstetrical 
complications, and carries a high mortality for both mother 
and child, especially the latter. 
Fig. 79.-Marginal placenta previa. (Bumm.) 
Premature Separation of the Normally Implanted Placenta.- 
This, obstetrical accident, unlike the separation in placenta 
previa, is usually caused by a blow or injury and the hemor- POSTPARTUM HEMORRHAGE 
181 
rhage is accompanied by severe pain. It is also known as 
accidental hemorrhage, an old name which dates back to 
1780, and abruptio placentae, a recent American term. The 
condition is even more dangerous to mother and child than 
placenta previa. It is practically impossible to control the 
hemorrhage, because the bleeding area is too high in the 
uterus to be reached by pressure, and immediate delivery 
is therefore the only hope. Caesarean section has been used 
as well as other operative methods. 
POSTPARTUM HEMORRHAGE. 
Postpartum hemorrhage means hemorrhage after delivery. 
It may begin during the third stage of labor, when the pla- 
centa is only partially separated, but more often it appears 
after the placenta has been expelled. It is usually caused 
by the failure of the uterine muscle to contract and retract, 
sometimes because of clots or placental tissue in the uterus. 
Bleeding may also come from a deep tear in the cervix or 
rarely from the rupture of varicose veins in the vagina. 
There is seldom any difficulty in diagnosing postpartum 
hemorrhage. In a typical case the blood almost pours from 
the vagina. There are times, however, when the hemor- 
rhage is concealed, perhaps by a clot blocking the cervix, 
perhaps because the placenta, separating by the Schultze 
mechanism, holds the blood back in the uterus. In such 
cases the diagnosis may be made by the usual signs of 
internal hemorrhage-weakness, pallor, faintness, rapid 
pulse, sighing respiration, air hunger-but palpation of the 
uterus throws additional light on the matter. The fundus 
will be found higher than it should be-at or above the 
umbilicus, instead of three fingers below it-and its con- 
sistency is soft and flabby, since its muscle is not firmly 182 
COMPLICATIONS OF LABOR 
contracted. Its cavity is sometimes distended with blood. 
Pressure on the fundus forces out clots and a fresh stream of 
blood. 
Postpartum hemorrhage is to be looked for in such cases 
as the following: 
1. When the uterine muscle is either naturally weak or 
has been weakened during pregnancy by overdistention or 
strain on the walls. 
2. When it has become fatigued during prolonged labor. 
3. When its contracting power has been interfered with by 
drugs or anesthesia, or by manipulations. 
It is therefore clear that preparations for the treatment 
of hemorrhage should be made in every operative case. 
Too vigorous and too early efforts at expressing the placenta 
before its separation are also a cause of hemorrhage. 
The preparations for hemorrhage include: 
1. An ice cap to be applied to the fundus. 
2. Fluidextract of ergot; ampoules of ergot and pituitary 
extract for hypodermic use; a hypodermic syringe which 
works. If there is much likelihood of hemorrhage, the 
syringe should be filled beforehand so as to be ready for 
immediate use. 
3. Hot sterile water or salt solution and a sterile outfit 
for giving an intra-uterine douche, including container, tub- 
ing and long glass nozzle. In an emergency a fountain 
syringe can be sterilized for this purpose, by boiling. The 
temperature of the fluid should be 112° .to 116° F. 
4. Gauze for uterine packing, four to six inches in width, 
with dressing forceps if the physician desires. More often 
the packing of the uterus is done by the manual method. 
All these things should surely be ready, and if the case is 
a grave one, the patient will require the introduction of 
saline solution by rectum or under the breasts by hypo- POSTPARTUM HEMORRHAGE 
183 
dermoclysis, or even into a vein by transfusion, to replace 
the fluid which has been . lost. Heart stimulants will be 
needed in such a case. One of the most rapid in its action is 
camphorated oil, which can be obtained in ampoules, ready 
for hypodermic use. Strychnine, caffeine and the various 
forms of digitalis are standard heart stimulants; hot coffee, 
or ammonium carbonate in salt solution, can be given by 
rectum. The patient's head should be low, and if there is 
danger of anemia of the brain, the foot of the bed should be 
raised on two chairs or on blocks of wood. Hot-water bottles 
placed at her feet and warm coverings raise the body tem- 
perature. In a desperate case oxygen may be tried. 
Pressure has been advised as a means of controlling the 
hemorrhage, usually by making direct pressure on the 
abdominal aorta through the abdominal wall for five minutes 
or more at a time. Momburg's method is to exert this 
pressure by a strong rubber tube tied tightly around the 
woman's waist. It is seldom used, but the nurse should 
know that such a method exists. 
The simplest, quickest and most effective methods of 
treatment in the average case are massage of the uterus 
through the abdominal wall and the intramuscular adminis- 
tration of ergot or pituitary extract, and the nurse who finds 
herself alone in this emergency will place her main reliance 
on these two measures. After the fundus begins to harden 
under the hand, it should be pressed downward and forward 
against the symphysis and held there, with an ice-cap placed 
over it, if this is available. If the hemorrhage is not con- 
trolled by these means, a hot vaginal douche may be given 
by the nurse while some other person present is deputed to 
hold and massage the fundus. The administration of an 
intra-uterine douche and the packing of the uterine cavity 
are procedures which are not familiar to most nurses. It 184 
COMPLICATIONS OF LABOR 
is to be remembered that ergot is always given deep into 
the tissues, preferably on the outer side of the thigh, near 
the gluteal region. If injected superficially under the skin, 
it is apt to cause irritation and even inflammation. 
After the bleeding has stopped, the patient will need care- 
ful watching for any symptoms of collapse or failing heart 
action, as well as for possible recurrence of the hemorrhage, 
which must be at once reported to the doctor. 
RUPTURE OF THE UTERUS. 
This is one of the most serious accidents of labor. The 
laceration is usually in the lower segment of the uterus, 
since the muscle here is not as thick and strong as in the 
fundus. It may occur when the muscle is weakened by 
disease or scar tissue (as after a Caesarean section), but more 
often results from the efforts of the uterus to push the fetus 
past too great an obstruction. Among the conditions which 
cause obstructed labor are deformed or contracted pelvis; 
overgrowth of the child or a monstrosity like hydrocephalus; 
malpresentations, especially transverse presentations and the 
rare posterior positions of the chin; rigid soft parts and 
tumors in the uterus and birth canal; and prolonged dry 
labor. When ergot was used to stimulate uterine contrac- 
tions during labor, it was responsible for many cases of 
rupture, and even pituitary extract, if given too early or in 
unsuitable cases, has had this untoward result. 
Impending rupture of the uterus is to be feared when in 
spite of prolonged and vigorous contractions no progress 
is made. It is sometimes possible to see through the abdom- 
inal wall what is called the contraction ring, a line of demar- 
cation between the upper and lower uterine segments, giving 
an appearance not unlike that of a distended bladder. RUPTURE OF THE UTERUS 
185 
In a typical case of rupture the patient complains of 
sudden and unusually severe pain and the sense of something 
giving way at the height of a contraction. The contractions 
then subside and symptoms of shock and hemorrhage follow. 
Uterine wall, 
upper segment 
Uterine wall, 
lower segment 
Fig. 80.-Thinning of lower segment of uterus in obstruction from 
hydrocephalus. 
If such an accident occurs, the patient must be prepared 
at once for operative delivery and perhaps for abdominal 
operation. If the laceration is very extensive, hysterectomy 
may be necessary. CHAPTER VIII. 
THE PUERPERIUM. 
Temperature, Pulse and Respiration.-In the typical normal 
case these should run a very level course, but variations are 
seen which are not necessarily pathological. During the 
process of involution there is bound to be a certain amount 
of absorption from the degenerating tissue in the uterus, 
and this shows itself by a slight rise of temperature. As 
long as this is not above 100° F. (38° C.), it is considered 
within the physiological limits. The pulse normally slows 
after the delivery and may drop as low as to 50 or even less 
without any bad effect. A rapid pulse-rate should always 
be regarded with suspicion. 
A morning and evening record of temperature, pulse and 
respiration is usually sufficient, during the greater part of 
the puerperium, but it is often better, and in many hospitals 
is routine, to keep a four-hour chart for the first few days. 
The nurse will, of course, report any rise above the normal. 
Lochia.-The amount and character of the lochia should 
be recorded on the nurse's chart. The amount can be 
gauged by the number of vulvar pads used in the twenty- 
four hours. It is always a wise plan for the nurse to ask 
the physician if he wishes a pad saved for his daily inspec- 
tion. When the condition shows anything out of the normal, 
one should be kept for him as a matter of course. If the 
discharge remains red for more than the allotted time or if 
it is freer than normal, it is likely to mean delayed involu- 187 
AFTER-PAINS 
tion. The odor of the normal lochia is only that of fresh 
blood; any offensive odor should be noted and reported, as 
it is often a sign of too much decomposing material in the 
uterine cavity and the physician may wish to order special 
measures to control the condition. The nurse should 
remember that she will add greatly to her patient's comfort 
by changing the vulvar pads and cleansing the -parts fre- 
quently, especially when the discharge has an unpleasant 
odor. The lochia should be slight in amount by the time 
the patient begins to get up and about; a temporary increase 
may be noted after she is up for the first time. 
Care of the Vulva.-This part of the after-care requires 
special attention. The vulvar pads should be frequently 
changed. After urination or a bowel movement or when 
there is enough discharge to make the woman uncomfort- 
able, the vulva is thoroughly cleansed and irrigated. An 
antiseptic solution, sterile water or salt solution may be used 
for the irrigation, according to the preference of the doctor. 
Careful drying of the parts afterward is important. If there 
are perineal stitches, the nurse will gently wipe off any dis- 
charge which may adhere to them, always taking care not 
to pull the sutures or irritate the wound. The after-care 
of a perineorrhaphy is described elsewhere. Swelling of the 
vulva is treated by hot or cold compresses. Boric acid and 
witch-hazel are among the favorite remedies. 
After-pains.-Painful contractions of the uterus constitute 
one of the most trying complications of the puerperium, com- 
ing as they do, at a time when the patient is not expecting 
further discomfort. These after-pains are far more common 
in multiparse, especially if there have been many pregnancies; 
they are particularly likely to occur when there are clots in 
the uterus which the contractions are trying to expel. Occa- 
sionally there are spasmodic contractions without any dis- 188 
THE PUERPERIUM 
coverable cause. In any case the nurse can assure the 
patient that the pains will not last more than two or three 
days. 
Treatment.-The treatment usually consists in measures 
to relieve the pain, such as hot applications or antispasmodic 
drugs. Opium in some form is occasionally necessary. 
Contrary to what might be expected, ergot sometimes acts 
successfully, by aiding the expulsion of material in the uterine 
cavity. 
Bowels.-The constipation of pregnancy is likely to con- 
tinue into the puerperium, since it takes some days for the 
intestines to regain their muscular tone after so many months 
of pressure from the uterus. As free elimination is an import- 
ant aid in counteracting the absorption from the uterus, a 
daily bowel movement is a particularly necessary part of 
the regimen of the puerperium. The simpler laxatives are 
often unavailing and the more drastic cathartics are con- 
traindicated on account of their depleting the milk supply. 
It is therefore customary for the doctor to give a standing 
order for an enema, if the bowels have not moved by the 
end of the day. The difficulty usually remedies itself after 
the patient is up and about. 
Urine. -It is not uncommon for the patient to have some 
difficulty in voiding urine during the first two or three days 
after the delivery. This is often due to the fact that the 
urethra has become swollen and bruised in the course of the 
labor, a condition which will right itself without any special 
treatment. Another frequent cause of this trouble is the 
inability of the patient to use the bed pan while lying down. 
If the bladder is not emptied, it becomes overdistended 
and rises into the abdominal cavity, pushing the uterus 
upward and to one side. The tumor formed by the bladder 
may be so prominent that it is mistaken for the uterus 
itself. LACTATION AND CARE OF THE BREASTS 
189 
Every eflfort should be made to avoid the necessity of 
catheterizing the patient. The usual expedients-hot com- 
presses over the bladder, irrigation of the vulva, pouring 
water from one vessel to another-should all be tried, and 
if the physician is willing, the woman may be allowed to 
sit up on the bed pan, as this measure is sometimes a happy 
solution of the problem. If all else fails, the catheter must 
be passed, with the strictest aseptic precautions. The 
nurse should always ask the obstetrician for explicit direc- 
tions as to the length of time which may be allowed to elapse 
before the'catheter is employed. 
Tympanites.-The intestines, which have been pressed upon 
by the enlarged uterus during pregnancy, tend to balloon 
out after the delivery, when released from the pressure, and 
the abdomen becomes distended and tympanitic. This is 
a temporary mechanical condition, not to be mistaken for 
peritonitis. It is soon relieved by laxatives and enemata to 
carry oft' the gas and a firm binder to reinforce the abdominal 
muscles. 
Lactation and Care of the Breasts.-The mother should be 
strongly urged to nurse her baby, not only for its sake but 
also because the act of nursing stimulates uterine contrac- 
tions and thus promotes involution. There are few condi- 
tions which make nursing injurious to mother or child; chief 
among them are serious mental disturbance or actual disease, 
such as tuberculosis or grave anemia. It is generally sup- 
posed that in many cases a woman is unable to nurse her 
baby because her milk is too scanty or does not agree with 
the child. In point of fact these cases are few and far 
between. A mother will often think that her milk is of poor 
quality, because it is not white and thick like cows' milk, not 
realizing that the bluish color and thin consistency are 
characteristic of the human secretion. Nursing must never 190 
THE PUERPER1UM 
be abandoned until chemical analysis has proved the milk 
unsuitable. It may be necessary to weigh the infant before 
and after feeding in order to convince the mother that it is 
really getting enough nourishment. The nurse's powers of 
persuasion, enlisted on the right side, will often turn the 
scale in favor of breast-feeding. 
For the first two or three days after delivery the breasts 
contain only a scanty secretion of colostrum. On about the 
third day the true milk appears, often coming in so rapidly 
that the breasts become much engorged before the baby can 
empty them by nursing. There is occasionally £ slight rise 
of temperature on account of the pain and discomfort, but 
this is by no means constant, and the old idea that the 
establishment of the secretion was uniformly attended by 
"milk fever'' is another of the discarded notions of our fore- 
fathers. As a rule this condition of engorgement does not 
last for more than twenty-four hours and is entirely relieved 
as soon as the child is taking its full quota of nourishment. 
It is hard to make an exact statement as to the composi- 
tion of human milk, because it varies so much, even in the 
same woman. A sedentary life and heavy protein diet usu- 
ally tend to make the milk rich in fat, perhaps even too much 
so; but sometimes the result is to make the mother take 
on flesh, while the milk grows scanty. Moderate exercise 
is likely to increase the quantity of milk, but hard work 
decreases the proportion of protein. It is a matter of com- 
mon knowledge that the amount of the secretion is increased 
by the addition of extra fluid to the regular diet, and a 
patient whose milk supply is small is always plied with 
milk, cocoa and gruel to stimulate the flow. While certain 
drugs have been shown to affect the milk, the various galacta- 
gogues which are so highly lauded in the claims of their manu- 
facturers are of little value in increasing the secretion. It CARE OF THE NIPPLES 
191 
must not be forgotten that the effect of some drugs is trans- 
mitted to the child through the milk, and that cathartics 
present a striking example of this fact. Scarcely less strik- 
ing is the effect of grave anxiety or mental conditions, which 
may so change the milk that it becomes actually injurious 
to the child. The average composition of human milk is 
fat 4 per cent, sugar 7 per cent and protein 1.5 per cent, with 
about 87 per cent of water. 
Care of the Nipples.-The care of the nipples bears an 
important part in the care of the breasts. If the nipples 
become sore or fissured, nursing is interfered with, since the 
act is so painful for the mother that she soon grows dis- 
couraged. Moreover there is always danger that an abra- 
sion may serve as a portal of entry for infection. The simple 
precaution of washing the nipples with boric acid solution 
and carefully drying them before and after each nursing 
seems to be all that is required in the majority of cases to 
prevent the entrance of infection. In some hospitals a small 
pad of gauze is placed over the nipple and secured by narrow 
strips of adhesive plaster. If so desired, a little boric ointment 
can be applied on the gauze. 
If in spite of such care the nipples become sore, the pain 
of nursing is relieved by the use of a nipple shield, which 
prevents the baby's mouth from coming in contact with the 
irritated surface. It must be remembered that the shield 
itself will add to the irritation as well as to the danger of 
infection unless it is carefully cleaned and kept in boric 
acid solution between nursings. Its use should not be con- 
tinued longer than is absolutely necessary, since the rubber 
occasionally gives the child a sore mouth. As an applica- 
tion for sore nipples, the compound tincture of benzoin is 
an old and tried friend. Another of the old favorites is a 
paste of castor oil and bismuth. Balsam of Peru also aids 192 
THE PUERPERIUM 
the healing. Compresses of boric acid kept on the nipples 
between the nursings have proved effective. Witch-hazel or 
alcohol will harden the surface. Deep cracks may have to 
be touched with silver nitrate or argyrol. 
Retracted nipples make nursing difficult but rarely impos- 
sible. By dint of patience and perseverance the nipple can 
be gently drawn out in most cases until the baby can take 
hold of it. A nipple shield may help to solve the problem. 
Fig. 81.-Breast bandages. (Bacon.) 
When the child seems unwilling to use the shield, it may be 
encouraged if the rubber nipple is filled with milk or water 
at the start. All possible means should be exhausted before 
it is decided to take the baby off the breast. 
Engorgement.-The engorgement of the breasts which 
comes with the establishment of the milk secretion is usually 
relieved by an ice cap and a saline cathartic. A supporting ENGORGEMENT 
193 
binder should be applied. If the baby cannot empty the 
breasts, it may be necessary to use a breast pump, but this 
Fig. 82.-Breast and abdominal bandages applied. (Bacon.) 
Fig. 83.-Massage of the breast. (Bacon.) 
should not be continued for any length of time. Massage 
is sometimes useful to bring the milk to the surface when 194 
THE PUERPERIUM 
the child has difficulty in nursing. The breast is anointed 
with warm oil and rubbed gently but firmly by a stroking 
motion toward the nipple. Neither the breast pump nor 
massage should be tried without the doctor's orders. The 
nurse should also find out his views on methods of massage. 
Some claim that the distention of the breasts is due not to 
the milk alone but to lymphatic engorgement as well and 
that the massage must therefore be away from the nipple 
toward the periphery of the gland. In any case the manipu- 
lation must be extremely gentle, lest it set up an inflam- 
mation. Some physicians have abandoned the use of 
massage entirely. 
Caked Breasts.-The familiar term "caked breasts" is 
used to describe a condition of apparent obstruction of the 
milk ducts in localized areas, which become hard, swollen 
and tender. The caking may be a forerunner of mastitis, 
if not properly treated. Here too the ice cap is effective, 
although some physicians prefer hot stupes to soften the 
breasts and others still use massage. A well-fitting binder 
for support is an important part of the cure. 
Drying-up of the Milk.-If the child is stillborn, or if some 
condition in the mother makes nursing inadvisable, it will 
be necessary to dry up the milk secretion. This is no longer 
the troublesome process that it once was, when tight binders, 
breast pumps, massage, hot stupes and belladonna oint- 
ment combined to give the patient a season of discomfort. 
It is now recognized that the best results are obtained by 
the least manipulation. If a binder is used, it is simply as 
a support when the breasts are large and heavy and not at 
all for the purpose of compression. It is quite likely that 
the breasts will become full, tense and somewhat painful 
for about twenty-four hours, but ice caps applied continu- 
ously will usually relieve the pain and check the milk secre- MASTITIS 
195 
tion to some extent. The doctor may order an opiate such 
as codeine for the pain and Epsom salts for a couple of days 
to carry off the fluid from the body. Pumping the breasts 
or any procedure which would tend to stimulate the secre- 
tion of the glands is absolutely contraindicated. 
Mastitis.-Mastitis is an inflammatory process in the breast 
tissue. It is caused by organisms which enter through the 
nipple as a rule, especially if cracks are present. The patient 
may infect herself through lack of cleanliness, or a careless 
nurse who neglects aseptic technic may be to blame. More- 
over it must not be forgotten that any injury or irritation, 
as from squeezing the breast, rough handling in massage and 
the too-prolonged use of the breast pump, also plays an 
important part in starting an infection. 
The inflammation is recognized by the classical symptoms, 
pain and tenderness, redness, heat, swelling and induration, 
which are at first localized in one small area. Fever is always 
present and a chill may usher in the infection. If discovered 
in time, the process can usually be aborted by giving rest 
to the breast and keeping ice caps on continuously. A sup- 
porting binder should be applied. Free catharsis is some- 
times helpful. Ointments of ichthyol and belladonna and 
the clay mixtures of the type of the cataplasm of kaolin have 
met with varying results. The Bier suction apparatus, 
which was so highly recommended for this condition some 
years ago, has not proved a marked success. Massage and 
the breast pump have no place in the treatment. 
If the inflammation goes on to the point of suppuration, 
hot applications may hasten the pointing of the abscess. 
The physician will then make an incision to evacuate the pus, 
and drain the cavity with gauze or a drainage tube, as the 
case may require. When the condition is far advanced, the 
breast tissue becomes fairly riddled with pockets of pus, 196 
THE PUERPERIUM 
and through-and-through drainage will be necessary. The 
nurse will be expected to help with the subsequent dressings. 
It is hardly necessary to remind her of the extreme care which 
must be taken to avoid carrying the infection to the vagina 
of the patient. As long as there is pus in the breast, the 
mother must not nurse the child. 
As in all other conditions, prevention is the important 
part of the treatment. Breast abscesses rarely appear when 
scrupulous cleanliness is observed and should be almost 
unknown in a well-conducted hospital or in the practice of 
a conscientious nurse. 
Rest and Exercise.-Rest and quiet are essential after an 
exhausting labor, but in the average case the patient recovers 
from the fatigue of the experience in a surprisingly short 
time. It is, however, a mistake to keep her flat on her back 
for several days. Not only is it irksome for her, but if she 
remains too long on her back, there is a chance that the heavy 
uterus, pulling on its stretched ligaments, may sag backward 
until a posterior displacement results. After the first day 
the woman should be encouraged to turn from one side to 
the other, and by the second week of the puerperium she 
should be able to be propped up on pillows and a back-rest. 
If there is a tendency to a backward displacement of the 
uterus, the patient should be directed to lie on her face for 
ten or fifteen minutes several times a day. Some physicians 
make it a routine to have their patients assume the knee- 
chest position for several minutes a day from the end of the 
first week. 
Many women complain that lying in bed makes them 
lose their strength, and there is something in this contention. 
For this reason bed-exercises have been devised to keep 
the muscles in tone and so prepare the patient for the return 
to the duties of her daily life. During the first days these PUERPERAL INFECTION 
197 
exercises include deep breathing and raising and rotating the 
arms. Leg movements are added by the end of the week, 
but are of course postponed if there has been a perineal 
repair. 
According to a time-honored routine the tenth day is set 
for the patient's first day out of bed. This day is chosen 
simply because the uterus is normally once more a pelvic 
organ by this time. The physician will be guided by the 
height of the fundus in deciding on the day for the individual 
case, and if the involution is slow, he will keep the woman in 
bed longer. Certain obstetricians, especially the advocates 
of "twilight sleep," believe in getting their patients up 
within the first few days, but they are in the minority. Any 
dispensary out-patient service affords plenty of examples of 
women grown old before their time, with subinvolution, 
uterine displacements and other pelvic troubles as a result 
of getting up too soon after confinement. 
The patient, as a rule, feels so well while she is in bed that 
she is likely to overestimate her strength, and she is often 
surprised to find herself feeling weak and "light-headed" on 
her first day out of bed. The nurse should always stay 
with her patient under these circumstances, to keep watch 
of her condition, as the woman will occasionally have an 
actual fainting-spell. The nurse must also see to it that the 
patient does not become too ambitious after she begins to 
get about the house. The tendency is almost always to do 
too much and see too many people. 
Puerperal Infection.-Puerperal infection is the modern 
name for childbed fever, long known as the scourge of 
obstetrical practice. In the old days it was a veritable 
epidemic in hospitals, and even in the private practice of 
the most skilful obstetricians the toll of deaths was high. 
We know now that this dreaded disease was nothing more 198 
THE PUERPERIUM 
nor less than septic infection, introduced by the carelessness 
of those in attendance and carried by them from one patient 
to another; but no one then knew what caused it, although 
many talked learnedly of noxious vapors, miasmata, atmos- 
pheric conditions, milk metastases and what not. 
It was not until the end of the eighteenth century that it 
began to dawn upon a few thinkers that the disease might 
be a contagion. In 1843 an American, Oliver Wendell 
Holmes, brought out what seems to us to-day a most con- 
vincing paper on the "Contagiousness of Puerperal Fever," 
in which he assailed the disease in no measured terms as a 
private pestilence. His views met with opposition and 
invective, but he lived to see them vindicated through the 
discoveries of bacteriology. 
Four years later Semmelweiss, an assistant at the great 
Maternity Hospital in Vienna, gave a more striking demon- 
stration of the truth of Holmes's ideas. It was a matter 
of common knowledge that puerperal fever was far more 
prevalent in the hospital wards reserved for the medical 
students than in those attended by the midwives. In trying 
to find out why this should be, Semmelweiss had the happy 
thought that the students' practice of going directly from 
autopsy work to attend confinement cases might be at the 
root of the trouble. In 1847 he introduced the startling 
innovation of requiring a rough sort of hand disinfection, 
by making it a routine procedure for the students to wash 
their hands and soak then in chlorine water before making 
vaginal examinations. The result was a drop in the puer- 
peral fever mortality from 11.4 per cent to 1.27 per cent by 
the next year. In spite of this brilliant proof of the correct- 
ness of his views, Semmelweiss, like Holmes, met with open 
hostility. Overcome by disappointment and chagrin, he 
finally became insane and, by a strange freak of fate, died PUERPERAL INFECTION 
199 
from sepsis following an infected wound. The work of 
Pasteur and Lister was needed to convince the world of the 
new truth. 
Without going into the details of exact pathological classi- 
fication, we may consider puerperal infection as divided into 
two general types. One of these, which still goes by the old 
name sapremia, might better be called an absorption toxemia, 
since it is the result of absorption from the decomposing 
material in the uterine cavity. Examples of this type are 
seen when bits of placental tissue, membrane or blood clot 
are left in the uterus or when there is some interference with 
the drainage from its cavity. The organisms concerned 
are those which produce decomposition and are normally 
present while the necrotic tissue of the mucous membrane is 
breaking down. 
The other type is what is generally understood when the 
term puerperal infection is used, since it is a true infection, 
produced by the pyogenic organisms, especially the strepto- 
coccus, staphylococcus, gonococcus and colon bacillus. The 
organisms make their way up through the vagina into the 
uterus and attack the raw surface left at the placental site 
just as they would infect an open wound in any other part 
of the body, setting up an endometritis in what remains of 
the mucous membrane. The infection may pass quickly 
through the uterine wall into the peritoneal cavity, with a 
resulting peritonitis, or it may enter the blood stream, 
causing a general septicemia; a gonococcus infection nearly 
always travels along the mucous membrane into the Fallo- 
pian tubes to start an inflammation there. The more viru- 
lent the organisms and the weaker the patient's powers of 
resistance, the more rapid the extension and, naturally, the 
more severe the symptoms. 
A typical case of puerperal infection shows itself about the 200 
THE PUERPERIUM 
third day, with a chill, sudden rise of temperature to 102 0 or 
103°F., rapid pulse and signs of prostration. There is often 
tenderness over the uterus, and if peritonitis is beginning, 
the characteristic abdominal pain, tenderness and disten- 
tion will appear. If the trouble is caused by necrotic 
material in the uterus, the lochia will be dark or dirty 
reddish in color, foul-smelling and profuse. In true septi- 
cemia, on the other hand, the discharge is likely to be pale 
and odorless and so scanty that it is not to be wondered at 
that obstetricians of former days ascribed the disease to 
suppression of the lochia. 
T realm ent.-Preventive treatment is all-important. Puer- 
peral infection is a preventable disease, if ever there was 
one, and all that is needed to drive it from our borders is to 
carry out conscientiously the rules of modern aseptic technic. 
Even to-day there still remain some people who try to excuse 
their neglect of asepsis by maintaining that it is useless to 
take such precautions when the patient is uncleanly in her 
person or her surroundings. It is true that a dirty or ignor- 
ant patient may infect herself by handling the parts or by 
using soiled dressings, in spite of the best efforts of doctor 
and nurse; but the splendid results of a well-conducted out- 
patient service in the poorest quarter of many a large city 
offer convincing proof that dirty surroundings make little 
headway in the face of clean obstetrics. 
The nurse's part in the prevention of the disease is to see 
to it that she is in no way a carrier of infection. It should 
go without saying that an obstetrical nurse will avoid septic 
and contagious cases as far as possible, that she will thor- 
oughly disinfect her person after attendance on such cases 
and that she will not go directly from them to a confinement. 
The modern nurse knows too that a focal infection such as 
a sore throat or a carious tooth may make her a source of PUERPERAL INFECTION 
201 
danger. The text-books still cite the well-known case of 
an unfortunate obstetrician who suffered from ozena and 
was thus the unwitting cause of a trail of puerperal fever 
in his practice. In her care of her patient the nurse must 
never relax her aseptic vigilance. In aiding the physician 
she must take the greatest care not to contaminate in the 
slightest way the obstetrical supplies and instruments. If 
she is not able to disinfect her hands while in attendance 
upon him, she should cultivate the habit of using sterile 
forceps. 
A century ago bleeding and purging still held their own as 
methods of treating childbed fever, but as the conviction 
grew that the disease was really an infection in the uterus, 
they gave way to local measures of douching, packing and 
curettement. These, however, involved so much manipu- 
lation within the uterine cavity and, in consequence, so 
much disturbance of Nature's healing process that they often 
defeated the very end which they sought to accomplish. 
The principle of the modern methods of treatment is to 
work against infection by destroying the organisms and 
raising the patient's powers of resistance. Unfortunately, 
in puerperal infection the attempt to fight the invading 
organisms directly with serum or vaccine has not been 
crowned with the success which was hoped for. Stress is 
therefore laid on supporting and stimulating the patient, 
and nourishment to keep up her strength is of prime impor- 
tance. 
Lowering the pelvis to secure better drainage and to keep 
the infection from ascending into the general peritoneal 
cavity is recognized as a valuable aid in the treatment. 
The Fowler position is therefore in common use for these 
cases. The patient can be raised on pillows or a bed-rest, 
or the head of the bed can be raised so that she lies on an 
inclined plane. 202 
THE PUERPERIUM 
Salt solution supplied to the tissues is an important part 
of the treatment. It is usually given by rectum, according 
to the familiar Murphy-drip method. The solution, warmed 
to body temperature, is placed in a fountain syringe or other 
container, which is surrounded by hot-water bottles to pre- 
vent cooling. A clamp on the tubing regulates the flow as 
may be desired, generally to the rate of fifty to sixty drops 
a minute. At first this is readily absorbed and can be given 
almost continuously, but if the tube is irritating to the patient 
or if after a time she cannot retain all the fluid, it will be 
better to allow her intervals of rest. If the bowel becomes 
so intolerant that the solution is often expelled, hypodermoc- 
lysis should be tried. 
Other measures will be determined by the patient's symp- 
toms and the practice of the physician. If there is much 
abdominal distention and distress from the gas, the rectal 
tube maybe passed or stupes applied to the abdomen; eserin 
and pituitrin are sometimes used. For abdominal pain an ice 
cap is often used, although some doctors prefer hot applica- 
tions. For purposes of diagnosis the physician may wish to 
have a microscopical examination made from a cervical 
smear, a blood count made and a blood culture taken. 
It must not be forgotten that rest is a powerful factor in 
the patient's recovery. The most excellent treatment may 
not accomplish the desired good, if the patient is constantly 
disturbed in the process. A wise nurse will carefully look 
over the list of things to be done and will so group them 
as to give the longest possible intervals of rest. 
Puerperal Thrombosis. Thrombo-phlebitis. Phlegmasia Alba 
Dolens.-In this condition, familiarly known as "milk-leg," 
the circulation of the leg is partly shut off by the formation 
of a clot in one of the larger veins. While usually con- 
fined to one leg, thrombosis has been known to affect PUERPERAL INSANITY 
203 
both, in succession or even simultaneously. First, there 
is pain over the course of the vein, then the leg becomes 
swollen and tender and the skin white and glazed in appear- 
ance. If the thrombus is infected, there will be fever and 
rapid pulse. 
The treatment is rest until the absorption of the clot is 
complete. The patient is put to bed, with the leg elevated, 
and is kept absolutely quiet to avoid embolism. The leg 
may be wrapped in cotton and various lotions and oint- 
ments applied to relieve the pain, but on no account should 
even the gentlest massage be employed. Convalescence is 
apt to be slow and tedious, and the leg may have a tendency 
to swell after the patient is up and about again. 
Puerperal Insanity. -In most cases of puerperal insanity 
the strain of pregnancy and labor is only the last step for a 
patient already well on the road to mental derangement. 
The more strictly obstetrical cases follow eclampsia and 
puerperal infection. 
The attack comes on within the first week or two after 
the delivery. After a period of deceptive calm, in which the 
patient seems perhaps unusually quiet and abstracted, she 
suddenly becomes excitable, even to the point of mania, or 
deeply melancholic. She may show a violent antipathy to 
the people about her and attempt to do them harm. In a 
moment of depression she may try to commit suicide. 
Because of these tendencies the patient must never be left 
alone for a single moment, and on no account should the 
baby be in the room with her. 
In the majority of instances puerperal insanity tends 
toward improvement and recovery. The outcome is most 
favorable in the eclamptic cases, although entire loss of 
memory concerning the events of the confinement is com- 204 
THE PUERPERIUM 
mon. Cases are on record in which the mother, after her 
recovery, has even refused to believe that the child is hers. 
Subinvolution.-This is a condition of defective involution, 
which results from poor tone of the uterine muscle. The 
fundus, instead of sinking into the pelvis by the tenth day, 
is felt well above the symphysis, and the heavy uterus drags 
on its ligaments, sagging out of place and making pressure 
on the surrounding organs. Subinvolution is common 
among multiparse who have had pregnancies in rapid suc- 
cession. Getting up too soon after confinement is a frequent 
cause, and a dispensary out-patient service is sure to furnish 
many examples among the women who are doing their 
housework and hanging out the wash when the baby is but 
a few days old. 
If the involution is slow, the patient must be kept in bed 
beyond the classic ten days until it is complete. Hot vaginal 
douches aid the process, and ergot, strychnine and hydrastis 
are often prescribed as a uterine tonic, Without treatment 
the condition is apt to become permanent, and old cases are 
little benefited by the above measures. 
Final Examination.-Before the obstetrician discharges his 
patient, he will wish to make an examination to see that 
her pelvic condition is satisfactory. For this final examina- 
tion the woman is placed in the dorsal position, preferably 
with her hips at the edge of the bed or table, and prepared 
as for any vaginal examination. The nurse should have in 
readiness whatever the physician will need for hand disin- 
fection, also a gown and sterile gloves. She should always 
ask what will be required for the examination. Usually a 
speculum, dressing-forceps and pledgets will be all-sufficient, 
but some physicians insert a medicated tampon at this time. CHAPTER IX. 
OBSTETRICAL OPERATIONS. 
Obstetrical operations are undertaken to hasten delivery 
in the presence of any condition which endangers the life 
of mother or child. The commonest indications are: (1) 
Delayed labor, due to inertia of the uterus or exhaustion of 
the mother; (2) danger to the child, as shown by failing 
heart tones; (3) malpresentations; (4) disproportion between 
the child and the pelvis, whether due to large size of the 
child or contraction of the pelvis; (5) obstetrical emergencies, 
such as eclampsia and hemorrhage. 
Preparation for Operation.-Since obstetrical operations are, 
as a rule, undertaken during labor, as the occasion arises, 
and often under conditions when delay may cost life, any 
prolonged preliminary preparation of the patient is out of 
the question, except in some cases of Caesarean section. 
Fortunately the routine care in a normal case includes 
emptying the bowels by an enema and either shaving or 
clipping the pubic hairs; moreover, the woman has usually 
taken only light nourishment since the beginning of labor, 
so that an anesthetic can safely be given her. In the average 
case all that is necessary, when the operation is decided upon, 
is to anesthetize the patient, place her in the most favorable 
position for the operation, catheterize her and make a better 
surgical field by cleansing the parts again and adding fresh 
sterile dressings. Catheterization should never be omitted, 
as a full bladder may act as an obstruction or receive some 
injury during the extraction of the child. 206 
OBSTETRICAL OPERATIONS 
The anesthetic is practically always ether, unless there 
is some special indication for the use of chloroform or nitrous 
oxide and oxygen. Twilight sleep in itself is not sufficient 
for the usual operative procedures. Since prolonged anes- 
thesia is particularly undesirable in obstetrical cases on 
account of its effect on the child, all possible preparations 
should be made before the ether is started, so that the 
patient will not be kept under its influence any longer than 
is absolutely necessary. 
Fig. 84.-Robb's leg-holder in position. (Cragin.) 
In all operations except Caesarean section the patient lies 
on her back, with her hips brought to the edge of the bed or 
table and her legs held up by stirrups or some similar appli- 
ance. The average bed is too low for operative work, but a 
satisfactory operating-table can be fitted up from an ordinary 
kitchen table. For private work Robb's leg-holder is a FORCEPS 
207 
valuable asset in place of the stirrups and a sheet twisted 
into a sling is a practical substitute; sometimes members of 
the family or friendly neighbors may be enlisted as leg- 
holders, if they can be relied upon not to become too excited 
or nervous in the course of the proceedings. As far as 
possible the moving of the patient should be done while she 
is still conscious and able to help herself, but it is usually 
wiser to wait until she is relaxed under the anesthetic before 
holding or fastening her legs, as she may struggle and hurt 
herself during the "excitement stage." The operating field 
is arranged as for a normal delivery, with the addition of 
a sterile towel placed over the anus and held in place by a 
broad band of adhesive plaster. The obstetrician will 
designate the instruments which he will require; these will 
include instruments for the repair of lacerations which are 
likely to occur. It must be remembered that an operative 
delivery greatly increases the chances of postpartum hemor- 
rhage for the mother and asphyxia for the child, and that it 
is therefore imperative to have everything at hand for the 
treatment of these complications. 
Forceps.-Delivery by forceps is the commonest obstetrical 
operation. The instrument dates back only as far as the 
early part of the seventeenth century and was for more than 
a hundred years a secret known only to the members of the 
Chamberlen family who had invented it. Before their time 
the only method of delivery in the majority of difficult cases 
was by means of mutilating operations on the child, which 
sacrificed its life and often resulted in serious injury or even 
death to the mother as well. 
The instrument is used to extract the child when the head 
is presenting. It has two separate blades curved to fit around 
the head and the handles lock in such a way as to ensure a 
firm grasp without exerting too much pressure. The opera- 208 
OBSTETRICAL OPERATIONS 
tion is called high, mid or low, according to the position of 
the head in the pelvis, and the forceps are varied somewhat 
to meet the needs of the case. An instrument to be used 
Fig. 85.-Simpson forceps. 
(Cragin.) 
Fig. 86.-Elliot forceps. (Cragin.) 
when the head is high in the superior strait must naturally 
have longer handles in order to reach far enough up into the 
birth canal, and a special attachment has been devised INDUCTION OF LABOR 
209 
which makes it easier to apply the traction in the axis of 
the pelvis and gives to the instrument the name of axis-trac- 
tion forceps. The type of forceps most commonly used for 
the low and mid-operations is the Simpson; the best known 
of the axis-traction instruments is the Tarnier model. 
The low forceps operation is easy for the obstetrician 
and often involves no more injury to the mother and child 
than may accompany a normal delivery; but the high opera- 
Fig. 87.-Tarnier axis-traction forceps. Traction handle attached. 
(Cragin.) 
tion may mean a long, hard pull, with laceration of the tissues 
of the birth canal and perhaps serious result to the child 
from the pressure of the instrument. 
The physician will usually tell the nurse which forceps to 
prepare, but if in doubt, it is always safe to sterilize both 
the axis-traction forceps and the Simpson (or whatever 
model the physician uses for the low and mid cases). 
Induction of Labor.-Labor may be brought on by artificial 
means, after the child is viable, if the physician is convinced 210 
OBSTETRICAL OPERATIONS 
that delay means danger to mother or child. Cases which 
might require such treatment would include: (1) Dispro- 
portion between the child and the pelvis; (2) toxemia, not 
Fig. 88.-Voorhees's modification of Champetier de Ribes's bags, 
(Cragin.) 
yielding to other treatment; (3) placenta previa; (4) certain 
heart, lung and kidney conditions. The procedure may be 
undertaken before full term or when the patient is apparently INDUCTION OF LABOR 
211 
at or even beyond term and does not fall into labor spon- 
taneously. It must not be confused with the induction of 
abortion, before the viability of the child. 
Various methods are employed, according to the needs of 
the case. If the patient is about at term, it may be enough 
to give her a full dose of castor oil, following it with quinine. 
Fig. 89.-Syringe used for distending elastic bags. (Cragin.) 
In a multipara, manual dilatation of the cervix or rupture 
of the membranes is occasionally successful. A far surer 
way is to introduce into the cervix and lower part of the 
uterus something which will act as an irritant and start up 
uterine contractions. This irritant may be: (1) Gauze 
packing; (2) a catheter or rectal tube; (3) a rubber bag, 212 
OBSTETRICAL OPERATIONS 
which can be filled with water through a tube after its 
insertion. The first two are easier to put in, but the results 
are more uncertain. The bags, being larger, are harder to 
insert, but surer in their effect, and by their pressure against 
the internal os aid in the dilatation of the cervix after the 
contractions have begun. 
The patient is prepared as for any vaginal operation. If 
she is a multipara with an open cervix, a small bag can be 
inserted without anesthesia. If a primipara, the cervix 
must often be dilated before the bag can be introduced, and 
anesthesia will than be needed. When there is sufficient 
dilatation, the bag, rolled as small as possible, is carried 
through the cervix on dressing-forceps, or better, on a special 
carrier with blunt tips. When it is well inside the internal 
os, a syringe or funnel is connected with the tubing of the 
bag and sterile water is then allowed to run in until the bag 
is filled. The tubing of the bag is then clamped or tied 
tightly to prevent the water from running out. Usually 
within six or eight hours uterine contractions have begun; 
if not, the effect of the pressure of the bag can be increased 
by attaching a one-pound weight to the tubing and letting 
it hang over the foot of the bed, so that it exerts a pull on 
the bag. The nurse should report when the pains begin. 
She should also look from time to time to be sure that the 
water is not escaping from the bag. 
The instruments needed for this operation are: Two 
retractors, or a weighted speculum and an anterior retrac- 
tor; a tenaculum; dressing-forceps; bags of different sizes; 
the carrier for the bag; two hemostats; scissors; a syringe or 
funnel for running the water in. The bags should be care- 
fully tested beforehand for any leak. They should be thor- 
oughly sterilized by boiling, a rule which also applies if a 
catheter or rectal tube is used. The only possible danger BREECH EXTRACTION 
213 
from the operation is the chance of infection, and this is a 
remote one if aseptic technic is observed. 
Fig. 90.-External version in a breech presentation. (Cragin.) 
Breech Extraction.-Breech extraction is used whenever 
immediate delivery is necessary in a case of breech presen- 
tation. The patient is thoroughly anesthetized and the 
operator introduces one hand into the uterus, brings down 
the feet and breech and extracts the child according to the 214 
OBSTETRICAL OPERATIONS 
mechanism described under breech presentations. The child 
is sometimes injured in the course of the rapid extraction, 
Fig. 91.-External version in a transverse presentation. Obstetrician above 
the pelvis. (Cragin.) 
and fractures of the limbs and paralysis have been recorded. 
The nurse will make the preparations and stand ready to 
give aid, as already detailed under the above heading. VERSION 
215 
Version.-Version is the turning of the child in the uterus 
so as to change the presentation. It is called external, inter- 
nal or combined, according as it is accomplished by external 
or internal manipulations or a combination of the two. 
In cephalic version the head is made the presenting part; 
in podalic version the breech and feet are brought down. 
Fig. 92.-Combined or bipolar version. (Cragin.) 
Whenever a breech or transverse presentation is found 
during a prenatal examination, external version is used in 
the attempt to correct the malpresentation. It is not always 
successful, and too much force must not be used, for fear of 216 
OBSTETRICAL OPERATIONS 
causing some injury. If there is a tendency for the mal- 
presentation to recur, the fetus can sometimes be held in its 
new position by a firm binder applied to the mother's abdo- 
men, with pads at the sides. 
Fig. 93.-Internal version. (Cragin.) 
Internal version can be used only during labor and after 
full dilatation of the cervix, since it involves passing the 
whole hand inside the uterus to turn the child. After the 
version is complete, the child is extracted by the feet, as in 
a breech extraction. This is the type of version which is CAESAREAN SECTION 
217 
meant when it is said that a child is born by version. It is 
suitable not only for cases of malpresentation but also for 
cases in which immediate delivery is required and the head 
is too high for the application of forceps. It is a dangerous 
operation when the membranes have been long ruptured, 
because the uterus has had time to contract down on the 
child and it is hard to turn even a small fetus without injury 
to the uterine wall. Rupture of the uterus has resulted from 
the attempt to do version in such cases. 
Vaginal Caesarean Section.-In this operation the uterus is 
opened from below by an incision anteriorly in the cervix 
and lower uterine segment; if the child is large, a posterior 
incision is added. The operation is performed in cases of 
rigid or undilated cervix, when immediate delivery is neces- 
sary, as, for instance, when eclamptic convulsions come on 
before the patient is in labor. It differs markedly from the 
more familiar abdominal Caesarean section in being contra- 
indicated when the pelvis is small, because the child must be 
born by the natural passages after the uterus is incised. 
The patient is prepared as for any vaginal operation. The 
instruments required are two tenacula, a scalpel, long straight 
scissors, six hemostats, two long clamps, curved needles, a 
needle-holder and small scissors. The usual sterile dressings 
should be provided, including uterus packing, as there is 
some danger of hemorrhage. In addition to these things 
everything should be in readiness for an operative delivery 
(usually by forceps), postpartum hemorrhage, and repair of 
lacerations. The instruments for perineorrhaphy are espe- 
cially needed because it is sometimes necessary to incise the 
perineum as well as the uterus. 
Caesarean Section.-Caesarean section is the well-known 
operation in which the child is born through an incision 
in the abdominal and uterine walls. It is called the Caesar- 218 
OBSTETRICAL OPERATIONS 
ean operation, not because Julius Caesar was born in this 
way, but probably because the old Roman or Caesarean law 
directed that it should be performed when a woman had died 
undelivered, so that she and her dead child could be buried 
separately. It is only within the last four or five hundred 
years that it has been practised upon the living woman to 
effect the birth of a living child, and even as late as fifty 
years ago the mortality was so high that it was undertaken 
only as a last resort in the most urgent cases. The develop- 
ment of modern aseptic technic in surgery has, however, 
wrought such a wonderful change that the operation is now 
in common use for cases (usually of pelvic deformity) in 
which delivery by the natural passages is either impossible 
or so difficult as to endanger the life of the child and perhaps 
that of the mother as well. It is also performed in certain 
cases of eclampsia, placenta previa and other conditions 
which may require immediate delivery. 
If there is a chance that the child can be born without the 
operation, it is usual to let the woman go into labor, espe- 
cially if she is a primipara, in order to see what the natural 
forces can accomplish before deciding to operate (to give her 
the "test of labor," in the common phrase). If it is clear 
from the start that Ceesarean section is the only possible 
solution of the problem, the operation is performed when the 
patient is at term, without necessarily waiting for the pains 
to begin. 
The patient is prepared as for any abdominal operation, 
according to the technic of the surgeon in charge. The 
field of operation is shaved and the abdomen thoroughly 
cleansed with green soap and water, followed by bichloride 
solution, alcohol, lysol or whatever antiseptic is preferred. 
Some surgeons' routine includes painting the patient's abdo- 
men with tincture of iodine just before the operation is begun. CAESAREAN SECTION 
219 
It goes without saying that the bladder and rectum should 
have been emptied before the patient is brought to the operat- 
ing-room; it is most undesirable to have the operation 
delayed by the catheterization of the patient after she is 
on the table. The abdomen is protected by the usual sterile 
sheets and towels. Gas or ether anesthesia is used. 
The instruments needed are as follows: 
2 pairs of scissors, one angled and one straight. 
2 scalpels. 
2 pairs of tissue forceps. 
2 abdominal retractors. 
2 peritoneal tenacula. 
2 needle-holders. 
18 to 24 hemostats (at least 6 long ones). 
Needles and catgut, No. 1 and No. 2. 
Cord scissors and two cord clamps. 
The supplies will include sterile towels, gauze sponges, 
large and small, with some strung sponges, and plenty of 
hot salt solution. Everything must be in readiness for 
resuscitating the child and for controlling hemorrhage. A 
hypodermic syringe should be filled with ergot so that it 
can be given without delay just before the placenta is 
extracted. 
The steps of the operation are as follows: 
1. Median incision through the abdominal wall. For 
this the operator will need a knife, tissue forceps, hemostats 
and angled scissors. 
2. Incision through the uterine wall. A fresh knife is 
used. 
3. Extraction of the child. Have ready two long clamps 
to clamp the cord and scissors to cut it. The child is then 
handed to an assistant to be resuscitated if necessary. 
4. Removal of the placenta and membranes. A sterile 220 
OBSTETRICAL OPERATIONS 
pan must be ready to receive the placenta. A hypodermic 
injection of ergot is given while the placenta is being sepa- 
rated or earlier, as the obstetrician may direct. 
5. Closure of the uterine incision. The uterus is wrapped 
in towels or large sponges wrung out of hot salt solution. 
Retractors may be needed. The muscular wall of the uterus 
Fig. 94.-Csesarean section. Site of abdominal incision. (Cragin.) 
is closed with interrupted sutures of chromicized catgut No. 2 
(one or two tiers, according to the technic of the operator,) 
and the peritoneal covering of the organ with a continuous 
suture of catgut No. 1. Bound needles are threaded and 
placed in the needle-holders and handed to the operator as 
fast as possible. 
6. Closure of the abdominal wound, according to the CAESAREAN SECTION 
221 
usual method: (1) The peritoneum, with a continuous suture 
of catgut No. 1; then the muscle, with interrupted sutures 
of catgut No. 2; then the skin, with a subcuticular suture of 
catgut on a sled-runner needle, or interrupted sutures of 
silk-worm gut on straight or curved cutting-edge needles. 
Sterile dressings are now applied, and held in place by 
wide strips of adhesive plaster. A firm abdominal binder 
is placed outside the dressing. 
Fig. 95.-Closure of the muscular wall of the uterus begun. 
The operation as here described is the classical Caesarean 
section. The extraperitoneal and transperitoneal opera- 
tions are recent modifications with a low uterine incision, 
which aim to lessen the danger of infection of the peritoneal 
cavity. 
Many cases of repeated Caesarean section are on record, 
and the operation has even been performed safely six times 
on the same patient. On the other hand conditions may 222 
OBSTETRICAL OPERATIONS 
be present which make it dangerous for a woman to undergo 
a second operation. If so, the surgeon may be called upon 
to sterilize the patient before closing the abdomen. This is 
usually done by tying each tube in two places with linen 
thread and cutting between the ties. In such conditions as 
Fig. 96.-Closure of muscular wall finished. (Davis.) 
uncontrollable hemorrhage, fibroid tumors of the uterus or 
infection, it may be necessary to remove the entire uterus 
after the extraction of the child. This is known as the 
Porro operation or Porro-Csesarean section, because it was 
urged by Porro, in the days before asepsis, as a way to pre- 
vent or lower the mortality from septic infection. CESAREAN SECTION 
223 
After-care.- The after-care is the same as for any abdom- 
inal operation. The patient should be specially watched 
for any signs of shock, hemorrhage or beginning infection, 
and any untoward symptoms promptly reported to the 
physician. Usually the patient does well, the sutures are 
Fig. 97.-Closure of peritoneal covering of uterus. (Davis.) 
removed by the tenth day, she sits up in two weeks, and is 
up and about in three weeks. An abdominal binder should 
be worn to give proper support. 
Besides the immediate dangers just mentioned, the ill- 
effects of a Caesarean section are weakening of the uterine 
or abdominal wall and adhesion of the uterus to the abdom- 224 
OBSTETRICAL OPERATIONS 
inal scar, with the possibility of rupture of the uterus at a 
subsequent pregnancy. The mortality in the hands of a 
good operator under favorable conditions is from 2 to 4 per 
cent. 
Symphyseotomy. Pubiotomy.-These are operations for 
enlarging the pelvis when it is too small to let the child pass 
Fig. 98.-Pubiotomy, showing incision made and needle passed. (Cragin.) 
through. Symphyseotomy, the older of the two, was first 
performed in 1773. It consists in cutting through the 
symphysis, at the joint, so that the pubic bones can gape 
apart and make more room in the pelvis. On account of 
the difficulty in securing good union at the joint, it has been 
largely abandoned ip favor of pubiotomy. SYMPHYSEOTOMY-PUBIOTOMY 
225 
In pubiotomy (also known as hebotomy and hebosteotomy) 
the pubic bone is sawed through just to one side of the 
symphysis by means of a wire saw, which has been threaded 
into a special needle and carried under the bone through a 
small incision. The operation can also be performed sub- 
cutaneously. When the bones haye been stretched apart, 
the child is delivered by forceps or version, as the case may 
require. The chief dangers of the operation are hemor- 
Fig. 99.-Pubiotomy. Flexible saw in place. (Cragin.) 
rhage, which may be alarmingly profuse, and injury to the 
bladder; there is also a likelihood of deep lacerations of the 
soft parts. Later dangers are infection of the wound and 
imperfect union of the bone. 
The instruments needed for a pubiotomy are a scalpel, two 
Gigli wire saws, a Doederlein pubiotomy needle, scissors, 
hemostats, needles, a needle-holder and suture material. 
There should be plenty of large sponges provided, in case 226 
OBSTETRICAL OPERATIONS 
of hemorrhage. Two saws should always be in readiness, 
lest one break while sawing through the bone. Forceps for 
the extraction of the child and instruments and. suture 
material for the repair of lacerations should also be at hand. 
In order to secure satisfactory union of the bone, the 
pelvis is held firmly in position by a twelve-inch strip of 
adhesive plaster, passed around the hips. The after-care 
is complicated by the fact that the woman is really quite 
helpless during the first part of the puerperium and must be 
lifted a great deal. Being unable to spread her legs apart, 
she finds it hard to void her urine and move her bowels, and 
the nurse will sometimes find it a problem to keep the parts 
clean and the wound free from contamination. A special 
bed has been devised for use after the operation, but the 
more familiar Bradford frame is quite as convenient. The 
patient should be able to sit up within three weeks. In some 
cases there is only fibrous union of the bone, but this does not 
seem to interfere with walking and may even prove an 
advantage, by allowing permanent enlargement of the pelvis. 
Embryotomy.-By this term is understood any mutilating 
operation on the fetus. In ancient times such operations 
offered the only method of delivery in difficult cases, and the 
child was sometimes extracted almost piecemeal. Forceps 
and version, Caesarean section and pubiotomy, have rendered 
them unnecessary in ordinary practice, unless the child is 
a monstrosity or dead and too large to pass through the 
birth canal. The necessity of performing such an opera- 
tion on a living child to save the mother's life is fortunately 
most exceptional, for it is one of the most dreadful things 
that the obstetrician is ever called upon to do. 
Craniotomy, or perforation of the head, is the most familiar 
of these operations. The instrument used is a perforator 
of the Smellie scissors type or, if the head is unusually hard, EMBRYOTOMY 
227 
a trephine. After the hole has been made in the skull, 
usually through a suture or fontanelle, a long douche nozzle 
is introduced through it, and the brain washed out, to allow 
Fig. 100.-Smellie's scissors. ■ (Cragin.) 
the head to collapse. If the head is the presenting part, it 
must be extracted by means of the cranioclast, an instrument 
which at first sight suggests a pair of obstetrical forceps. 
One blade is, however, solid and toothed, and this is inserted 228 
OBSTETRICAL OPERATIONS 
into the hole in the skull, while the other fits over the outside 
of the head, so that a firmer hold is secured than with the 
forceps. Craniotomy is performed in practically all cases of 
hydrocephalus (an accumulation of fluid in the child's head). 
The head collapses with the escape of the fluid and the child 
can then be extracted, sometimes by version, without the 
use of the cranioclast. 
If the shoulders cannot be extracted by the usual methods, 
a blunt hook may be passed under the axilla, and traction 
made. If they are too broad to pass, one or both clavicles 
must be cut with a long pair of scissors. This operation is 
called cleidotomy. 
In the rare cases of impacted transverse presentation with 
a dead child, it has sometimes been necessary to decapitate 
the fetus. A blunt hook, a sickle knife or a long pair of 
scissors is used. 
Repair of Lacerations.-In spite of the obstetrician's best 
efforts it is not always possible to prevent lacerations of the 
perineum and vagina, especially if the patient is a primipara. 
The nurse should therefore have in readiness the necessary 
instruments, suture material and dressings, so that the repair 
can be done without delay. 
Lacerations are classified as complete and incomplete. A 
complete tear is one which involves the sphincter of the anus 
and often the rectum as well, while an incomplete tear, how- 
ever deep, stops short of the sphincter. Lacerations are 
also divided into tears of the first, second and third degrees, 
as follows: 
First degree lacerations are superficial, involving the skin 
surface of the perineum or the mucous membrane of the 
vagina. 
Second degree lacerations extend into the muscle of the 
perineal floor but not through the sphincter ani. REPAIR OF LACERATIONS 
229 
Third degree lacerations pass through the sphincter and 
sometimes through the rectal mucous membrane. 
Lacerations of the cervix are fairly common, but for the 
most part they are slight and heal so well without suturing 
that their repair is not a routine procedure. If a cervical 
tear is deep enough to cause hemorrhage, immediate repair 
may be urgent to control the bleeding. 
After a prolonged labor the tissues are sometimes so 
swollen and edematous that the obstetrician will prefer to 
wait until the next day before operating, but in the great 
majority of cases the repair is done at the end of the third 
stage of labor. Indeed, the sutures may even be placed 
while the doctor is waiting for the placenta to be expelled, 
and tied as soon as it has been extruded. 
The patient lies in the dorsal or better, in the lithotomy 
position, with the buttocks brought to the edge of the bed 
or table. In a hospital the feet are held up by stirrups, but 
in a private house a leg-holder or a sheet may be used, or 
someone may be asked to hold the legs. If the laceration is 
very extensive, an anesthetic will be necessary, especially in 
the case of a complete tear; in most cases of first degree 
lacerations the patient will prefer to bear a few minutes' 
pain rather than to take ether. 
The instruments required for an ordinary perineorrhaphy 
are tissue forceps, curved and straight scissors, six hemo- 
stats, a needle-holder, two retractors and dressing-forceps. 
The needles should include large perineal needles as well 
as the curved needles suitable for vaginal work. Chromi- 
cized catgut No. 1 and No. 2 are used for the vagina, and 
some operators use it for the skin surface also, while others 
prefer silkworm gut. The parts must be carefully cleansed 
before the stitches are placed, and sponges and square gauze 
will be needed for this purpose. During the operation the 230 
OBSTETRICAL OPERATIONS 
nurse may be asked to assist by threading needles, holding 
retractors, sponging the field and handing instruments. 
For a cervical repair two long tenacula will be needed in 
addition to draw down the lips of the cervix, and the nurse 
may be asked to hold these after they have been applied. 
After-care of Sutures.-The best way to promote healing 
after a perineorrhaphy is to keep the sutures and the line of 
the repair as clean and dry as possible. This can be done 
by cleansing the parts, irrigating them with sterile water 
after micturition and defecation, and carefully drying them, 
wrapping the sutures in sterile gauze and changing the vulvar 
pads frequently. There is no apparent advantage to be 
gained from the use of antiseptic solutions in dressing the 
wound. If the repair is extensive, the patient should be 
cautioned against moving about in such a way as to put 
strain on the stitches; the old method of tying the legs 
together has been given up. If the parts become swollen 
or edematous, the stitches are likely to cut into the tissues, 
and the condition should therefore be reported to the doctor. 
It is usually treated by cold compresses of witch-hazel, boric 
acid or salt solution. 
If there has been a complete laceration through the 
sphincter ani, the physician will probably give orders for the 
bowels to be kept locked for some days, lest the straining 
at stool should cause the sutures to tear through. An oil 
enema is given before the first bowel movement in order to 
soften the fecal matter. 
Removal of Sutures.-In the ordinary case the perineal 
sutures are removed on the eighth day. After a superficial 
laceration good union will take place earlier than this. If 
the stitches are cutting, they may have to be removed on this 
account. 
The patient is placed across the bed and the vulva and EPISIOTOMY 
231 
perineum are cleansed in the usual manner. A good light 
is an important requisite. For the removal of the sutures 
the doctor will want only tissue forceps and a pair of scissors 
which cut well at the points. Some prefer a probe instead 
of the forceps to lift the stitches. 
The catgut used in the repair of the vagina and cervix 
can usually be left to absorb and these stitches are therefore 
not removed. 
Fig. 101.-Episiotomy. (Bumm.) 
Episiotomy.-This very minor operation is simply cutting 
the perineum when the vulvar opening is too small or the 
tissues too rigid to allow the child's head to pass without a 
laceration of the perineum. A single central incision may 
be made, or two oblique slits, one at either side of the median 232 
OBSTETRICAL OPERATIONS 
line posteriorly. The repair of the resulting wounds is 
after the manner of any perineorrhaphy, but it is claimed 
that the healing is more satisfactory because they are clean- 
cut incisions and not ragged and irregular tears. The only 
instrument required for the operation is a pair of straight 
scissors, but the perineorrhaphy instruments will be needed 
for the repair afterward. 
MINOR OPERATIVE PROCEDURES. 
Douches.-Douches are used for the purpose of cleansing 
the vagina and the uterine cavity. They were formerly 
almost a routine part of the conduct of an obstetrical case, 
but their popularity has waned of late years, and they are 
now used only in special conditions, by the express order 
of the doctor. A douche is either vaginal or intra-uterine, 
according as the fluid is introduced into the vagina or the 
uterine cavity. Vaginal douches are given by the nurse, but 
intra-uterine douches by the physician. 
As a preparation for the douche the nurse sterilizes a 
douche pan, a douche bag or other container and a glass 
nozzle, short or long, according as the douche is vaginal or 
intra-uterine. The solution will be prescribed by the physi- 
cian. It may be sterile water or salt solution or an anti- 
septic solution such as lysol, bichloride of mercury, alcohol 
or potassium permanganate. The nurse should ask for 
precise directions when antiseptics are used, especially in 
the case of the poisonous ones, so that there may be no mis- 
take about the strength of the solution and the amount to 
be used. Most douches are given at a temperature of about 
100CF., just above the body temperature; when they are 
used for the purpose of applying heat to the pelvic organs 
or controlling a hemorrhage, the temperature is from 112° to MINOR OPERATIVE PROCEDURES 
233 
120°F. For a vaginal douche one to two quarts of the solu- 
tion is the usual quantity. 
Vaginal Vouches.-These are sometimes prescribed for 
cases of gonorrhea during pregnancy, when the discharge is 
profuse. They were formerly recommended to soften and 
relax the parts during labor as well as to wash out any organ- 
isms which might have gained entrance to the vagina, but 
they have been practically abandoned at this time. In the 
puerperium they are of value when the patient has an 
offensive discharge and also in inflammatory conditions. 
A vaginal douche is given with the patient lying on her 
back in bed. The parts are carefully cleansed as for any 
vaginal procedure and the douche pan is slipped under her. 
The greatest care must be taken to prevent any material 
from being carried up from the vulva into the vagina. Before 
the nozzle is introduced, the fluid should be allowed to run 
through it, so that no air will be forced in. The nurse 
spreads the labia apart with the fingers of one hand, opening 
the vagina as wide as possible, and then gently slips the 
nozzle in, pointing it obliquely downward. If any material 
is washed out, it should be saved for the physician to see, 
if he so desires. After the douche has been given, the vulva 
is dried carefully and a pad applied to absorb any fluid which 
may ooze out from the vagina later. 
Intra-uterine Vouches. - Intra-uterine douches have their 
greatest value in checking postpartum hemorrhage. They 
were formerly used in puerperal infection as a method of 
introducing antiseptic solutions into the uterus, with the 
idea of destroying the infecting organisms. Since it has been 
shown that these organisms are buried too deep in the uterine 
wall to be reached even by a strong solution, intra-uterine 
douches have been omitted from the treatment. Cases of 
fatal poisoning have been reported following the use of 
solutions of carbolic acid and bichloride of mercury. Rarely 234 
OBSTETRICAL OPERATIONS 
an intra-uterine douche may be given to wash out retained 
lochia or clots from the uterine cavity, but it is seldom 
advisable. There is danger of absorption from the decom- 
posing material as it is spread over the surface of the lining 
membrane, and even a possibility that it may be forced up 
into the tubes. A sudden rise of temperature or a chill 
may result from a douche. 
The preparations for the douche include: (1) A sterile 
container, best of glass or white agate, although in an emer- 
gency a fountain syringe will serve every purpose; and (2) a 
thermometer for testing the heat of the solution. It is never 
safe to guess at the temperature of a douche to be used in 
a case of hemorrhage. 
When the douche is given for the treatment of postpartum 
hemorrhage, the patient is probably already lying with her 
buttocks brought to the edge of the bed or table, with a 
Kelly pad or similar appliance beneath her. In the puer- 
perium, she should be placed across the bed, and the pad or 
pan used. The vulva is cleansed as usual, and the physi- 
cian will generally douche out the vagina before inserting 
the long uterine nozzle. It is wise to have all preparations 
for a hot intra-uterine douche ready in every case of opera- 
tive delivery, as hemorrhage of at least moderate grade is 
not uncommon. Delay in the treatment of such hemorrhage 
is sometimes disastrous and even fatal. 
Packing or Tamponade. - Tamponade of any part of the 
birth canal may be performed for the purpose of arresting 
hemorrhage. It is most often used in postpartum hemor- 
rhage, when the entire uterine cavity must be tightly packed 
with gauze. In a case of hemorrhage from abortion or 
placenta previa the packing is introduced into the vagina 
and perhaps into the cervix as well. 
Uterine packing should be from four to six inches wide. 
It is usually cut in six-yard lengths and packed into a glass MINOR OPERATIVE PROCEDURES 
235 
container which can be kept tightly closed, but it may also 
be rolled and wrapped in a square of muslin and the whole 
packet sterilized. The instruments needed for the intro- 
duction of the packing are a speculum or retractor, a cervical 
tenaculum and a pair of long dressing-forceps. In a case of 
postpartum hemorrhage, when every moment counts, the 
obstetrician will not wait for these instruments to be boiled 
but will use his hand in packing the uterus. Indeed, some 
physicians prefer the hand to the dressing-forceps, because 
with it they can feel whether the gauze is being carried 
to the very fundus. The patient lies in the dorsal position 
and is prepared as for any vaginal procedure. After the 
tamponade she must be carefully watched for signs of inter- 
nal hemorrhage, as the uterus may relax even when filled 
with gauze, although the bleeding cannot be detected exter- 
nally until the packing has become saturated. If the hemor- 
rhage is controlled, the packing can be removed in from 
twelve to twenty-four hours. 
Curettement.-This operation is indicated in cases of 
abortion when the uterus must be emptied. It formerly 
played an important part in the treatment of puerperal 
infection, but is now limited to the cases in which there is 
too much decomposing material in the uterine cavity to come 
away with free drainage and is rarely used, even in these. 
Curettement may be performed with the finger or with a 
metal instrument. In abortions it is often necessary to 
dilate the cervix before curetting. The patient is prepared 
and anesthetized as for vaginal operation. The instru- 
ments needed are retractors or specula, tenaculum, uterine 
sound, uterine dilator, curettes and the outfit for an intra- 
utering douche. Gauze packing is sometimes inserted after 
a curettage. All material that is removed should be saved 
for the doctor's inspection and perhaps for laboratory 
examination as well. CHAPTER X. 
THE NEWBORN BABY AND ITS CARE. 
The daily chart for the baby will include the following 
data: The temperature; the weight; the condition of 
umbilicus, eyes, mouth, genitalia, buttocks, skin; the bowel 
movements, their number and character; urination. Under 
the heading "remarks" the nurse will note any special con- 
dition which requires attention. For hospital charts it is a 
great convenience to have under the entry of the weight three 
divisions as follows: Weight at birth, weight yesterday and 
weight to-day. 
Temperature. Pulse. Respiration,.-The first record on the 
baby's chart will be the temperature. At birth this is often 
subnormal, as might be expected, when we consider how 
much colder the outside world is than the interior of the 
mother's body; but the child soon becomes adjusted to its 
new surroundings. After two or three days a rise of tem- 
perature above the normal is sometimes noticed, which is 
often referred to as a "starvation temperature" and seems 
to be due to the fact that the baby is not yet getting what 
it needs from its mother. This inanition fever soon passes 
away as the mother's milk becomes more abundant. 
There is nothing notable about the pulse, except that it is 
a little slower than the fetal heart has been. The respira- 
tions are about 30 to 40, but are very variable. A child 
which has been asphyxiated must be carefully watched for 
any changes in pulse, respiration and color, and the condi- 237 
UMBILICAL CORD 
tion at once reported to the doctor. If it is in a hospital, 
the oxygen tank should be kept close at hand for use in an 
attack of cyanosis. 
Weight.-The next note will be the weight, a point of prime 
importance to the baby's family. In a hospital the weighing 
is done daily; in a private home this is not routine, because 
the scales are not always available or reliable. Moreover, 
it is apt to make the mother anxious if she follows the daily 
fluctuations too closely. 
The average weight of the newborn infant is from seven 
to seven and one-half pounds. Although it varies within 
rather wide limits, eleven pounds can be set as the maximum, 
barring exceptional cases. One should always be chary of 
believing the tales of twelve- and fifteen-pound babies, which 
are recounted by proud parents. 
During the first few days of life the weight goes down 
steadily, as much as one-half to three-quarters of a pound 
being lost in many cases. This initial loss is not surprising, 
since the child is not getting any nourishment from its 
mother and is losing • actual weight in its bowel movements 
and urine. As soon as the mother's milk comes in and the 
baby begins to nurse well, the loss is quickly made up, and 
and by the tenth or twelfth day the birth weight has been 
regained. From this time on, a gain of an ounce daily is 
the rule in the first month. 
Umbilical Cord.-The stump of the umbilical cord becomes 
hard and dry and, in most cases, sloughs off within the first 
week. The small granulating area which remains quickly 
heals over. The main points in the care of the cord are to 
keep it dry and surgically clean. Any dressing which 
accomplishes this will be satisfactory. It is not even neces- 
sary to change the original dressing for three or four days 
unless it becomes wet or soiled, but it is safer to examine 238 
THE NEWBORN BABY AND ITS CARE 
the umbilicus each day and apply a fresh dressing of sterile 
gauze. Various cord powders have been suggested to hasten 
the separation. One of the best is salicylic acid and starch 
powder, 1:4. Aristol also gives good results, and boric 
powder is often used. Alcohol has been a favorite dressing 
of late years. Iodine is also used. The stump will dry more 
quickly if the powder is applied about its base. 
Fig. 102.--Umbilical hernia. 
The physician's attention should be called to any secre- 
tion or offensive odor from the umbilicus or redness about 
it, as these may be signs of a beginning infection. The 
nurse must not try to improve on Nature's process by pulling 
or clipping the stump loose from its base; she should handle it 
as little as possible and only with clean hands^ remembering 
that asepsis is as necessary in the care of the cord as in the 
dressing of any wound and that many a baby has died of 
septic infection which gained entrance through this channel. EYES 
239 
Umbilical Hernia.-Newborn babies often show a tendency 
to a slight protrusion at the navel, which may develop into 
an actual hernia unless proper care is taken. Treatment is 
unsatisfactory before the cord has dropped, but after the 
umbilicus is thoroughly healed, a small pad of gauze or cotton 
and a wide band of adhesive plaster make an effective 
dressing. The adhesive strip should be applied snugly 
enough to hold the recti muscles together. 
Fig. 103.-Adhesive plaster dressing for umbilical hernia. 
Eyes.-Even though the Crede treatment for the eyes may 
have been used at the birth of the child, there is always the 
possibility that it has not been able to check a virulent infec- 
tion or that the baby may acquire an infection from the 
mother later in the puerperium. For this reason the con- 
dition of the eyes should be carefully noted as a part of the 
daily routine and any discharge reported to the doctor. 
A slight sticky discharge at the corners of the eyes is 
usually without significance and soon clears up after fre- 
quent flushing with boric acid solution. The silver catarrh 240 
THE NEWBORN BABY AND ITS CARE 
which sometimes results from the use of silver nitrate in the 
Crede treatment may set up considerable inflammation. 
Gonococcus Infection. Ophthalmia Neonatorum.-The typ- 
ical gonococcus infection, or ophthalmia neonatorum, makes 
a picture which is not soon forgotten. The lids are swollen 
and edematous and tightly closed; at the slightest attempt to 
separate them, thick green pus comes welling out. The 
mucous membrane of the conjunctiva on the inner side of 
Fig. 104.-Ophthalmia neonatorum. (Bacon.) 
the lids is red and inflamed-"beefy" is the term often 
used to describe its appearance. If the condition is allowed 
to go on without proper treatment, the infection attacks the 
cornea, ulcers form and blindness results. 
A baby with gonorrheal ophthalmia should have a special 
nurse, since it needs almost constant attention and there 
is moreover always a chance that the infection may be carried 
to others. If this cannot be arranged, the nurse in charge 
must never for a moment forget the danger. The child CARE OF THE MOUTH 
241 
must be isolated as in any contagious disease and the nurse 
must observe the most rigid precautions, including careful 
hand disinfection after handling it. 
In general the treatment consists in frequent flushing of 
the eyes to wash away the pus; hot or cold compresses to the 
swollen lids; and argyrol, 25 per cent, or some similar prepa- 
ration of silver, dropped into the eyes at stated intervals. 
The details of the treatment will vary according to the 
practice of the physician. Gonococcus vaccine is sometimes 
administered in stubborn cases. The nurse should make it 
a point to have all directions fully written out, as a mistake 
may be disastrous. 
If only one eye is affected, careful watch must be kept 
for signs of beginning trouble in the other. The plan of 
sealing the latter with a pad of gauze or cotton has the draw- 
back of making it more difficult to examine the eye at 
frequent intervals. The baby should always be laid on the 
affected side and during the treatment the head must be 
turned so that there is no possibility of discharge or solution 
running into the sound eye. 
Care of the Mouth.-The practice of cleaning the baby's 
mouth with a piece of gauze before and after each nursing 
is being discarded because of the injury to the delicate mucous 
membrane which is almost sure to result from such frequent 
rubbing. It is enough to swab once a day with a cotton 
stick dipped in boric acid solution, and even this must be 
done gently. The mouth must be inspected daily for erosions 
or sores. 
Thrush.-This rather common form of stomatitis in young 
infants is characterized by milk-white patches on the mucous 
membrane of the mouth and tongue, which leave an abraded 
surface when removed. It is caused by a thread-like fungus 
which can be seen under the microscope. This fungus is 242 
THE NEWBORN BABY AND ITS CARE 
found in the air, ready to attack any portal of entry which 
may be afforded by an erosion of the mucous membrane, 
such as might result from rough cleaning of the mouth. 
Thrush is usually due to lack of cleanliness and is often seen 
in babies who are allowed to suck pacifiers and dirty rubber 
nipples. It is so contagious that it will run rapidly through 
a nursery unless great care is taken. 
The treatment is first of all preventive. If the condition 
appears in spite of precautions, the mouth should be gently 
swabbed with pledgets of cotton soaked in a solution of 
borax or bicarbonate of soda, to remove the white flakes. 
An occasional application of argyrol will hasten the cure. 
If the child is being fed with the bottle, the nipple may cause 
so much irritation that a dropper must be used for two or 
three days. As a rule, thrush is easily controlled, but in a 
weak or sickly infant it may be a long process, as the fungus 
affects the digestion. 
Bathing.-If the baby has been well oiled to remove the 
vernix and warmly wrapped in blankets, it can wait several 
hours for its first bath. It is not given a full bath, that is, 
it is not put in the bath-tub, until the cord has separated 
and the umbilicus is completely healed. Instead, it is held 
on the nurse's lap or laid on a table, and washed with soap 
and water, great care being taken not to wet the cord. 
The wash-cloth should be of soft material, like gauze or 
cheese-cloth, made up into a pad, with no raw edges to fray 
or irritate. Castile soap has long been considered the most 
satisfactory for the baby's bath; fancy soaps are to be 
avoided. The temperature of the water should be about 
105°F., and a thermometer should be used to register it. 
The nurse's hand has been too long inured to extremes of 
heat and cold to be a reliable guide. If no thermometer is 
available, she should test the water on her wrist or forearm. 243 
CLOTHING 
It should be needless to warn against handling the baby 
roughly or irritating its delicate skin by too vigorous rubbing. 
When a sponge bath is given, the child must be kept covered 
as much as possible so that it may not become chilled. The 
body is carefully dried and lightly dusted with powder, par- 
ticular attention being paid to all the creases of the skin. 
It is a mistake, however, to suppose that powder liberally 
shaken into these creases will replace the drying, as it only 
cakes and causes irritation. Special care must be taken to 
remove any smegma which may have accumulated about 
the genitalia; the anus and the region around it must be most 
thoroughly cleansed. As a part of the bath we may include 
swabbing out the mouth and nostrils with cotton sticks 
dipped in boric acid solution. This is to be done with 
extreme gentleness, as the mucous membrane is easily 
abraded. Flushing the eyes is no longer considered a neces- 
sary part of the daily routine; wiping them with cotton 
pledgets wet with boric acid solution is sufficient. 
Clothing.-The clothing for the newborn baby should be 
light and warm and simple to adjust. The outfit consists 
of a shirt, band and diaper, a petticoat and a slip. The 
shirt will probably be of cotton or cotton and wool, according 
to the season; all-wool shirts are likely to shrink in washing. 
The band is a strip of flannel, fifteen to eighteen inches long, 
and four to five in width. The diaper is generally of birdseye; 
the canton flannel which is so often used is apt to become 
rough and scratchy after washing. Cheesecloth makes a 
particularly soft diaper. The petticoat hangs from the 
shoulders, according to the Gertrude or princess model, or 
has a body attached to it. The slips for the first few weeks 
should be of the simplest; the prettiest ones are better saved 
until the baby is a little older and does not soil and wet 
itself so often. Pins should be eliminated from the clothing 244 
THE NEWBORN BABY AND ITS CARE 
as far as possible, by substituting buttons and tapes. A 
method has even been devised for fastening diapers with 
tapes. 
Bowels.-Mention has already been made of the meconium, 
the material which fills the intestines of the fetus during 
intra-uterine life. It may be some days before all traces 
of this disappear, but as the baby begins to take nourish- 
ment, the dark-green of the meconium is replaced by the 
golden-yellow color of the normal infant stool. A healthy 
baby's stools are neither formed nor liquid, but soft and pasty 
in consistency and homogeneous in character. If the food 
is not well digested, white curds are found, which may be 
composed of either fat or casein. Mucus gives the stool 
a stringy, glistening appearance. Variations in color are 
common. Long tradition has made the green stool a source 
of alarm. It must be remembered, however, that during 
the transition from the meconium to the normal bowel 
movement a green color is to be expected, and that even a 
yellow stool, after exposure to the air, may become green 
through oxidation processes. A dark-brown color may 
indicate the presence of blood. If the stool shows anything 
out of the normal, it should be saved for the physician's 
inspection. 
It is hardly necessary to state that the child's bowels 
should move every day. The number of stools, even in a 
healthy baby, may vary from one to four, but is usually two 
or three. In case of constipation an enema is given by means 
of a soft rubber bulb. Laxative drugs are better omitted. 
Calomel and castor oil are given only by order of the physi- 
cian. As the baby grows older, olive oil or milk of magnesia 
will be useful in overcoming a constipated habit. Colon 
lavage is indicated when a thorough cleansing of the lower 
bowel is necessary, as in cases of irritating or mucus-con- BOWELS 
245 
taining stools. It is also employed to bring down the tern, 
perature, in febrile conditions. 
Fig. 105.-Colon irrigation. 
A colon lavage is best given with the baby lying on its back 
on a table, with its buttocks close to the edge. The hips 
are a little elevated, and a piece of rubber sheeting is laid 
under them, so arranged as to carry off the water and other 246 
THE NEWBORN BABY AND ITS CARE 
material into a pail which stands on the floor. The ordinary 
fountain syringe can be employed, but the tubing is too long. 
In a hospital the irrigation is usually given through a glass 
funnel attached to a piece of rubber tubing ten or twelve 
inches long. A hard-rubber or glass tip should not be used 
but a soft-rubber catheter, which can be connected with 
the tubing by means of a glass cuff. The catheter must be 
inserted gently and not more than a few inches. The best 
solution for the flushing is salt solution at body temperature. 
Only two or three ounces are allowed to run in at one time, 
but the irrigation is repeated until the fluid returns clear. 
Urine.-The kidneys secrete a small amount of urine even 
during the intra-uterine life of the fetus, and as a general 
rule the child begins to void within a few hours of its birth. 
The first urine is apt to be rather concentrated and often 
stains the napkin a light reddish color; uric acid crystals 
may be present which make micturition slightly painful. 
This condition soon passes off as the normal secretion is 
established, especially if the baby is given water to drink. 
The fact that in some cases no urine is passed for twenty- 
four hours may be a source of anxiety to the family. This 
is usually because the secretion is scanty or delayed, al- 
though sometimes the bladder is full and the child seems 
to lack the stimulus to empty it. Only exceptionally is 
the trouble due to actual malformation or obstruction. Hot 
wet compresses over the bladder and kidneys are used to 
bring on the flow of urine, and sweet spirits of nitre is a 
favorite diuretic. Probably time would cure most of the 
cases unaided. 
Once the secretion is well established, there is no longer 
any cause for apprehension on the score of scanty urination. 
As it is nothing uncommon for the newborn infant to void 
from twelve to twenty times a day, the problem now is how GENITALIA 
247 
to keep the child dry and clean. The nurse will, of course, 
remember the importance of changing the diapers frequently 
lest the urine irritate the baby's skin. 
Genitalia.-If the child is a boy, part of the daily care is 
the retraction of the prepuce, so that the smegma which 
accumulates at the base of the glans penis can be wiped 
away. Sometimes the foreskin is so tight that it constricts 
the glans when retracted, or perhaps it cannot be pushed 
back all the way. In such a case the nurse must not use too 
much force or irritate the tissues by too prolonged manipu- 
lation. She should report the condition to the physician, 
who may be able to correct the trouble by stretching the 
prepuce or breaking up adhesions which may be present. 
For this procedure a probe and perhaps a hemostat will be 
needed, and pledgets of cotton or gauze. Some doctors 
apply olive oil afterward. 
If the phimosis is so marked that the foreskin cannot be 
retracted satisfactorily, the baby should be circumcised 
while it is still young, to prevent trouble later. Some 
physicians advise circumcision in every case. It is well 
known that the Jews consider the operation a religious rite, 
to be performed on the eighth day of the child's life. For 
this reason the nurse must remember not to retract or 
stretch the prepuce of a Jewish baby. 
In the care of a girl baby too, special attention should be 
paid to cleansing the parts in order to remove the smegma. 
A slight mucoid discharge from the vagina is sometimes 
seen, but is usually of no serious import. If the discharge 
is purulent, profuse or irritating, it should be mentioned 
to the doctor, who will probably wish to make a smear for 
microscopic examination, especially if the mother has a 
discharge. Sterile slides and cotton sticks should be pro- 248 
THE NEWBORN BABY AND ITS CARE 
vided for this purpose. A bloody discharge which is wrongly 
termed precocious menstruation may occasionally appear, 
for a few days, but does not recur. The only treatment 
needed for the simpler conditions is to keep the parts clean 
by wiping away the discharge with pledgets wet in boric 
acid solution. A true gonorrheal vulvo-vaginitis will require 
special treatment. 
Circumcision.-This operation consists in cutting away 
enough of the prepuce to prevent the possibility of constric- 
tion of the glans. The foreskin is drawn forward with 
hemostats and cut across with a sharp knife, after the glans 
has been protected by a special clamp. The mucous mem- 
brane which lines the prepuce is then slit anteriorly and 
trimmed off even with the skin. Sutures of catgut No. 00 
are generally used, although the Jewish rabbis take no 
stitches. A sterile gauze dressing is applied. The nurse 
must be on the lookout for hemorrhage afterward, as a slight 
but continuous oozing may follow the operation. 
Skin.-The skin of a newborn infant is so tender and deli- 
cate that it is easily irritated, even by heat or perspiration. 
A fat baby often becomes chafed in the creases of its skin. 
The region about the thighs and genitalia, where the diaper 
rubs, is especially likely to become irritated, and for this 
reason, if for no other, wet diapers must never be allowed 
to remain on the child, although it requires constant vigilance 
to keep them changed fast enough. In cases of intestinal 
indigestion with acid stools the buttocks may become 
inflamed and sore, even though every effort is made to 
change the napkins promptly. Among ignorant people and 
even among those who ought to know better, a frequent 
source of trouble is the pernicious practice of drying wet 
diapers and putting them back on the baby without washing CIRCUMCISION 
249 
them. It certainly should not be necessary to tell a nurse 
that the napkins must be thoroughly washed and rinsed 
before they are used again. The rinsing is an important 
part, because washing-powder or a strong soap may be in 
itself a cause of irritation. 
It is not uncommon for the skin to dry and peel when 
the child is a few days old. While most cases are without 
significance, the desquamation is sometimes similar to that 
after scarlet fever and is counted among the skin diseases 
of the newborn. Scaling of the skin in the region of the 
umbilicus may follow the use of cord powder, especially if 
the powder contains much salicylic acid. 
If the baby has a tendency to scratch its face, the nurse 
must see to it that its nails are kept short. No attention 
should be paid to the superstition that it is unlucky to cut 
them, except to reassure the mother, if she is troubled on 
this point. It will sometimes be necessary to cover the 
child's hands with mitts. 
Among the actual eruptions to which the baby is subject 
are the familiar "prickly heat" and the fine red rash known 
as red gum. Some forms of skin trouble are due to digestive 
disturbances; the skin lesions of congenital syphilis will be 
described under that heading. 
Talcum powder or a similar dusting power is commonly 
used to prevent chafing, but unless it is very fine, it may be- 
come caked by the moisture of the parts and only add to the 
trouble. Oil is often better. For sore buttocks a simple 
ointment like vaseline or boric ointment will usually serve to 
protect the skin from further irritation and hasten the heal- 
ing. If the condition is serious or caused by specific infection, 
special measures will be needed, as the physician may 
prescribe. 250 
THE NEWBORN BABY AND ITS CARE 
FEEDING. 
Breast-feeding.-It cannot be too strongly emphasized that 
the best food for a newborn infant is its own mother's milk. 
Although the milk secretion is not established until about 
the third day of the puerperium, it is best to begin putting 
the baby to the breast as soon as the mother is rested from 
the strain of labor. In this way the child becomes accus- 
tomed to the act of suckling by the time the milk actually 
appears, and perhaps receives some benefit from the small 
amount of nutriment and reputed laxative action of the col- 
ostrum. It will be enough to let the child nurse three or 
four times a dgy at first, but after the milk comes in, feed- 
ing at regular intervals is a rule to be strictly enforced. 
As there are pronounced differences of opinion as to the 
interval between the feedings, the nurse should make it a 
point to find out the routine preferred by the physician in 
charge. In general it may be said that the smaller and 
weaker the child, the shorter should be the interval, and that 
from two to three hours is the average. The schedule of 
feeding is usually from 6 a.m. to 10 p.m. A newborn baby 
must often be nursed twice during the night, but it can soon 
be trained to take only one feeding, and as it grows older, 
this too can be dropped out, so that the child will sleep 
through the night without the disturbing its mother. If it 
wakes, it can be given a little water, and if it finds that noth- 
ing else is forthcoming, it will soon decide that it is not worth 
while to wake for that. 
The length of time that the baby should nurse will depend 
on the needs of the individual child. Naturally a large, 
hearty infant must have more nourishment than one who is 
small and weak. Moreover, it requires but little observation 
to show that some infants nurse slowly, even dropping off to FEEDING 
251 
sleep from which they must be roused to complete their 
work; while others gulp down their food so fast that they 
swallow air and take more milk than their stomachs can 
hold, and hiccough and regurgitate in consequence. The 
amount of milk in the mother's breasts and the ease with 
which they can be emptied add another factor to the prob- 
lem. Perhaps fifteen minutes may be mentioned as the 
average time that the baby should remain at the breast. 
If there is any question as to the quantity that the child is 
getting, this can be settled by weighing the infant before 
and after nursing. 
Most babies take naturally enough to nursing, but it will 
often fall to the nurse to teach the infant and its mother how 
to manage the process, especially if the mother has had no 
previous experience. The woman should lie on her side, 
supporting the baby in the hollow of her arm so that it can 
easily reach the nipple. It is often necessary to coax the 
infant by putting the nipple into its mouth. Some babies 
persist in falling asleep before they have finished nursing, 
but this habit must not be permitted. Nor should the child 
be left so long with its mother that she herself goes to sleep, 
as there is very real danger that she may smother the baby. 
Absolute regularity is the secret of success in establishing a 
proper habit of nursing. 
Artificial Feeding.-Artificial feeding is too large a subject 
to be taken up in detail in a text-book of obstetrics and it 
will therefore be enough to lay down merely a few general 
considerations. The obstetrical nurse meets comparatively 
few cases in which the child must be exclusively bottle-fed 
from the start, because, as has been already pointed out, few 
woman are unable to nurse their babies. The matter of arti- 
ficial feeding as she sees it resolves itself into additional 
feeding for an infant whose mother's milk is deficient in 252 
THE NEWBORN BABY AND ITS CARE 
quality or quantity. This is often only a temporary measure, 
because after the mother is up and about, the milk will 
probably improve and increase until there is no further need 
of the bottle. 
It is well known that undiluted cows' milk cannot be given 
to young infants as a substitute for mothers' milk, partly 
because its percentage composition is different, but also 
because its fat and protein are in a less digestible form. The 
composition of cows' milk as compared with that of human 
milk is as follows: 
Human milk. 
Cow's milk. 
Per cent. 
Per cent. 
Fat 
4.00 
4.00 
Sugar 
7.00 
4.75 
Protein 
1.50 
3.50 
Salts 
0.20 
0.70 
The formulas for a healthy baby in its first month will 
vary from 2 to 3 per cent of fat, 0.5 to 1 per cent of protein, 
and 5 to 6 per cent of sugar. Premature or sick infants 
will require special modifications. The physician will decide 
on the proportions of the milk mixture and give directions 
as to its preparation. The nurse should always find out 
from him whether the milk is to be used raw, boiled or 
pasteurized. It is certainly unnecessary to go into the 
familiar details of the keeping of the milk on ice and the 
sterilizing of bottles and nipples. The nurse also knows 
well that the mixture should be warmed almost to body 
temperature before each feeding. She sometimes forgets, 
however, how quickly the milk cools in the bottle and how 
often cold milk is responsible for digestive upsets. When- 
ever possible, she should be with the baby until it has 
finished its feeding. If the child is left alone, it may fall 
asleep or lose hold of the nipple. On no account should it 
be allowed to suck at an empty bottle, drawing air into its 
stomach to cause colic later. BIRTH INJURIES 
253 
Wet-nursing. -If for any reason the mother cannot nurse 
her baby and it cannot digest artificial mixtures, recourse 
must be had to a wet-nurse. The woman must be in good 
health and cleanly in her person and her habits. Syphilis 
must be excluded by the Wassermann test. In fairness to 
her the Wassermann test should also be made on the child, 
so that she is not unwittingly exposed to infection from it. 
BIRTH INJURIES. 
The distortion of the head and the marked caput which 
are seen in cases of exaggerated head-moulding can hardly 
be classed among injuries. Nevertheless' the appearance of 
the child is rather disquieting to anyone who is not familiar 
with the condition, and the nurse may be called upon to 
reassure the family on the subject. It is really surprising 
to see how quickly the head resumes its natural shape. 
The cephalhematoma is a swelling of the head which might 
be confused with the caput, except that it makes its appear- 
ance just when that would be subsiding. It is produced by 
the gradual oozing of blood under the pericranial membrane 
of one of the bones of the skull, usually a parietal bone. 
Since the hematoma is outside the skull, it cannot possibly 
cause pressure on the brain substance, and even when the 
swelling is large, it apparently gives the baby no discom- 
fort. No treatment is required, as the clot will become 
absorbed in the course of a few weeks. The nurse has only 
to remember to lay the child in its crib in such a way as to 
avoid any irritation of the surface. 
Cuts and abrasions from the forceps usually require only 
a protective dressing, but the physician may prescribe an 
antiseptic or some ointment. Bruises will disappear in due 
time without treatment; sometimes the purplish discolora- 254 
THE NEWBORN BABY AND ITS CARE 
tion resembles that of a birth-mark, but time clears up the 
diagnosis. Swelling about the eye is relieved by cold or hot 
compresses. If the eye itself is irritated, it should be 
Fig. 106.-Fracture of both clavicles; mode of dressing; recovery. 
(Carr.) 
flushed with boric acid or salt solution. The edema of the 
face which results from face presentations usually subsides 
without treatment. Members of the family are likely to 
feel considerable anxiety as to the outcome of all such BIRTH PARALYSES 
255 
injuries; fortunately we are usually justified in assuring 
them that all marks will disappear. 
A fracture of the humerus, femur or clavicle may occur in 
the course of a difficult delivery, more often in a version or 
a breech extraction. Prompt treatment almost always 
results in good union of the bone. The application of splints 
is sometimes difficult because the parts are so small, and the 
dressing may have to be modified accordingly. For example, 
one of the most satisfactory dressings for a broken collar- 
bone is arranged with a T-shaped splint at the child's back, 
held in place by a double figure-of-eight bandage over the 
shoulder. Remembering how easily the baby's skin is irri- 
tated, the nurse will take special care in padding the splints 
and protecting the parts from pressure with plenty of cotton 
and gauze. If the fracture is in the thigh, she is faced by 
the problem how to prevent the bandages from becom- 
ing soiled, and in spite of all her efforts it will prob- 
ably be necessary to change the dressing rather often. 
Fractures of the skull are so rarely seen in these days of 
improved obstetrical technic that they need only passing 
mention. 
BIRTH PARALYSES. 
The pressure of the forceps in a difficult delivery occa- 
sionally causes paralysis of one side of the child's face. In a 
marked case the mouth is drawn down at one corner and the 
eye on that side cannot be closed. The distortion may not 
be noticeable when the baby is asleep, but is conspicuous 
enough when it cries. Fortunately the paralysis usually clears 
up in the course of a few weeks. No treatment is necessary, 
but massage may have some effect in hastening the recovery. 
It also makes the mother feel that something is being done. 
Birth paralysis of one or even both arms is another result 256 
THE NEWBORN BABY AND ITS CARE 
of difficult deliveries (usually breech extractions), which has 
become familiar to us through the well-known example of 
the ex-Kaiser. The affected arm hangs limp from the 
shoulder, although there is motion in the hand and at the 
elbow-joint. The position is characteristic. The whole arm 
is rotated forward until the palm of the hand turns outward. 
Fig. 107.-Facial paralysis following forceps delivery. (Complete 
recovery in six weeks.) 
It is believed that in many instances there is some injury or 
slight dislocation at the shoulder-joint. The milder cases 
improve with massage and passive motion, leaving a useful 
arm, but the more serious ones will require electrical treat- 
ment and probably an operation later on. The nurse should 
be on the lookout for this condition, as she has the best 
opportunity to notice it. MALFORMATIONS AND MONSTROSITIES 
257 
MALFORMATIONS AND MONSTROSITIES. 
It is always a matter of grave concern to the parents to 
know whether the baby is "marked" in any way or has any 
sort of deformity, since it is not at all uncommon for such 
things to occur. While some of these malformations are the 
result of arrested development at a certain point and are 
connected with malnutrition of the fetus in the uterus, many 
cannot be explained and none can be prevented by any sort 
of prenatal treatment, as far as our present knowledge goes. 
Among the commonest deformities are hare-lip and cleft 
palate, club-foot, umbilical hernia, imperforate anus and 
spina bifida. A very minor deformity, which is often 
encountered and which, fortunately, can be easily remedied, 
is tongue-tie. The treatment of these conditions is largely 
surgical, but unless urgently needed, operations are usually 
postponed until the child is older and stronger-in other 
words, after it has passed beyond the care of the obstetrical 
nurse. In the case of imperforate anus immediate opera- 
tion is, of course, necessary, as the child will die without it. 
Hare-lip and cleft palate are of moment because they 
prevent the baby from sucking effectively and so interfere 
with nursing. It may be necessary to contrive a nipple 
with a rubber flap to fit over the roof of the mouth, or even 
to feed the child with a dropper. Because tongue-tie has a 
similar effect, although to a lesser degree, the nurse should 
always inspect the tongue carefully and report to the doctor 
if it is held down by the frenum. The condition is relieved 
by making a nick in the frenum with sharp-pointed scissors 
and tearing it gently down with the finger-tip, to avoid 
injuring a vessel. If oozing from under the tongue follows, it 
should be reported at once. 
Minor degrees of club-foot are treated by massage and 258 
THE NEWBORN BABY AND ITS CARE 
manipulation in the simplest cases, or by correcting the 
deformity and holding the foot in place with adhesive strap- 
ping or a plaster bandage. Cases which do not respond to 
this treatment will be operated on later. It is interesting 
to note that club-foot is sometimes due to pressure on the 
feet while the child is in the uterus, if the amniotic fluid is 
scanty. 
Fig. 108.-The first application of the plaster bandage, showing the improved 
position. (Whitman.) 
Umbilical hernia is often cured by strapping with a wide 
band of adhesive plaster. This must not be done until the 
cord has dropped and the umbilicus is wrell healed and dry. 
Spina bifida, the protrusion of a sac of spinal fluid through MALFORMATIONS AND MONSTROSITIES 
259 
a defect in the spinal column, is often fatal, even with 
operation. The great danger is from infection or rupture 
Fig. 109.-The adhesive-plaster support as used after correction of the 
deformity. (Whitman.) 
Fig. 110.-Spina bifida. 
of the sac, and the nurse's treatment is to keep the parts 
protected with sterile gauze. 
Monstrosities range technically from the slight anomaly of 260 
THE NEWBORN BABY AND ITS CARE 
supernumerary fingers or toes to the various double monsters 
and joined twins. The supernumerary digits can be easily 
removed in most cases, as often there is no bony connection. 
The commonest monsters are anencephalus and hydro- 
cephalus. The former has no skull and no brain except 
occasionally a small tuft protruding through the defect in 
the top of the head. Since the face makes up the main part 
of the head, it is often the presenting part. The delivery is 
Fig. 111.-Monstrosity with encephalocele (protrusion of brain) 
usually easy. In a case of hydrocephalus it is quite the 
reverse, since the head is so distended with the fluid that 
it cannot pass through the pelvis without injury to the 
mother. Rupture of the uterus has occurred as a result. 
The treatment is craniotomy, after which the head collapses 
and can be extracted. Double monsters are extremely rare; 
they naturally present special difficulties according to their 
size and the extent of the malformation. 
On no account should the mother be allowed to see a DIGESTIVE DISTURBANCES 
261 
monstrosity or a mutilated child, and even the knowledge 
of its condition should be kept from her as far as possible. 
If she persists in asking questions about it, the nurse must 
refer her to the doctor in charge. 
ATELECTASIS. 
By atelectasis is meant inability to expand the lungs. 
The condition is noticed at birth in babies who are weak, 
premature or deeply asphyxiated. Even after the child is 
resuscitated, its breathing is shallow and labored and it keeps 
up a continual whining cry with each respiration. Atelec- 
tasis is also caused by the consolidation of lungs which occurs 
in pneumonia alba, the result of syphilitic lesions in the lungs 
of the fetus. Oxygen, artificial respiration, external heat 
and stimulation make up the treatment. Often, however, all 
measures are in vain, the child grows cold and cyanotic and 
finally dies. 
JAUNDICE. ICTERUS NEONATORUM. 
Jaundice in the newborn is due to various causes, such as 
changes in the blood, conditions in the liver and infections. 
One type is so commonly seen that it is often called physio- 
logical; it does the child little harm and can be counted on 
to pass away in a few days. A small dose of calomel and 
castor oil may hasten its departure. If accompanied by 
fever, the jaundice is probably part of an infective process 
and the prognosis is not always good. Some cases are 
hopeless from the start. 
DIGESTIVE DISTURBANCES. 
A healthy infant should not be troubled with indigestion. 
The causes of digestive disturbances lie largely in the methods 262 
THE NEWBORN BABY AND ITS CARE 
of feeding. The heartiest and strongest of babies will soon 
have its digestion upset, if fed too often or irregularly, when- 
ever it cries. If it is allowed to take too much at a feeding, 
regurgitation is the natural result. It is not always recog- 
nized that the child may have indigestion if it is not kept 
warm enough. 
Indigestion shows itself in a train of familiar symptoms, 
chief among which are colic, diarrhea and vomiting. The 
stools are green and undigested, with curds scattered through 
them. 
Prevention is the important thing in this condition, but 
it often takes all the tact and firmness that the nurse possesses 
to establish a proper regimen for the baby in the face of time- 
honored family tradition. Once the disturbance is under 
way, more than regularity of nursing is required to stop it. 
The digestive tract may need to be well cleared out by an 
enema or colon lavage or a dose of castor oil. In some cases 
the chief requisite is rest for the stomach, which is secured by 
stopping the feeding for a while and giving only water. 
Colic.-Colic is one of the commonest of the ills besetting 
young infants, and deserves a little space to itself. Like 
other digestive disturbances it usually is due to a faulty habit 
of nursing. Many babies have indigestion as a result of 
swallowing air in nursing too fast, and cold milk and sucking 
on an empty bottle are responsible for many a digestive upset 
in bottle-fed babies. It should not be taken for granted 
that every child who cries is suffering from colic. Babies 
cry because they are wet, cold or hungry, or because they 
are uncomfortable in some way. The cry due to pain can 
often be distinguished from that in other conditions, and a 
child with colic has a characteristic way of drawing up its 
legs during the attack. Not uncommonly the gas can be 
heard rolling about in its abdomen. HEMORRHAGIC DISEASE OF THE NEWBORN 
263 
In a mild case it may be enough to lift the baby and let 
the gas escape. A hot-water bag placed against the abdo- 
men often relieves the pain. An enema or a colon irrigation, 
by emptying the lower bowel, gives opportunity for the gas 
to pass out. Peppermint water and anise water are favorite 
remedies. Plain hot water will sometimes do as well. Pare- 
goric and the soothing syrups which contain it are absolutely 
prohibited. The nurse must resolutely set her face against 
the various concoctions which are urged upon her by the 
family and interested friends. It is a wise plan for her to 
get from the physician a few directions as to his treatment 
for such cases. 
HEMORRHAGIC DISEASE OF THE NEWBORN. 
As the name suggests, this is a disease of the newborn, 
characterized by bleeding. Its cause is unknown. Syphilis 
is sometimes blamed for it, but is seldom a factor. 
In many cases the trouble begins with continuous oozing 
from the umbilicus; hemorrhages from the mucous membrane 
of the gastro-intestinal tract are also common. In other 
cases the slightest abrasion is followed by a steady trickle of 
blood and hemorrhagic areas may appear even under the 
unbroken skin. The disease occurs most often within the 
first week of life and progresses rapidly to a cure or a fatal 
ending. The mortality is extremely high. 
The nurse should always be on the watch for any signs of 
this disease, since in early treatment lies often the only hope 
of cure. The blood in intestinal hemorrhage may be bright 
red and profuse, but is often so dark by the time it is passed 
that the stools are black and tarry in appearance. This 
form of the disease is called melena neonatorum. 
Various remedies have been suggested for this condition, 264 
THE NEWBORN BABY AND ITS CARE 
but few have met with success. The best results are obtained 
by the use of blood serum or fresh human blood injected 
hypodermically. Transfusion has saved many apparently 
hopeless cases. 
MASTITIS. 
The breasts of a young infant not infrequently become 
filled with a watery secretion which is familiarly known as 
"witches' milk." This is apt to appear during the first 
week. The breasts are slightly swollen and hard, but if 
they are left alone, the secretion gradually subsides without 
giving any trouble. Unfortunately the members of the 
family are sometimes obsessed with the idea that the milk 
must be squeezed out, and their efforts may be rewarded by 
the development of inflammation or even an abscess. The 
nurse must be firm in preventing any handling of the breasts. 
If there is much swelling, hot or cold compresses may be used; 
if actual suppuration, the physician will make an incision to 
let out the pus. 
CONGENITAL SYPHILIS. 
In the discussion of syphilis as a complication of preg- 
nancy it has already been mentioned that the disease is 
likely to be transmitted to the unborn child. Even though 
the infection is not virulent enough to kill the fetus, the 
disease is almost sure to develop sooner or later. Its signs 
may be present at birth, but more characteristic is the case 
in which the child is born apparently strong and healthy, only 
to droop and lose ground unaccountably, until at last the 
diagnosis is cleared up by the appearance of more distinctive 
syphilitic lesions. In more than one-half the cases the 
symptoms begin to show themselves from the second to CONGENITAL SYPHILIS 
265 
the fifth week of life. According to Jonathan Hutchinson, 
the great English authority, one should always suspect 
syphilis when the history reveals that the child at birth was 
"as beautiful a baby as you need wish to see, but began to 
fall off when a month old." 
Fig. 112.-Congenital syphilis. Bull® on soles of feet. (Cragin.) 
The outstanding symptoms are coryza, skin lesions and 
wasting. Swelling of the epiphyses, enlargement of the 
liver and hemorrhages are also characteristic of syphilis. 
Coryza or "snuffles" is usually the first to appear. The 
nasal discharge may be so irritating as to cause the formation 
of crusts in and about the nose. 
Typical of syphilis is the dry skin, with cracks and fissures 266 
THE NEWBORN BABY AND ITS CARE 
in the creases, and especially at the corners of the mouth and 
about the anus. A rash may appear and also little blisters 
or bullae on the palms and soles. The buttocks become red 
and sore, and small ulcers develop, in spite of the greatest 
care. 
The wasting is in great part due to the syphilitic infant's 
defective digestive powers and may progress rapidly. The 
child becomes fretful and emaciated and the skin hangs in 
folds, giving it the appearance of a little wizened old man. 
The pale grayish-yellow color of the skin is also characteristic. 
Treatment.-The time to treat congenital syphilis is before 
the child is born. Medication given to the mother during 
pregnancy will act upon the fetus, which may thus escape 
the disease entirely. Nevertheless it is always safe to give 
additional treatment to the child of a syphilitic mother. 
Mercury in some form is the most satisfactory drug; if given 
by mouth, gray powder, in doses of | to | gr., and calomel, 
to gr., are the most popular; it is also administered by 
inunctions of mercurial ointment, well diluted with lanolin or 
vaseline. If the mother is having injections of arsphenamine 
the child may receive some benefit from the treatment through 
the milk; the drug is seldom administered to newborn infants, 
although it will be of great value as the child grows older. 
A syphilitic baby should always be isolated, if in a hospital 
where there is danger of the disease being passed on to other 
infants in the nursery. In any case the nurse should exercise 
the greatest care to prevent any possible spread of infection; 
she should remember to disinfect her hands after handling 
the child and to see that all its clothing is disinfected before 
being sent to the wash. The dangers of wet-nursing should 
never be forgotten in this connection. CARE OF THE PREMATURE INFANT 
267 
CARE OF THE PREMATURE INFANT. 
A premature infant comes into the world handicapped, not 
only because it is small and weak but because it is unde- 
veloped. It cannot keep the body temperature up to 
normal in the cold outside world, nor can it digest easily the 
food needed to give it strength. Every muscular exertion 
means using up energy which it can ill afford to lose. 
The principles of the care required in such a case are there- 
for to keep the child warm and quiet and supply nourishment 
which it can assimilate. 
The incubator is generally looked upon as the only con- 
trivance by which a premature baby can be kept alive. It 
undoubtedly does secure an atmosphere of constant high 
temperature, but so many models sacrifice the freshness of 
the air in the process that some of our best hospitals have 
practically discarded them. The ideal arrangement which 
modern hospitals are adopting is the "incubator room," 
which provides both heat and ventilation. 
Nevertheless, premature infants can be saved with much 
simpler equipment and a deep basket lined and padded with 
cotton and warmed by hot-water bottles makes an excellent 
substitute for an incubator. One of the bottles should be 
hung near the head of the crib so as to warm the air which 
the child is breathing. The basket should be kept in the 
warmest corner of the room, away from all draughts. The 
bed-clothes must not be made too heavy in the attempt to 
keep the baby warm. Besides the blankets which are 
tucked in, one should be hung over the lower part of the crib, 
adding a little warmth and protection without weight. 
The baby must not be handled more than is absolutely 
necessary. It should go without saying that showing off 
the child to curious visitors is prohibited. Indeed, the baby 268 
THE NEWBORN BABY AND ITS CARE 
should not even be taken to its mother to nurse for some days, 
if it is very weak. The usual bath is omitted and a rub with 
warm oilsubstituted. 
Feeding is a difficult proposition. It must be begun before 
the mother's milk has come in, as the child cannot stand the 
loss of weight which is normal for the newborn in the first 
days of life. In a hospital, mother's milk can sometimes 
be obtained from another patient in the interval, but if this 
is not possible, the doctor may order a very weak formula. 
Fig. 113.-Premature baby in its crib (lifted to show cotton wrapped 
about head.) 
Not all premature infants can use a nursing-bottle, and feed- 
ing by a medicine dropper, a Breck feeder or even by means 
of gavage may be necessary. Small quantities of milk, given 
slowly, bring about the best results. The baby may not be 
able to take more than one or two teaspoonfuls at first. 
The intervals between feedings should be short, not more 
than an hour or an hour and a half. Whether the milk used 
is pumped from the mother's breast or made up by a formula, 
special care is required to keep it sterile, as these babies are 
extremely susceptible to infection. THE NURSERY IN THE HOME 
269 
It is the custom to wrap a premature infant in cotton wool, 
but lambs' wool is preferable. As clothing, a sleeveless 
woollen slip or bag is the most practical garment, and a 
flannel hood should be added as a covering for the head. 
THE NURSERY IN THE HOME. 
Whenever possible, a room should be devoted to the baby. 
The ideal nursery should be bright and sunny, opening on a 
balcony which can be used for a sleeping-porch as the child 
grows older; it should have an open fire-place, since this not 
only adds to the cheer and comforts of the place but also can 
be relied upon to keep the room at an even temperature on 
the chilly days between seasons and to give extra warmth 
during the baby's bath. The nursery must be warm, 70° to 
75° F., during the first weeks, since the child has been 
used to a temperature of 98° to 99° during intra-uterine life, 
and will require a little time to grow accustomed to the ordi- 
nary temperature of even our overheated houses. The room 
must be well ventilated, as fresh air is more essential for 
babies than many people realize. The usual practice of 
opening the windows at intervals while the room is empty, is 
well enough in its way, but it may cool down the tempera- 
ture too much. A ventilator in' the window is better in cold 
weather. A newborn infant should not be left so near an 
open window that the cold air will blow on it. The role 
of fresh air later on is outside the province of a book on 
obstetrical care. 
The baby must sleep alone. This is an imperative rule 
which allows of no exception. Its importance is attested 
by too many cases of death of the child from overlying 
by the mother. If a crib is not available, a basket makes an 
excellent substitute. Even in the poorest home a clothes- 270 
THE NEWBORN BABY AND ITS CARE 
basket of some sort can be provided. A pillow protected 
with rubber sheeting or oil-cloth will serve as a mattress. 
The basket is carefully .padded so that the baby will run no 
risk of hurting itself against the rough sides, and is warmed 
by hot-water bottles for the first day or two-longer if the 
room is cold or if the baby runs a persistent subnormal 
temperature. The most practical crib is one large enough to 
be used for the first two years of the child's life; a bassinet 
is charmingly attractive but is soon outgrown. The crib 
must be light and on castors or small wheels, so that it can 
be easily moved about the room. The sides should be high, 
to prevent the baby from falling out and the bars close 
together or so protected that it cannot injure itself by 
pushing arms or head through between them. The blankets 
should be warm but light; a heavy weight of bed-clothes is 
exhausting to the baby. The pillow, if used at all, should be 
small and soft. 
THE HOSPITAL NURSERY. 
A properly organized and well-equipped nursery is essential 
to the well-being of the newborn child. The room must be 
large, for a young infant is even more sensitive to over- 
crowding than an older child. Like the nursery in the home, 
it must be well ventilated without being draughty; ventila- 
tors should, therefore, be used in preference to the open 
window. Sunshine is indispensable, but the babies' eyes 
must be protected from the glare. The artificial lighting 
should be electrical and the switches so arranged that 
different parts of the room can be lighted separately. The 
indirect system of lighting is to be preferred. The ideal 
open fire-place is not practical for heating a hospital nursery, 
and the usual steam or hot water radiator is the best that THE HOSPITAL NURSERY 
271 
we can do until heating by electricity becomes less expensive. 
The room is most evenly heated when the radiator is at 
the center. As has already been stated, a nursery must be 
kept at an even warm temperature. A thermometer is an 
absolutely necessary part of the equipment. It is futile to 
try to gauge the temperature by the feelings of those who are 
working in the room. 
Fig. 114.-Single crib in its carrier 
The cribs are of white-enamelled iron, with handles by 
which they can be easily lifted. They are arranged to hang 
on rolling carriers, which can be wheeled from the nursery 
to the ward at feeding-time, so that the nurse will not have to 
carry the babies back and forth in her arms. The cribs are 
lined with quilted padding, which is tied on with tapes so 
that it can be easily changed and washed. The mattresses 272 
THE NEWBORN BABY AND ITS CARE 
are protected by rubber sheeting and covered with small 
sheets.. A square of padding is provided to be placed under 
each baby. There should be an abundant supply of these 
pads, so that they can be changed whenever soiled or wet. 
The crib blankets must be of a quality to withstand repeated 
washing. They should be large enough to tuck under the 
mattress. As a general rule, a baby should not be wrapped 
in a blanket when put in its crib. The attractive appear- 
ance of the nursery as a whole is enhanced by the addition 
of a thin white spread to each crib. 
Fig. 115.-Cribs on rolling carriers. 
The bath-room should be separate from the nursery, but 
adjoining it. The common bath-tub has no place in the 
modern nursery, as it is impracticable and almost impossible 
to sterilize it between baths. The ideal arrangement is to 
wash the baby under running water on a specially devised 
slab. The drying and dressing of the child are then done 
on an electrically heated table. All articles which may be 
required are arranged beforehand, so as to be within the 
nurse's reach. The baby must never be left alone whdh it THE HOSPITAL NURSERY 
273 
is lying on the table, lest it unexpectedly roll to the edge and 
fall off. 
The babies are weighed in the bath-room, either before 
or after the bath, as may be preferred, but at the same time 
each day. The scales should be of the even-balance type; 
the spring-balance scales are less accurate. As many hospi- 
tal nurseries use the metric system of weights, the nurse 
must familiarize herself with this method; she must also be 
able to make rapid translations into pounds and ounces for 
Fig. 116.-Scales, with basket. 
the benefit of the family and friends. The scale-pan is cov- 
ered with a clean diaper before the baby is laid in it. Too 
often in a hospital nursery this diaper is not changed for the 
succeeding babies. 
In a hospital some means of identifying the babies is 
a necessity. Various methods have been suggested, even to 
strings of beads, but none is as yet thoroughly satisfactory. 
Probably the most commonly used identification mark is a 
piece of adhesive plaster on which is written the child's name; 
this is pasted on the infant's back or chest or around its 274 
THE NEWBORN BABY AND ITS CARE 
wrist. The nurse should not fail to examine this after the 
child's bath to be sure that it is still in place and that the 
name has not become blurred and illegible. The fear that 
babies will be mixed in the nursery haunts many mothers 
and actually deters them from entering a maternity. 
An unromantic, but very necessary part of the nursery 
equipment, is a covered pail partly filled with an antiseptic 
solution, into which the diapers are dropped to be disinfected 
as soon as they are taken off. Napkins which have been 
washed should never be hung in the nursery to dry. 
The nurse must never forget that the danger of cross-infec- 
tion lurks in every nursery unless the most scrupulous care 
is taken to keep each baby and its belongings separate from 
the rest. Individual wash-cloths should be provided for 
the bath, or better still, cotton balls which can be thrown 
away after using. It is against every rule of hygiene to wash 
all the babies with the same cake of soap, and since it is not 
practicable to keep an individual cake for each one, soap 
flakes or liquid soap will answer the purpose. The mixing 
of blankets, clothing and diapers is inexcusable in a well-run 
nursery. When contagion spreads in a nursery, someone's 
carelessness is to blame. 
In general, it may be said that the best results in a hospital 
nursery are obtained by the nurse who considers each baby 
as an individual, knowing its special needs and caring for it 
accordingly. APPENDIX. 
Outfit for Patient 
2 agate or enameled basins. 
2 large pitchers. 
2 hot-water bags. 
1 ice-cap. 
1 two-quart fountain syringe. 
1 bed-pan. 
1 bath thermometer. 
2 hand-brushes. 
2 medicine droppers. 
1 tube of vaseline or K-Y jelly. 
1 tube of green soap or 4 ounces liquid soap. 
25 tablets bichloride of mercury. 
3 ounces liquor cresol comp., lysol or similar preparation. 
8 ounces alcohol (if obtainable). 
8 ounces boric acid solution. 
1 ounce fluid extract of ergot. 
1 can of ether. 
3 ounces olive oil. 
1 sterile cord dressing and tape. 
2 pieces rubber sheeting or oil-cloth (1x2 and lxl yds.). 
5 yards unbleached muslin. 
3 quilted bed-pads. 
3-4 dozen sterilized vulvar pads. 
z 276 
APPENDIX 
25 yards gauze. 1 
2 pounds absorbent cotton j 
for making pads, etc. 
(If the vulvar pads are bought ready-sterilized, half 
this amount of gauze and cotton will suffice.) 
Outfit for Nurse 
Hand-brush and nail file. 
Soap. 
Soft rubber catheter. 
Scissors. 
Cord clamp. 
Sterile cord tape and dressing. 
2 pairs rubber gloves. 
2 hypodermic syringes, with at least 4 needles. 
2 thermometers. 
1 dressing-forceps. 
1 bottle bichloride tablets. 
3 ounces lysol or similar preparation. 
2 medicine droppers. 
2 gowns. INDEX. 
A 
Abderhalden test for pregnancy, 
63 
Abdomen, pendulous, in preg- 
nancy, 152 
striae of, in pregnancy, 57, 58 
Abdominal binder, 138, 153, 189, 
216 
distention in puerperium, 189, 
202 
examination, 86 
pregnancy, 157, 158 
Abortion, 53, 155 
causes of, 156, 157, 161, 163 
criminal, 53, 156 
induction of, 159, 160 
prevention of, 102,~157 
therapeutic, 147, 155 
treatment of, 157 
tubal, 157 
Abruptio placentae, 180 
Abscess of breast, 195 
Accidental hemorrhage, 181 
Accidents of labor, 166 
Acini of breast, 33 
Acute infections in pregnancy, 161 
Adherent membranes, 137 
Adhesion of uterus to abdominal 
wall after Caesarean section, 223 
After-birth, 38. See Placenta. 
After-pains, 187 
treatment of, 188 
Albuminuria in toxemia, 146 
Amnesia, scopolamin-morphine, 130 
Amnion, 36 
Amniotic fluid, 36 
function of, in labor, 75 
in pregnancy, 36, 50 
sac, 189 
Anemia, contraindication to nurs- 
ing, 189 
Anencephalus, 260 
Anesthesia, 128 
in Caesarean section, 219 
cause of asphyxia of fetus, 51 
in heart disease, 160 
in labor, 121, 128, 167 
Antiseptics, 96, 97 
Anus, imperforate, 257 
laceration of sphincter of, 228 
Areola in pregnancy, 57 
Artificial respiration, methods of, 
141 
Byrd-Dew, 140, 141 
insufflation, 142 
Prochownik, 142 
Schultze, 142 
Asphyxia of newborn, 139 
causes of, 139 
livida, 141 
operative delivery as factor in, 
207 
pallida, 141 
pressure on cord, causing, 41, 
139 
signs of, before delivery, 139 
treatment of, 141. See Resus- 
citation. 
Atelectasis of newborn, 261 
Auscultation of fetal heart, 92, 94 
Axis traction forceps, 209 
B 
Baby. See Newborn. 
blue, 47 
Bag of waters, 75 
Bags, rubber, for inducing labor, 
210 
introduction of, 212 
Bartholin's glands, 25 
i Bath for asphyxia neonatorum, 141 278 
INDEX 
Bath during labor, 117 
of newborn baby, 242 
of premature infant, 268 
Bathing in pregnancy, 101 
Baudelocque's diameter, 86 
Bed, arrangement of, for delivery, 
110, 111 
of newborn, 270 
for pubiotomy cases, 226 
Bed-pads,lll 
Binder for abdomen. See Abdom- 
inal binder. 
for breasts, 192-195 
T-, 138 
Bipolar version, 216 
Birth injuries, 253 
Bladder, 32 
distention of, in labor, 32, 123 
in puerperium, 188 
injury to, in pubiotomy, 225 
pressure on, in pregnancy, 32, 55, 
60 
Blastodermic vesicle, 42 
Bleeding. See Hemorrhage and 
Venesection. 
Blood-pressure in eclampsia, 148 
in pregnancy, 61, 104 
in toxemia of pregnancy, 61 
Bones of fetal head, 47 
Boric acid solution, 191 
Bowels, care of, in newborn, 244 
in pregnancy, 101 
in puerperium, 188 
Bradford frame in after-care of 
pubiotomy, 226 
Braxton-Hicks version in placenta 
previa, 179 
Breast, 33 
abscess of, 195 
anatomy of, 33 
areola of, in pregnancy, 57 
caked, 194 
care of, in pregnancy, 102 
in puerperium, 189 
changes in pregnancy, 57 
drying-up secretion of, 194 
engorgement of, 192 
ice-cap for, 192, 194, 195 
infection of, 195 
inflammation of, 195 
massage of, 193 
pumping of, 193, 194, 195, 196 
secretion of, established, 34, 190 
striae of, 57 
Breast-binder, 192-195 
Breast-feeding, 189, 190, 250 
Breast-pump, 193 
Breck feeder, 268 
Breech presentations, 68, 69, 72, 
170 
delivery in, 171 
diagnosis of, 90, 91, 117 
external version in, 213, 215 
extraction in, 213 
forceps on after-coming head 
in, 172 
injuries to child in, 214 
laceration of perineum in, 172 
mechanism of labor in, 170 
meconium passed in, 125 
nurse's part in assisting in 
delivery of, 172 
Bregma, 49 
Broad ligament, 31 
Brow presentations, 72 
Buttocks, sore, 248 
Byrd-Dew method of artificial 
respiration, 140, 141 
C 
Caesarean section, 217 
after-care in, 222 
dangers of, 223 
description of operation, 219 
in eclampsia, 151 
extraperitoneal, 221 
indications for, 218 
instruments for, 219 
low operation, 221 
mortality of, 224 
in placenta previa, 180 
Porro's operation, 222 
repeated, 221 
sterilization after, 222 
transperitoneal, 221 
vaginal, 217 
Caked breasts, 194 
Caput succedaneum, 81 
in face presentations, 170 
Cardiac conditions complicating 
pregnancy, 159 
Cariincula; myrtiformes, 27 
Castor oil for induction of labor, 
211 
Cathartics in pregnancy, 101 
Catheter, tracheal, 141 INDEX 
279 
Catheterization, cause of cystitis! 
and pyelitis, 161 
in labor, 121 
in preparation for operation, 205 
in puerperium, 189 
Cephalhematoma of newborn, 253 
Cephalic version, 215 
Cervical smear at prenatal examin- 
ation, 104, 106 
Cervix uteri, 29, 30 
congestion of, in pregnancy, 
56 
dilatation of, in labor, 74, 75, 
116 
laceration of, cause of post-! 
partum hemorrhage, 181 
repair of, 229 
obliteration of, 75 
rigidity of, 167, 217 
softening of, in pregnancy, 56 
Chafing, 249 
Chamberlen family, inventors of 
forceps, 207 
Chart for mother in puerperium, 
186 
for newborn baby, 236 
Child. See Newborn. 
Childbed fever. See Puerperal in- 
fection. 
Chill, postpartum, 139 
in puerperal infection, 200 
Chloasma, 58 
Chloroform in eclampsia, 150 
in labor, 129 
Chorio-epithelioma, 153 
Chorion, 36-40 
villi of, 37 
Circulation of fetus, 46 
Circulatory system, changes in 
pregnancy, 58 
Circumcision, 248 
Cleft palate, 42, 257 
Cleidotomy, 228 
Clitoris, 25 
Clothing during pregnancy, 99 
of newborn, 243 
Coccyx, 19 
Colic, 262 
Colon bacillus, 116, 199 
irrigation, 244 
Colostrum, 34, 57, 190 
reputed laxative action of, 250 
Complete abortion, 156 
Concealed hemorrhage, 138, 181 
Confinement, arrangement of bed 
for, 110, 111 
care after, 138 
date of, how calculated, 52 
preparations for, in home, 109 
in hospital, 112 
supplies for, 113 
Conjugate, diagonal, measurement 
of, 88 
external, measurement of, 86 
Conjunctivitis of newborn, 163, 240 
Constipation in newborn, 244 
in pregnancy, 33, 60, 101 
in puerperium, 188 
Contracted pelvis, 103, 167 
Caesarean section for, 104, 218 
cause of dystocia, 103, 167 
contraindication to vaginal 
Caesarean section, 217 
indication for operative deliv- 
ery, 205 
induction of labor for, 104 
pubiotomy for, 104, 224 
types of, 23, 167 
Contraction of abdominal muscles 
in labor, 77 
pelvic. See Contracted pelvis. 
ring in impending rupture of 
uterus, 184 
tetanic, caused by ergot, 166 
of uterine muscle in labor, 75, 77 
Convulsions, eclamptic, 60, 104, 
148 
Cord, umbilical. See Umbilical 
cord. 
Cord-powder, 238 
Cord-scissors, 133 
Corpus luteum, 32 
extract in pernicious vomiting, 
147 
Corset in pregnancy, 100 
Cotyledons of placenta, 41 
Cracked nipples, 191 
Cramp in leg during labor, 120 
I Cranioclast, 227 
Craniotomy, 226 
"Cravings" in pregnancy, 61 
Crede method of expressing pla- 
centa, 137 
of treating eyes of newborn, 
134, 163 
Crib for newborn baby, 271 
"Cross-birth," 73, 172 
Croton oil in eclampsia, 147 280 
INDEX 
Curettement, 235 
in abortion, 157 
in puerperal infection, 201 
Cyanosis after asphyxia, 144 
in atelectasis, 271 
in eclampsia, 150 
D 
Date of confinement, calculation 
of, 52 
Death of fetus during pregnancy, 
161, 164 
Decapitation, 228 
Decidua, 36, 37, 39 
Deformed pelves. See Contracted 
pelvis. 
Deformities of fetus, 257 
Delivery, 79, 121, 123 
care after, 138 
management of normal, 126 
preparations for, 125 
supplies for, 113 
Delivery-room in home, 109 
in hospital, 112 
Descent of fetus in labor', 79, 80 
Detachment of placenta, 83, 136 
premature, 155, 180 
Diabetes in pregnancy, 160 
Diaper, 243 
Diet in pregnancy, 98 
in toxemia, 99, 146 
in vomiting of pregnancy, 147 
Dilatation of cervix, artificial, 167, 
211 
in normal labor, 74, 75 
Disinfection of abdomen for Caesar- 
ean section, 218 
of hands, 97 
of vulva, 96 
Displacements of uterus, 196 
Disproportion between child and 
pelvis, 103, 205, 210 
Diuretics in pregnancy, 102 
in pyelitis, 160 
in toxemia, 146 
Doederlein pubiotomy needle, 225 
Douche, 232 
in gonococcus infection, 163 
intra-uterine, 233 
in labor, 119 
in postpartum hemorrhage, 182, 
183 
Douche, preparation for, 232, 234 
in puerperal infection, 201, 233 
teipperature of, 232 
vaginal, 233 
Drainage in puerperal infection, 
201 
Dress of infant, 243 
in pregnancy, 99 
Drop method (Murphy's) of giving 
salt solution by rectum, 202 
Drying-up breasts, 194 
Dublin method of expressing pla- 
centa, 137 
Ductus arteriosus, 46 
Duncan mechanism of separation 
of placenta, 84 
Dystocia, 166 
E 
Eclampsia, 60, 146, 148 
Caesarean section for, 218 
cause of puerperal insanity, 148, 
203 
indication for operative delivery, 
205, 217, 218 
symptoms of, 148 
treatment of, 149 
vaginal Caesarean section for, 217 
Ectopic pregnancy, 157. See Ex- 
tra-uterine pregnancy. 
Edema of face in face presentation, 
170 
of lungs in eclampsia, 148 
symptom of toxemia, 103, 106 
Embolism, 203 
Embryo, 41, 42 
Embryotomy, 226 
Endometrium of uterus, 29 
changes during menstruation, 
34 
decidua during pregnancy, 36 
formation of new, in puerper- 
ium, 84 
Enema in preparation for labor, 117 
Engagement of head, 55, 79, 80, 89, 
, 153 
Episiotomy, 231 
Ergot after normal labor, 138 
dangers of use of during labor, 
166 
for after-pains, 188 
method of administration, 184 INDEX 
281 
Ergot in postpartum hemorrhage, 
182, 183 
Eruptions of newborn, 249 
Erysipelas, 161 
Ether in eclampsia, 150 
in normal labor, 130 
in operative delivery, 130, 206 
Examination of patient, abdominal, 
86 
external, 86 
final, 204 
internal, in labor, 114-117 
preliminary, in pregnancy, 86, 
95 
preparation of patient for, 87, 
95 
rectal, 115 
vaginal, 115, 116 
Exercise in pregnancy, 100 
in puerperium, 196 
Exhaustion of mother, an indica- 
tion for operation, 205 
Expression of placenta, 137 
Expulsion of fetus, 77-79 
of placenta, 83 
Extension, birth of head by, 79, 80 
of head in face presentations, 169 
External genitalia, 24 
os, 30 
rotation, 80 
version, 215 
Extraction of breech, 213 
Extra-uterine pregnancy, 35, 157 
hemorrhage in, 35, 159 
rupture in, 35, 159 
symptoms of, 159 
treatment of, 159 
Eye symptoms in toxemia, 103, 106 
Eyes of newborn child, care of, 133, 
239 
Crede treatment of, 134 
infection of, 240 
F 
Face presentations, 66, 67, 72, 169 
Facial paralysis of newborn, 255 
Fallopian tubes, 31 
Feces, extrusion of, during labor, 
118 
of newborn child, 244 
Feeding, artificial, of newborn, 251 
breast, 250 
I Feeding of premature infant, 268 
rectal, in hyperemesis, 147 
Fertilization, 34 
Fetal dystocia, 167 
heart, 44, 61, 62 
auscultation of, 92, 94 
changes of, in asphyxia, 139, 
170 
movements, 44, 61, 62 
ovoid, 72 
souffle, 94 
Fetus, 42 
circulation of, 46 
death of, in uterus, 53, 164 
effect of anesthesia and drugs 
on, 50, 51 
full term, 46 
head of, 47 
length of, at different months, 45 
macerated, 53, 164 
mature, 52 • 
movements of, 44, 61, 62 
nutrition of, 38, 50 
overgrowth of, 167 
physiology of, 47 
position of, in uterus, 63, 72 
premature, 52 
protection of, from injury and 
disease, 50 
viability of, 53 
weight of, 45 
Fever, inanition, 236 
milk, 190 
puerperal, 197. See Puerperal 
infection. 
starvation of newborn, 236 
Fissures of nipples, 191 
i Flat pelvis, 167 
Flexion of fetus in uterus, 72 
of head in labor, 79 
Follicle, Graafian, 32 
Fontanelles, 47 
Footling presentation, 170 
Foramen ovale, 46 
Forceps, 207 
after pubiotomy, 225 
।; Fowler position in puerperal infec- 
tion, 201 
Fractures in newborn, 255 
। Frank breech, 170 
Full term, 52 
Fundus uteri, 29 
height of, after delivery of 
child, 136 282 
INDEX 
Fundus uteri, height of, after de- 
tachment of placenta, 
136 
expulsion of placenta, 137 
in pregnancy, 54, 55 
- in puerperium, 85 
massage of, in postpartum 
hemorrhage, 183 
palpation of, in suspected 
hemorrhage, 138 
Funic souffle, 94 
Funis. See Umbilical cord. 
Funnel pelvis, 167 
G 
Galactagogtjes, 190 
Generally contracted pelvis, 167 
Genitalia, external, 24 
Gestation. See Pregnancy. 
Gigli saw for pubiotomy, 225 
Glands of Bartholin, 25 
of Montgomery, 57 
Gloves, rubber, in gonococcus in- 
fections, 163 
in obstetrical examinations, 98 
in rectal examinations, 116 
Gonorrhea, cause of abortion, 163 
of ophthalmia neonatorum, 
133, 163, 240 
of puerperal infection, 163, 199 
of vulvo-vaginitis, 163, 248 
complicating pregnancy, 162 
Graafian follicle, 32 
Gum, red, 249 
H 
Haase's table, 45 
Hands, disinfection of, 97 
Hare-lip, 42, 257 
Hairs, pubic, 24, 25 
clipping or shaving of, in labor, 
118 
Head of fetus, 47 
molding of, in labor, 80 
Headache in toxemia, 103, 146 
Heart conditions in pregnancy, 104, 
159 
Heart-burn, 145 
Hebotomy or hebosteotomy, 225. 
See Pubiotomy. 
। Hemorrhage in abortion, 154, 156 
accidental, 181 
after Caesarean section, 222, 223 
in chorio-epithelioma, 154 
concealed, 138, 181 
from injury to uterine wall, 56 
from umbilical cord, 135 
indication for operative deliv- 
ery, 205 
in newborn, 263 
in placenta previa, 155, 177, 178 
postpartum, 181. See Postpar- 
tum hemorrhage. 
in pregnancy, 154 
in premature separation of pla- 
centa, 155 
preparations for, 114, 182 
in pubiotomy, 225 
in rupture of uterus, 185 
treatment of, 155, 183 - 
Hemorrhoids in labor, 124 
in pregnancy, 33, 101 
Hip-bones, 19 
Holmes, O. W., paper on childbed 
fever, 198 
Hook, blunt, for impacted shoulder 
228 
Hydatidiform mole, 153 
Hydramnios, 153 
cause of inertia, 166 
of non-engagement of head, 
153 
of prolapsed cord, 175 
in twin pregnancy, 174 
Hydrocephalus, 260 
cause of rupture of uterus, 184 
indication for craniotomy, 228 
Hymen, 25 
Hyperemesis gravidarum, 146 
therapeutic abortion for, 147 
treatment of, 147 
Hypodermoclysis in eclampsia, 150 
in pernicious vomiting, 147 
in postpartum hemorrhage, 182 
in puerperal infection, 202 
Hysterectomy after Caesarean sec- 
tion, 222 
for chorioepithelioma, 104 
I 
Ice-cap for breast conditions, 192, 
194, 195 INDEX 
283 
Ice-cap for postpartum hemor- 
rhage, 182, 183 
in puerperal infection, 202 
Icterus neonatorum, 261 
Identification of babies in hospital 
nursery, 273 
Impacted shoulders, 128 
Imperforate anus, 257 
Implantation of ovum, 34, 36 
Impressions, maternal, 44 
Inanition fever, 236 
Incarcerated uterus, 151 
Incubator, 267 
Indigestion in infants, 261 
in pregnancy, 145 
Induction of abortion, 153, 160 
of labor, 104, 160, 209 
indications for, 210 
methods of, 211 
Inertia of uterus, 166 
indication for operative delivery, 
205 
Infant. See Newborn. 
Infection of breast. See Mastitis. 
of eyes in newborn, 163, 240 
puerperal, 197. See also Puer- 
peral infection. 
of umbilicus, 238 
Infectious diseases, acute, in preg- 
nancy, 161 
Inferior strait, 20 
Influenza in pregnancy, 161 
Injuries of newborn, 253 
Inlet, pelvic, 20 
Insanity, puerperal, 203 
Instruments for Caesarean section, 
219 
for circumcision, 248 
for cleidotomy, 228 
for craniotomy, 227 
for curettement, 235 
for decapitation, 228 
for episiotomy, 232 
for final examination of patient, 
204 
for forceps delivery, 209 
for insertion of bag, 212 
for packing, 235 
for pubiotomy, 225 
for removal of sutures, 231 
for repair of cervix, 230 
of perineum, 229 
for vaginal Caesarean section, 217 
Internal examinations in labor, 114 
I Internal examination in preg- 
nancy, 95 
os, 30 
rotation, 79 
version, 172, 216 
Intra-uterine douche, 232, 233 
in postpartum hemorrhage, 182 
Inverted nipples, 192 
Involution of uterus, 85 
stimulated by nursing, 189 
Irrigation of vulva, 187, 189 
J 
Jaundice of newborn, 261 
Joints of pelvis, 19 
motion of, increased in preg- 
nancy, 20, 56 
K 
Kelly pad, 111 
Kidneys in pregnancy, 60 
Knee-chest position in prolapsed 
cord, 176 
in puerperium, 196 
L 
Labia ma j ora, 24 
minora, 25 
Labor, 17 
abnormal, 167 
anesthesia in, 128 
asepsis in, 112, 201 
bath in, 117 
bladder in, distended, 32, 123 
care of patient in, 117 
complications of, 166-169 
delivery of child in, 126 
dilatation of cervix in, 74, 75 
douche in, 119 
dry, 75 
duration of, 76, 79, 83 
examinations in, 114 
expulsion of placenta in, 83, 136 
first stage of, 75, 117 
full term, 52 
induction of, 104, 160, 209 
lacerations in, 228 
ligation of cord in, 132 284 
INDEX 
Labor, management of, 109 
mechanism of, 79. See Mechan- 
ism of labor. 
normal, 74 
onset of, 74 
pains of, 74, 75, 77 
physiology of, 74 
posture in, 120, 121 
premature, 52, 53 
preparations for, 109 
pulse in, 125 
second stage of, 74, 77, 119 
"show" in, 75 
stages of, 74 
third stage of, 74, 83, 136 
uterine contractions in, 75, 77 
Labor-bed, preparation of, 110, 111 
Lacerations, cervical, 229 
complete, 228 
degrees of, 228 
incomplete, 228 
perineal, 228 
prevention of, 126 
repair of, 228 
vaginal, 228 
Lactation, 85, 189 
Lanugo hairs, 44 
Laxatives in pregnancy, 101 
in puerperium, 188 
Leg-holder, 206 
Levator ani muscle, 23 
Ligaments of uterus, 31 
"Lightening," 59 
Linea alba, pigmentation of, 58 
Lithopedion, 158 
Lithotomy position, 123 
Lobes and lobules of breast, 33 
Lochia, 85, 186 
alba, 85 
amount of, 187 
in delayed involution, 186 
duration of, 85 
in puerperal infection, 200 
retention of, 199 
rubra, 85 
serosa, 85 
Lower uterine segment, 29, 175 
Lungs, edema of, in eclampsia, 148 
M 
Macerated fetus, 53, 164 
Malformations of fetus, 257 
Malpresentations, 167 
breech, 170 
brow, 169 
causes of, 152, 153 
correction of, by external manip- 
ulation, 104, 215 
danger to mother and child from, 
103 
face, 169 
occiput-posterior, 167 
operation for, 205 
transverse, 172 
version in, 217 
Massage of breasts, 193, 194 
contraindicated in thrombosis, 
203 
of fundus, in postpartum hemor- 
rhage, 183 
Mastitis, 195 
causes of, 195 
of newborn, 264 
prevention of, 196 
treatment of, 195 
Maternal impressions, 103 
Maturity of fetus, 52 
Mauriceau method of delivering 
after-coming head, 171 
Measurements of pelvis, 86 
Mechanism of labor, 79 
in breech presentations, 170 
in face presentations, 168 
in L. O. A., 79 
in occiput-posterior, 167 
Meconium, 46 
passage of, in breech presenta- 
tions, 125, 140 
in labor, 125 
sign of asphyxia, 125, 139 
Membranes, fetal, 36 
adherent, 137 
diagnosis of unruptured, 117 
rupture of, 35, 75, 77, 81 
Menstruation, 34 
cessation of, in pregnancy, 34, 
56 
date of, in calculating date of 
confinement, 52, 105 
' Mental disturbance after eclamp- 
sia, 148, 203 
contraindication to nursing, 
189 
Micturition, delayed, in newborn, 
246 
' frequent, in early pregnancy, 56 INbEX 
285 
Milk. See also Breast and Lacta- 
tion. 
comparison of human and cow's, 
252 
composition of, 190, 191, 252 
drying-up of, 194 
effect of diet on, 190, 191 
of work and exercise on, 190 
establishment of secretion of, 34, 
190 
Milk-ducts, 33 
Milk-fever, 190 
Milk-leg, 202 
Miscarriage, 53, 103,155. See also 
Abortion. 
prevention of, 102, 104 
Molding of fetal head, 80 
in fetus beyond term, 167 
Momburg's tube in postpartum 
hemorrhage, 183 
Mons veneris, 24 
Monstrosities, 259, 260 
Montgomery's glands or tubercles, 
57 
Morning sickness, 59 
Morula, 36 
Mulberry mass, 36 
Multipara, 17 
duration of stages of labor in, 76, 
77, 79 
pendulous abdomen in, 151 
Multiple pregnancy, 173 
Murphy drip, 202 
N 
Nausea in pregnancy, 57, 106 
Newborn, atelectasis of, 261 
bathing of, 242, 272 
birth injuries of, 253, 254 
bowels in, care of, 244 
care of, 132, 236 
cephalhematoma in, 253 
chart for, 236 
clothing of, 243 
colic in, 262 
colon irrigation of, 244 
constipation in, 244 
cord in, umbilical, care of, 237 
digestive disturbances in, 261 
eyes in, care of, 133, 239 
feeding of, 250, 251. See also 
Breast-feeding. 
Newborn, fractures of, 255 
genitalia in, care of, 247 
head-molding in, 253 
hemorrhagic disease of, 263 
hernia in, umbilical, 239, 257, 258 
icterus of, 261 
inanition fever of, 236 
jaundice of, 261 
laxatives for, 244 
malformations of, 257 
mastitis in, 264 
"menstruation" of, 248 
mouth in, care of, 241 
nose in, care of, 243 
ophthalmia of, 163, 240 
paralysis of, 255 
phimosis in, 247 
pulse of, 236 
respiration of, 236 
skin of, 248, 249 
stools of, 244 
syphilis of, 236 
temperature of, 236 
thrush in, 241 
umbilical cord in, care of, 237 
urine of, 246 
vaginal discharge in, 247 
vulvo-vaginitis of, 163, 248 
weighing of, 237, 273 
weight of, 237 
wet-nursing for, 253 
Nipples, care of, in pregnancy, 102 
in puerperium, 191 
changes in, due to pregnancy, 57 
retracted, 192 
Nipple-shield, 191, 192 
Nitrate of silver treatment of 
eyes of newborn, 134 
Nitrous oxide anesthesia, 130 
Nurse, duties of, as anesthetist, 132 
at breech delivery, 172, 214 
in delivery of normal case, 126 
during labor, 114, 117, 119- 
121, 124, 138 
in eclampsia, 151 
in hemorrhage, 155, 183 
in postnatal work, 18, 108 
in prenatal work, 18, 105-108 
in prevention of cross-infec- 
tion, 274 
of puerperal infection, 200 
in private nursing, 18, 109 
in promoting breast-feeding, 
190, 251, 262 286 
INDEX 
Nurse, duties of, in puerperium, 
187, 197 
in reporting to physician, 124, 
155, 159, 175, 186, 239, 247 
in venereal disease cases, 163, 
240, 266 
engagement of, 18 
outfit of, 276 
Nursery in home, 269 
in hospital, 270 
prevention of cross-infection 
in, 274 
temperature of, 269 
ventilation of, 269 
Nursing of baby, contraindication 
to, 189 
importance of, 189, 250, 251 
Nutrition of fetus, 38, 50 
O 
Obstetrical month, 52 
nursing, 18 
Obstetrics, 17 
Occiput, 49 
Oligohydramnios, 153 
Operations, obstetrical, 205 
anesthesia in, 206 
indications for, 205 
preparations for, 205 
Ophthalmia neonatorum, 133, 163, 
239 
Crede's preventive treatment 
of, 134, 163, 239 
douches in pregnancy as pre- 
ventive of, 163 
symptoms of, 240 
treatment of, 241 
Os, external, 30 
dilatation of, in labor, 75 
internal, 30 
dilatation of, in labor, 75 
Outfit of nurse, 276 
of patient, 275 
Outlet of pelvis, 20, 22 
decreased in funnel pelvis, 167 
increased by lithotomy posi- 
tion, 123 
Outlining fetus by palpation, 61, 62 
Ovaries, 31 
Oviducts, 31. See Fallopian tubes. 
Ovoid, fetal, 72 
Ovulation, 31 
Ovulation, cessation of, in preg- 
nancy, 56 
Ovum, 32, 41 
development of, 41 
fertilization of, 34 
implantation of, 34, 36 
Oxygen and nitrous oxide anesthe- 
sia, 129, 130 
in asphyxia, 142 
in atelectasis, 261 
for cyanosis in newborn, 144 
in eclampsia, 150 
P 
Pack, hot, in eclampsia, 149 
Packing, 234 
in abortion, 234 
in placenta previa, 234 
in postpartum hemorrhage, 182, 
183, 234 
removal of, 235 
Pad, bed, 111, 138 
vulvar, 138, 186, 187 
Pains, after-, 187 
bearing-down, 77, 121 
labor, 75, 77, 121 
premonitory, 74 
Palate, cleft, 257 
Pallid asphyxia, 141-144 
Palpation of abdomen, 90 
of presenting part through peri- 
neum, 125 
Paralysis in newborn, 128, 255 
Parturient, 17 
Parturition, 17. See Labor. 
Patient, examination of, final, 204 
in labor, 114, 124 
in pregnancy, 86, 106 
outfit of, 275 
position of, in labor, 120, 121, 
125 
preparation of, for examination, 
87, 95 
for labor, 117 
Pelvimeter, 86 
Pelvis, 19 
anatomy of, 19 
cavity of, 19 
contracted, 22, 167. See Con- 
tracted pelvis. 
deformed, 22, 167 
female, 22 INDEX 
287 
Pelvis, flat, 167 
floor of, 23 
funnel, 167 
inlet of, 20 
male, 22 
measurements of, 20, 86, 87 
muscles of, 23 
outlet of, 20 
rachitic, 23, 167 
straits of, 20 
Pendulous abdomen, 152 
Perforation of fetal head, 226 
Perforator, 226, 227 
Perineorrhaphy, 228-230 
Perineum, 23 
lacerations of, 228 
repair of, 229 
protection of, during delivery, 
126 
Peritonitis in puerperal infection, 
199 
Pernicious vomiting, 59, 146 
Phimosis, 247 
Phlebitis, 202 
Phlegmasia alba dolens, 202 
Pigmentation in pregnancy, 58 
Pituitary extract for abdominal 
distention in puerperium, 
202 
for inertia, 167 
for postpartum hemorrhage, 
182, 183 
Placenta, 38, 41 
detachment of, in third stage, 83, 
84, 136 
expression of, 84 
expulsion of, 83, 84 
premature separation of, 180 
previa, 176-180 
diagnosis of, 117 
indication for Caesarean sec- 
tion, 218 
for induction of labor, 210 
treatment of, 178 
in twin pregnancy, 173, 174 
Podalic version, 215 
Porro-Caesarean section, 222 
Position of fetus, 63 
diagnosis of, 90 
knee-chest, in prolapsed cord, 175 
in puerperium, 196 
lithotomy, in labor, 123 
of patient, during delivery, 123 
labor, 120, 121, 122 
Position of patient during opera- 
tion, 206 
in puerperium, 196 
posterior, of occiput, 168 
Sims, 176 
Trendelenberg, 176 
Walcher, 121 
Posterior positions of occiput, 168 
Postnatal clinics, 18, 108 
Postpartum chill, 139 
hemorrhage, 181 
Pregnancy, 17 
Abderhalden's test for, 63 
bathing in, 101 
bowels in, 101 
breasts in, 59, 101 
cardiac conditions in, 57, 102 
changes during, 53 
circulatory system in, 58 
clothing in, 99 
complications of, 145 
constipation in, 60, 101 
diagnosis of, 61 
diet in, 98 
digestion in, 59 
duration of, 52, 89, 90 
ectopic, 157. See Extra-uterine. 
examination of patient in, 86 
exercise in, 100 
extra-uterine, 35, 157 
gonorrhea in, 104, 162 
hemorrhage in, 154 
hygiene of, 98 
kidneys in, 60, 101 
management of, 86 
metabolism in, 60 
multiple, 173 
nervous system in, 61 
physiology of, 52 
pyelitis in, 160 
signs of, 61 
syphilis in, 104, 164 
toxemia of, 60, 102, 145 
tubal, 35, 157 
tuberculosis in, 104, 164 
twin, 173 
urine in, 60 
varicose veins in, 59, 160, 174 
vomiting in, 59, 148 
pernicious, 146 
rr-ray in diagnosis of, 63 
Premature infant, 53, 267 
care of, 267 
clothing of, 268 288 
INDEX 
Premature infant, feeding of, 269 
resuscitation of, 144 
labor, 53 
induction of, 162, 164, 209 
separation of placenta, 180 
Prematurity, 52 
Preparation of patient for delivery, 
125 
for external examination, 85, 
88, 95 
for internal examination, 95 
for labor, 117 
for operation, 205 
of room for confinement, 109,112 
Presentation and position, 63 
diagnosis of, 89, 90, 116 
Presentations, breech, 68, 69, 72, 
169 
brow, 72, 169 
face, 66, 67, 72, 169 
occiput-posterior, 167 
shoulder, 72. See Transverse, 
transverse, 70, 71, 72, 73, 172 
vertex, 64, 65, 72 
Presenting part, 72 
Primigravida, 17 
Primipara, 17 
Prochownik's method of artificial 
respiration, 142 
Prolapse of umbilical cord, 124, 
170, 175 
diagnosis of, 117, 176 
treatment of, 175 
Puberty, 32 
Pubiotomy, 224 
after-care of, 226 
Pubis, 19 
Puerpera, 17 
Puerperal infection, 197 
douches in, 201, 233 ' 
history of, 197 
organisms causing, 163, 199 
prevention of, 200 
treatment of, 201 
types of, 199 
insanity, 203 
thrombosis, 202 
treatment of, 203 
Puerperium, 17, 84, 186 
after-pains in, 187 
binder in, 138, 193, 194, 195 
bladder in, 188 
bowels in, 188 
breasts in, 189 
Puerperium, care during, 186 
catheterization in, 189 
chart in, 139, 186 
constipation in, 188 
cystitis in, 160 
duration of, 85 
embolism in, 203 
exercises in, 197 
fever in, 191 
final examination in, 204 
getting up in, 197 
gonorrhea in, 163, 199 
infection in, 197 
insanity in, 203 
involution of uterus in, 85 
mastitis in, 195 
milk secretion in, 85, 190 
physiology of, 84 
pulse in, 186 
pyelitis in, 160 
respiration in, 186 
rest in, 196 
subinvolution in, 175, 197, 204 
syphilis in, 164 
temperature in, 186 
thrombosis in, 202 
tuberculosis in, 161 
tympanites in, 189 
vulva in, care of, 187 
Pulse after delivery, 138, 139 
in labor, 125 
in puerperium, 186 
Pyelitis, 160 
Q 
Quadruplets, 173 
Quickening, 62, 105 
Quinine for induction of labor, 211 
for inertia, 167 
R 
Rachitis, cause of contracted pel- 
vis, 167 
Rectal examinations, 115 
Rectum, 33 
Red gum, 249 
Reproductive organs, 23 
Respiration, artificial, methods of, 
141 
embarrassment of, in pregnancy, 
59, 153 INDEX 
289 
Respiration in puerperium, 186 
Rest in puerperium, 196 
in treatment of puerperal infec- 
tion, 202 
Resuscitation of asphyxiated child, 
141 
Retracted nipples, 192 
Retraction of uterine muscle after 
delivery, 83 
Rickets, 167 
Robb's leg-holder, 206 
Rotation, external, 80 
internal, 79 
in posterior positions, 168 
Rubber gloves, 98 
sheeting for delivery-bed, 111 
Rupture of extra-uterine preg- 
nancy, 157 
of membranes, 75, 77, 211 
of uterus, 184 
conditions causing, 166, 172, 
184, 217, 224 
treatment of, 185 
S 
Sacroiliac joint, 19 
Sacrum, 19 
Salt solution, administration of, in 
hemorrhage, 182 
by hypodermoclysis, 150, 
182, 202 
intravenous, 183 
Murphy drip method, 202 
in puerperal infection, 202 
by rectum, 150, 182, 202 
Sapremia, 199 
Saw, Gigli, for pubiotomy, 225 
Scales, infant, 273 
Schultze method of artificial respi- 
ration, 142 
of separation of placenta, 84, 
181 
Scissors-perforator, Smellie's, 226 
Scopolamin-morphine anesthesia, 
130 
Second stage of labor, 74, 77 
management of, 119 
pituitary extract in, 167 
Semmelweiss, 198 
Separation of placenta, premature, 
155, 180 
in third stage of labor, 83, 84, 
136 
Septicemia, 199 
Serum in puerperal infection, 201 
Sex of child, 44, 62 
in twins, 174 
Sheet, twisted, as leg-holder, 207 
Shock after Caesarean section, 223 
Shoulder presentation, 172 
Shoulders, delivery of, 128 
impaction of, 128 
rotation of, 80 
Show, 75 
Silver catarrh, 239 
nitrate solution for prevention of 
ophthalmia, 134 
Simpson forceps, 209 
Sims' position in prolapsed cord, 176 
Sinciput, 49 
Skin of newborn, 248 
Smegma, 247 
Smellie scissor-perforator, 226, 227 
Smellie-Veit method for after-com- 
ing head, 171 
"Snuffles," 265 
■ Solutions, antiseptic, 97 
Souffle, 94 
| Spermatozoon, 35 
Sphincter ani, 228 
Spina bifida, 257, 258 
Stages of labor, 74. See First, 
Second and Third stages. 
Starvation temperature in new- 
born, 236 
Sterility after gonococcus infec- 
tion, 163 
Sterilization after Caesarean sec- 
tion, 222 
Still-birth, 53 
Stitches. See Sutures. 
Stools of newborn, 244 
Streptococcus infection in preg- 
nancy, 164 
in puerperium, 199 
Striae, 57, 58 
Stupes, 194, 202 
Subinvolution, 174, 204 
Supernumerary fingers and toes, 
260 
Sutures in Caesarean section, 219- 
221 
removal of, 223 
of fetal head, 47 
in perinorrhaphy, 229 
after-care of, 230 
removal of, 230 290 
INDEX 
Sylvester method of artificial respi- 
ration, 141 
Symphyseotomy, 224 
Symphysis pubis, 19 
Syphilis complicating pregnancy, 
104, 164 
congenital, 164, 165, 264 
symptoms of, 265 
treatment of, 266 
transmission of, from mother to 
fetus, 50, 164 
T 
Tamponade, 234. See Packing. 
Tarnier axis-traction forceps, 208, 
209 
T-binder, 138 
Teeth in pregnancy, 61 
Temperature of baby's bath, 242 
of newborn infant, 236 
of nursery, 269 
in puerperium, 186 
Test of labor before Caesarean sec- 
tion, 218 
Therapeutic abortion, 145, 157 
Third stage of labor, 74, 83 
management of, 136 
Thrombosis, puerperal, 202 
treatment of, 203 
Thrush, 241 
Tongue-tie, 257 
Toxemia of pregnancy, 60, 102, 145 
coma in, 146 
convulsions in, 146 
danger to mother and child 
from, 104 
diet in, 99 
indication for induction of 
labor, 210 
in multiple pregnancy, 174 
prevention of, 60, 99, 101, 102, 
146 
symptoms of, 103, 106, 146 
treatment of, 99, 146 
vomiting in, 146 
in puerperium from absorption, 
199 
Tracheal catheter, 141 
Transfusion for hemorrhagic dis- 
ease of newborn, 264 
Transmission of disease to fetus, 
50, 162, 164 
Transverse presentations, 71-73, 
172 
version in, 172, 214, 215 
Trendelenburg position in pro- 
lapsed cord, 176 
Trephine perforator, 226 
Triplets, 173 
Tubal pregnancy, 157 
Tubercles of Montgomery, 57 
Tuberculosis complicating preg- 
nancy and puerperium, 104, 
162 
contraindication to nursing, 189 
Tubes, Fallopian, 31 
Twilight sleep, 130 
Twin pregnancy, 173 
Tympanites in puerperium, 189 
U 
Umbilical cord, 38, 40, 41 
bloodvessels of, 41 
care of, in newborn child, 132, 
237 
coiled around child's neck, 128 
dressing for, 133 
hemorrhage from, 135, 263 
infection through, 238 
ligation of, 132 
pressure on, cause of asphyxia, 
41, 171, 173 
prolapse of, 170, 173 
hernia, 239 
Urethra, 32, 188 
Urinary tract, diseases of, in preg- 
nancy, 160 
Urination, delayed, in newborn, 246 
difficult, in early puerperium, 188 
Urine of newborn, 246 
in pregnancy, 101, 160 
examination of, 60, 102, 104 
in toxemia, 103, 106 
Uterine arteries, 31 
tubes, 31 
Uterus, 29 
anatomy of, 29 
blood supply of, 31 
body of, 29 
cervix of, 29 
changes in, during menstrual 
cycle, 34 
labor, 74, 75 
pregnancy, 53 INDEX 
291 
Uterus, changes in, during puer- 
perium, 84 
contractions of, 74, 75 
displacements of, 151 
fundus of, 29 
incarceration of, 151 
involution of, 84, 85 
ligaments of, 31 
pressure of, on bladder, 55 
rupture of, 184 
segments of, 29, 184 
V 
Vaccine in puerperal infection, 201 
Vagina, 23, 25, 27 
anatomy of, 27 
changes in, during pregnancy, 56 
lacerations of, 228 
secretion of, 29, 56 
Vaginal Caesarean section, 217 
douche, 232, 233 
examination, 95, 115 
preparation of patient for, 95 
lacerations, 228 
Varicose veins in pregnancy, 59, 
160, 174 
of vagina, rupture of, 181 
Venereal disease, 104, 162 
warts, 162 
Venesection, 150 
Ventilation of nursery, 269 
Vernix caseosa, 45 
Version, 213-217 
Vertex, 49 
■| Vertex presentations, 64, 65, 72 
Vestibule, 25 
Viability, 53 
Villi of chorion, 37 
Vision, affected in toxemia, 103,106 
Vomiting in newborn, 262 
pernicious, 210 
in pregnancy, 59, 106 
Voorhees bags, 210 
Vulva, 24 
care of, in puerperium, 187 
discoloration of, in pregnancy, 56 
swelling of, in puerperium, 187 
Vulvovaginitis, 163, 248 
W 
। Walcher position, 121 
Warts, venereal, in pregnancy, 162 
Wassermann test in prenatal exam- 
ination, 104 
Waters, bag of. See Membranes. 
Weighing of baby, 273 
Weight of fetus, 45 
of newborn, 237 
Wet-nurse, 253 
Wharton's jelly, 41 
"Witches' milk," 264 
Womb. See Uterus. 
X 
X-ray in diagnosis of pregnancy, 
63