MATERNITY NURSING INA NUTSHELL E.H. WICKHAM, R.N. Maternity Nursing in a Nutshell BY ELIZABETH H. WICKHAM, R.N. Graduate of the Boston City Hospital, and Boston Lying-in Hospital Training School for Nurses; Former Supervisor of the Maternity Depart- ment, Lebanon Hospital, New York City; also Late Field Nurse, Maternity Center Association, New York City. WITH 28 ILLUSTRATIONS PHILADELPHIA F. A. DAVIS COMPANY, Publishers 1924 COPYRIGHT. 1924 BY F. A. DAVIS COMPANY Copyright, Great Britain. All Rights Reserved PRINTED IN U. S. A. PRESS OF F. A. DAVIS COMPANY PHILADELPHIA. PA. TO M. L. J. PREFACE The information this little book contains has been gained by the actual experience of the writer, whose untiring efforts in maternity nursing have been pro- ductive of much definite success. There are various books written on this subject and all have their dis- tinct value; but the author felt that nurses who had not made a specialty of maternity nursing would ap- preciate a ready reference manual, small enough to fit a corner of their bag or suitcase; to serve its pur- pose at some critical moment. She trusts it will save unnecessary steps and be of general assistance to those who consult its pages. Many nurses, on graduating, find themselves equipped with a limited knowledge of maternity nurs- ing and when asked to take a case often refuse on account of their lack of ability. Those with insuffici- ent knowledge who do accept cases cannot render the care that mother and baby rightfully deserve. The waste of time and energy incurred by poor methods is probably responsible for the generally accepted idea that maternity nursing is the hardest. When once mastered, it is more interesting and certainly less com- plicated than some of the other branches of nursing. V VI PREFACE. Those of us who like the work should make it a specialty; for in so doing we not only prove ourselves more valuable to those who seek our services, but we are afforded the opportunity for self expression which undoubtedly demonstrates our true worth. Further- more, in every line of endeavor specialists are always in greater demand than those less skilled. The public, too, is realizing more every day the importance of securing skilled attention during preg- nancy, knowing that the best care at that time may prevent a life of invalidism or possibly death. Even the poorest laborer in the tenement will seek the ser- vices of those he thinks most capable of attending his wife during her confinement. The best care possible is none too good for any woman going through the ordeal and inferior care is little short of crime. We cannot hope to produce a healthy race if the pregnant women are neglected until the actual confinement; for they are generally the ones who bring forth weaklings. Whereas, the women who can have prenatal care and advice from the beginning of conception, cannot help but produce the sturdy stock which the world desires. Elizabeth H. Wickham, R. N. CONTENTS CHAPTER I. Anatomy and Physiology of the Female Pelvis, Ovula- tion, etc 1 CHAPTER II. Duration and Signs of Pregnancy 8 CHAPTER III. Prenatal Nursing Care 12 CHAPTER IV. Complications of Pregnancy 26 CHAPTER V. Dressings and Outfits 47 CHAPTER VI. Preparation for Delivery in the Home 59 CHAPTER VII. Positions and Presentations-Normal Delivery 64 CHAPTER VIII. The Nurse's Delivery 79 CHAPTER IX. Care of the Mother After Labor 84 VII VIII CONTENTS. CHAPTER X. PAGE Care of the Baby-Full Term and Premature 106 CHAPTER XI. Infant Feeding and Baby's Development 115 CHAPTER XII. Disorders, Diseases, and Congenital Deformities of the Newborn 130 CHAPTER XIII. Complications of the Puerperium 138 CHAPTER XIV. Twilight Sleep 144 Appendix 147 Glossary . 151 Index 159 CHAPTER I. ANATOMY AND PHYSIOLOGY OF THE FEMALE PELVIS, OVULATION, ETC. The basin-like lower portion of the trunk known as the pelvis is composed of four bones, which are the 12.75 cm. 12-75 cm. 15 ._5 'CM. 1 1 -CM. Fig. 1.-Measurements of the pelvic inlet. ossa innominata or two hip bones situated on the sides and in front, and the sacrum and coccyx behind. The innominate bones are divided into three parts, the ilium, ischium and pubis. In childhood these parts are separate bones joined by cartilage and when puberty is reached the cartilage begins to ossify and 1 2 MATERNITY NURSING. gradually forms one complete bone. The sacrum and coccyx behind are the termination of the spinal column. The pelvis is divided into two parts by its brim; the upper or inlet is the wider and contains the abdom- inal organs. The lower or outlet is the true pelvis and encloses the pelvic cavity. The upper or false pelvis .9_ie JJcJm. Fig. 2.-Measurements of the pelvic outlet. is of minor importance since its function is simply to guide the presenting part of the fetus toward the true pelvis. The true pelvis should be studied as to its size, shape and position, for the fetus always passes through this narrow canal except in cesarean- section. An estimation of the size of the pelvis is gained by external and internal measurements which are accom- plished by digital examination and the use of an in- strument known as a pelvimeter. The external meas- Pelvimetry ANATOMY AND PHYSIOLOGY OF PELVIS. 3 urements are: inter-spinous, inter-crestal and external conjugate. Sometimes the distance between the great trochanters is measured which is normally about 32 centimeters. The inter-spinous is the distance between Fig. 3.-Pelvimeter. the antero-superior spines, which normally measures 26 centimeters. The inter-crestal measurement is the distance between the widest points of the iliac crests and normally is about 29 centimeters. The third measurement, external conjugate, is the distance be- 4 MATERNITY NURSING. tween the upper border of the symphysis pubis to the depression above the spine of the first sacral vertebra, this is normally 21 centimeters. The first two meas- urements are taken with the patient lying on her back, External conjugate Fig. 4.-External conjugate measurement. while the external conjugate is ascertained as the patient lies on her side. The internal measurements of the pelvic inlet are: the antero-posterior or true conjugate, transverse di- ameter and the two diagonal or oblique measurements. The true conjugate is the distance between the top of the symphysis pubis to the edge' of the sacrum and ANATOMY AND PHYSIOLOGY OF PELVIS. 5 normally is 11 centimeters. The transverse diameter is the distance between the* two widest points of the pelvic inlet and normally measures 13.5 centimeters. The right and left oblique measurements normally are 12.75 centimeters each. Inter-crestal Inter-spinous Fig. 5.-External inter-crestal and inter-spinous measurements. The transverse diameter of the pelvic outlet is measured with the patient in the dorsal position and the legs and thighs flexed. The distance between the ischial tuberosities is this measurement which is nor- mally 9 to 11 centimeters. In the antero-posterior diameter of the outlet the distance from the lower edge of the symphysis pubis to the tip of the sacrum is 6 MATERNITY NURSING. measured. In labor this diameter is enlarged by the backward displacement of the coccyx. Female generative organs The internal organs of reproduction are contained in the true pelvis and consist of the uterus, vagina, Fal- lopian tubes and the ovaries. Viscera surrounding these organs are the bladder, ureters, urethra and rec- tum. The external organs are the mons veneris, labia majora, labia minora, vestibule, clitoris, urethra orifice and the vaginal opening. Menstruation and ovula<- tion Menstruation is the monthly discharge of blood from the uterus which is expelled through the vagina. It is manifested at puberty and continues to the meno- pause. By ovulation is meant the maturation and escape of an ovum from its Graafian follicle in the ovary. The matured unfertilized ovum is transported through the Fallopian tube to the uterus where it is discharged in the menstrual flow. The fertilized ovum is retained and normally finds lodgment in the uterine cavity, where in about two weeks the development of the embryo begins. The placenta has its origin about the third month. Its function is to supply the fetus with oxygen and the essentials for body growth. All waste matter is carried into the maternal circulation and excreted through the various eliminatory organs. During the second month the embryo shows the first signs of hands and feet with the fingers and toes webbed; the eyes, ears and nose also appear. In the ANATOMY AND PHYSIOLOGY OF PELVIS. 7 third month the fingers and toes shed their webs and the nails appear. The eyes are drawn closer together and protected by the lids. About the fourth month sex may be distinguished and the fetus is about five inches in length. During the fifth month the fetal heart sounds may be heard and the mother experiences fetal movements or quickening. The eyelids begin to open and the head is unusually large in proportion to the rest of the body. At the sixth month eyebrows and eyelashes are well defined as well as the hair on the scalp. At the end of the seventh month the fetus measures about fifteen inches and the soft downy hair called lanugo, which makes its appearance in the fourth month, now becomes pronounced and covers the whole body. At the eighth month the hair on the scalp is more plentiful and the lanugo disappears on the face. At the ninth month the fetus measures about seventeen inches and by the tenth month it arrives at maturity. Development of the embryo CHAPTER II. DURATION AND SIGNS OF PREGNANCY. Duration of pregnancy The usual duration of pregnancy is two hundred and eighty days, very seldom over three hundred. To calculate the probable date of delivery, take the first day of the last menstruation, count back three months and add seven days. Labor may then be counted upon to occur a week either way of that date. See page 9 for Phillips Pregnancy recQrd. Signs of pregnancy Presumptive. Absence of menstruation, nausea and vomiting, irritability of the bladder, and colostrum in the breasts. In a woman who usually menstruates regularly, ab- sence of menstruation is one of the first signs of preg- nancy. Nausea and vomiting, or morning sickness as it is commonly called, may begin any time after con- ception and usually subsides between the third and fourth months. Some patients have a mild attack in the early morning which gradually wears off as the day progresses, leaving them as well as though it had not occurred. Others have repeated attacks with severe vomiting, and if persistent it is known as per- nicious vomiting. Many patients complain of a fre- 8 DURATION AND SIGNS OF PREGNANCY. 9 Jan ... 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Oct... 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 1 2 3 4 5 6 7 Nov. Feb... 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 Nov... 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 1 2 3 4 5 Dec. Mar. .. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Dec... 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 1 2 3 4 5 Jan. April.. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 Jan... 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 1 2 3 4 Feb. May .. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Feb... 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 1 2 3 4 5 6 7 Mar. June.. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 Mar.. 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 1 2 3 4 5 6 April July... 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 April. 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 1 2 3 4 5 6 7 May Aug... 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 May.. 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 1 2 3 4 5 6 7 June Sept... 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 June.. 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 1 2 3 4 5 6 7 July Oct. .. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 July... 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 1 2 3 4 5 6 7 Aug. Nov... 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 Aug.. 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 1 2 3 4 5 6 Sept. Dec... 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Sept.. 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 1 2 3 4 5 6 7 Oct. Supposing the upper figure in each pair of horizontal lines to represent the first day of the last menstrual period, the figure beneath it, with the month designated in the margin, will show the probable day of confinement. OBSTETRICAL TABLE Fig. 6.-Phillips' pregnancy record. 10 MATERNITY NURSING* quent desire to urinate, not only in the early months of pregnancy, but in the later as well. This may be caused by nervousness or the enlarging uterus press- ing on the bladder. The relief experienced after the first few months is due to the uterus rising in the pel- vis; but when it begins to sink again, the irritability returns. Presence of colostrum in the breasts is not always indicative of pregnancy in a woman who has already borne children, but in a primipara it is strongly suggestive. Probable. Changes in the breasts and abdomen (pigmentation and enlargement), inter- mittent uterine contractions and mur- mur, softening of the cervix. The breasts increase in size and sometimes are quite tender, and the pigmented area around the nipples becomes darker. Quite often there is also a dark pig- mented line called the linea nigra extending upward from the pubis toward the umbilicus. The vaginal mucosa usually takes on a purple tinge. Enlargement of the abdomen is not a reliable sign, as tumors, ascites, etc., may be the cause of the enlargement. Intermittent uterine contractions begin in early preg- nancy, the patient is wholly unconscious of the con- tractions which last throughout the entire pregnant period. Softening of the cervix is almost always present. DURATION AND SIGNS OF PREGNANCY. 11 Positive. Fetal heart sounds and fetal movements. The fetal heart beats at the rate of about 120 to 160 a minute, and the sounds may be heard as early as the fifth month. Movements of the fetus may be heard as early as the fourth month; the outlines of the fetal body are ascertained by abdominal palpation, and the presenting part may easily be distinguished. The ac- tive movements are those felt by placing the hand on the abdomen, the passive movements are ascertained through ballottement. At four months the fundus is half-way between the symphysis and the umbilicus; at six months, level with the umbilicus; at seven mouths, four fingers above; at eight months, half-way between the umbilicus and en- siform cartilage; at nine months, even with the ensi- form cartilage. Toward the end of this period the uterus gradually descends into the mother's pelvis and the abdomen seems to become smaller. A decided re- lief from pressure upon the respiratory organs is ex- perienced and breathing seems easier. About this time irritability of the bladder is often complained of, which is due to pressure of the presenting part of the fetus on the bladder. Height of the fundus CHAPTER III. PRENATAL NURSING CARE. It used to be the theory that no care was necessary during pregnancy; but it is now unusual for a woman even in poor circumstances not to seek some medical attention for the welfare of herself and child. In most large cities today prenatal clinics have been estab- lished for the benefit of the pregnant woman in all walks of life. Every nurse should advise the pregnant woman to consult an obstetrician in the early weeks of pregnancy; she should be under his supervision throughout the whole period, which would give him the opportunity to recognize any abnormal symptoms early enough to avoid dangerous complications. Fre- quent visits to him during the latter months of preg- nancy is most essential. Instruction in the hygiene of pregnancy should be given if the nurse has the case in time to do so, for most doctors are far too busy to go into all the many details relating to exercise, cleanliness, clothes, diet, etc. Better still, if there is a prenatal clinic in the vicinity urge the patient to register there. Should she already have her doctor engaged, get into communica- tion with him first and see if he is willing that she 12 PRENATAL NURSING CARE. 13 should be taken care of at the clinic for nursing advice only. Most doctors with a large practice and those who specialize in obstetrics see the advantage of such a service as it relieves them of many small but never- theless important details. Then, too, through the regular clinic visits, symptoms that are regarded by many patients as naturally due to the pregnant state and consequently not serious enough to warrant medi- cal attention, can be detected and if considered serious enough are referred to the patient's doctor-who probably would not have been consulted at all were it not for the efforts of the prenatal clinic. Therefore, much can be said in favor of such establishments. They offer the best service yet devised for better motherhood, and it is to be hoped that in the near future they will not only be nation-wide but world- wide and recognized as a part of our duty to the future generations. The main point is to have the clothing simple and warm. Flannel next to the skin keeps it active; but if this is found too irritating, a mixture of silk and wool is the next best thing. A pregnant woman need not look conspicuous today; for there are a wide variety of maternity dresses to choose from, which can be ad- justed with little effort to make the figure appear as normal as usual. As far as possible all clothes should hang from the shoulders, thereby causing no restric- tions; hence, tight corsets and circular garters should Clothes 14 MATERNITY NURSING. not be worn. The ordinary corset should be discarded altogether during pregnancy, or at least as soon as the abdomen begins to enlarge, in favor of a pair of Fig. 7.-Elastic maternity corset suitable for a tall, slender figure. the many excellent maternity corsets; these are very comfortable and give support where needed. The illustrations, Figs. 7 and 8, were furnished by the courtesy of Messrs. Sears, Roebuck and Company, Chicago. PRENATAL NURSING CARE. 15 A corset with the front panel entirely of elastic, lacing up the sides, finds instant favor with tall, slen- der women; while short, stout women derive more Fig. 8.-Type of maternity corset adapted to a short, stout person. comfort from wearing a corset made of heavier and less resilient material than elastic. Such corsets or- 16 MATERNITY NURSING. dinarily clasp at the center front and have side lacings. No maternity corset should lace at the center of the back, for the spine needs all the support possible dur- ing pregnancy. Note illustrations following: Hose supporters One of the disadvantages of the ordinary corset is the suspenders, which when attached to the stockings Fig. 9.-Velvet Grip hose supporters. Made with ad- justable strap "A" to keep shoulder straps from slipping down. have a tendency to compress the abdomen. Unfor- tunately, this fault has not been corrected in most maternity corsets; so the best way to overcome it is These supporters (Fig. 9) are obtainable from the George Frost Company, 551 Tremont Street, Boston, Mass. PRENATAL NURSING CARE. 17 to have the patient purchase a pair of "Velvet Grip" hose supporters. As the accompanying illustration shows, they offer no constrictions and support the stockings from the shoulder, which is proper. For the benefit of those who prefer to make a pair of hose supporters at home, the necessary articles are, 4% yards of soft upholsterer's webbing inches wide, and 2 "Y"-shaped suspender garters with a safety pin attached to each. Cut the material into seven lengths as follows: One-1% yards for waistband. Two-1 yard pieces for shoulder straps. Two-9 inch pieces for joining shoulder straps. Two-9 inch pieces for attaching suspenders to waistband. The longest piece is for the waistband which should be fastened loosely with button and button-hole in cen- ter front. Attach two shoulder straps to the waistband and sew one of the nine-inch pieces crosswise to the shoulder straps front and back to prevent them fall- ing over the arms. The two remaining nine-inch pieces sew to the waistband each side of front, leaving one end of each free to fasten to the suspenders with safety pin. No doubt these suspenders will be found to be too large during the early months of pregnancy; but it is wise not to cut any of the material off; in- stead, large pleats should be taken and let out as occasion arises. 18 MATERNITY NURSING. Shoes Shoes with broad toes and flat heels do much to assist the spine, as it must be remembered that it bends as the pregnant woman grows larger and there- fore requires solid support. Women who persist in wearing high-heeled shoes during pregnancy run a great risk; for in slipping or catching the heel in any- thing one's balance is not always easily regained, and many bad falls are the outcome. Exercise Plenty of fresh air and a moderate amount of ex- ercise should be taken. A daily walk is beneficial, and although no stated mileage can be given, the patient should be warned not to walk to the extent of fatigue. Violent exercise, reaching, heavy lifting, horse-back riding and most outdoor sports must be avoided. The best exercise in conjunction with a daily walk is the performance of household duties. Excessive exercise in any form is liable to cause miscarriage. Particular care should be taken in fear of this occurrence at the time immediately before and after she would, in the ordinary course, menstruate. Sleep More sleep is necessary during pregnancy than at any other time. An hour or so every afternoon should be devoted to sleeping, or at least resting in the re- cumbent position, with the room well ventilated. Late hours should be avoided. Bathing: Extreme hot or cold baths are detrimental. A daily- cleansing bath at moderate temperature followed by a PRENATAL NURSING CARE. 19 good rubbing assists the eliminatory organs. Sea bathing generally is too cold; but in the summer months, seemingly, no harm results from an occasional dip taken by some robust women. There need not be any great variation in the diet ordinarily. The patient may eat any kind of food in moderation that seems to agree with her. Occasionally there is nausea, certain foods are sometimes held re- sponsible and these should be eliminated. It must not be overlooked that the stomach is greatly interfered with by the growing' uterus, and heartburn is some- times quite prevalent. Oftentimes it will be found that a carefully regulated diet will overcome or consider- ably lessen this tendency. Eating between meals should not be indulged in except during the last months of pregnancy; then it is advisable to eat little and often on account of the small capacity of the stomach. When there is distention caused by flatu- lence, such foods as pastry, starch and certain vege- tables may have to be avoided. Meat should be re- stricted to once a day. Cocoa, milk and buttermilk are excellent nourishing drinks. Tea and coffee freshly made can be taken in moderate amounts. The diet should consist chiefly of cereals, vegetables and fruits, milk and plenty of water. Diet One of the most frequent disorders of pregnancy is the so-called morning sickness. It may occur within a week or so after conception and usually subsides Nausea 20 MATERNITY NURSING. about the fourth month. Normal cases call for no special medical treatment, for the symptoms disap- pear as the day progresses. The nurse can do much to assist the patient by inducing her to remain in bed in the morning until she has partaken of a light break- fast, such as tea or coffee and toast and then rest quietly for some time before arising. If the symp- toms are severe so that the patient gradually becomes emaciated, losing strength and sleep, the doctor should be notified as it may be a serious condition known as pernicious vomiting. Constipation This troublesome condition is nearly always present; drugs taken to remedy it should not be encouraged. Advise the patient to eat plenty of fruit, very coarse cereals, crackers, etc., all to be thoroughly masticated. Impress the importance of taking at least five or six glasses of water daily as it is the best diuretic and also aids in overcoming constipation. Prunes and senna is an excellent remedy and is very pleasant to take if prepared properly as follows: Put one pound of prunes in a saucepan and cook until partially done, then add five cents worth of senna leaves (previously tied in a gauze or muslin bag). Cook all together until prunes are tender. Remove the senna leaves, add sufficient sugar and when cold place in the ice box. Lemon to flavor may be added if de- sired. Eat three to six prunes three times a day as needed. It will require several days, before the correct number / PRENATAL NURSING CARE. 21 of prunes are found to regulate the bowels. More than the amount stated is liable to cause griping and diar- rhea. Exercise is also beneficial. Vaginal douches should never be given unless or- dered by the doctor. Douches Make special note of headache, dizziness, albumin in the urine, swelling, etc., for manifestation of these may indicate toxemia or kidney disorder, the most dreaded complication of pregnancy. Always see that the patient voids sufficient urine, at least forty ounces should be passed in twenty-four hours. It is a good plan to teach her to measure same. A simple way to do this is to have the patient void in a slop jar and then measure the urine in a quart mason jar which has been marked in ounces with adhesive plaster on the outside. Urine should be examined at least once a month during the first six months, then every week or two thereafter. If albumin is present it must be understood that the urine will be examined more fre- quently and the attending physician notified. Edema Induce the patient to spend as much time as possible lying down. If the veins in the legs are very greatly enlarged a silk elastic stocking will afford much relief; but should the patient be unable to indulge in one on account of the price, a flannel bandage cut on the bias, three inches wide and eight yards long can be applied to the limb before the patient arises in the morning. This should be worn throughout the day and removed Varicose veins 22 MATERNITY NURSING. at night when in bed. If for any reason the bandage must be applied during the day, it is best to have t-he patient on the bed with the leg elevated on pillows for some time before bandaging, as this will assist in reducing the swelling. Bandage the foot leaving the heel and toes free and go up the leg as far as the veins are distended or to the hip. Elevation of the limbs while sitting down will prove beneficial as it favors circulation. Teeth All dental work should be attended to early in pregnancy. It is not wise to have extractions done later; for at that time neuralgia is quite common and the pulling of one or even several teeth might not afford relief. Blood- pressure The blood-pressure is most important, but this is usually left to the doctor unless the patient is enrolled at a prenatal clinic, where it is taken, as a rule, on each visit. Mental occupation That the mother can make what she will of her un- born child, is the contention of at least one well-known psychologist and in the coming age, after more study has been given to the very important subject of men- tal suggestion, few will deny the character forming possibilities of the pregnant mother's mental attitude on her child. Thought, we know, is constantly working in our mind, body and affairs, either constructively or de- structively according to our mental standard; then it PRENATAL NURSING CARE. 23 is perfectly logical to assume that if the mother con- trols her own thoughts to constructive thinking and not to health-wrecking fear and worry, while the foun- dation of her child's life is being laid, it cannot help but prove advantageous to the offspring and certainly contribute to its being "born well." In giving prenatal advice, nurses as a rule, are apt to overlook the patient's mental outlook. Those en- gaged in field work, especially in the poor districts, are offered unlimited opportunities for true reconstruction by including in the usual routine, definite advice as to how the pregnant mother should conduct herself men- tally. The writer has seen remarkable changes for the better in the general health of patients and their homes transformed as if by magic, from dens of squalor to really comfortable abodes; all brought about by the inspiration derived from merely a change in the trend of thought. Many women pregnant for the first time are in- clined to be guided by and listen too intently to the idle gossip of women who have already gone through the same ordeal. This habit on the part of the pros- pective mother should be discouraged, as it creates fear in her mind. She should cultivate a spirit of optimism by refusing to see the faults and imperfec- tions of people and things around her and to recognize only the good and beautiful in connection with them. Such an attitude limits the mental actions to construe- 24 MATERNITY NURSING. tive thinking and if persisted in, will in time eliminate destructive unhealthy thoughts, such as fear and worry, which are so detrimental to the human race at large and especially to the expectant mother. The reading of good literature is always beneficial to the patient; but it is just as well not to encourage the perusal of books on pregnancy. Those dealing with children, however, form profitable reading material. Salivation There is an increase in the secretion of saliva from the mouth during pregnancy. Although the use of various mouth washes is sometimes helpful, salivation when profuse is most disagreeable and remains per- sistent despite all effort to overcome it. Most women will find it beneficial to use a mouth wash frequently and for this purpose Phillips' milk of magnesia is excellent. Syncope Some women are troubled more or less with these attacks throughout pregnancy. They may not prove serious; however, it is always wise to call the doctor's attention to same for there may be some heart or lung trouble responsible for this condition. Care of breasts A colorless fluid known as colostrum is secreted from the breasts any time after the third month. The breasts and nipples need no special care and are best left entirely alone, with the exception of the daily bathing with warm water and soap to remove any possible crusts formed by colostrum. Manipulation of PRENATAL NURSING CARE. 25 the breasts is liable to have a direct influence on the uterus, so they must be handled with care. During the last weeks of pregnancy cold cream may be applied to the nipples after the usual daily bathing; also at this time inverted nipples may be drawn out with the fin- gers and developed to a satisfactory degree, care being taken to have the hands thoroughly cleansed for this procedure. Filter, then boil the urine in a clean test-tube; if opacity results, pour a few drops of acetic acid (4%) slowly down the inside of the tube into the urine. The cloudiness will then disappear if due to phosphates, otherwise albumin is present. Simple albumin test for urine CHAPTER IV. COMPLICATIONS OF PREGNANCY. The chief complications of pregnancy may be classi- fied as follows: The premature termination of preg- nancy ; ante-partum hemorrhages; and the toxemias. Premature Termination of Pregnancy. Abortion is the term applied to the expulsion of an embryo before the fourth month; miscarriage the expulsion of a fetus between the fourth and sixth month; premature labor signifies the termination of pregnancy any time after the sixth month and before the full term. There are various causes of abortions and miscarriages, some of which may be prevented, therefore it is important for a nurse to become familiar with them. Abortions and miscarriages are due to certain abnormalities of the fetus, diseases of the mother such as syphilis and acute infections diseases, traumatism, displacements of the uterus, physical shocks and mental distress. Some of our most noted doctors claim that one abortion occurs in every four pregnancies, although it is impossible to give a correct estimate due to the fact that many of them are concealed purposely, others abort so early in pregnancy that they are not conscious of pregnancy existing, then again, some abortions are 26 COMPLICATIONS OF PREGNANCY. 27 so complete that they do not require medical attention, hence are never known. In order to determine the out- line of treatment, abortions and miscarriages must be recognized as threatened, incomplete and complete. However, the symptoms of each do not vary. Often during pregnancy especially in the early part there is a slight discharge of blood from the vagina, which may not be serious; but if persistent it should never be allowed to continue without calling the atten- tion of the doctor to it, for threatened abortion may be indicated. In threatened abortion there is usually pain in the back and lower abdomen accompanied with loss of blood from the vagina without the expulsion of the embryo. However, in some cases pain may be entirely absent, especially in the early months. The treatment consists of rest in bed and the administration of opiates which are prescribed by the doctor to lessen muscular activity. In incomplete abortion the embryo is expelled while the placenta and membranes are retained. The empty- ing of the uterine cavity as early as possible is indi- cated, as hemorrhage will persist until this is accom- plished. In complete abortion the entire contents of the uterus are expelled intact. Abortion cases call for the same sterile technique observed by the nurse in full term deliveries, for there is the same danger of infection. 28 MATERNITY NURSING. The symptoms of miscarriage are similar to those of ordinary labor. In some instances if treated early enough a threatened miscarriage may go on to full term. Frequent miscarriages if not due to other known causes are strongly suggestive of syphilis. Any woman having such a history should be referred to a doctor who will most likely take a Wassermann test. If syphilis is present he will no doubt give a salvarsan or mercurial treatment. Should it fall to the lot of the nurse or the patient's relative to administer mercurial inunctions, it is wise to wear rubber gloves as a protection against possible infection and salivation from the mercury. Ante-partum Hemorrhages. Hemorrhage in the early months of pregnancy may be due to abortion, miscarriage, or indicate a condition of ectopic gesta- tion. Detachment of a normally located placenta from the uterine wall, a ruptured uterus, or placenta previa are responsible for bleeding in the latter months. In hemorrhage from ectopic gestation there is absence of menstruation until rupture of the sac, when the patient suffers intense pain at the seat of rupture fol- lowed by symptoms of shock. The hemorrhage which is always concealed may be so profuse as to cause death before surgical aid can be rendered. Placenta previa is where the placenta is adherent to either side of the uterine wall near the cervix. It may be lateral, marginal, or complete. External hemor- COMPLICATIONS OF PREGNANCY. 29 rhage is always present but no pain is complained of by the patient. Early surgical treatment is necessary in the interest of both mother and child. All hemor- rhages need not be manifested externally; that due to the detachment of a normally located placenta may be concealed or bleeding may be present. When concealed all the symptoms of hemorrhage would be demon- strated as well as severe pain at the point of separation. In case of hemorrhage put the patient to bed, apply a sterile pad to the vulva, reassure her and maintain quiet. While waiting for the doctor, observe the pa- tient closely, for unfavorable symptoms may arise to necessitate the services of the nearest doctor. Danger is indicated by the condition of the pulse, facial pallor, and other symptoms of hemorrhage. If bleeding is severe elevate the foot of the bed. Always reserve for the doctor's inspection all clots and soiled pads. Toxemias of Pregnancy. This is an exaggerated form of the nausea and vomiting that occurs usually in the first three months of pregnancy. It seems to be more common in primigravidae, multiple preg- nancies, hydramnios, inflammations and displacements of the uterus, and in a disordered state of the nervous system; although little is known of its origin. Some cases respond to treatment, which is quite wide and varied; while with others where the stomach becomes almost or quite unretentive, the outlook is usually a grave one, on account of emaciation from the lack of Pernicious vomiting 30 MATERNITY NURSING. food and weakness resulting from incessant vomiting. Therapeutic abortion is a last resort. The patient is best confined to bed in a darkened room and kept free from disturbance in order to conserve her strength. The utmost is called for in careful nursing as the com- plaint must be regarded as a neurosis. Nephritic toxemia While a chronic nephritis may or may not be ac- quired during pregnancy, its presence at this period is graver than at any other time due to the extra work thrown upon the kidneys. The symptoms-headache, albumin in the urine with casts, edema, drowsiness, and high blood-pressure are usually pronounced in the early months of pregnancy if the disease had its origin in the non-pregnant state. The development of them later in pregnancy signifies the disease is a dis- turbance associated with that condition. Acute neph- ritis may result from sudden chilling of the body, in- sufficiency of proper clothing, and exposure to cold. When once the above symptoms appear, no matter how slight, it is very important to keep the patient under close observation and have the urine and blood-pres- sure tested at frequent intervals, for her condition may develop into one of coma quite suddenly. The nursing care is similar to that of pre-eclamptic toxemia. Pre-eclamp- sla Probably no disturbance of pregnancy demands more careful recognition than this one, for the reason that if allowed to go untreated it may result in the more serious and much dreaded disease known as COMPLICATIONS OF PREGNANCY. 31 eclampsia. When discovered early most cases respond very well to treatment which is usually quite a simple procedure. The symptoms are sometimes so slight as to occasion the patient no great alarm, while in others these are much exaggerated. Attacks seldom make their appearance much before the sixth month of pregnancy and primiparae seem to suffer more fre- quently from them than women who have already born children; but the latter seem to be more seriously af- fected when attacked. The characteristic symptoms are: edema, frontal headache, drowsiness, blurred vision with dark spots or flashes before the eyes, dizzi- ness, epigastric pain, and vomiting. There are also changes in the urine which becomes scanty and con- tains albumin. The blood-pressure is always above normal. Although the exact cause of pre-eclampsia is not known it is supposed to be due to faulty elimination, and the belief that a highly nitrogenous diet aggravates the condition is held by most authorities. The medi- cal treatment is quite varied; but no matter what kind is adopted, catharsis and diaphoresis must also form a part of it. Rest in bed is most essential. The diet indicated is one of a low protein nature. Milk is widely prescribed; in many instances this and a saline purgative given frequently in small doses and the forc- ing of water with complete rest seems to be the main outline of treatment. All cases receiving medical care 32 MATERNITY NURSING. call for practically the same nursing attention. The patient should be put to bed in a well ventilated dark- ened room and allowed to rest; but watched closely for unfavorable symptoms especially convulsions. She should be preferably between blankets and arrayed in a flannel gown fastened down the back. Elimination of body waste by perspiration is important; but to al- low the patient to sweat profusely for a time and then subject her to a possible chilling by the removal of bed-pans, etc., is not only very unwise but positively dangerous. Free, continuous perspiration should be aimed at though not to the extent of causing the pa- tient physical discomfort, for she will rebel and if left alone will be sure to uncover herself. Carefully measure and record all the urine passed. Eclampsia This is one of the most dangerous complications of pregnancy and it is the general belief that if all mothers placed themselves under the constant care of a doctor during pregnancy most cases might be prevented. Eclampsia frequently follows pre-eclampsia and is characterized by convulsive attacks which may occur either before, during, or after childbirth. Usually the other symptoms accompanying the disease are similar to those of pre-eclampsia only more severe, although some cases show no premonitory symptoms whatever and a convulsion is the first evidence of the disease. The nursing care is the same as outlined for pre- eclampsia. The patient should never be left alone. COMPLICATIONS OF PREGNANCY. 33 When the convulsions occur it is necessary for the nurse to keep a cool head and exercise care in adust- ing the mouth gag. The best gag is the ordinary wooden tongue depressor or instead the handle of a spoon or tooth brush covered with gauze. When using the gag carefully insert it between the side teeth never in front. False teeth should be removed from the mouth of all eclamptic patients, cleaned and put away in a safe place. Special care must be taken to prevent the patient injuring herself during the convulsions. Keep a record of all medicines and treatment adminis- tered, also the number and character of convulsions. The medical treatment of eclampsia is quite varied; some doctors use chloroform for the convulsions, others are quite prejudiced to its employment contend- ing that it increases liver necrosis and that oxygen is more necessary to the patient during the attack. Mor- phia is prescribed in many cases, the patient being held under its influence for some time. It is the nurse's duty to observe the respirations carefully, never allow- ing them to go below twelve or fourteen without call- ing the doctor's attention to it. Should a hot wet pack be ordered proceed as fol- lows : Protect the entire mattress with a rubber sheet, cover same with a blanket on which the patient is to lie: Place a hot-water bag to her feet and an ice-cap to her head. Wring a large blanket out of hot water, turn the paiient on her side so that the blanket may be Hot wet pack 34 MATERNITY NURSING. rolled under her body. Then when the patient lies on her back, quickly wrap her whole body in the wet blanket. Cover this with a dry blanket doubled length- wise, and draw up the sides of the dry blanket and rubber she is lying on for extra covering. Leave the patient in the pack from twenty minutes to one hour according to her condition. If she reacts quickly and perspires freely, take her out, dry the body thoroughly and place her between two dry, warm blankets. Some doctors prescribe an alcohol rub after the pack, claiming that it minimizes the danger of the pa- tient taking cold; others contend that it closes up the pores which is not desirable. Frequent hot drinks during the pack will assist perspiration. Dry packs These are given practically the same way as wet packs except that the blankets are dry and the patient is surrounded with hot-water bags to help produce perspiration. Colonic irrigations Eclamptic treatment almost always includes the giv- ing of these irrigations and while some doctors pre- scribe the Murphy drip method, most of them, how- ever, prefer the return flow system. Various solutions are employed such as saline solution containing one dram of salt to the pint of water, plain water, or a two per cent, sodium bicarbonate solution. The tem- perature of the solutions should be about no° F., for it must be remembered that if the temperature is too low the patient may become quite chilled and if too COMPLICATIONS OF PREGNANCY. 35 high a degree is used the intestinal tract may be burned. The patient must be comfortable and warm, for this procedure requires some time to give-due to the large quantity of liquid used and the slowness of its flow. Have the patient lie on her left side with the knees flexed, as this position encourages the solu- tion higher into the intestines and renders the insertion of the tubes much easier. In addition to the usual ap- paratus for giving an enema another tube should be carefully inserted under the rectal tube into the rectum. Do not place the tubes together as the fluid will flow from one directly into the other. It is far more effi- cacious to insert the tube through which the solution flows into the rectum about fourteen to twenty inches and then insert the return flow tube about six to eight inches. In this way one is sure to produce a good flushing. Have the solution low and the flow so regu- lated that it will require about twenty minutes for each gallon of fluid used. Colonic irrigation if given prop- erly has a double effect, it not only removes the toxic material from the intestinal tract, but a considerable quantity of the solution is absorbed as well. The bed should be well protected and if the return flow tube is made long it can empty itself into a slop jar on the floor. There may be a mild condition of jaundice existing in the non-pregnant state; but in pregnancy this is liable to become quite serious and develop into yellow Atrophy of the liver 36 MATERNITY NURSING. atrophy as a result of the extra work thrown upon the liver. The symptoms associated with the latter dis- ease are: Jaundice; scanty urine containing blood, casts, and albumin; abdominal pain; headache; vomit- ing and diarrhea. When these symptoms are very severe they are usually followed by coma, convulsions, and even death. The methods of treatment are quite similar to those of eclampsia. Gonorrhea This highly infections venereal diseasie calls for vigorous treatment immediately it is discovered on account of the deleterious effect the discharge has on the baby's eyes, as well as the possibility of further infection of the mother during the puerperium. When acquired early in pregnancy and the inflammation is acute, treatment is then very important for the disease is most likely to extend to the uterine cavity and even the Fallopian tubes, which would in all probability produce abortion. There is a purulent vaginal dis- charge which causes intense itching and sometimes vulvo-vaginal abscesses may form. The usual treat- ment is frequent antiseptic vaginal douches and the employment of tampons and suppositories. When caring for these patients the nurse should exercise scrupulous technique in order to prevent the spread of the disease, especially in safeguarding herself; the eyes must be protected and rubber gloves worn while treat- ment is being administered to the patient. All vaginal pads, sponges, etc., should be removed through the COMPLICATIONS OF PREGNANCY. 37 use of a sponge holder or forceps. Bedclothes and utensils used for the patient should be kept separate and thoroughly disinfected after use. When a patient gives a history of frequent miscar- riages and stillbirths it is very important that she be given a Wassermann test in order to determine whether syphilis is present; for the treatment of this disease is very necessary in the interest of the child. Syphilis Pregnancy very often has an unfavorable influence on tuberculous women, some who seem to have the disease apparently arrested become active again in pregnancy and are oftentimes incurable. Others may show improvement during pregnancy only to rapidly decline after delivery. However, when the utmost care has been afforded to the patient, pregnancy has been known to terminate with apparently little detri- ment. Tuberculosis This very rare disease is characterized by the con- version of the chorion villi into grape-like clusters of small vesicles varying in size. The cause of such a remarkable formation is not known; but it is associated in some way with the growth of the ovum. In the disease the uterus may enlarge very rapidly and be accompanied with nausea. Appearing as a rule in the first two months of pregnancy, there is a bloody vaginal discharge in which some of the vesicles may be expelled; but such is a very unusual occurrence. A prolonged retention of the cystic mass in the uterus is Hydatidi- form mole 38 MATERNITY NURSING. considered harmful, so in most cases the uterus is emptied as soon as the diagnosis is determined. Hy dramnios When the quantity of amniotic fluid is excessive the condition of hydramnios exists. Its onset is usually a gradual one, appearing about the fifth month. There are two forms, chronic and acute, the latter being much more tolerable to the patient than the former. The pressure from the distended uterus in hydramnios causes much distress from breathlessness and palpita- tion, which seem t© be the chief symptoms, although pain, more or less is also experienced. Some authorities regard the condition of fetal origin. The treatment in acute and severe chronic cases is usually the induction of labor. Rupture of the uterus Rupture of the uterus is due to a number of causes, such as overdistention of the lower uterine segment, diseased walls, old cesarean scar tissue, injury and operative manipulations. While the rupture may take place in any part of the uterine wall the most common point is in the lower uterine segment. The tear may be slight or so extensive as to force the entire contents of the uterus into the abdominal cavity. The symp- toms are similar to those of accidental hemorrhage; but there is this distinction, accidental hemorrhage occurs either before or in the first stage of labor, while rupture of the uterus usually occurs late in labor. There is acute abdominal pain and the patient may cry out that something has happened to her at the time COMPLICATIONS OF PREGNANCY. 39 of rupture. Uterine contractions cease and if the rup- ture is complete the uterus may be felt as a hard mass and the fetus can be distinguished alongside of it. The skin is cold and clammy, the pulse weak and com- pressible and the face presents a pinched, anxious ex- pression. There is uterine tenderness and blood may flow from the vagina or be retained in which case there is usually abdominal distention due to the re- tained blood. If the rupture is spontaneous and severe the symptoms will appear immediately; but if the tear is a gradual one some time may ensue before the symp- toms are very pronounced. The treatment is accord- ing to the severity of the tear; if the tear is small the child may be delivered hastily by version, forceps, or a destructive operation may be performed. The uterus is then repaired through the vagina. Where there is a complete tear the abdomen as a rule is opened, the fetus and placenta extracted and the uterus either repaired or removed. Accidental hemorrhage is due to the separation of a normally located placenta from the uterine wall, and is termed accidental to distinguish it from that of placenta previa, which is known as "unavoidable." The causes are various and oftentimes obscure. In many cases the bleeding comes on spontaneously due to a diseased condition of the decidua; while in others the accident may result from shock, trauma, death or disease of the fetus, short umbilical cord, etc. Where Accidental hemorrhage 40 MATERNITY NURSING. the lower border of the placenta is detached, the blood escapes from the vagina; on the other hand, if the center or upper part of the placenta is separated the bleeding may be entirely concealed and the more bleed- ing is concealed the graver is the outlook for mother and child. The accident may occur any time during the latter part of pregnancy or before the end of labor. It is more frequent in multipane. Where the detach- ment is slight the only symptom complained of is sud- den pain at the point of separation with or without the escape of blood from the vagina. In concealed acci- dental hemorrhage the onset is sudden with severe ab- dominal pain, followed in a short while by all the signs of hemorrhage-facial pallor, cold, clammy skin, restlessness, dyspnea, feeble, rapid pulse and faintness. There is also shock and usually distention of the uterus with blood. The concealed type of accidental hemor- rhage is fortunately rare. Treatment depends on the severity of the hemor- rhage, when it is not severe the patient may possibly be allowed to continue in labor unassisted; profuse hemorrhage always calls for prompt emptying of the uterus. Placenta previa Instead of the point of attachment of the placenta being high up on the uterine wall as is normally the case, in placenta previa it may be located so far down in the lower uterine segment as to completely cover the internal opening; this degree is known as complete COMPLICATIONS OF PREGNANCY. 41 placenta previa. There are also two others, namely: Marginal and lateral. In marginal the attachment is to one side of the cervical canal; in lateral the placenta is located to one side of the opening with its edge slightly overlapping same. The cause of placenta previa is not known; it is commonest in women of the poorer classes who have to work hard and have borne several children. The symptom is hemorrhage. Bleed- ing may occur quite early in pregnancy; but this is not usual. Repeated hemorrhages during the latter months are strongly indicative of placenta previa. When dis- covered during active labor, the main course of action seems to be directed toward the control of the hemor- rhage either by means of tampons or inflated bags which also helps to dilate the cervix. Where the hem- orrhage is very severe manual extraction of the fetus is almost always resorted to by perforating the placenta if necessary and delivering the baby by grasping its legs. Cesarean section is the term applied to the operation of extracting the fetus through an abdominal and uterine incision. Due to the improvement of present day surgery over that of bygone times, the mortality of cesarean section is quite small. The indications for it are: Contracted or deformed pelves, placenta previa, accidental hemorrhage, rupture of the uterus, eclamp- sia, or obstructions caused by pelvic tumors. It is also Cesarean section 42 MATERNITY NURSING. resorted to as a possible means of saving the life of the baby after the death of the mother. Cesarean section is usually performed about two weeks before the expected time of confinement, or at least before the onset of true labor, although many patients enter into the second stage of labor before examination discloses that a cesarean operation is necessary. There are three varieties of cesarean section: con- servative, radical and extraperitoneal. In conservative the abdomen and uterus are incised in the median line, the baby and placenta removed and the uterine and abdominal walls sutured. In the radical operation after the baby and placenta are extracted, the uterus is also removed. This operation is usually resorted to when there is great fear of infection. The extraperi- toneal operation is one that is seldom used. There are several methods of performing it; but the one which seems to be preferred by most doctors is that in which the peritoneal cavity is not entered; the peritoneum being stripped back from the bladder and uterus. Vaginal cesarean section This operation is resorted to where hasty delivery is imperative, in such cases as eclampsia and accidental hemorrhage. Pubiotomy Pubiotomy is performed by sawing through the pubic bone on one side of the symphysis. When the patient is well advanced in labor and forceps have been applied and failed to effect delivery pubiotomy is some- COMPLICATIONS OF PREGNANCY. 43 times resorted to. This operation increases the dimen- sions of the pelvis and thus renders possible the deliv- ery of the baby either by forceps or version. Serves the same purpose as pubiotomy does. It con- sists of cutting through the cartilage of the symphysis instead of through the bone. Of the two, pubiotomy is considered the best as the bladder and urethra are less liable to be injured. Moreover, as the cartilage does not heal as readily as the pubic bone, locomotion is frequently interfered with. Symphysi- otomy The forceps is used whenever conditions indi- cate a hasty delivery as in uterine and abdominal iner- tia, certain diseases and exhaustion in the mother; also prolonged pressure of the fetal head, premature separation of the placenta, prolapsed cord and irregu- larity or marked change in the fetal heart rate. For- ceps extraction is made when the head presents and sometimes in breech cases when the after-coming head is delayed. The danger attending the use of forceps depends to a great degree on the mode of application; a low forceps delivery can be performed with little danger to the mother and child, whereas in a high forceps the outlook is often very serious for both. One of the most important things for a nurse to remember when preparing for a forceps delivery is to be sure to have the patient's bladder empty. In an emergency she should always boil up a catheter for Forceps 44 MATERNITY NURSING. the doctor to catheterize the patient with just before the operation. Version This is turning of the child in the uterus in order to effect or hasten delivery. It may be brought about by external, internal, or combining both manipulations. In external version the turning is accomplished by both hands operating on the abdomen. If the opera- tion is to be performed by internal means the hand is inserted through the vagina into the uterine cavity. In combined version one hand of the doctor works on the abdomen and at the same time the fingers of the other hand are inserted into the uterine cavity. There are two varieties of version, cephalic and podalic. In cephalic the fetal body is turned so that the head pre- sents ; the breech is the presenting part in podalic. The most important indication for version is found in a transverse presentation. Episiotomy In some instances when the perineum is very rigid and the head cannot be delivered naturally without an extensive tear episiotomy is resorted to. This opera- tion is performed by an incision on one or both sides of the margin of the vulva. After the baby and pla- centa have been delivered the incision is repaired. Embryotomy This is performed to render possible the delivery of the fetus by mutilation such as decapitation, craniot- omy, evisceration and dismembering of the extremities. These operations are very rare today, for improved surgical technique has rendered cesarean section pre- COMPLICATIONS OF PREGNANCY. 45 ferable in the majority of cases warranting operative interference. Many women, especially those giving birth to their first child, acquire perineal lacerations during the de- livery of the baby. These tears may be caused by a small vaginal outlet, rigidity of the perineum or < large fetal head, although the expulsion of the present- ing part during a pain before the perineum is fully distended as in a precipitate labor, is a very frequent cause. There are three degrees of perineal lacerations, namely: First degree or incomplete tear is superficial and involves the mucous membrane only; a second degree tear extends through the perineum but does not involve the sphincter ani and is also termed incom- plete ; a third degree tear extends backward through the perineum and sphincter ani. This is called com- plete. Most perineal lacerations are repaired during or after the third stage of labor. Perineal lacerations When induced for therapeutic reasons induction of labor is accomplished under the strictest possible asep- tic precautions in order to prevent infection and with good care the majority of these cases do not show any bad after-effects. In most criminal abortions when no sterile technique has been observed a septic condition often results and sometimes death follows. In the early months when termination of pregnancy is brought about in the interests of the mother it is called therapeutic abortion. The maternal indications Induction of labor 46 MATERNITY NURSING. for the induction of labor are of various acute and chronic diseases, hemorrhage, and displacements of the uterus. Fetal indications are: death of the fetus, con- tracted or deformed pelvis, monstrosity, and pregnancy supposedly beyond full term. The methods favorable to the induction of labor de- pend upon the advancement of pregnancy and the urgency claimed. The usual methods are: dilatation of the cervix, the insertion into the uterus of bougies, gauze or inflated bags; operative procedure is also resorted to. Breech extraction A breech presentation is where the buttocks of the fetus presents. If the pregnancy is full term, labor in such cases is liable to be prolonged and fatiguing. When there is considerable delay, causing exhaustion in the mother as demonstrated by a rapid and weak pulse and possible changes in the fetal heart rate, hasty interference is necessary. CHAPTER V. DRESSINGS AND OUTFITS. Patients who plan to lie confined in a hospital have only the baby clothes to think of, as all of the neces- sary equipment for delivery and care during the first part of the puerperium are usually supplied by the hospital. Some institutions make it a rule to use their own baby clothes, claiming that they cannot be respon- sible for those belonging to patients; others supply only diapers, so that it would be well for a patient to ascer- tain what the requirements are in this respect. She should, at least, take one set of clothing for the baby to wear home. The patient who is reluctant to go to a hospital and prefers to be confined at home should engage her nurse several weeks or even months before the actual confine- ment, which gives the nurse an opportunity to pre- pare all articles necessary. She should visit the ex- pectant mother as early as possible and instruct her in the preparation for the event, which of course, includes prenatal care. The sterilization of all goods must be done by the nurse, never by anyone who does not thoroughly understand sterilization technique; al- though the making up of pads, sponges, etc., may be Engagement of nurse 47 48 MATERNITY NURSING. left to the patient, which will save a great deal of the nurse's time. If a sterile outfit from a reliable firm can be afforded, so much the better. In some of the large cities these sets may be rented, complete even to a folding delivery table. This service, without doubt, is an excellent one; but ordinarily, patients are reluct- ant to go to this expense. When the nurse is to be responsible for the preparation of the outfit, it be- comes her to economize in every possible way, for at its best confinement is an expensive ordeal. Mothers are always first to recognize and appreciate all efforts made to reduce expenses. Nurses owe this to their patients; but quite often careless ones are extravagant because the money spent on articles used does not come from their own pocket. LIST OF NECESSITIES FOR DELIVERY AT HOME. 2 drams tincture of benzoin. / pound boric acid crystals. 5 ounces olive or sweet oil. 4 ounces lysol. 8 ounces tincture of green soap. 1 tube cold cream. 1 tube vaseline. 1 ounce fluid extract of ergot. Argyrol 10 per cent., or silver nitrate 1 per cent, (smallest quantity). Bath thermometer. Glass drinking tubes (or straws). Rubber combination douche and hot-water bag. Douche pan or "Ideal" bed-pan. DRESSINGS AND OUTFITS. 49 2 hot-water bags, (one if above combination set is secured). 1 stone heater. 2 enamel basins (12 in.). 1 enamel pitcher. Baby scales. 1 nail brush (new). 2 medicine droppers. Nursing bottles (wide mouth) with nipples-"Faultless" or "Hygeia." 3 dozen large safety pins. 1 dozen small safety pins. 1 paper ordinary pins. 1 enamel or rubber baby bath tub. 1 medicine glass. Paper bags or newspapers. 1 piece of rubber sheeting to completely cover bed. 1 piece of rubber sheeting, 1 X 1% yards, for draw sheet. 1 piece of rubber sheeting for baby crib. 35 yards gauze. 5 or 6 pounds absorbent cotton. 8 yards unbleached muslin, 44 inches wide, for breasts and abdominal binders-of the latter 20 X 44 inches is a good size. 1 yard, % inch wide bobbin tape. Old receiving blanket for baby. Pieces of old linen. Old night-dresses. 1 pair white stockings. 5 small sheets. 12 towels. 1 package tooth picks. 1 olive bottle (for sponge holder). 1 roll gauze, 4 inches X 4 yards, hemorrhage packing. From this list the patient may make up sponges, vulva and delivery pads ready for sterilization. 50 MATERNITY NURSING. Delivery- pads About six are necessary, three-quarters of a yard square made of old linen on a newspaper base. Sponges These should be about three inches square, with all raw edges turned in. Make one dozen unwrapped for delivery pack and several packages for nurse's cord dressings, etc. (Six sponges in each package.) Cord dressings In making these, employ four of the above sponges, cutting two through the center from one side to within one and one-half inches of the opposite edge. Cut the one yard bobbin tape into four even lengths. Make two gauze bands 4x18 inches. Arrange in two pack- ages as follows: band, gauze sponge, split gauze sponge and two pieces of tape. It is always wise to make two delivery cord dressings, in case one should accidentally become unsterile. Cotton sponges These may be made with small pledgets of absorbent cotton and are used as delivery sponges, eye sponges, etc. Make several packages containing one dozen each, then fifty unwrapped for delivery pack. Vulva pads As a rule, one finds these poorly made and wholly inadequate. It is no economy to have them small. Large ones are infinitely more comfortable and prevent the bed clothes from becoming soiled. There is also less danger of infection and not so many are required as the small ones. Four yards of gauze and one pound of cotton is usually sufficient for two dozen pads. Use the width of the cotton for length of pad and cut four inches wide. Some grades of cotton yield only DRESSINGS AND OUTFITS. 51 one dozen pads; but these are, of course, much heavier and more absorbent than the thinner kind. Make as many as the cotton and gauze permits, putting one dozen in a package. Leave one dozen unwrapped for delivery pack. It is a good plan to save one package of cotton and some gauze for emergency use. An inexpensive grade of unbleached muslin about ixi% yards may be utilized as sterile sheets for delivery. Sheets If it is necessary to buy towels for the delivery out- fit, it is economical to make them of birdseye diaper cloth. They may be used afterward for baby towels or even diapers if the "Vanta" kind are not employed. Towels Applicators are made with toothpicks by wrapping a small piece of cotton tightly around one end, cover- ing the point carefully. One package of a dozen or so is enough for baby's ears, nose, etc. Applicators Clean old household linen is excellent for covers for packages; wrap crosswise, envelope fashion, using no more than one pin for each package. Covers for packages 1 roll gauze hemorrhage packing. 1 old night-gown. 1 abdominal binder. 12 vulva pads. 1 receiving blanket. 4 small sheets. 1 pair white stockings. 12 towels. 50 delivery sponges. 2 packages cord dressings. One large pack for delivery 52 MATERNITY NURSING. 1 dozen gauze sponges. 1 large sheet (in case the doctor forgets his own gown). Sterilization One method of sterilizing the delivery pack is to utilize a large wash boiler found in most homes. Stand enough mason jars (without covers) upside down in the boiler to support the pack. Have four or more inches of cold water in boiler, but not enough to touch the goods by several inches. Keep the cover of boiler on tight with heavy weights to prevent the steam from escaping. Boil at least four hours, then dry the pack in oven, but do not burn. It is a good idea to sterilize the pack when it is made up, in case the patient is delivered before her expected time. It can then be sterilized again during the latter part of pregnancy. If the family have a steam cooker, the small packages may be sterilized very well in this. The list given is not an elaborate one and contains the smallest possible number of articles necessary for any ordinary case. Very often one finds the home equipped with too much of one thing and not enough of another. The most common fault is a deficiency of vulva pads and unbleached muslin for abdominal and breast binders, with an enormous supply of baby clothes. Baby's outfit "Vanta" baby clothes, manufactured by the Earn- shaw Knitting Company, Chicago, Ill., are very sat- isfactory and certainly the most modern in the market. DRESSINGS AND OUTFITS. 53 One of the many commendable points about these gar- ments, is the twistless tape method of adjusting them, which does away with the use of pins entirely; the Fig. 10.-"Vanta" baby at chest of drawers. abdominal binder, shirt and diaper merit special recommendation. Most of the clothes in the following list can be sup- plied by this firm: 54 MATERNITY NURSING. 6 wash-cloths made of several thicknesses of gauze or cheesecloth sewn together, 8X8 inches. Castile soap (powdered-shaker top box). Unscented talcum powder (Johnson and Johnson). Comb and brush. 3 dozen diapers. Fig. 11.-"Vanta" baby diaper. 3 Gertrudes, flannel or flannelette. 3 night-gowns. 3 silk and wool undervests (2d size). 3 or 4 abdominal binders. 2 or 3 shoulder blankets (woolen). 4 nainsook dresses. 2 or 3 pairs silk and wool socks (2d size). Several quilted mattress pads. DRESSINGS AND OUTFITS. 55 If it is desired to make the diapers at home, a free pattern similar to the diagram on page 57 can be ob- tained from the Earnshaw Company of Chicago. Two ten-yard pieces of twenty-four inch wide birdseye is Vanta diaper Fig. 12.-"Vanta" baby shirt. sufficient to make twenty "Vanta" diapers, small size for the first few weeks. The same quantity of twenty- seven inch wide birdseye will make eighteen larger size diapers. Some of each size should be made up. Six bolts "Vanta'' twistless tape three-eighths inch width, will be found sufficient for the above number of diapers. 56 MATERNITY NURSING. Nurse's bag In addition to the personal contents, the following articles will be found absolutely necessary: 1 "Sterno" canned heat. 1 urinalysis set. 1 hypodermic syringe with needle. 1 long thin needle for probable hypodermoclysis. 1 pair sponge holders. 1 rectal tube. 2 small rubber catheters. Fig. 13.-"Vanta" baby binder. 1 glass Murphy drip regulator. 2 thermometers (mouth and rectal). 1 connecting tip. 1 douche nozzle. 1 orange wood stick. 1 nail brush. 1 sterile gown. 1 safety razor. 1 pair rubber gloves. 2 enamel basins (medium). 1 enamel basin (small) for placenta. 2 enamel custard cups for boric solution and oil. 1 pair spring scales. 1 electric torch. 1 auscultation towel for listening to the fetal heart. Ergot ampules for hypodermic use. Charts. DRESSINGS AND OUTFITS. 57 Fig. 14.-How to make and fold "Vanta'' diaper. All maternity nurses should have as a part of their equipment the above-mentioned enamel articles, they take up very little room and the cost of them is insig- 58 MATERNITY NURSING. nificant when once their usefulness is appreciated. They are, in fact, indispensable, forming as they do a complete set for delivery in the home and after-care. Few homes are equipped with these and even if they are, the inconvenience of depriving the kitchen of their use is a consideration. Moreover, most mothers are reluctant to buy them especially for the delivery. The canned heat is useful when making hypodermic injections. Prenatal nurse's bag All nurses contemplating prenatal work should carry in their bag necessities as follows: 3 ounce bottles (sterilized) for urine samples. Canned heat (2 cans). Urinalysis set. Acetic acid. One pair Velvet Grip hose supporters. Soap and paper napkins for washing and drying the hands. The urinalysis set should include urinometer and holder, litmus paper, test-tube and holder. The canned heat comes in useful when making the heat test with acetic acid. Before making a urine test in a patient's home, spread out a paper napkin and place urine and the urinalysis set on this clean field. CHAPTER VI. PREPARATION FOR DELIVERY IN THE HOME. In preparing the room for delivery, all unnecessary articles of furniture including rugs should be removed and sufficient protection given to the walls and floor. Old sheets and newspapers are very useful for this purpose. Room Completely cover the mattress with rubber sheet and muslin sheet, draw tight and tuck well under mattress, using no safety pins which are very destruc- tive and wholly unnecessary. Over these, in the cen- ter of the bed place a rubber draw sheet and muslin sheet, both to be tucked in. As a further protection, one of the improvised delivery pads may be placed over this. The amount of top clothing is left to individual requirement. A large twisted sheet should be tied to the foot of the bed. During the second stage of labor, the patient may be induced to pull on this to assist her during a pain. A bed board should be placed under the mattress to prevent sagging. (A dining room table leaf serves the purpose well.) Delivery bed An unlimited supply of hot and cold sterile water should be the next consideration, also the sterilizing of all enamel ware. If large coffee pots can be secured they make excellent receptacles for sterile water. Sterilization of utensils 59 60 MATERNITY NURSING. There is less danger of contamination if the spouts are stuffed with absorbent cotton before boiling. Should coffee pots not be available, use any well cov- ered containers and put in a safe place away from the family. For a continuous supply of hot water, keep the tea kettle boiling on a low fire. Take two basins of the same size, fill one with water, use the other basin as a cover and boil for about fifteen minutes. Then drop in the doctor's rubber gloves and boil for another five minutes. The gloves will surely be needed for vaginal examinations before delivery. Wrap the douche bag and accessories in a clean piece of old linen or towel, boil in a tightly covered vessel and set aside for emergency. The pitcher, placenta pan, olive jar, teaspoon for measuring lysol solution, and cus- tard cups may be boiled in a like manner. Never sterilize rubber goods as long as other articles, because the life of the rubber soon becomes impaired from the intense heat. Place the set of basins containing the gloves on a well protected table by the bedside, also packages of sterile sponges for use during the vaginal examina- tions. Any desired disinfectant may be instantly pre- pared in these basins by the addition of lysol or bichlo- ride. Usually of a i-per cent, lysol or 1: 5000 bi- chloride solution is employed. Prepare another table or the top of the bureau to serve as a goods and instrument table. On this put PREPARATION FOR DELIVERY. 61 the delivery pack and when unpinned the cover serves as a sterile sheet on which the goods are arranged; thus saving a sheet or towel that may be needed later. Much unnecessary work can be eliminated in prepar- ing this table by employing the sponge holders previ- ously sterilized to serve the purpose of sterile fingers. The olive bottle filled with lysol solution may receive them when not in use. With the holders place the placenta pan and one of the custard cups on the sterile drygoods table. In the custard cup pour some boric acid solution to be used for the infant's eyes after birth of the head, then cover the table with a sterile sheet. During the actual delivery it would be folly for the nurse to pretend to be "scrubbed'' when she and the doctor are alone, but much valuable assistance may be rendered through the medium of the above-mentioned sponge holders by passing instruments, sponges and in fact anything that is sterile to the doctor. Hot and cold water pans for the resuscitation of baby should always form a part of the delivery room equipment. Arrange these on a long table near the baby basket, in a warm corner of the room, preferably behind screens out of the sight of the mother. The hot water should be about i io° F. On this table have a bath thermometer, medicine droppers, gauze sponges, small rubber catheter, argyrol or silver nitrate solution, olive oil, ergot, medicine glass, spoon and glass of 62 MATERNITY NURSING. ice water with drinking tube. To this a sterilized hypodermic set should be added. A small rubber cath- eter is sometimes used by the doctor in resuscitation of the baby. Baby's bed Many styles of cribs and bassinettes are on the market, but the cheapest and best in the end are those without elaborate draperies and made with easily cleaned material, such as white enamel. If the nurse is consulted on the choice of one, she will be wise in suggesting the above type. Oftentimes, however, she finds her patient is not prepared to go to any great expense and an excellent one may be made at home with a clothes basket. In an emergency a bureau drawer may be utilized as a temporary crib. Never place the newborn baby anywhere but in a safe place. For a mattress a hair pillow answers the purpose, pro- tected with a rubber and small muslin sheet. Place a quilted pad between these. Complete the bed with top sheet, blanket and spread, and keep it warm with hot-water bag or stone heater. If there is the usual basket scale which can be detached from its base, this may be used to receive the baby, for it can be arranged near the doctor, with a sterile blanket cover- ing it. Paper bags Pin one of these on the bottom of the mother's bed to receive all soiled sponges and pads. Only one other receptacle for waste material will then be necessary, that is a slop jar or pan for the Kelly pad to drain into. PREPARATION FOR DELIVERY. 63 When the doctor arrives, boil the instruments in a covered vessel, containing a small quantity of sodium bicarb, (to prevent rust). The water can then be drained off and the instruments left covered until needed, or if preferred, they may be placed on the drygoods table, using the sponge holder for this purpose. Clean the Kelly pad thoroughly in a lysol solution before utilizing it. Instruments and Kelly pad CHAPTER VII. POSITIONS AND PRESENTATIONS- NORMAL DELIVERY. The position and presentation of the fetus is deter- mined by auscultation, abdominal palpation and rec- tal and vaginal examinations. Auscultation of fetal heart This is usually accomplished with a stethoscope and is quite valuable in helping to prove, in conjunction with palpation, the exact presentation and position of the fetus. Auscultation is described more fully under "Fetal heart" in this chapter. Palpation Abdominal palpation is performed by a series of movements with the hands on the patient's abdomen. As an illustration, supposing the position to be one of left occipito-anterior. In order to determine this it would be necessary to have the patient lying on her back; then, standing by the side of the patient and facing the upper part of her body, the nurse places both hands on the abdomen about four inches from the umbilicus on each side, and by gentle but firm move- ments with the finger tips, feels up and down slowly for the fetal parts. On the left side definite resistance will be produced by the fetal back. On the right side small parts (fetal extremities) will be felt as irregular and movable masses. Then turning around so as to 64 POSITIONS AND PRESENTATIONS. 65 face the patient's feet, the nurse places her hands low down on the abdomen so that the fingers are inclined into the pelvic cavity. Giving the same pressure with the finger tips, the head will be felt as a hard, round mass. Sometimes the chin and occiput may be clearly outlined. Rectal examinations are being performed more fre- quently than ever, due to the fact that the obstetrician may feel the presenting part through the rectal walls without danger of infecting the patient through the vaginal tract. Rectal examination Vaginal examinations are not made as often today as formerly, as it has been learned that the fewer vaginal examinations made the less danger there is of infecting the patient. Some obstetricians, however, make a careful examination when the patient has been in labor some time to ascertain the progress of cervical dilatation; also to determine the fetal presenting part. The extent of dilatation is defined as one, two and three fingers, etc. Vasina! examination When the expulsion of the child from the mother's body is about to take place, certain forces come into operation-these forces are known as the forces of expulsion and resistance. To effect delivery, the ex- pulsive forces must be slightly in excess of those of resistance, thus producing only a gradual dilatation of the soft structures. Mechanism of labor 66 MATERNITY NURSING. It is suitable to divide the mechanism of labor into a series of positions assumed by the fetus in its descent through the birth canal. Taking a normal vertex presentation, summed up, they are as follows-flexion, descent, rotation, extension, restitution, external rota- tion and descent and rotation and birth of the shoul- ders, followed by delivery of the rest of the body. Presentation Vertex or head presentation is the most common, forming about ninety-five per cent of all cases. Of these, face and brow presentations are rare. The posi- tions of the various presentation are as follows: L. O. A., left occipito-anterior. Of all vertex presentations about seventy per cent, are L. O. A. L. O. P., left occipito-posterior. R. O. A., right occipito-anterior. R. O. P., right occipito-posterior, forming about thirty per cent, of all vertex presentations. Vertex R. M. A., right mento-anterior. R. M. P., right mento-posterior. L. M. A., left mento-anterior. L. M. P., left mento-posterior. Face R. S. A., right sacro-anterior. R. S. P., right sacro-posterior. L. S. A., left sacro-anterior. L. S. P., left sacro-posterior. Breech POSITIONS AND PRESENTATIONS. 67 The breech presents in about three per cent, of all cases. Transverse positions are rare; when encount- ered, delivery is effected by version. Labor is divided into three stages, viz.: The first stage commences with the first true labor pain and ends with the full dilatation of the cervix. The second stage commences with the full dilatation of the cervix to the birth of the baby. The third stage commences from the birth of the baby to the delivery to the placenta. False labor pains may appear within three or four weeks before the termination of pregnancy. They are irregular and confined chiefly to the lower abdomen, never extending around to the back. If there is doubt as to whether the patient is in true labor, she should be given an enema, which sometimes dispels the doubt. Pains extending toward the back from the lower part of the abdomen are indicative of true labor. Defin- ite uterine contractions may be felt by placing the hand on the abdomen. At first, labor is not especially painful, but as time goes on the pains become stronger, more frequent and may be timed. At the commence- ment of true labor the doctor should be notified, and he will then be prepared to respond to the second call. The patient should be given an enema, a bath and have her hair braided. The shaving of the genitals should always be submitted to, although there are instances where the patient emphatically objects. Ap- 68 MATERNITY NURSING. ply sterile pad to vulva held in place with a sanitary belt or a "T" binder. The patient may be allowed to walk around the room during the first stage of labor, to favor the descent of the infant's head. A night gown and wrapper is all the clothing she need wear. While labor is progressing, attention may be given to the preparation of the delivery room. It is a good plan to induce the patient to take some liquid nourish- ment during the first stage, especially if she is a primi- para and labor is likely to be prolonged. It is not wise to give food of any kind during the second stage, as the process of digestion is greatly interfered with in active labor and there is always the possibility of the patient having to take an anesthetic. Aseptic precautions should be observed throughout the whole period of labor, for it must be remembered that a patient never gets infected from within. The rectum especially should be considered a constant source of possible infection and while watching a case of labor, this part should be kept thoroughly clean by washing with an antiseptic solution, such as lysol after urination and defecation. Vulva pads should never be replaced once they have been taken off. When the end of the first stage is reached the patient oftentimes vomits, which is a favorable sign. "Show" Accompanying the stage of dilatation there is a dis- charge from the vagina of mucus tinged with blood, this is the result of the rupturing of small cervical POSITIONS AND PRESENTATIONS. 69 capillaries and is called the "show." It has no signi- ficance unless profuse. At or about the time of full dilatation of the cervix the membranes may rupture. Oftentimes, however, the amniotic sac remains intact until it protrudes from the vagina. In such a case, if the doctor is not present, it is perfectly safe to rupture the sac with the fingers covered with a sterile towel. Membranes Always make it a practice when the membranes do rupture to listen to the fetal heart. A stethoscope, al- though desirable is not absolutely necessary for this purpose, as the sounds are quite audible to the ear if placed on the abdomen and resemble the tick of a watch under the pillow. The normal fetal heart rate is 120 to 160 per minute; the beat is a double one, the same as the maternal and is often mistaken for the beat of the maternal aorta, which is a single beat; so that it is best to take the mother's pulse while listen- ing to the fetal sounds. After some experience, any great variation or irregularity may be recognized. Few nurses realize that they can render much valuable aid to the doctor by this important procedure. It is a good plan to accustom oneself to keep track of the fetal heart sounds from the commencement of labor. This is especially valuable in prolonged labors where irregularity and marked decrease in the rate is liable to occur. Should there be any great variation notify the doctor at once, as this is an indication that the Fetal heart 70 MATERNITY NURSING. baby is becoming exhausted. From 140 to 144 seems to be the rate most frequently encountered. In vertex presentations the sounds may be heard best just below the umbilicus, either to the right or left. In breech presentations the sounds may be heard best above the umbilicus and in transverse positions, low down on the abdomen near the symphysis. If the fetal heart sounds are not heard, it may be due to certain positions or death of the fetus, etc. The beginning of the second stage is ushered in with severe bearing down pains, which increase in force and frequency. It is the hardest one for the patient, who should be on the prepared bed and watched closely. Remove all articles as they become soiled and keep the vulva covered with a sterile pad when not watching the perineum. The sheet tied to the foot of the bed for her to pull on during a pain will be found helpful at this stage. When to call the doctor It is impossible to give a definite time as to when the doctor must be called for delivery. This varies with each case and so is left to the nurse's own judg- ment. Experience alone will teach her just when to call him; for instance, while bulging on a pain or even sight of the presenting part in a multipara would in- dicate the hasty summons of the doctor, the same condition in a primipara, may mean the delay of an hour or perhaps several, unless instrumental interfer- ence is resorted to. While it is much better to call POSITIONS AND PRESENTATIONS. 71 the doctor too soon than too late, it must always be remembered that a doctor's time is very valuable, and if at night, an extra hour in bed is sure to be appreci- ated by him. Of course, it is to be reasonably expected the doctor will be notified should anything abnormal happen, such as prolapsed cord, which is likely to occur any time after the rupture of the membranes. Should this hap- pen while waiting for the doctor, put the patient in the knee chest or Trendelenburg position and while in either of these postures, with sterile hand, push the cord beyond the presenting part. Thorough asepsis must be observed and if the first attempt fails, try again for it may mean an infant's life. Retention of urine may be present as labor progres- ses, owing to pressure on the bladder. It causes much discomfort and is liable to prolong labor. The fact that the patient voids urine frequently and in small quantities, does not signify that the bladder is empty. She may complain of severe pain in the region of the bladder and on close examination a distended bladder may be clearly outlined. If micturition cannot be in- duced, call the doctor's attention to the fact, who will in all probability order catheterization. Never use any other than a catheter, glass ones are dangerous In a case of prolonged labor, it may be necessary to give the patient a second enema, in order that the rec- tum be empty at the time of actual delivery. Retention of urine 72 MATERNITY NURSING. If the patient is to be delivered in the dorsal position, it will be found more convenient to place her cross- wise on the bed, before "scrubbing" her. Then, if forceps have to be applied, later, no change of position will be necessary. There will also be better drainage for the "Kelly pad" and more room to work in case an anesthetic is given. Sterile field Just before delivery prepare to "scrub'' the patient. For this procedure, place some cotton sponges in the empty sterile basin with a solution of tincture of green soap. Have a solution of lysol (half of a one per cent.) in the sterile pitcher. Sterilize the bed-pan and put the patient on it. With sterile hands, prepare the field for delivery, always scrubbing a large area, using both hands with long downward strokes from the pubis, never retracing field with the same sponge. When once the rectum has been touched, throw the sponge away. Always finish by pouring over the parts lysol solution from the pitcher. The bed-pan and all solutions coming in contact with the patient must be comfortably warm. Have some vulva pads within reach in case the presenting part has to be held back before the doctor finishes his own prepara- tion for the delivery. Remove the bed-pan and put the patient on the "Kelly" pad covered with a sterile towel. Take the sponge holders and uncover the table on which are the drygoods, etc. The doctor, in gown and gloves, will then proceed to drape the patient. All POSITIONS AND PRESENTATIONS. 73 articles needed by him may be handed at the right time by means of the sponge holders. When the patient is about to be delivered, be pre- pared to follow the fundus down as delivery progresses with the hand under the sterile sheet and occasionally keep track of the pulse. Immediately the head is born, with the sponge holders pass the custard cup containing boric solution and sponges to the doctor, who will wipe the baby's eyes. Have the instruments and cord dressing within reach and keep the doctor well supplied with sponges. Note time of baby's birth. After the cord has been tied, cut and dressed, the doctor will usually hold the fundus himself. Then proceed to put in each eye of the infant one drop of either 10-per cent, argyrol or i-per cent, silver nitrate solution, as preferred by the doctor. The eye treat- ment will only take a few seconds and if a practice is made of doing it at this time, it will never be over- looked. Oiling the baby may be left to a more con- venient time. Before the baby is placed in the warm crib, hot-water bags should be removed to the top covers for the time being, to prevent burns. Actual delivery The placenta or afterbirth is usually expelled within twenty minutes after the bifth of the baby and should be received in a sterile pan. If ergot is to be given at all, the doctor will usually order it after the placenta is expelled. The ordinary dose is from one to two drams, given through a drinking tube in cold water. Placenta 74 MATERNITY NURSING. Holding the fundus All maternity nurses should know how to hold the fundus after delivery. Some doctors do not want it held at all, but most of them appreciate a nurse's abil- ity in this respect. It is not necessary to sit by the patient and continually hold the fundus, unless there is profuse bleeding. Under no circumstances should it be left if the pulse is over no. A uterus to be satisfactory, must be firmly contracted and compara- tively low down in the pelvis. To keep it in this con- dition, gentle massage and pressure of the fundus may be necessary at intervals. All soiled linen should be removed as soon as pos- sible, the perineum irrigated with lysol solution and sterile pads applied. Wash off all blood stains from the patient's body, adjust abdominal binder tightly from ensiform cartilage to well down below the tro- chanters. Vulva pads must be firmly pinned to it back and front. The hands and face may then be bathed, the hair attended to, a clean night gown put on and the bed made. Give the patient a hot or cold drink and leave her to rest. While putting things in order, do not forget to ob- serve the infant closely, see that it is warm and its throat kept free from mucus. If there seems to be much trouble in this respect, it may be necessary to suspend the infant by the feet and clear the obstruc- tion by means of a piece of gauze over the finger. POSITIONS AND PRESENTATIONS. 75 When in the crib, the lower part of the infant's body may be elevated by means of a small pillow. Hemorrhage from the cord, an alarming condition, if severe, may be temporarily controlled by continued pressure with the thumb and sterile gauze sponge over bleeding point until the doctor's arrival. Where there is only slight oozing, all nurses should be able to re- tie the cord, using antiseptic precautions. Hemorrhage from cord Keep a watchful eye on the mother while she is resting. A general idea as to her condition may be obtained by close observation of her face and pulse. She need not necessarily be disturbed to ascertain the extent of bleeding, if the above are favorable. A complete record of all happenings during labor should be kept. This includes the duration, character and frequency of pains, the voiding of urine, ruptur- ing of membranes, fetal heart sounds, patient's pulse and the actual delivery data. Record While the employment of an anesthetic to relieve labor pains is not without its dangers most doctors agree that if an anesthetic is properly given and not pushed too far, the relief afforded the patient far out- weighs its disadvantages which are then greatly mini- mized. Some of the chief disadvantages claimed are the prolongation of labor, and the patient's disposition to post-partum hemorrhage and puerperal sepsis. Of the agents in general obstetrical use, chloroform and ether seem to be the most popular; although nitrous Anesthetics 76 MATERNITY NURSING. oxide gas is preferred to either by most doctors, but owing to the bulkiness of the apparatus necessary for its administration and the fact that it is expensive places it outside of the reach of the masses. Cocain, scopolamin, chloral, and morphine derivatives are some of the other agents used to lessen the pains of labor. Chloroform is very easy to administer and its action soon recovered from. It is not usually given until labor has progressed well into the second stage. When a general anesthetic is called for as in an opera- tive delivery where the anesthetic is likely to be con- tinued for any length of time, ether is mostly em- ployed. Like chloroform, it can be used to produce light obstetrical anesthesia. To give chloroform have the patient in a supine position; remove the pillow from under the head and loosen all constrictions around the neck and chest; take the pulse, and grease the entire face with vaseline or cold cream; place a folded piece of gauze over the eyes. Instruct the patient to breathe naturally and then sprinkle a few drops of chloroform on the mask. An excellent mask can be improvised with a tea strainer found in almost every kitchen. It should be covered with several thicknesses of gauze held in place with a rubber band. See following illustration: At the beginning of a pain hold the mask about one inch from the patient's face to permit a free admixture of air; remove the mask at the end of the pain and re- POSITIONS AND PRESENTATIONS. 77 apply it at the beginning of another, using more chloro- form each time. This method relieves the intense Fig. 15.-Improvised chloroform mask. pain; but does not interfere with the expulsive forces of labor; furthermore, perineal tears are not so apt to occur as the obstetrician has better control over the 78 MATERNITY NURSING. presenting part. It is very important to watch the patient closely, for even though only a few whiffs of chloroform be given, there is always danger of cardiac failure with little or no warning. The condition of the pulse, respiration, and pupils must be kept track of. A fixed dilated pupil is indication that the anes- thetic should be discontinued. Ether To produce obstetrical anesthesia prepare the pa- tient as directed for chloroform anesthesia and pour one dram of ether into the cone just before the onset of a pain, which can be determined by placing the hand on the abdomen and feeling the definite uterine con- traction. When this takes place hold the cone closely over the patient's face until the pain ceases; then re- move it and prepare for the next pain by adding more ether. The amount of ether to be used each time can be decided by the severity of the pains and the degree of anesthesia reached. Before giving anesthetics always be sure to ask the patient if she has false teeth in order that they may be removed; also see that there are no open flames in the room such as kerosene lamps, gas, etc. CHAPTER VIII. THE NURSE'S DELIVERY. The actual delivery can oftentimes be delayed while waiting for the doctor, by pressing on the vulva with a sterile towel during a pain, at the same time instruct- ing the patient not to bear down, but to open her mouth and take short breaths, in order that her expulsive forces may be lessened. Do not leave the patient under any circumstance at this stage, but continue pressure when needed and if the delivery must fall to you, pro- ceed to hold back the baby until the perineum is fully distended. It will be found much easier to have the patient in the left "Sims" position than the dorsal, as it requires less strength to prevent the sudden ex- pulsion of the presenting part before its time. In a normal vertex delivery (head presentation) the chin of the infant may be held with the left hand at the back of the rectum, and pushed forward or held back, as the condition of the perineum indicates, while the right hand controls the head. An idea as to the right time to deliver can be determined by the appearance of a white line at the extreme edge of the perineum. This denotes full dilatation, then deliver at the end of a pain, not during one, as laceration is more liable to 79 80 MATERNITY NURSING. occur if delivery is effected during full dilatation. This is the most essential point to guard against. When the head is born bathe each eye with boric acid solution using separate sponges. Feel around the neck for the umbilical cord, if it is there, draw 5t carefully over the head, or if this cannot be done, slip it down over either shoulder. If neither of these methods can be resorted to it may be necessary to clamp and cut the cord, using two clamps and cutting between both. This is a rare emergency. Deliver the anterior shoul- der first and the rest of the body will then come easily. If the patient is in the left "Sims" position, it will be necessary to sit down opposite her during delivery and when the baby is born, place it on its right side on your knees, covering it well with sterile towels, care being taken to prevent traction on the cord. If the baby does not cry immediately, suspend it by the heels and give it several sharp slaps with your hand on the back, and at the same time, free the throat of mucus with the little finger wrapped in gauze. A few drops of cold water sprinkled on the chest may also prove of value. Before tying the cord, wait until pulsation in same has ceased. The ligature may be placed about one inch from the baby's body and tied firmly with a good tight square knot. Clamp the placenta end of the cord as near the mother as possible, but if a clamp is not available use a second ligature, about one inch from the first and cut between both. (The reason for THE NURSE'S DELIVERY. 81 adjusting the clamp near the mother's instead of the baby's body, is because the clamp may become unfast- ened if the cord is very long.) First apply the split sponge and over this place the gauze square sponge, using the gauze band to hold the dressing firmly in position until bathing time. Wrap the baby in the receiving blanket and have it removed to the crib or some prominent place of safety. Dressing the cord While the average time for the expulsion of the placenta is about twenty minutes after the delivery of the baby, by no means is it necessary or wise to use force to this end, unless there is undue bleeding. Sometimes the delay may be as long as an hour. Never use traction on the cord, as this may cause hem- orrhage and has been known to occasion inversion of the uterus. When the uterus is well contracted, no harm can result by gentle pressure on the fundus to assist nature to expel the placenta. When the pla- centa is received, be sure that it is intact and leave in a sterile pan, for the doctor may want to inspect it. Keep a watchful eye on the patient for hemorrhage and proceed as you would in an ordinary delivery. Expulsion of placenta In a case of breech presentation (when the buttocks comes through the vagina first) receive the baby as it is delivered and have pressure made on the fundus, which may possibly prevent the arms extending above the head, a condition to be avoided, on account of the difficulty in extracting the head. Should this occur, Breech presentation 82 MATERNITY NURSING. pull the arms down. As soon as the body is delivered, wrap it in warm towels or a blanket, to prevent chill- ing or any respiratory attempt on the part of the baby. Grasp the feet and turn the body upward toward the mother's abdomen, which inclines the head forward, thereby effecting delivery. It is seldom that a nurse has to adapt herself to the above requirements, for in a full term breech presentation, the process after the presenting part first appears is usually delayed long enough to enable the doctor to be present, and in the event of a premature breech presentation, no special manipulation is necessary, as the baby is small enough to slip through. Meconium Coming from the vagina always indicates that the presentation is a breech. Asphyxia If the baby's condition is one of asphyxia, do not wait until pulsation in the cord has ceased or waste time tying it-clamp in the usual two places and cut between. Next place the baby in hot water (temperature 105° F.) for a few moments, then transfer to the cold water for one instant only and again dip in the hot water. If the baby fails to respond, perform artificial respiration as follows: With the left hand support the back of the baby's neck and with the right holding the legs double the body up until the knees and chest almost touch. This affords expiration. The unfold- ing of the body causes inspiration. Repeat this pro- THE NURSE'S DELIVERY. 83 cedure about twelve times a minute. The shock of again placing the baby occasionally in the hot and cold water, may produce the normal respirations. Air may be blown into the baby's mouth by first placing a piece of gauze over its lips. Continue with the above treatment even if no signs of life are visible for at least an hour. If it proves successful put the baby in a warm bed and maintain body heat by means of stone heaters or hot-water bags. Watch the baby closely for a relapse may occur. There are two types of asphyxia, livid and pallid. The latter is the most serious, but both call for the same method of resuscitation. CHAPTER IX. CARE OF THE MOTHER AFTER LABOR. Postpartum chill This may occur a short time after delivery, which is of nervous phenomenon. Keep the patient warm with hot-water bags and extra blankets; also give a hot drink. The chill must not be confounded with those that might occur later in the puerperium, as they are entirely different and call for medical treatment. Temperature, pulse and respiration There is usually a decided drop in the patient's tem- perature immediately after delivery and it may remain subnormal for several hours. The pulse-rate during the same time shows an increase; but for the remain- ing period of the puerperium is inclined to be some- what slower than normal The temperature, pulse and respiration should be taken every four hours for the first week, then twice a day is sufficient for normal cases. Perineal dressings Proper care of the perineum during the post-partum period is most essential. Put the patient on a sterile bed-pan every four hours whether she requires it or not, in order that fresh pads may be applied. With the knees wide apart the vulva should be thoroughly cleansed with warm lysol solution (J4 teaspoonful to i pint of sterile water) poured from a pitcher, using 84 CARE OF MOTHER AFTER LABOR. 85 sterile cotton sponges in the sponge holder to remove particles of lochia, etc. Then turn the patient on her side in order to clean the rectal area, which should be accomplished by sponging away from the vagina and not toward it. The employment of a dressing tray containing the following articles for the above procedure will be found most convenient: DresHing tray Enamel pitcher for lysol solution. Sponge holder in olive jar containing lysol solution. Sterile cotton sponges. Vulva pads. Paper bags. All soiled vulva pads and sponges should be thrown in a paper bag at the bedside immediately they are dis- carded. If the dressing tray is not used, it will be necessary to thoroughly scrub and disinfect the hands and arms before doing a perineal dressing. Where a lacerated perineum has been sutured, the same care as outlined above should be given the perineum, provid- ing the doctor has no special suggestions to make of his own; for it will be found that some are averse to douching for cleansing purposes and prefer as dry a surface as possible for the first few days after labor. Sometimes it will be found necessary to tie the knees of a very restless patient recovering from an anesthetic to prevent the possible tearing away of the sutures. The character of all soiled pads must be noted, also the amount of lochia secreted and odor of same. Any Lochia MATERNITY NURSING. 86 suspicious pad should be saved for the doctor's inspec- tion. This is especially important where there is any elevation of the temperature. The lochia for the first few days is bright red, and is known as the lochia rubra; from then on it gradually fades and becomes less in amount when it is termed the lochia serosa. Around the twelfth day the discharge has a white or yellow and sometimes very light green hue. At this time it is known as the lochia alba. At first it will be found rather difficult to recognize the normal character of pads soiled with lochial discharge; a good guide is to note the odor which must be somewhat "musty" to be normal; but never foul. A decidedly offensive odor with marked diminution or a scanty amount of the discharge is suggestive of infection. There is usually an increase in the flow for a short while after the patient gets out of bed for the first time; but it has no great significance unless profuse and remains bloody in color, which goes to signify that involution is not pro- gressing as it should. After-pains These are caused by the alternate relaxations and contractions of the uterine muscles. They seem to be more common in women who have borne several child- ren than those who have had one or even two, which can be accounted for in the fact that the muscles of the former, through frequent pregnancies, have lost some of their tone and therefore show a tendency to relax. In character these pains resemble those of labor, and CARE OF MOTHER AFTER LABOR. 87 are sometimes quite as severe. The baby nursing at the breast seems to aggravate them and when especially painful the doctor often prescribes a sedative to relieve the suffering. For the first few hours of the puerperium the pa- tient should remain on her back and take all nourish- ment through a drinking tube. Always ask the doctor to outline a diet for her; sometimes, however, he may leave this entirely to the nurse, in which case it is advisable to give liquids only for the first twelve hours, then soft solids. The amount of solid food should be restricted until after the result of the cathartic usually given on. the second or third morning. About the fourth day a light diet may be given and for the re- maining lying-in period, the patient may be allowed any kind of food within reason. A generous varied diet is called for, but overfeeding must be guarded against. *A milk drink given between meals is beneficial. Diet Difficulty in voiding urine is very often experienced during the first twenty-four hours, especially after a hard instrumental delivery. This condition is due chiefly to the removal of internal pressure and the blad- der being less sensitive than usual is therefore able to retain more urine without distress to the patient. Only in rare cases is catheterization necessary. The many methods known to every nurse to induce micturition should be resorted to, some of which are: placing the Urine 88 MATERNITY NURSING patient on a bed-pan containing steaming hot water, hot drinks, hot-water bag to the suprapubic region, and allowing water to run from the faucet. A hot high enema will generally produce results when all other means fail. Catheteriza- tion No procedure requires more scrupulous technique than this one, and it should be accomplished with as little disturbance to the patient as possible. A tray should be provided containing 2 sterile rubber cathet- ers, 1 pair sterile dressing forceps, sterile cotton sponges, sterile towels, sterile oil for lubricating cath- eter (rarely needed), small basin of % of a i-per cent, solution of lysol, and sterile vulva pads. Before the above articles are placed on the tray cover it with a small sterile sheet, and after the articles are arranged it will only be necess'ary to fold over the four sides, envelope fashion, making a completely closed tray, which is not always secured by using towels. Have the patient in the dorsal position on a sterile bed-pan, with the knees flexed, drape her with sheets as for a vaginal examination and turn the bed clothes neatly in folds down to the foot of the bed. Be sure the patient is warm. Always use a drop light, for it is so easy to break one's technique, even in day- light, if the proper illumination is not given to the meatus. Pin a paper bag to the bedside to receive all soiled sponges and vulva pads. Wash and disinfect the hands, then drape the patient with sterile towels CARE OF MOTHER AFTER LABOR. 89 and separate the labia with two dry sponges, using the left forefinger and thumb. With the sterile forceps pick up a cotton sponge saturated in the lysol solution and wash the meatus with a downward stroke. This operation should not be repeated a second time with the same sponge, although it is necessary to use several sponges in succession to be sure of a thorough cleans- ing of the area. Insert the catheter gently into the urethra several inches until the urine begins to flow. Never draw off all the urine if the bladder is greatly distended, as the sudden emptying may cause cystitis or other trouble. Before withdrawing the catheter, pinch same tightly near the meatus and maintain the pressure until after its removal; then if the catheter is held in an upright position when the pressure is re- leased, what urine remains in it will, at once, flow into the bed-pan. The urine secreted during the puerperium is usually in excess of the normal and it is quite important to keep a record of the quantity passed at least for the first week. Preparation for bladder irrigation is the same as outlined for catheterization, with the addition of the following articles : Flask of warm sterile solution to be used for irrigation, a sterile enamel funnel and con- necting tip, also a piece of sterile rubber tubing about twelve to fourteen inches in length. Have the tubing fit well over the funnel, and the large end of the con- Bladder irrigation 90 MATERNITY NURSING necting tip. After the urine has been drawn off through the catheter, fill the funnel with the solution allowing some to flow through the tube to expel all air before inserting the small end of the connecting tip into the catheter. Allow from six to eight ounces of the solution to flow into the bladder, then lower the funnel so as to permit a return flow of the injection. Siphonage is best obtained when the funnel is lowered before becoming empty. Repeat the operation until all the solution has been used. Vaginal douches In giving vaginal douches in the puerperium, the two most important factors to remember are to have everything absolutely sterile and to guard against the possible injection of air into the uterus. About the only occasion arising where a nurse would give a vaginal douche without the doctor's order would be in severe post-partum hemorrhage, when she is left to her own resources and the life of the patient is in danger. The necessary articles for giving a vaginal douche are: A tray containing sterile irrigating can with tubing and glass nozzle, the sterile solution to be used for douching, sterile towels, sponges, vulva pads, sponge holder and basin to receive the douche nozzle after use. Place the patient on a sterile bed-pan and drape her warmly as for a vaginal examination, observing the same technique as suggested under catheterization. The temperature of the solution used is usually no0 F. to 1150 F., except in hemorrhage, when it should CARE OF MOTHER AFTER LABOR. 91 be 1240 F. In giving the douche allow some of the solution to flow through the nozzle before inserting it into the vagina, this will expel all the air from the tube; also take care to shut off the solution just before it all escapes from the douche can which should be hung slightly higher than the patient's hips. Restrict all visitors but the patient's immediate relatives-the fewer the better for the first day or so, until the flow of breast milk is well established. Visitors A breast tray is essential in order that the best possible care may be rendered This requires a tray large enough to accommodate the following articles: Care of the breasts Bottle of boric acid solution. Bottle of tincture of benzoin. Bottle of grain alcohol 50 per cent, (if procurable). Medicine dropper. Cold cream. Sterile gauze sponges for nipple protectors. Sterile absorbent cotton. Enamel custard cups (2) for use when "scrubbing" the breasts preparatory to the first nursing. Before the baby goes to the breast for the first time, both breasts should be thoroughly cleansed with tinc- ture of green soap and warm water, followed by the application of a 2-per cent, solution of warm boric acid and lastly 50 per cent, alcohol which is allowed to evaporate. Each nipple should then be covered with a sterile gauze sponge held in place by a comfortable breast binder. It will be found that square pieces of 92 MATERNITY NURSING. old linen sterilized are much softer and preferable to gauze sponges for nipple covers. If a Murphy breast binder is used, these covers may be held in place with adhesive plaster strips cut into eight 5-inch lengths; turn over one end of each about 1% inches, so that the covers will not stick to the plaster. Then cut a small hole in the double end of the plaster for tape ties. Four of these strips are applied to each breast and tied in the center with the tapes. Before and after each nursing, the nipples should be carefully washed with boric acid solution. Once a day in the center of each nipple apply a drop of tinc- ture of benzoin with a medicine dropper and cover with cold cream. This acts as a preventive to sore nipples. At no time other than the actual nursing, should the breasts be exposed and never touched with unclean hands. This simple treatment is all that is necessary in the care of the normal breasts after delivery, and if rigidly adhered to minimizes soreness of the nipples and helps to prevent possible breast infection. Most breast troubles are, without doubt, due to faulty nurs- ing care. Soreness of the nipples is most apt to occur during the first few days of nursing and women with their first baby seem to have more trouble in this respect than others. When severe the use of a nipple shield will prove helpful. If the combination glass and rub- CARE OF MOTHER AFTER LABOR. 93 ber one is used, the infant may fret and probably refuse to take it at first. A little warm sterile water or breast milk placed in the shield will oftentimes induce the infant to become accustomed to it sooner. Superior by far to this one is the soft all-rubber shield shaped like the mother's breast manufactured by the Davol Rubber Company, Providence, R. I. All infants take to it immediately. Less strength is required to draw the milk through the nipple and in consequence it is Fig. 16.-"Davol" all rubber nipple shield. of great value where a delicate infant is concerned. Furthermore, it is less trouble for the mother and absolutely sanitary. In the event of only one nipple giving trouble, as is often the case, it is advisable to take the baby off that breast entirely for about one day and during this time apply witch-hazel compresses to the nipple occasionally, but under no consideration pump the breast. When the baby goes back to nurse, use the nipple shield until nursing gives no discomfort. Continued nursing on sore nipples without the aid of a shield and necessary treatment is likely to cause cracks, which offer a very 94 MATERNITY NURSING. good field for bacteria and may result in an actual fis- sure. In this case, extreme asepsis is most important to keep the breasts from becoming infected. Any bleeding from the nipples should be reported to the doctor and nursing discontinued immediately. Breast massage If proper care is given the patient by a nurse who thoroughly understands her work, occasion to mas- sage the breasts should never arise. However, if re- quired, the nurse should first cleanse and disinfect het own hands and also the patient's breasts. Then, hold- ing the base of the breast with the left hand, with the fingers of the right previously dipped in sterile oil, she should grasp the breast gently but firmly, making even pressure toward the nipple and at the same time draw the breast upward. This manipulation should be repeated for the length of time ordered by the doctor. Breast binder One of the most essential things for the nurse to know is how to adjust a breast binder satisfactorily. Surprising as it may seem, very few do, and when the binder is applied without fulfilling the purpose for which it is intended, probably more harm than good is done. A breast binder is employed for three rea- sons-to give support, thereby assuring comfort; to protect the nipples; and to render pressure when needed, as in cases where the breast secretion must be suppressed on account of the death of the infant or other causes. CARE OF MOTHER AFTER LABOR. 95 'Stitch Shoulder straps. Cut here Fig. 17.-The "Y" breast binder in the making. 96 MATERNITY NURSING. Several varieties of binders are in general use, but the most satisfactory one to the author is the so-called "Y" binder if properly adjusted. Although it may take a little longer time at first to do this., it has a decided advantage over all others in the fact that when once applied, it need not be removed every day unless soiled. Then again, one pin only is removed at nursing time and the comfort of the patient is assured, because the breasts are supported in their natural position. Last but not least, it affords protection to the nipples at all times. The constant readjustment of other binders is necessary in order that the breasts may be prevented from sagging, a condition especially un- comfortable to the patient. The "Y" binder is very easily made and takes no more material than most others. The width is deter- mined for each individual by the size of the breasts. Small, about four inches; medium, five inches; large, six inches. All material should be torn and not cut. Strong unbleached muslin is the best To make the binder in diagram, which is similar to that used in the Boston Lying-in Hospital, take two even lengths of double material, about one and a half yards long and four, five or six inches wide according to the size of the breasts Cut one of the lengths crosswise in the center, join these two pieces, making half a square and sew to the other long strip, which completes the CARE OF MOTHER AFTER LABOR. 97 Fig. 18.-Showing the "Y" breast binder adjusted and fastened to abdominal binder. Right nipple exposed ready for nursing. Left nipple covered with sterile gauze. 98 MATERNITY NURSING. "Y." The shoulder straps are made three inches wide and eight inches long, doubled lengthwise. Adjusting; the binder Before applying, have ready small and large safety pins, sufficient absorbent cotton to serve as padding for hollow places, sterile gauze sponges for nipple protec- tors, the binder and the two shoulder straps. Stand on the right side of patient and pass the two short ends of the binder underneath her back, so that the point of the half square comes to the left axilla. Pad under arms with cotton, then bring the two short ends over both breasts and fasten to the long tail on right side with one large safety pin. With gentle manipula- tion of the hand inside binder, incline both breasts up- ward toward the center, so that the nipples come within a few inches of each other. To keep them in this posi- tion, two more pins will be needed to fasten under right arm. Pad center of chest and hold the two front pieces of binder together by means of two large safety pins placed within an inch or so of each other. Pin the sterile gauze sponges over nipples to upper piece of binder with small safety pins. Turn patient on her side and adjust shoulder straps tightly to back and front of binder. To close binder draw long flap over the breasts and pin to left side. At all times except when baby nurses, or breast treatment is being given, this piece is to be kept fastened. Pin the breast binder to the abdominal binder with two large safety pins as shown in diagrams on pages 97 and 99. CARE OF MOTHER AFTER LABOR. 99 If for any reason the breast milk is no longer needed, as in a case of death of the infant, and the secretion must be "dried up" apply the "Y" binder "Drying up'' the breasts Fig. 19.-Showing the *'Y" breast binder with long flap drawn over the breast and fastened on left side with one safety pin. tightly. Then leave the breasts entirely alone-never pump them as this manipulation tends to stimulate the secretion. It is wise to restrict fluids especially 100 MATERNITY NURSING. milk in the patient's diet during this period. In addi- tion to this, many obstetricians prescribe a large dose of magnesium sulphate for three successive mornings and in a few days the breasts become quite soft and seldom ever give further trouble. However, the bin- der must be readjusted whenever it becomes loose so as to maintain even pressure at all times, and in four or five days when the breasts are soft it may be dis- carded. Abdominal binder This should be at least twenty inches wide and forty- four inches in length and applied well down over the hips, so that the vulva pads may be pinned to it back and front. "T" binders for this purpose are not neces- sary. Use a clean binder every day and aim to-apply it when making the bed in the morning. While the patient is turned on her side to adjust the lower sheets, place one-half of the abdominal binder in position over her hip, taking care that the center of the binder comes to the middle of the patient's back. The other half may be rolled and neatly tucked with the sheets under the patient's lower side, so when she is turned they may be all pulled out together. Have the patient flat on her back, stand on her right side to pin the binder in position. Turn in both ends of binder evenly so that there is a space of about one inch of patient's body visible the whole length of binder. Then begin to pin binder from the bottom as tight as possible, at the same time see that the uterus is well contracted by the fun- CARE OF MOTHER AFTER LABOR. 101 dus being low down in the pelvis. Between the second and third safety pin place two others lengthwise, to hold the vulva pads in position. When within about six inches or so from the top of binder, make darts on both sides to conform to patient's body, using safety pins (provided darts have not previously been stitched). Then continue to pin up the remainder of the binder. The principal object of an abdominal bin- der is to afford comfort to patient; but this cannot be accomplished if it is not adjusted firmly and properly. A daily bed bath although not absolutely necessary adds materially to the comfort of the patient and is best given just before making the bed in the morning. All binders should be removed before giving the bath and the adjusting of fresh ones left until after the bed is made. Put the breast binder on first, then neatly turn the bed clothes down far enough to permit the application of abdominal binder. This method protects the patient from unnecessary exposure. All good obstetrical nurses aim to have abdominal binders long enough and vulva pads sufficiently large to absorb all lochial discharge, in order to prevent soiling of bed linen; for while a daily change of same is desirable it is not then essential, furthermore, the patient's com- fort is assured. Bathing Although this is a matter for the doctor to decide, some leave it to the nurse's own judgment by remark- ing: "If the patient does need a cathartic, give her Cathartics in the puerperium 102 MATERNITY NURSING. what you think best." Under such circumstances it will be found that one good dose of castor oil (about two ounces) given on the second or third morning will prove satisfactory. After this the bowels should move every day without fail. If they do not act naturally, give an ordinary soapsuds enema for a day or two. About the fifth day compound licorice powder (two to four drams) can take the place of the enema and is best given at night. It must always be remem- bered that plenty of stewed figs, prunes, orange juice, coarse grained cereals and whole wheat or bran bread help greatly to overcome constipation, and for this reason these foodstuffs should be included to a large extent in the dietary during the puerperium. Deficiency of breast milk This is quite a handicap especially so to premature babies, and all efforts to increase the milk supply should be employed. Contrary to the opinion of some author- ities, it is a known fact that milk taken in large quan- tities by some mothers has a marked influence on the breasts which become heavy and yield an abundance of milk in a surprisingly short time. This then, should be borne in mind by all nurses who are faced with the problem of increasing the secretion of breast milk in the mother. In such cases, milk should form a large part of the diet and be used freely in the preparation of most foods. If there is a distaste for milk, it can be made quite palatable by mixing with vichy or carbon- ated water and by way of variety, in combination with CARE OF MOTHER AFTER LABOR. 103 other drinks such as malted milk, cocoa, etc. A mouth- ful of carbonated water taken plain after a glass of milk, helps wonderfully to counteract that "milky taste" found so disagreeable to some patients. Plenty of other nourishing foods are advisable; shell fish is excellent and has been known to increase the milk supply when all other foods seemed to fail. Cooked cereals are also very valuable. Keeping the mother free from worry is an important point to be aimed at especially if she is of a nervous temperament. It is customary in many lying-in hospitals for the nurse to measure daily the height of the fundus above the symphysis to ascertain the progress of involution. Where there are no complications in the puerperium, involution is usually completed from the sixth to the tenth week. Before the patient passes from the care of the nurse into that of her former daily life, she should be instructed what to do and what not to do in order that involution may not be interfered with. Where a patient has her own private doctor, he will attend to this and in all probability examine her in six weeks, to ascertain the position of the uterus, invo- lution, etc. There are, however, many patients who are delivered by midwives and have no care or advice after the first ten days of the puerperium; so that it is well for a nurse to realize the importance of a post- natal examination. A nurse who is doing public health work is a valuable asset to these women: for if there Involution of the uterus 104 MATERNITY NURSING. is a prenatal clinic in the neighborhood, she can urge them to go there for their postnatal examination, fail- ing this, she may take them to a hospital clinic for same. Exerciwes Many obstetricians today prescribe a set of exercises for their patients, claiming that they not only strengthen and give tone to the abdominal muscles, but benefit the health generally. These exercises vary with different doctors. Some start the course very early and others late in the puerperium. Getting: out of bed When the patient is to sit up on a back rest is en- tirely up to the doctor. The usual time is around the ninth day, provided the temperature and everything else is favorable. It is unwise to immediately prop the patient up in bed when a back rest is permitted for the first time and allow her to remain thus for hours or the whole day long. At first place a few extra pillows under her head at meal times. The next day, raise her a little higher for a longer period and so get her to sit up gradually. This same advice holds good when the patient is allowed to get out of bed. All maternity patients feel more or less weak on getting out of bed and for this reason it is best to allow them up for about twenty minutes the first time. Some patients cannot remain up this long and are compelled to go back to bed on account of fainting spells. The most favorable arrangement is to have the patient sit CARE OF MOTHER AFTER LABOR. 105 up in a chair for a short time during the morning and again in the afternoon and gradually increase the periods until she is able to stay up all day. Do not permit her to walk too soon; encourage only a few steps at a time. CHAPTER X. CARE OF THE BABY-FULL TERM AND PREMATURE. Nursery All nurses should try to secure a separate room as a nursery for the baby. It not only affords a better start off for the young one; but proves of material benefit to all concerned, especially to the mother who is not then disturbed by the infant's crying, etc. The room should be exposed to sunlight, be well ventilated and have a porch if possible, on which to place the baby during favorable weather. Hot water heat is most desirable, as an even temperature can then be maintained. The temperature of the room should be around 70° F., reg- istered by a thermometer, as it is a poor rule to rely on one's own judgment. Care should be exercised to keep the room at this degree all the time. Some nurses have a mistaken idea that when the bathing ordeal is commenced, the room must be sealed and the heat turned on to a sweltering degree. Oftentimes, these same nurses will take the baby to its mother immedi- ately after the bath through a cold corridor without even a blanket covering it. OU bath There is no need to be in a hurry to give the baby its first bath. Indeed it is better to wait several hours. 106 CARE OF THE BABY. 107 The most convenient time for this is just before the first nursing. The oil bath, however, should be given as soon after birth as possible; but choose a time to do it when the doctor does not need assistance, or some more important duty has to be attended to. Pour the oil into a small custard cup and keep it warm in a basin of hot water. Use plenty of oil in anointing the baby, especially on the head, under the arms and where most vernix caseosa seems to be. This treatment will also keep small particles of blood that adhere to the hair soft and so render its removal easier when bathing the baby with soap and water. If possible it is much bet- ter to have the baby in a warm room by itself, but if this is not convenient, select a corner of the mother's room for the crib, away from the light and draughts, preferably near a radiator. A high table with a drawer is excellent to bathe the baby on. If a screen is obtain- able it may be used to enclose this corner of the room. Before the actual bathing is commenced, everything needed must be placed within reach. Put the wash rags and a small quantity of water in the baby's bath tub and boil. Have a pitcher of hot sterile water and another of cold sterile water in readi- ness. Cover the table with a folded blanket and sheet, then place in the center the bath tub. On the left hand side of the table, put the crib rubber sheet covered with a clean old piece of woolen blanket. This side can be used to soap and bathe the baby on. The right side First cleans- ing bath 108 MATERNITY NURSING. covered with a similar piece of blanket may be utilized for dressing baby. Keep all small articles used for the baby in the drawer. Pin two paper bags to the table, one to receive refuse, the other soiled diapers. All baby's wearing apparel and towels may be placed on the warm radiator, which has previously been covered with a clean cloth. A temperature of 98° F. is con- sidered correct for the bath at birth and should be maintained throughout the procedure. Clean the baby's buttocks with cotton, weigh, examine for any deformity, take rectal temperature and keep it covered with warm blanket as much as possible. With separ- ate pieces of cotton, saturated in warm boric acid solu- tion, bathe each eye and swab the mouth. Wash and dry the face, soap the head, then hold it over the tub and rinse well. Dry thoroughly and comb and brush the hair. Remove the gauze abdominal binder, but leave the umbilicus protected with its dressing, then quickly soap the whole body without disarranging the dressing and with the left hand supporting the head at the back of the neck and the right hand under the but- tocks, gently lower the baby into the bath and keep it there for a few seconds, taking care not to let the water touch the umbilicus. Rinse off all soap, dry the body thoroughly but gently, and apply a fresh sterile dressing to the cord, keeping it in place with a firmly adjusted silk and wool binder. If this is applied tight enough, there is less danger of infection and it need CARE OF THE BABY. 109 not be removed unless soiled for several days. Use toilet powder sparingly on the baby, or better still none at all unless there is chafing. Always apply it from a sprinkler top box, using clean absorbent cotton to spread it, in place of the unsanitary powder puff. In the diaper put a large piece of old linen and tuck it well under the binder, when soiled it can be burned, thus avoiding the difficulty that must be encountered when washing diapers soiled with defecation. One article of clothing may be arranged inside an- other and drawn over the baby's feet, thereby prevent- ing undue handling. It is well to keep the head as well as the body covered with a woolen shawl when taking the baby out of the crib. The bath should be given daily at the same time, preferably before one of the morning feedings. Do not give a full tub bath until the cord has fallen off and the umbilicus is perfectly dry, otherwise proceed as with first bath. Dressing baby When this does occur note whether the umbilicus is dry or moist and if there is any odor or discharge. Then clean well with boric acid solution and apply sterile dressing. Thereafter, this is all the treatment necessary for the normal umbilicus and should be car- ried out daily. Of course, if there is much moisture or discharge, call the doctor's attention to it at once, who will then order the treatment he thinks best. Cord off 110 MATERNITY NURSING. Premature baby The mortality of premature infants is very high, but it could be reduced by proper nursing care. When confronted with the care from birth of a premature baby, always bear in mind that warmth, sufficient food, fresh air and rest are the principal factors to be regarded. There are many excellent incubators on the market, but there are also those that do not afford the desired satisfaction. A careful nurse can oftentimes render better care herself to a premature infant than would a faulty incubator. Bed In some of the large cities there are hospitals that offer incubator service. This without doubt is the ideal care that baby rightfully should have, however, if it cannot be secured we must render the best care pos- sible at home. By no means is it necessary to choose an expensive crib. Very often those costing the most money, which serve the purpose admirably for full term infants, are not the best suited for a premature. In fact the author has met with far more success by improvising one out of the ordinary oblong (square bottom) clothes basket, than with all others. Their original purpose may be entirely disguised by the addition of stain, varnish and ribbon. No matter what kind of a crib is chosen, line it carefully with pieces of old woolen blanket held in place with safety pins. A hair mattress properly pro- tected with rubber sheet and blanket must then be CARE OF THE BABY. 111 placed in it. Do not have the mattress too thick, for the deeper the finished crib is, the better. On three sides of the crib put hot-water bags, preferably a stone heater at the bottom and one rubber hot-water bag on each side, all well protected with covers. The two hot-water bags are best pinned to the sides of the crib in their covers, to prevent them touching the baby. Over the bed place a blanket and pin its overhanging ends to both sides of the crib, leaving a space of about six inches at the top for air. Place bath thermometer in the crib and maintain a bed temperature of 98° F., as near as possible. However, this is really regulated by the actual temperature of the baby; if it goes down very much below normal, an increase of bed tempera- ture must be made in proportion. Sometimes as high as 1050 F. is necessary. The room temperature should be 80 to 85° F. Have the room well ventilated and screen the bed from light and draught. If lamb's wool can be obtained for a jacket, it is to be preferred. Otherwise use ordinary absorbent cotton. It may be made in a very short time, all the articles necessary are cotton, gauze, needle and thread and tape enough for eight strips to fasten the jacket together, or in place of the latter safety pins may be used. Cut two pieces of cotton the same size as given in the diagram on page 112, and two thicknesses of gauze to cover each piece of cotton, an inch or so larger than the cotton to turn in. Place the cotton Jacket 112 MATERNITY NURSING. between gauze and sew altogether around the edges of both pieces. Quilting them with large basting stitches helps to keep the cotton in place. Sew the hood and 3l/2in. Seam 4in. 8in. I6in. 12 in. Fig. 20.-Premature jacket. body piece together and join the two edges of the hood. This simple little jacket is then ready for use. The premature baby requires the same care after birth as the normal one in regard to eyes, mouth, cord, etc. But in place of the usual wearing apparel, a pre- mature jacket should be employed. Place a piece of cotton under buttocks, secure in position by small CARE OF THE BABY. 113 diaper made of old linen, which can be destroyed when soiled. Wrap baby in a piece of warm soft flannel and then put on the jacket. Do not forget to do this first, as the flannel prevents the jacket from becoming soiled by the oil on the body. All this should be done in the shortest time possible, as too much handling and Fig. 21.-Stone hot-water hottie. exposure is sure to be detrimental to the baby. Take care that the heaters are not near the infant when plac- ing it in the prepared bed, as burns occur very easily where there is low vitality. The oil bath should be continued every day and the face and buttocks bathed with warm water. About every three days a warm dip bath is very beneficial to circulation and also helps to remove the stale odor of the oil. (This does not mean a regular tub bath as given to normal infants. MATERNITY NURSING. 114 simply hold the baby very carefully in the water for one or two seconds and dry quickly but gently.) Do not let the baby lie in one position too long, frequent turn- ing from side to side is most important. Record A full daily record should be kept of all babies- normal and premature, regarding their weight, tem- perature, nursing, condition of the cord, number and character of the stools, urine, and remarks in general. CHAPTER XI. INFANT FEEDING AND BABY'S DEVELOPMENT. When the mother has had a good rest, usually about six hours after delivery, and her breasts have been prepared, it is well to let the baby nurse. Put it to the breast every three hours during the day unless the doctor orders otherwise; 7 a. m. will be found a convenient hour to start. Omit the 4 a. m. feeding, which will give the mother six hours of uninterrupted sleep. At first, some trouble may be experienced in training the baby to this schedule and it may cry around 4 or 5 o'clock in the morning. Should this happen, appease its hunger with sterile water. If this rule is rigidly adhered to baby will awaken a little later every morning, until the hour of seven is reached. During the first few days, supplement the breast feed- ings with a ten per cent, solution of milk sugar or sterile water if the baby is not satisfied. After this time, if the breast milk is not sufficiently established, do not let the mother get discouraged, baby may take what little is in both breasts, at each feeding and the required amount can then be made up by the doctor's formula. This amount can be determined by weighing Full term baby 115 116 MATERNITY NURSING. the baby before and after nursing. (Weigh with all clothes on.) Even a small quantity of mother's milk is better than none at all, but baby should never be allowed to nurse on empty breasts. Weighing the in- fant daily, at the same time, will furnish sufficient proof as to whether enough nourishment is taken. During the first few days of life a loss of weight will be found, but the birth weight is usually regained about the tenth day. After that time the baby should gain from one-half to several ounces daily. No stated time can be given for the baby to remain at the breast; although twenty minutes seems to be the usual period, it cannot be made a rule, for some babies require a longer or shorter time than others to consume enough nourishment to satisfy them. Punctuality should be the golden rule to be observed from the beginning. It is impossible to expect a well behaved baby, or any great degree of success, unless the baby is put to the breast regularly. When the time arrives for feeding and baby happens to be asleep, wake it up, put it to the breast and keep it from sleep- ing until the usual time is up and you think enough nourishment has been taken. Sleeping at the breast is a bad habit and should not be encouraged. When feeding is over, return the baby to its crib dry and clean, and keep it there undisturbed until the next feeding. A well-nourished baby will give no trouble at all if started out right from the beginning. Crying INFANT FEEDING AND DEVELOPMENT. 117 between feedings does not necessarily indicate that in- sufficient food is the cause. Never take the baby up in an effort to quiet it. Keep it dry, change position and give it a small quantity of sterile warm water in a nursing bottle. These measures will usually induce sleep. Persistent crying, however, shows that either the baby is not getting enough food, or the milk itself is at fault. Crying immediately after leaving the breast, indicates not enough or too much rich food has been taken; if due to the former, it will be found on investigation that probably baby slept at the breast. The latter condition will be demonstrated by distress- ful crying similar to that of hunger. There will also be regurgitation of milk and presence of gas. Much relief can be afforded by allowing baby to rest on its stomach and making pressure there with the left hand, gently pat the back of the infant with the right hand. This will, in a little while induce eructation of gas, followed by sleep. Several of the large milk laboratories are now pre- paring formulas according to individual requirements at a minimum cost. However, under certain condi- tions, it may be more convenient to modify the milk at home and a good method is as follows. Into a large covered vessel, set aside for the purpose, put the following articles to boil thoroughly: Modification of milk Sufficient wide mouth nursing bottles for each feed- ing with rubber covers and nipples ("Faultless" or "Hygeia"). 118 MATERNITY NURSING. 1 pint measuring graduate (glass). 1 teaspoon. 1 quart empty milk bottle. 1 "Skimit" syphon, or an improvised one made with two glass drinking tubes connected with about eight inches of rubber tubing to form a "U" shape. (The above mentioned rubber goods should only be boiled during the last three minutes of steriliza- tion.) To complete the equipment have ready: Pasteurized bottle milk. Milk sugar. Sterile water. Lime water. Sterile cotton. Bottled milk is best, for a more accurate idea of the percentage of cream it yields can be estimated than when other milk is used. If enough nursing bottles cannot be secured to contain the required amount for each feeding, then choose one large sterilized milk bottle for the whole quantity and from this pour each feeding, as required, into the nursing bottle. To ob- tain the cream (or top milk) use a "Skimit" syphon or fill the improvised syphon with sterile water and hold a piece of sterile cotton over one end to prevent the water from escaping. With a quick movement insert the other end of the syphon into the bottle of milk, having previously arranged the empty bottle ready to receive the fat-free milk as it flows after re- moving the cotton. (Have the empty bottle several INFANT FEEDING AND DEVELOPMENT. 119 inches lower than the bottle of milk.) Remove the syphon when the cream reaches the bottom of the bottle. Ordinarily after standing eight hours, there will be about six ounces of 16 per cent, cream. Put into the graduate measuring glass the required amount of milk sugar, add the lime water, mix well, then add the milk and cream according to formula. Make up the number of ounces required with plain boiled water, and pour into sterile bottles sufficient milk for each feeding. Adjust the rubber covers and put bottles in the refrigerator. If after the expiration of several days, the doctor decides a formula is needed, but fails to leave definite instructions for the making of it, either of the follow- ing ones may be employed to meet the emergency: (1) Milk 1 ounce Cream 16 per cent 2 ounces Lime water 1 ounce Milk sugar 1 ounce (by weight), or 3 tablespoons. Add sufficient boiled water to make 16 ounces. Give one to two ounces every three hours. Whole milk method preferred by some on account of being very easy to make up: (2) Whole milk (shaken well in bottle) 5 ounces Boiled water 10 ounces Lime water 1 ounce Milk sugar (by weight) 1 ounce Give one to two ounces every three hours. 120 MATERNITY NURSING. In these formulas and the one for premature babies on page 126 simplicity has been especially aimed at in order to avoid confusion. They will be found as reliable as most for ordinary use; but it must not be overlooked that each baby's food requirements differ Fig. 22.-Skimit sanitary milk syphon. This device is highly recommended for obtaining gravity cream for baby formulas, and also proves very useful in the kitchen. from that of every other baby, which renders neces- sary the adaptation of a formula to individual need. Daily increase in the weight, a satisfactory condition of the stools, normal temperature and the baby's evi- dent contentment all go to signify that the formula is agreeable. Persistent crying either just before the feedings are due, or immediately after the feedings INFANT FEEDING AND DEVELOPMENT. 121 have been taken indicates the baby is not getting enough food. It is then advisable to increase the quantity of each feeding from y2 ounce to vy2 ounces according to the need. Toward the end of the first week the formula should be made stronger by adding Fig. 23.-"Hygeia" nursing bottle. y2 ounce of milk every fifth day. The water should be increased by y2 ounce about every nine days. Undoubtedly the mother's milk is the ideal food for premature as well as all full term babies, but unfor- tunately, this is not always obtainable, so that artificial feeding must be resorted to. Oftentimes, a variation will be found in the amount taken at a feeding, but it is better to feed the baby regularly with a small quan- tity at first. Too much is liable to cause digestive dis- turbance, which must be rigidly guarded against. The Premature baby 122 MATERNITY NURSING. baby's weight every day will serve as the best indicator as to whether enough food is given. One ounce lost in a day by a premature is a serious consideration. A Fig. 24.-"Hygeia" nursing bottle cap. gradual increase in the quantity of food may be made as the infant's condition warrants. The sooner the baby is strong enough to nurse at its mother's breast, Fig. 25.-"Hygeia" nursing bottle nipple. the more chance it has of living. Until this time ar- rives, the milk must be pumped from the breasts, warmed and given to the baby by means of a "Breck" or some improvised feeder. One of the best kind in the author's estimation, is made with an ordinary glass INFANT FEEDING AND DEVELOPMENT. 123 Fig. 26.-"Breck" and improvised premature feeders. 124 MATERNITY NURSING. connecting tip and two rubber medicine dropper nip- ples, one pierced in the center with a small, red-hot needle to permit the milk to flow. An important fea- ture of this feeder is that the warmth of the milk is maintained longer than with the larger ones, for it is necessary to fill it frequently. This is especi- ally desirable where more time is required to take the food than usual. No effort on the part of the baby is needed when the "Breck'' or small feeder is used, except to swallow, and the danger from choking is minimized. Never take a premature baby out of its crib to feed it, as moving almost always causes re- gurgitation of food. Small pieces of gauze or old linen under both cheeks and chin will protect jacket, which if soiled with milk soon smells and becomes a source of discomfort and even infection to the infant. Between feedings a little warm sterile water may be given. The premature will undoubtedly prove of great at- traction to relatives and friends, but on no account should they be allowed to handle baby. It is positively essential that great care be given all feeding utensils Thoroughly clean and boil articles before using in a covered receptacle set aside for the purpose. The usual equipment consists of: Small feeder. Medicine glass. Medicine dropper. Breast pump. 2 small enamel basins. INFANT FEEDING AND DEVELOPMENT. 125 At feeding time place the required quantity of milk and medicine dropper in the glass and set in one of the Fig. 27.-Breast pump. basins containing hot water. The feeder can then be filled as often as necessary during feeding time. In pumping the breasts strict precautionary meas- ures must be taken to avoid possible infection of the Pumping breasts 126 MATERNITY NURSING. breasts. Always wash the nipples with boric acid solution before and after this procedure. Exhaustion of baby Feed baby as soon as possible after birth in order to maintain its strength. However, fainting spells with marked cyanosis are apt to occur from time to time. Giving the baby a warm dip bath and a drop of whiskey in several of sterile water sometimes proves beneficial. Lay baby on right side after feeding. Breast milk Start with about one dram or one dram and a half every hour for the first day, increasing the hourly feeding about fifteen drops each day thereafter, if baby can take it. Of course, it will be found that some babies require more and others less than the above quantity. It is impossible to set down a definite rule to go by. The daily weight of baby is the best guide, a regular gain of one ounce a day is very favorable; while on the other hand, an ounce lost must be re- garded as serious and every effort should be made to see that baby regains it the next day. Formula If breast milk is not procurable, the following for- mula may serve the purpose temporarily, until the doc- tor makes out his own. Milk 54 ounce Cream 16 per cent 1% ounces Lime water 1 ounce Milk sugar 1 ounce Add sufficient sterile water to make 16 ounces. Even if only a small quantity of breast milk is ob- tainable, by all means give it to the baby and supple- INFANT FEEDING AND DEVELOPMENT. 127 ment same with formula, for a few drops is always better than none at all. All bottles, nipples and covers, irrespective of the time of the year, should be sterilized by boiling at least once daily. Carelessness in this respect is responsible for much sickness during infancy, as is also the thoughtlessness of many mothers in allowing the nurs- ing bottles to lie around either before or after feeding to meet with contamination by flies, etc. No doubt the narrow-neck nursing bottles also offer a fine field for disease germs, and for this reason especially they should not be used. The "Hygeia" nursing bottle (see illustration page 121) unquestionably ranks among the best we have today. It meets a long-felt want, being absolutely sanitary and natural in shape. The last- mentioned feature is very desirable, as it consider- ably helps to overcome the trouble experienced by many mothers during the weaning period. The employment of rubber covers for these bottles is a great improve- ment over the old-fashioned method of using absorbent cotton, which is unsanitary and wasteful. In one week sufficient cotton is saved to cover the initial cost of one of the covers To have as many bottles as there are feedings in the twenty-four hours is best, as the ster- ilization of all those used can be done at the same time, thus minimizing work. Immediately after each feeding rinse bottles and nipples thoroughly under cold running water to re- Care of nurs- ing bottles 128 MATERNITY NURSING. move the milk stains. Put the nipples and covers in an empty mason jar and keep the lid on. The bottles may be left to soak in cold water. In the morning be- fore getting ready to prepare the feedings, wash the bottles, nipples and covers in a hot soapsuds solution (using Ivory soap and not the ordinary yellow house- hold kind as it is detrimental to the rubber). Give them all a final rinsing in clear water and place bottles and other articles needed for milk modification, except the rubber goods, in a large covered vessel filled with cold water and boil. The covers may be put in last for a one to three minutes boiling, never longer. Baby's development For the first month baby should sleep at least eighteen hours out of the twenty-four. At this time it is most important to establish regular habits. If baby has a habit of crying, something is wrong, for a well-nourished, strictly regulated baby seldom cries. The old idea that crying is necessary exercise for the lungs is no longer adhered to. About the fourth month baby begins to take an in- terest in things, and from this time to just before teething, vaccination is usually done. Between the fifth and the ninth month is the time for the first teeth. The lower front ones appear first and the full set of twenty should be complete in from two to three years. About the seventh month baby is usually able to sit erect. At twelve months to walk a little and say a word or two. INFANT FEEDING AND DEVELOPMENT. 129 It is wrong for anyone to attempt to hasten baby's development, by urging it to walk, etc. Leave baby alone to progress by itself and if within a reasonable time walking is not accomplished, let the mother seek medical advice. CHAPTER XII. DISORDERS, DISEASES AND CONGENITAL DEFORMITIES OF THE NEWBORN. Sprue or thrush This is an affection of the mouth of infants charac- terized by the presence of white spots with a reddened area of the mucous membrane surrounding them. It is due to a parasite and owing to present day advan- tages is far less common than formerly. As bottle-fed babies seem to suffer with the malady more than those breast-fed, there is no doubt but what the condition is due, in part at least, to uncleanliness in the preparation of the food and unsanitary conditions generally. Pre- vention is always better than cure and it cannot be too strongly impressed upon nurses to exercise strict clean- liness in all operations relating to baby feedings, etc. A recognized treatment is to swab the mouth gently with a sterile absorbent cotton sponge saturated in boric acid solution, 4 per cent., or sodium bicarbonate solution (one and one-half drams to a quart of sterile water) as often as the severity of the case calls for. Vaginal discharges Quite often female infants have a discharge from the vagina. Its consistency may be thin or thick and very tenacious and sometimes it will be found of gonorrheal origin acquired from the mother or possibly through 130 DISORDERS OF THE NEWBORN. 131 contamination after birth. The doctor should always be informed of its existence, especially when there is any redness or swelling of the vulva. Ordinarily, a thor- ough cleansing of the parts frequently with warm boric acid solution will be found all that is necessary. When treating such discharges, a nurse cannot be too careful in disposing of all soiled sponges which should be re- ceived with other refuse in a paper bag and burned im mediately in order to avoid the spread of possible in- fection; a good scrubbing of the hands, too, is neces- sary after each treatment. Bloody discharge from the vagina, which may ap- pear any time after birth, lasting only a few days, must not be looked upon with alarm, as it is not dan- gerous and requires no treatment. Doctors regard it as a true menstrual function. Bloody dis- charge from the vagina Inanition fever, or otherwise known as starvation fever, is very often demonstrated about the third or fourth day after birth. As its name indicates, the cause is insufficiency of food. The baby's temperature may go as high as io6° F. or even higher; but this will show a decided drop very soon after the baby receives the required quantity of food. Sometimes a drink of sterile water will favorably influence such a high tem- perature in its descent to the normal. Coincident with this rise of temperature there is always exceptional loss of weight. Inanition fever 132 MATERNITY NURSING. Engorgement of the breasts This condition usually begins several days after birth and may affect the breasts of both sexes, which become hard, enlarged, and reddened. Most doctors consider the best thing to do is to let them entirely alone with the exception of the application of a moder- ately tight breast binder. Under no consideration should the breasts be squeezed, as such manipulation would most likely cause suppuration. "Snuffles" When this is not a symptom associated with syphilis, it is usually due to exposure to drafts. Where the nasal secretion is excessive it should be removed with an applicator. Eyes Any discharge from the baby's eyes should be re- ported to the doctor without delay and strict precau- tionary measures taken. While waiting for definite instructions from the doctor, isolate the baby in a dark- ened room and wrap it firmly in a blanket, taking care to have the arms well down to the infant's sides to prevent any attempt to scratch the face or touch the eyes. If only one eye seems to be infected lay the baby partly on that side in order to avoid, if possible, infection of the other eye. When a culture is taken by the doctor as is the custom, he will in all probability order, with other treatment, the application of cold compresses. These should be of muslin, single thick- ness, about one and a half inches square. Heavy com- presses are liable to injure the eyes. Keep them cold by changing every two or three minutes and do not DISORDERS OF THE NEWBORN. 133 use the same one twice. It is impossible to administer any eye treatment to a baby unless it is first wrapped in a covering to prevent any movement of the arms as previously explained. When frequent irrigations are necessary in conjunction with the compresses, it is best accomplished with a medicine dropper, using absorbent cotton very gently as wipes afterward. Throw all refuse into a paper bag immediately and burn as soon as possible. From the nursing stand- point it is wise to consider all cases of discharging eyes as highly infectious until the culture taken proves to the contrary and to proceed as one would in any other kind of infectious disease in regard to personal clean- liness, disinfection, etc., to prevent its spread. A nurse cannot be too careful, especially in safeguarding her- self, when she comes in contact with venereal diseases. The great majority, alas! are very careless in this respect. If once innocently infected, there are many people who would question the fact that the nurse had contracted the disease while performing the duties peculiar to her profession. Surely this is sufficient warning to us careless ones. If the case is known to be one of gonorrheal ophthalmia, the treatment neces- sary involves the constant undivided attention of a nurse to carry out the prescribed treatment. Unless this can be arranged, the baby should be admitted to the nearest hospital without delay in order to save its sight. 134 MATERNITY NURSING. Stools and urine It is always wise to note the character of the stools passed, especially if the baby is bottle-fed, as abnormal stools are the first manifestation of errors in the diet. The intestinal discharge for a day or so after birth is known as meconium; it is of a thick, black, tar con- sistency, which gradually changes to a dark green color, until about the fourth or fifth day, when the stools should be yellow, soft and smooth. From three to six stools a day should be considered normal up to around the third week, then there is usually a decrease in the number. Green stools indicate fermentation; but they are sometimes due to too much sugar in the formula. The presence of hard curds in the stools indicate there is too much casein in the diet; yellow, soft curds, too much fat. Constipation is sometimes present in very young babies which can be overcome by an occasional small dose of castor oil; but it is rarely necessary. Green stools almost always show improvement from this treatment. Healthy babies should pass enough urine to soil several diapers a day; when it is scanty, highly colored, and stains the diaper, faulty metabolism is indicated. Sore buttocks Neglect is usually responsible for this condition and no nurse should allow it to occur. Occasionally, when the baby is suffering from improper feeding and the stools are consequently green, unless the utmost care DISORDERS OF THE NEWBORN. 135 is given to the removal of all diapers immediately they become soiled, sore buttocks usually develop; then the condition is difficult to cope with. If the parts are merely reddened through neglect to change the diaper, clean well with sweet or olive oil. When the skin is broken, a paste made with bismuth subnitrate and cas- tor oil may be spread on a piece of linen and used to cover the denuded area. This treatment has been known to give desired results in a surprisingly short time, when all other methods failed. Icterus or jaundice, as it is commonly called, is sup- posed to be due to some obstruction in the bile duct. When slight, the condition usually calls for no treat- ment. There are, however, rare cases where the whole body is a deep jaundice indicating derangement of a possible septic nature. Such cases are considered grave and almost always prove fatal. Icterus Atelectasis is a condition where the air cells of the lungs fail to expand. The causes are not known al- though some doctors claim it may be due to obstruc- tion of the air passages. Atelectasis Hemophilia is an inherited tendency to bleed from slightly injured or apparently normal surfaces of the body. It is always transmitted through the mother to male children who do not in turn convey the tendency. It is transmitted by female children who show no evidence of the disease. Hemophilia 136 MATERNITY NURSING. Congenital cyanosis Congenital cyanosis or "blue baby" as it is com- monly called may be due to a number of causes and not to a defective heart alone. The most frequent causes are congenital malformations of the respiratory tract, heart, and blood-vessels. Tuberculosis If the children born of tuberculous parents do not actually inherit the disease, they show marked lowered resistance to the invasion of the tulnercle bacillus. Such children thrive best when bottle-fed as it pre- vents the possibility of infection from the mother through the milk supply. The mother also seems to fare better under this plan. Syphilis Many babies inheriting this most loathsome disease, curiously enough, show little or no external evidence of it at birth. Several weeks may elapse before signs of the disease are manifested; of these, snuffles seem to appear first, then there is rapid loss of flesh and skin eruptions of various kinds which mostly affect the mouth and external genitals. Thus viewed, a syphilitic child is a pitiable spectacle-some respond to good care and treatment, but the outlook is usually a gloomy one for the child if it survives. Surely it would seem we have arrived at the age when such inflictions should not be an inheritance. Melena Melena, otherwise known as gastrointestinal hemor- rhage, occurs most frequently a few hours after birth and is due to a variety of causes, hemophilia being a very common one. The blood vomited may be of a DISORDERS OF THE NEWBORN. 137 bright red or a dark brown color. That expelled from the intestines is not always easy to distinguish, being quite similar in appearance to meconium which it is mixed with. Caput succedaneum is a serous tumor of the present- ing part of the baby's head and is most marked when the labor has been a prolonged one. It is often con- fused with cephalhematoma; but contrary to that con- dition disappears a few days after birth without treatment. Congenital Deformities. Some of the commonest are: Hydrocephalus, acephalus, cephalhematoma, harelip, cleft palate, tongue-tie, supernumerary digits, umbilical hernia, spina bifida, imperforate rectum, club-foot. Caput succedaneum CHAPTER XIII. COMPLICATIONS OF THE PUERPERIUM. Postpartum hemorrhage Undoubtedly, no condition warrants such prompt action on the part of a nurse, as postpartum hemor- rhage. It is highly important for her to meet this emergency in a cool and brave manner, for the treat- ment rendered, until the arrival of a doctor, may be the means of saving a patient's life. It very seldom happens that some doctor cannot be secured to render the necessary treatment and this should be the nurse's first thought. Even if out in the country many miles from a doctor, she should send somebody for the nearest one and proceed immediately to meet the emer- gency. The first thing to do is to remove the pillow from under the patient's head, give one ampule of ergot hypodermatically or one dram by mouth; then massage the fundus vigorously and while engaged in this have some member of the family elevate the foot of the bed on a table. If these measures do not have the desired effect and bleeding still continues, a hot vaginal douche should be given at 1240 F. A lower degree of heat than this would only tend to increase the hemorrhage. By this time if the doctor has not ar- rived, and all attempts to arrest the hemorrhage have 138 COMPLICATIONS OF THE PUERPERIUM. 139 failed, as speedily as possible proceed to pack the uterus with the hemorrhage packing mentioned in the list on page 49. Dispatch members of the family for hot-water bags and place them around the patient. If her condition becomes grave, stimulants such as strychnia, whiskey, hypodermoclysis, and salt solu- tion by rectum may have to be resorted to. The object in massaging the fundus is to induce con- tractions ; this manipulation is accomplished by grasp- ing the fundus with one hand through the abdominal wall. Knead and rub it vigorously with the fingers, having the palm of the hand over the fundus and the thumb in front. If within a short time this irritation does not bring about the desired result, namely, hard- ening of the fundus, a piece of ice may be rubbed over the surface and if this does not immediately produce contractions it should be stopped as its continued use is inclined to have a relaxing effect. Maternity nurses are usually familiar enough with the doctor's methods to know how to proceed in such an emergency. It is very necessary that the nurse should be able to perceive at the right time any abnormal symptoms that might indicate a septic condition, in order that the doc- tor may be able to render appropriate treatment. Puer- peral septicemia, as it is known, with rare exception is claimed to be due to infecting organisms being car- ried into the genital tract before or during delivery. Puerperal sepsis 140 MATERNITY NURSING. Hence the importance of faultless technique at that time. The symptoms of this condition are usually manifested several days after delivery. There is a sudden rise of the temperature accompanied by chills, headache, restlessness and general discomfort. The nurse must not conclude that all elevation of the tem- perature indicates septicemia, for a woman after labor can demonstrate fever from other causes. In puer- peral septicemia the lochia may be absent or scanty and have a foul smelling odor. All pads which seem abnormal should be saved for the doctor's inspection. He should also be told whether the patient complains of any tenderness or actual pain in the region of the uterus. A great deal may be accomplished by good nursing measures. Keep the patient quiet and cheer- ful, excluding all household responsibilities. Her room should be light with an abundance of fresh air and sunshine, or if it can be arranged open air treatment is preferable. If a liquid diet is ordered, no pains should be spared to make it as varied, nourishing and tempt- ing as possible. Serve all cold drinks cold and the hot ones hot. Force all nourishment, for one of the most important things to do is to keep up the patient's strength. Phlegmasia alba dolens This disorder commonly known as "milk leg'' is caused by a blood clot in the veins of the legs or pelvis. It is accompanied by stiffness of the limb, swelling, severe pain, and high temperature. The nursing care COMPLICATIONS OF THE PUERPERIUM. 141 consists of absolute rest and quiet. A pillow splint is often employed to afford extra protection to the leg, which should be moved as little as possible in fear of dislodging the blood clot which might prove fatal. The bed clothes should be supported with a cradle or hang from the foot posts of the bed. Plenty of fresh air and good nourishing food are most essential. Bed sores should be carefully guarded against. With good nursing care the formation of a breast abscess is a remote possibility. Where inflammation has set in the patient usually complains of chills, head- ache, and pain in the breast which becomes red and somewhat swollen; there is always elevation of the temperature. Should these symptoms occur, it is best to leave the breast entirely alone, take the baby off and notify the doctor. The treatment usually consists in the constant application of ice bags to the breast and a saline purgative in large doses. Should the in- flammation not subside and the condition results in an abscess, surgical interference is then indicated. Mastitis It is claimed that about one in four hundred women confined become insane. The types of insanity range from mania to mental confusion and women are more apt to be affected during the puerperium than in preg- nancy. Melancholia is more common during the lat- ter period, while mania is the most frequent form of mental breakdown occurring during the puerperium. The treatment is best carried out in a psychopathic Puerperal insanity 142 MATERNITY NURSING. institute, but if this cannot be arranged the patient should be under the constant care of a trained attend- ant to prevent her from doing possible injury to her- self and child, and given a rest cure with plenty of nourishing food, fresh air, exercise, and sleep. Cystitis and pyelitis The failure to take aseptic precautions when passing the catheter is one of the chief causes of cystitis. It is a very distressing malady and is dangerous in pro- portion to the extent of the infection which if not ar- rested may go as far as to involve the kidney thus caus- ing inflammation of the pelvis of that organ known as pyelitis. When once contracted this disease may impair the patient's health for the rest of her life, or even cause death from septic infection. The symptoms of cystitis are: Painful and frequent urination and tenderness over the bladder area. In pyelitis the pain and tenderness extends to the lumbar region with ele- vation of the temperature and sometimes chills. The urine is loaded with pus and bacteria. Treatment con- sists of absolute rest; a nourishing diet with increased fluids to drink. Irrigations of the bladder with weak solutions of either boric acid, potassium permanganate, or iodine may prove helpful in cystitis and possibly prevent the infection spreading to the kidneys. Sometimes sur- gical drainage of the kidney in pyelitis is necessary, or even complete excision of the organ is resorted to. COMPLICATIONS OF THE PUERPERIUM. 143 This accident may be caused by traction on the um- bilical cord in an effort to express an adherent pla- centa, or sometimes by a short cord pulling upon the placenta during labor; or the uterine wall may be- come so relaxed as to sag down. The condition often proves very alarming especially when complete and accompanied with shock and hemorrhage. Fortunately it is quite a rare occurrence. The treatment is usually reinversion. Inversion, of the uterus CHAPTER XIV. TWILIGHT SLEEP. As the author has had under her personal nursing supervision many hundred cases of twilight sleep, she feels that the experience thus gained has prepared her to be able to express a few words concerning it, from a purely nursing standpoint; for it may prove interesting to many nurses. Much prejudice is met on the basis that such treat- ment is experimental. Experiments are made and tolerated with keen interest in all new ideas pertaining to other branches of science, but when it comes to ex- periments being made in the interest of human suffer- ing, many are skeptical. Be this as it may few, if any, lives have been sacrificed in the cause and even in its present stage of development, much pain lias been elim- inated and thousands of mothers benefited by pain- less childbirth. A number of obstetricians in New York, London, Germany, and elsewhere are continuing with the good work in the hope that its administration may ulti- mately reach as near as possible the stage of perfec- tion, so that the majority of mothers may never know the suffering of childbirth. The obstacles to be over- 144 TWILIGHT SLEEP. 145 come while striving to this end are not numerous. In order to take up the study much expense would be incurred. It recpiires a building devoted exclusively to the work, also the individual attention of obstetric- ians and skilled nurses to assist them. Although much success has been gained by administering twilight sleep in hospitals and other institutions not originally Fig. 28.-Twilight sleep babies, Lebanon Hospital, New York. (Courtesy New York Evening Journal, Copyright, 1914.) intended for the purpose, such a practice is by no means fair. A great degree of success can only be hoped for or expected, when the obstetrician is able to give his individual attention to each case, assisted by a tactful, untiring nurse who is interested in maternity work. These essentials could not be expected in ordinary institutions, private, houses or tenements. Scopolamin and a derivative of morphin, such as narcophin are the drugs usually employed. As an idio- syncrasy for these exist in certain individuals, as is 146 MATERNITY NURSING. the case with all other drugs, the most important point to arrive at is how much of the drug is required in every case to bring about the desired state of analgesia to afford a painless childbirth. Quite recently adequate follow-up work by a well- known obstetrician revealed no marked after-effects, which shows the treatment is being improved. When after-effects are encountered it usually signifies that the case was a poorly chosen one which should not have received the treatment at all. APPENDIX HELPFUL HINTS. How to Keep Drinks, etc., Cold Without Ice.-Milk and other liquids, as well as butter, etc., may be kept cold even during intense summer heat by following these simple directions: Place the receptacles containing the foods in a shallow pan, previously covering each with a single thickness of muslin wrung out of cold water; then pour into the pan sufficient cold water to measure about one or two inches from the bottom-no more. To obtain the desired result the outfit must be placed in a draught to permit evaporation and away from the sunlight. Mason jars with lids and small salt bags to cover them are excellent to use for the above. Removal of Blood Stains.-To remove blood stains from sheets and other linens, do not place them in hot water; in- stead, soak in cold water for a few hours, then wash in the usual way and boil. Hypodermic Injections.-Give these in the fleshy part of the outside of the thigh, never near bony prominences. Do not put the needle into the superficial layers of flesh as though darning a stocking, inject it deeply and quickly. This method causes the least discomfort to the patient and leaves no pain- ful lump. Use a fine needle and keep it wired when not in use. Hot-water Bags.-Rather have no hot-water bag in the baby's bed than place one there carelessly when in a hurry and risk a burn. Removal of Adhesive Plaster from the Skin.-To accomplish this easily, soak the plaster with ether, alcohol, or benzine, then grasp one end of it and pull off quickly. 147 148 APPENDIX. Castor Oil.-Make a dose of castor oil as palatable as pos- sible. A good way is to first rinse the glass out with cold water; into it pour a small quantity of lemonade, add castor oil carefully, then some more lemonade or a few drops of spirits of peppermint. Serve as cold as possible. Iodine Stain.-May be removed by pouring boiling water over the stain, or sponging with grain alcohol. SYMBOLS. aa of each. a. before meals. ad fib as much as desired. b. i. d twice a day. with. c cubic centimeter. dil dilute. gtt drop or drops. mix- o d once daily. ol oil. p. after meals. p. r. as occasion arises. q. d four times daily. q. h every hour. q. as much as is sufficient. B recipe, take. s. o. if necessary. half. t. i. dthree times a day. tr tincture. ungointment. APPENDIX. 149 APOTHECARIES' WEIGHTS AND MEASURES. W eight. Grains Scruples Drams Troy Ounces Pound 20 1 60 3 1 480 24 8 1 5,760 288 96 12 1 Measure. Minims Fluidrams Fluidounces Pints Gallon 60 1 480 8 1 7,680 128 16 1 61,440 1,024 128 8 1 TABLE OF EQUIVALENTS. Grains Grams or Cubic or Minims Centimeters %4 0.001 y32 o 002 i/w 0.004 y8 • 0 008 0 032 1 0 065 5 0.333 10 0.666 15 1.000 20 1.333 30 2.000 Drams or Grams or Cubic Fluidrams Centimeters 1 4 2 8 4 16 6 24 150 APPENDIX. TABLE OF EQUIVALENTS (Continued). Troy Ounces or Grams or Cubic Fluidounces Centimeters 1 30 2 60 4 120 6 180 8 240 16 480 16.9 500 32 960 33.8 .... 1000 Inches Millimeters %2 0.8 1.0 ¥16 .................... 1.6 % 3.2 14 6.4 % 12.7 1 25.4 Inches Centimeters 6 15.2 12 30.5 24 61.0 36 91.4 39.37 100.0 Fahrenheit 32° Centigrade 0° 41° 5° 50° 10° 68° 20° 77° 25° 86° 30° 95° 35°' 98.5° 36.9° 100° 37.8° 102° 38.9° 104° 40° 105° 40.54° 106° 41.8° 122° 50° 140° 60° 176° 80° 194° 90° 212° 100° GLOSSARY Abdomen. The body cavity between the thorax and pelvis. Abdominal pregnancy. Extrauterine fetation in the abdominal cavity. Abort. To miscarry. Abortion. Expulsion of an embryo up to the end of the fourth month. Acephalous. Without a head. Alexander's operation. A shortening of the uterine round ligaments. Amenorrhea. Irregularity or suppression of the menstrual flow. Amnion. One of the embryonic membranes. Amniotic fluid. The fluid in the sac of the amnion; it sup- plies water to the embryo, equalizes pressure and helps labor by dilating the cervix. Anteflexion. The bending forward of the uterus upon itself. Anteversion. The tipping forward of the uterus. Areola. The dark colored ring around the nipples. Asphyxia neonatorum. Respiratory inability of the newborn. Atelectasis. Failure of the air cells to expand in the lungs of the newborn. Ballottement. A falling back of the fetus when the uterus is given a sudden push with the finger in the vagina. Bandl's ring. A depression sometimes felt above the pubes during labor pains. Basiotribe. An instrument used to crush the fetal head. Breech presentation. That position in which the buttocks of the fetus presents. Caput succedaneum. A serous tumor on the head of .the fetus. Caul. Fetal membrane covering the head at birth. 151 152 GLOSSARY. Celiohysterectomy. Removal of the uterus through an ab- dominal incision after the extraction of the child. Celiohysterotomy. Incision of the uterus through the ab- dominal wall as in cesarean section. Cephalic version. The turning of the fetus in the uterus to make a head presentation. Cephalometer. A head measuring instrument. Cervix. The neck of the uterus. Cesarean section. Abdominal extraction of the fetus. Chorion. The fringe-like membrane that forms the outer envelope of the embryo. Colostrum. A thin colorless fluid secreted by the breasts after the third month of pregnancy. Confinement. The period of giving birth. Craniotomy. A crushing of the fetal head. Crede's method. The placing of silver nitrate solution (1 to 2 per cent.) in the eyes of the newborn as a prophylactic measure against ophthalmia neonatorum; the term also alludes to the manual expression of the placenta. Decapitation. Cutting the head off of the fetus in labor. Decidua serotina. The part of the uterine wall to which the ovum is attached. Decidua vera. The membranous folds which envelope the ovum in the uterus. Dermoid cyst. Cyst containing hair, teeth, etc. Dysmenorrhea. Painful menstruation. Dysuria. Painful or difficult urination. Eclampsia. A toxemia of pregnancy characterized by con- vulsions occurring either before, during, or after labor. Ectopic gestation. Fetation outside of the uterus. Embolism. Obstruction of circulation caused by lodgment of a blood clot or other body. Embryo. The impregnated ovum up to the end of the fourth month. Embryonic abortion. Abortion up to the end of the fourth month. Embryotomy. The dismemberment of the fetus in the uterus. GLOSSARY. 153 Emmenagog. An agent that stimulates the menstrual flow. Encephalocele. Hernia of the brain. Endometritis. Inflammation of the membrane lining the uterus. Enuresis. Inability to hold the urine. Episiotomy. Incision of the labia during labor to preserve the perineum. Evisceration. A removal of the viscera. Extrauterine pregnancy. Development of the fecundated ovum outside the uterine cavity. External os. The external orifice of the uterus. Fallopian tubes. Small tubes connecting the uterus and ovaries through which the ova from the ovaries is con- veyed into the uterus. Fecundity. The power of producing young. Fetal abortion. Abortion after the end of the fourth month. Fetation. Pregnancy. Fetus. The fecundated germ after the end of the fourth month. Forceps. Instruments used for extracting the baby from the uterus. Fowler's position. Semi-erect position brought about by elevating the head of the bed and supporting the pa- tient on pillows. Fundus. The upper head-like portion of the uterus. Funis. A cord-like structure; a term sometimes applied to the umbilical cord. Galactagog. An agent which stimulates the flow of milk. Genitalia. The generative organs. Genupectoral. The knee-chest position. Gestation. Pregnancy. Gonorrhea. A highly contagious disease having a purulent discharge. Graafian follicles. Round vesicles found in the ovary in which the ova are developed. Gynecology. The science which treats of female diseases. 154 GLOSSARY. Hematoma. A blood tumor. Hemophilia. A tendency to hemorrhage. Hydatidiform mole. Cystic degeneration of the chorionic villi. Hydramnios. Excessive fluid in the amniotic sac. Hydrocephalus. Dropsy of the brain. Hysterectomy. Excision of the uterus. Hysterotomy. Incision of the uterus. Icterus. Jaundice. Impregnation. Fertilization. Internal os. The inner opening of the uterus into the cervi- cal canal. Involution. The return of the uterus to its former size after childbirth. Kyllosis. Club-foot. Kyphosis. Spinal curvature, hump-back. Labor. A bringing forth of young. Linea alba. The white line in the middle of the abdomen. Linea nigra. A dark line extending from the pubes upward in the median line present in some pregnant women. Lithotomy position. One in which the patient lies on the back with the legs flexed and knees wide apart. L. O. A. Abbreviation for the left occipito-anterior position of the fetus. L. O. P. Abbreviation for the left occipito-posterior position of the fetus. Lochia. The vaginal discharge that takes place during the first week or two after childbirth. Lues. Syphilis. Mammary glands. Compound milk secreting glands. Mastitis. Inflammation of the breasts. Meatus. External opening of the urethra. Meconium. The first intestinal discharge of the newborn. Menopause. Cessation of menstrual activity. Menorrhagia. An excessive menstruation. Menostasis. A suppression of the menses. GLOSSARY. 155 Menstruation. The monthly flow of blood from the uterus. Metrorrhagia. Hemorrhage from the uterus between men- strual periods. Micturition. The act of passing urine. Miscarriage. The expulsion of the fetus after the fourth and before the sixth month. Multipara. A woman who has borne more than one child. Nevus. Birth mark. Nullipara. A woman who has not produced young. Obstetrics. The science of the care of women during preg- nancy. Omphalocele. Umbilical hernia. Oocyesis. Ovarian pregnancy. Oophorectomy. Excision of an ovary. Ophthalmia neonatorum. Purulent conjunctivitis of the new- born. Os uteri. The mouth of the uterus. Ovaritis. Inflammation of an ovary. Ovary. The ova-producing organ in the female. Ovulation. The maturation and escape of ova from the ovary. Ovum. The reproductive cell of the female. Oxytocic. An agent used to promote uterine contractions. Parturition. The giving birth to young. Pelvimeter. An instrument for measuring the pelvis. Pelvis. The bony structure formed by the innominate bones, sacrum and coccyx. Perineorrhaphy. The suturing of the perineum. Perineum. The region between the anus and external geni- talia. Pessary. An instrument worn in the vagina for uterine sup- port. Phlebitis. Inflammation of a vein. Phlegmasia alba dolens. Milk-leg, edema brought about by venous obstruction. Placenta. The afterbirth. 156 GLOSSARY. Placenta previa. Placenta presenting in the uterus before the fetus. Podalic version. A turning of the fetus in the uterus to make the feet present. Polyuria. Excretion of a large quantity of urine. Post partum. After child-birth. Precipitate labor. Delivery with undue haste. Pregnancy. The condition where an impregnated ovum is within the body. Premature labor. Delivery of a viable fetus before the normal time. Prenatal. Before birth. Primigravida. A woman pregnant with her first child. Primipara. A woman giving birth to her first child. Progeny. Offspring. Prolapse. A falling down of an organ. Pruritis. Itching. Pubiotomy. A sawing through of the pubic bone to facilitate delivery. Pudendum. The female external genitals. Puerperial. Following child-l irth. Puerperium. The time from the birth of the child to the completion of involution. Purulent Characteristic of pus. Pygal. Pertaining to the buttocks. Pyosalpinx. Pus in the Fallopian tubes. Quadroon. The offspring of a white person and mulatto. Quadruplet. One of four children born .together. Quickening. The first fetal moveme t felt in the uterus. Rectum. The lower part of the large intestine. Retroflection. A bending back of the uterus upon itself. Retroversion. A backward displacement of the uterus. R. O. A. Abbreviation for the right occipito-anterior position of the fetus. R. O. P. Abbreviation for the right occipito-posterior position of the fetus. GLOSSARY. 157 Salpingectomy. Excision of a Fallopian tube. Salpingitis. Inflammation of a Fallopian tube. Septicemia. An infection of the blood. Sims position. That in which the patient lies on the left side with the right leg drawn up and the left arm placed along the side. Sims speculum. A vaginal instrument shaped like a duck's bill. Snuffles. A nasal discharge. Spina bifida. A congenital fissure of the spine. Sphygmomanometer. A blood-pressure machine. Spontaneous abortion. An abortion not induced artificially. Still-born. Born lifeless. Striae gravidarum. Atrophic marks on the abdomen during pregnancy. Subinvolution. Defective involution. Suprapubic. The area above the pubis. Symphysiotomy. Division of the pubic joint. Syphilis. An infectious venereal disease, may be hereditary. Talipes. Club-foot. Thelitis. Inflammation of the nipples. Therapeutic abortion. Abortion induced in order to save the life of the mother. Thrombus. A blood-clot in a vessel at the point of obstruc- tion. Trendelenburg's position. That in which the patient lies on the back with the pelvis elevated higher than the head. Umbilical cord. The jelly-like string connecting the placenta with the fetus. Umbilicus. The round depression in the median line of the abdomen. Uterus. The pear-shaped, hollow, female organ of generation. Vagina. The canal extending from the vulva to the uterus. Vemix caseosa. The cheese-like substance covering the fetus. Version. The turning of the fetus in the uterus. 158 GLOSSARY. Viable. Able to maintain life. Vulva. The external female genitals. Wharton's jelly. The gelatinous substance of the umbilical cord. INDEX Abdomen, changes in during preg- nancy, 10 Abdominal binder, adjusting, 100, 101 Abdominal palpation, 64 Abortion, complete, 27 fetal indications for, 46 incomplete, 27 symptoms and treatment of, 27 therapeutic, 45 Abscess of breast, 141 Accidental hemorrhage, 38, 39 Adhesive plaster, removal of, 147 After birth, see Placenta. pains, 86 Albumin, test, 25 in urine, 21 Alcohol rub in eclampsia, 34 Anatomy and physiology of the female pelvis, 1 Anesthesia, 75 administration by nurse, 76 chloral, 76 chloroform, 75, 76 for convulsions, 33 cocaine, 76 narcophin, 145 nitrous oxide, 75 scopolamin, 145 Ante partum hemorrhage, 28 Apothecaries' weights and meas- ures, 147 Appendix, 147 Applicators, how to make, 51 Asphyxia, 82 livid, 83 pallid, 83 treatment of, 82 Atelectasis, 154 Atrophy of liver, 35 Auscultation of fetal heart, 64 Babies, twilight sleep, 145 Baby, blue, 136 care of, 106 dressing, 109 full term, feeding and schedule for, 115 premature, 110 jacket, 111 how to make, 112 resuscitation of, 61 "Vanta" at chest of drawers, 53 clothes, 52 diaper, 54, 55 how to make, 57 shirt, 55 Baby's bed, 62, 110 daily record, 114 development, 115, 128 eyes, care of, 132, 133 during delivery, 73 discharges from, 132, 133 formation of, 6, 7 159 160 INDEX. Baby's first cleansing bath, 107 how to give, 107 food, breast and artificial, 126 oil bath, 106 outfit, 52 Back rest, 104 Bags, hot water, 147 inflated, 41, 46 for nurses, 56 paper, 62, 108 Ballottement, 11 Bandage, how to apply, 21, 22 Bathing during pregnancy, 18 the puerperium, 101 sea, 18 Binder, Murphy breast, 92 "T," 68, 100 "Y," breast, adjusting, 98 "Y," breast, closed, 99 "Y," breast, in the making, 95, 96 Bladder distention during labor, 71 irrigation, preparation for, 89 irrigation, resorted to in cystitis, 142 irritability, 8, 11 Blood, discharge from vagina dur- ing pregnancy, 27 in the newborn, 131 pressure, during pregnancy, 22, 30 stains, how to remove, 147 Bottle, "Hygeia" nursing, 121 cap, 122 stone heater, 113 Bottles, care of nursing, 127 Bougies, use of, 46 Breast binder, Murphy, 92 "Y," 95-99 Breast changes during pregnancy, 10 milk for prematures, 126 pieces, 91 pump, 125 use of, 125 shield, "Davol," 93 tray, 91 Breasts, care of during pregnancy, 24 during the puerperium, 91, 92 drying up the, 99 engorgement of, in the newborn, 132 Breck feeder, 123 Breech extraction, 46 presentation, 66, 81 Buttocks, sore, 134, 135 Caput succedaneum,. 137 Castor oil, when to give in the puerperium, 102 how to give, 148 Cathartics in pregnancy, 20 during the puerperium, 101 Catheter, kind to use in preg- nancy, 71 Catheterization, after labor, 87 procedure, 88 Cervix, softening of, 10 Cesarean section, 2, 41, 42 indications for, 41 vaginal, 42 varieties, 42 Chloroform, administration, 75, 76 mask, improvised, 77 Chorion villi, conversion of, 37 INDEX. 161 Circulation, maternal, 6 Cleansing bath, baby's first, 107 during pregnancy, 18 the puerperium, 101 Clinic, postnatal, 104 prenatal, 12, 13 Clothes, during pregnancy, 13 Coccyx, 1, 2, 6 Colonic irrigations, 34 Colostrum in breasts, 8, 10, 24 Complications of pregnancy, 26 of the puerperium, 138 Congenital cyanosis, 136 deformities, 137 Conjugate, external, 3, 4 true, 4 Constipation during pregnancy, 20 in the puerperium, 102 Convulsions, 32, 33 Cord, dressing, how to make, 50 the, 81 hemorrhage from the, 75 prolapsed, 71 off, 109 after-care, 109 Corsets, maternity, 13, 14, 15 Covers, for packages, 51 Craniotomy, 44 Cystitis, 89, 142 Davol's nipple shield, 93 Decapitation, 44 Deficiency of breast milk, 102 Deformities, congenital, 137 Delivery, actual, 73 at home, necessities for, 48 dorsal position for, 79 eye treatment during, 73 Delivery forceps, nurse's prepara- tion for, 43 nurse's, 79 pack, 51 pads, 50 preparation for, 59 record of, 75 Sims position for, 80 stages of, 67 when to call the doctor for, 70 Diet, during pregnancy, 19 the puerperium, 87 Digital examination, 2, 65 Discharges, infants vaginal, 130, 131 vaginal, 36 Disinfectants, 60 Disorders, of the newborn, 130 Displacements and inflammations, 29 Dizziness, 21 Douches, during pregnancy, 21 the puerperium, 87 in gonorrhea, 36 Dressing the cord, 81 perineum, 84, 85 tray, perineal, 85 Dressings and outfits, 47 sterilization of, 47 Drinks, after delivery, 74 hot in eclampsia, 34 how to keep cold, 147 how to serve, 140 Dry packs, 34 Drying up the breasts, 99 Eclampsia, 32 use of morphia in, 33 convulsions in, 32 162 INDEX. Eclampsia, hot, wet pack for, 33 medical treatment for, 33 nursing care in, 33 Ectopic gestation, 28 Edema, 21 Elastic stocking, 21 Elimination, faulty, 31 of waste, 6 Eliminatory organs, 18 Embryo, development of, 6, 7 ' Embryotomy, 44 Enema during labor, 67, 71 puerperium, 102 Episiotomy, 44 Equivalents, table of, 149, 150 Ergot, giving of, 73 Ether, administration of by nurse, 78 Examination, postnatal, 103, 104 prenatal, 12, 13 rectal, 65 vaginal, 65 Exhaustion of premature baby, 126 Exercise, during' pregnancy, 18, 21 the puerperium, 104 External measurements, 4, 5 External hemorrhage, 28 Extraction, breech, 46 Evisceration, 44 Extra uterine pregnancy, 28 Eyes, discharges from, 132 nursing, care of, 133 treatment of, during delivery, 73 Face presentation, 66 Fallopian tubes, 6 Feeders, Breck and improvised, 123 Feeding, infant, 115 full term baby, 115 premature baby, 126 Female generative organs, 6 Fetal heart, auscultation of, 64, 69 in breech presentation, 70 transverse presentation, 70 vertex presentation, 70 rate, 69, 70 Fluids, restrictions of, 99 Follicle, Graafian, 6 Forceps, 43 Formulas, for full term baby, 119 Formula for premature baby, 126 Full term baby, nursing schedule for, 115 Fundus, height of during preg- nancy, 11 holding the, 74 Garters, 13 Gastrointestinal hemorrhage, 136 Generative organs, female, 6 Genitals, shaving of the, 67 Gestation, ectopic, 28 Getting out of bed, 104, 105 Gonorrhea, 36 Gonorrheal ophthalmia, 133 Glossary, 151 Graafian follicle, 6 Green stools, 134 Heart, fetal, 64, 69 Heart-burn, 19 Helpful hints, 147 Hemorrhage, accidental, 38, 39 INDEX. 163 Hemorrhage, ante partum, 28 from cord, 75 external, 28, 29 concealed, 28, 29 post partum, 138 Hemophilia, 135 Hose supporters, 16, 17 "Velvet Grip," 16 Hot water bags, 62, 147 heater, 113, 62 wet pack, 33 dry pack, 34 Hydatidiform mole, 37 Hydramnios, 29, 38 Hygeia nursing bottle, 121 nipple, 122 cap, 122 Hygiene of pregnancy, 12 Hypodermic injections, where to give, 147 set, sterilized, 62 Icterus, 135 Inanition fever, 131 Induction of labor, 45 Infancy, constipation in, 134 Infant feeding, 115-129 Injections, hypodermic, 147 Inlet, pelvic, 1-4 Insanity, puerperal, 141 Instruments, sterilization of, 63 Intercrestal measurements of pel- vis, 3-5 Interspinous measurements of pel- vis, 3-5 Internal measurements of pelvis, 4 Inversion of the uterus, 143 Inverted nipples, treatment of, 25 Involution of the uterus, 103 Iodine stains, removal of, 148 Irrigation of the bladder, 89 Irritability of the bladder, 8 Jacket, premature, how to make, 111, 112 how to apply, 112, 113 Jaundice, 36, 135 Kelly pad, 63, 72 Kidneys, action during pregnancy, 21, 30, 31 Labor, catheterization after, 88 induction of, 45 mechanism of, 65, 66 pains, 67 stages of, 67 Lacerations, perineal, 45 Lanugo, 7 Limbs, elevation during pregnancy, 22 Linea nigra, 10 Lochia, 85, 86 Lysol, strength of, 60 Mania, treatment of, 141 Massage of the breasts, 94 Mastitis, 141 Maternal circulation, 6 Maternity corsets, 14, 15 Measurements, 5 antero-posterior diameter, 5, 6 external conjugate, 4 great trochanter, 3 inter-crestal, 3, 5 inter-spinous, 3, 5 outlets, 2 164 INDEX. Measurements, right and left ob- lique, 5 transverse diameter, 5, 6 Measures, apothecaries weights and, 149 Measuring urine during preg- nancy, 21 Mechanism of labor, 65, 66 Meconium, 82 Melancholia, treatment of, 141 Melena, 136 Membranes, protrusion of, 69 rupture of, 69 Menopause, 6 Menstruation, 6, 8, 18 Mental occupation, 22 Mercurial inunctions, 28 Micturition, methods to induce, 87 Milk, breast, 126 deficiency of, 102 formula for premature baby, 126 formulas for full term baby, 119 modification of, 117-119 syphon, Skimit, 118, 120 Miscarriage, 26, 28 Mole, hydatidiform, 37 Morning sickness, 8, 19, 20 Mouth gag, use of, 33 Multiple pregnancy, 29 Murphy breast binder, 92 Murphy drip, 34 Narcophin, 145 Nausea during pregnancy, 8, 19, 20 Nephritic toxemia, 30 nursing care, 30 symptoms, 30 Nipple shield, Davol, 93 Nipple shield, use of, 92 Nipples, care of during preg- nancy, 25 the puerperium, 91, 92 Nurse, engagement of, 47 Nursery, baby's, 106 temperature of, 106 Nurse's bag, 56 Nursing bottle, Hygeia, 121 cap, Hygeia, 122 nipple, Hygeia, 122 Nursing bottles, care of, 127 care in gonorrhea, 36 in post partum hemorrhage, 138 in puerperal sepsis, 139 prenatal, 12 post natal, 103, 104 tray, 124 Occupation, mental, 22 Oil bath, 106, 107 castor, how to give, 148 Organs, female generative, 6 Ossa innominata, 1 Outlet, diameter of, 5 Pack, dry, 34 hot, wet, 33 Packages, covers for, 51 Pads, vulva and delivery, 50 Pains, after, 86 labor, 67 Palpation, 64 Paper bags, 62 Pelvic measurements, 2 Pelvimeter, 3 Pelvimitry, 2, 3 Pelvis, anatomy of female, 1, 2 INDEX. 165 Perineal dressings, 84, 85 lacerations, 45 Pernicious vomiting, 8, 20 Phillips' milk of magnesia, 24 pregnancy record, 9 Phlegmasia alba dolens, 140 Pigmentation, 10 Placenta, expulsion of, 73, 81 origin of, 6 previa, 28, 40 cause of, 41 complete, 40 lateral, 41 marginal, 41 medical treatment, 41 nursing care, 29 symptoms of, 41 Position, dorsal for delivery, 79 Sims for delivery, 79 knee chest, 71 Trendelenbu rg, 71 Positions and presentations of fetus, 64, 66 Post partum chill, 84 examination, 103, 104 evercises, 104 hemorrhage, 138 nursing care in, 138 Pre-eclampsia, 30 cause of, 31 medical treatment, 31 nursing care, 31, 32 Preface, V Pregnancy, complications of, 26 duration of, 8 hygiene of, 12 positive signs of, 11 presumptive signs of, 9 probable signs of, 10 Pregnancy record, 9 toxemias of, 29 Premature baby, 110-121 bed, 110 care after birth, 112, 113, 114 feeders, 123 feeding, 121 formula for, 126 jacket, 111, 112 mother's milk for, 126 Prenatal clinic, 12, 13, 104 nursing care, 12 Preparation for delivery in the home, 59 Presentations and positions of the fetus, 44, 64, 66, 67, 81 Prolapsed cord, 71 Prunes and senna recipe, 20 Puberty, 1 Pubiotomy, 42 Pubis symphysis, 4, 5 Puerperal insanity, 141 sepsis, 140 Puerperium, cathartics in the, 101 complications of the, 138, 143 Pump, breast, 125 Pumping breasts, 125 Pyelitis, 142 Quickening or fetal movements, 7, 11 Record, Phillips' pregnancy, 9 baby's, 114 mother's, 75 Rectal examination, 65 Respirations, 84 in eclampsia, 33 Rest, 31 166 INDEX. Resuscitation of baby, 61, 82, 83 Retention of urine, 71 Room, preparation of, for de- livery, 59 Rupture of membranes, 71 uterus, 38 Sac, amniotic, rupture of, 69 Sacrum, 4, 5 Salivation, 24 Salvarsan treatment, 28 'Sepsis, puerperal, 139 Scopolamin, 76, 145 Sheets for delivery, 51 Shoes, kind to wear, 17 Show, 68 Sickness, morning, 8, 19 Signs of pregnancy, 8, 10, 11 Simple albumin test for urine, 25 Sims position, 79, 80 Skimit milk syphon, 118, 120 Sleep during pregnancy, 18 twilight, 144, 146 Snuffles, 132 Sore buttocks, 134 Sponges, gauze and cotton, 50 Sprue, treatment of, 130 Stages of delivery, 67 Stains, blood, to remove, 147 iodine, to remove, 148 Sterile field, 72 Sterilization of dressings, 52 utensils, 59 Stools and urine of infants, 134 Supporters, hose, 16, 17 Symbols, 148 Symphysiotomy, 43 Symphysis pubis, 4, 5 Syncope, 24 Syphilis,.in infancy, 136 in the pregnant mother, 37 T-binder, 68, 100 Tampons, 41 Teeth during pregnancy, 22 removal of false in eclampsia, 33 Termination of pregnancy, 26 Thrush, 130 Towels for delivery, 51 Transverse diameter of the pelvis, 4 position of the fetus, 44 Toxemia, 21, 30 Trendelenburg position, 71 Trochanters, great, 3 Tuberculosis in infancy, 136 influence of during pregnancy, 37 Tuberosities, ischial, 5 Tying the cord, 80 Umbilical cord, tying the, 80 Urine, difficulty in voiding after labor, 87 measuring during pregnancy, 21 retention of during labor, 71 test, albumin, 25 in nephritic toxemia, 30 Urine and stools, infants, 134 Utensils, sterilization of, 59 Uterine contractions, 10, 67 murmur, 10 Uterus, causes of rupture, 38 inversion of, 81, 143 involution of, 103 rupture of, 38 INDEX, 167 Vagina, discharge of blood from, during pregnancy, 27 discharge of blood from, in the newborn, 131 Vaginal discharges, 27, 130, 131 douches, 21, 90,. 138 cesarean section, 42 examination, 65 mucosa, 10 Vanta baby clothes, 52 at chest of drawers, 53 diaper, 54, 55 diaper, how to make, 57 shirt, 55 Varicose veins, 21 Velvet grip hose supporters, 16 Version, 44 cephalic, 44 podalic, 44 Vertex presentation, 66, 70 Visitors, during puerperium, 91 Vomiting, pernicious, 8, 29 Vulva pads, how to make, 50 Wassermann test for syphilis, 28, 37 "Y" breast binder, adjusted for nursing, 97 adjusting, 98 closed after nursing, 99 in the making, 95