CHAPTER XII
THE NURSE’S DUTIES DURING LABOR
The extent of the nurse’s helpfulness during labor, both to the patient and to the doctor, will depend very largely upon the intelligence with which she grasps what is taking place and upon her own attitude, as an individual, toward the patient and the miraculous event which approaches. Important as is the preparation of the room and dressings, this other factor is almost equally influential.
It will be wiser, therefore, for the nurse to try to picture the process of labor in each instance, and to be guided by a few broad principles that apply to all cases under all conditions, rather than to try to memorize the details of her duties and of the desirable equipment and preparation.
The process of labor we have just described.
As to the general principles: If there is any time in a nurse’s career when she should give scrupulous attention to establishing and maintaining asepsis, it is during labor, for the patient’s life may, and often does depend upon it. If there is any time when she should be watchful for developments and for symptoms of complications, it is during labor, for again the patient’s life may depend upon this.
Her powers of adaptability to doctor, patient and surroundings may be severely tried, for though they all may be infinitely varied, the nurse must invariably be clear-headed and efficient and the adequacy of her service must never fail.
The sympathetic insight, which should constantly underlie the work of the obstetrical nurse, will be needed at this crucial time of labor in the fullest and finest and completest sense. This is almost her test as a nurse and as a womanly woman, for she needs to be both, supremely.
Perhaps she had better imagine for a moment what this occurrence, that we baldly term labor, may mean to the patient and look at it as nearly as possible from the standpoint of the patient herself. It is one of the most stirring and momentous experiences of her life, particularly if the expected baby is her first child. She is about to realize the sweetest and tenderest of dreams—that of motherhood—cherished throughout nine long months. She is also approaching a period of excruciating pain, and knows it, with her eyes wide open to the possibility of not surviving it; and an event so amazing in its mystery and wonder that to only the most stolid can it fail to be a deeply emotional experience.
And so, the young woman, to whom we refer so impersonally as “the patient,” is an intensely personal being at this time, experiencing a number of the most poignant of the human emotions: awe, expectancy, doubt, uncertainty, dread and in some cases fear amounting almost to terror. And through it all her body is being racked and exhausted with pain that grows harder and harder to bear.
It is known that the ravaging effects of pain, coupled with great emotional stress, such as fear, worry, doubt, anger or apprehension, upon the physical well-being of surgical patients, is such that death itself may be caused by excessive fear and suffering. Accordingly, many careful surgeons take elaborate precautions to tranquillize a patient who is about to be operated upon, if for no other reason than to increase his chance for recovery.
There can be no doubt that nervous and emotional disturbances are detrimental to the physical well-being of the patient in labor, also, and this fact alone is enough to warrant an effort to avert them. If the nurse appreciates the significance of the emotional influence and shapes her attitude and conduct accordingly, she will thereby help to increase the ease and safety of the actual delivery. Just what that attitude shall be, no one can say, for it must be developed, in each case, in such a way as to win the confidence and meet the needs of that particular patient.
But in all cases the nurse should impress her patient with her sincere sympathy and appreciation of the fact that she, the patient, is going through a difficult time. Through it all the nurse must be cheerful, encouraging and optimistic; very gentle; very calm and reassuring in all that she does in preparing for the delivery. She must steadily increase the patient’s realization of the part which she herself must play in the effort which is being made to carry the event through to a happy issue.
The occasion need not, should not, be a mournful one but it is often a very sacred one to the patient, and the nurse should be dignified, almost reverential in her bearing.
If the patient feels secure in the belief that her ordeal is not being taken lightly; that it is being regarded seriously, as it merits, and that every known precaution is being taken, and taken confidently, to safeguard her and her baby’s welfare, her actual physical condition will be favorably affected by the condition of mind thus produced. And her patience and courage will often be strengthened if the nurse will explain, from time to time, the cause of certain conditions that normally arise, and which otherwise might give her alarm. It is the mysterious events, the unexpected and unexplained that so often terrify.
This giving of comfort and strength to the variety of temperaments and mentalities which the nurse meets among her patients will involve a very sensitive adjustment of manner on her part, but it is one aspect of her duty, none the less, and one which will give her great satisfaction.
FIRST STAGE
Happily, the onset of labor is usually gradual, as has been described, and there is accordingly ample time during the first stage for deliberate and unhurried preparation for the birth of the baby. The character of the preparation and of the nurse’s assistance will vary greatly according to the wishes of the attending doctor; the duration of labor; the circumstances and condition of the patient, and whether she is at home or in a hospital.
It is a fairly general routine, at present, both in hospitals and in the home, to give the patient a soap-suds enema and a shower or sponge bath, at the onset of labor; to braid her hair in two braids and dress her in freshly laundered stockings and nightgown and a dressing gown. The enema is given to empty the rectum of material which might be expelled during labor and contaminate the field. For this reason, enemata are often given until the fluid returns clear, virtually irrigating the rectum, and are repeated every six or eight hours during the first stage. The enema should be given to the patient in bed and expelled into a bed-pan, as it is not wise for her to use the toilet after labor has begun. Sometimes the vulva and perineal region are shaved and scrubbed at the onset of labor, either before or immediately after the bath and enema. But the time and sequence of the different steps in the preparation for labor are governed entirely by the wishes of the individual doctor, to which the nurse may very easily adjust herself.
The patient should be given a bed-pan and encouraged to void every four hours. If she is unable to do so, and the bladder becomes distended, the doctor will usually wish to have her catheterized, and with a rubber catheter. This distension is not uncommon, and in extreme cases the bladder may reach to the umbilicus. The nurse should therefore observe the amount of urine which the patient voids and also watch the lower abdomen for bladder distension, which may be observed easily, excepting in very fat patients.
The seriousness of a distended bladder lies in the fact that it may markedly retard labor, partly by interfering with the descent of the baby’s head and partly through reflex inhibition of the uterine contractions. The prevention of a distended bladder during labor, therefore, is of considerable importance.
As the pains are infrequent and not severe at first, the patient will usually prefer to be up and about, most of the time during the first stage, when it occurs in the daytime, and many doctors think it important that she should be. They feel that patients tend to stay in bed too much during the first stage, since being on their feet would really promote their comfort and also have a tendency to make the pains more regular and efficient. But, on the other hand, the patient must be cautioned against tiring herself, and should, therefore, lie down often enough and long enough to avert fatigue. When labor begins at night, it is well to advise the patient to stay in bed and to sleep as much as possible until morning. Even though her sleep be disturbed and broken by the labor pains, she will be much less tired in the morning than if she had gotten up and had no sleep at all.
The patient should also be advised against trying to hasten labor by bearing down during first stage pains, since the only result at this time will be to waste her strength which will be needed later. This is one of the points that the nurse will do well to explain; that no voluntary effort on the patient’s part, during the first stage, will advance labor and if she tires herself by making such efforts before the second stage pains begin she will not be able to use them as effectively as she would were she in a rested condition.
Bearing in mind the importance of conserving all of her forces, it is usually advisable for a patient in labor to have no visitors, particularly the type of person who would be likely to offer advice and gratuitous information.
She should drink water freely and take some kind of light nourishment about every four hours. As pain of any kind tends to retard digestion, the diet during labor is usually restricted to fluids, such as broths, weak tea or coffee and sometimes milk or cocoa; while occasionally crackers and crisp toast are allowed. Whatever nourishment is given must be very light because of the probability of the patient’s vomiting and the possibility of her having to be given complete anesthesia before the termination of labor.
The maternal temperature, pulse and respirations should be taken every two or four hours and the fetal heart rate from every hour to every two hours, according to the wishes of the doctor.
The time at which the nurse should call the doctor is the subject of considerable discussion. Doctors never want to be called too late, neither do they wish to be called unnecessarily early, though they prefer to have the nurse err on that side, if at all. On general principles the doctor should be notified as soon as the patient goes into labor, in order that he may make his various plans with the pending delivery in mind. But if the nurse remembers that in primiparæ the first stage of labor usually lasts about sixteen hours and in multiparæ about eleven hours, she will realize that if the pains begin between the hours of eleven p.m. and seven a.m., and are of average character, mild and infrequent, she is not warranted in disturbing the doctor’s much needed sleep, unless he has explicitly requested her to do so. But under average conditions he should be notified by seven o’clock in the morning that the patient is in labor; at what hour the pains began; their character and frequency at the time of the report; the patient’s temperature, pulse and respirations and general condition and the fetal heart rate.
During the early hours of the first stage the nurse should begin to arrange the room and bed for delivery. She will need two, or preferably, three tables, though the top of a bureau may be used in place of one table. A washstand or the bathroom should be equipped for the doctor with soap; two sterile brushes; nail scissors or clippers and file or orange stick; hot water; alcohol and a solution of bichlorid 1–1000, biniodid 1–5000, lysol 2 per cent. or any solution that he may wish; sterile gloves and sterile vaseline or albolene to lubricate his hands. In short, an equipment which will enable him to prepare his hands exactly as he would for performing a major operation.
A large receptacle of water may be boiled, covered and set aside to cool; a boiler or large kettle placed in readiness for boiling instruments or other appliances that the doctor may bring; the room may be given a final cleaning: floor wiped up, furniture and all small articles wiped with a damp cloth; the unopened packages of dressings, sterile douche pan, irrigation-bag and basins may be placed on the tables, ready to be opened when needed, together with the other articles which have been prepared.
In preparing the bed in a patient’s home, it is practically always advisable to make it firm by slipping a board, or the leaves from a dining-table, between the mattress and springs. The bed should be made up with three freshly laundered sheets, the entire mattress being protected by means of a rubber placed under the lower sheet; next a rubber draw sheet, covered by one of muslin, while the top sheet, light blanket and counterpane should be left free at the foot. A flat hair pillow is better than one of feathers.
If the doctor wishes to make a vaginal examination, it devolves upon the nurse to prepare the patient with the most scrupulous care, as it is by means of vaginal examinations, made without careful preparation, that so many parturient women are infected. In fact, even the most conscientious preparation sometimes seems to be an inadequate safeguard, for infection has been known to follow in its wake. For this reason, some obstetricians prefer to make no vaginal examination during labor, when previous inspection has indicated that the case is normal, depending rather upon rectal examinations for guiding information.
The patient should be placed in bed, on a douche pan, with knees flexed and well separated; gown tucked up under her arms; draped with a sheet or the bedding folded down to her knees according to the extent of the area to be prepared; and the articles needed for the preparation arranged on a table at the bedside. The nurse should trim her nails, scrub her hands with soap and hot water; shave the vulva, supra-pubic region and inner surface of the thighs and rinse with sterile water. In shaving the vulva, the strokes should be from above downward, greatest care being taken not to allow hair, soap or water to enter the vaginal opening. She should then scrub her hands vigorously for three minutes, scrubbing about the nails with especial thoroughness. Some obstetricians have the entire area from the umbilicus to the knees prepared as for an operation, while others prepare only the supra-pubic region, inner surface of the thighs and the vulva. The number and kind of solutions which are used in this preparation also vary greatly, but in general the shaving is followed by a thorough scrubbing, by clean hands, with green soap and sterile water, then iodin, lysol or alcohol and bichlorid or biniodid solution, according to the custom of the doctor. (Fig. 74.)
But the kind and number of the solutions are probably not so important as the nurse’s technique. Throughout the entire course of the preparation she must apply the principles of what she was taught about the technique of preparing the skin for an operation and regard the perineal region in the same light as she would the field which was being prepared for a major operation; scrubbing from the centre toward the periphery, always, in order not to carry infective material from an unclean to a clean area, which in this case is the vaginal outlet.
The supra-pubic region and abdomen are scrubbed across, back and forth, working up from the symphysis; the strokes on the thighs are up and down; in the groin, down toward the rectum, and away from the vagina, _never toward it_, and fluids poured upon the vulval region must never run into the vagina from over surrounding skin. A sponge or scrub ball must be discarded after approaching the rectum, or stroking away from the vagina in any direction. Some obstetricians instruct the nurse to place a firm, sterile cotton pad or scrub ball between the labia, against the vaginal opening while scrubbing and flushing the adjacent areas, to preclude the possibility of introducing fluids. But with a painstaking nurse this is scarcely necessary.
After the surrounding areas have been prepared, the labia are separated and the inner surfaces scrubbed, first across, then from above downward, and flushed by pouring the solution directly between the folds. After the patient has been given this preparation, a dry sterile towel or pad is placed over the vulva; the douche pan is removed, the back and hips are dried, after which the patient is so draped with a clean sheet that only the perineal region is exposed, and a sterile towel is slipped under the buttocks. (Fig. 75.)
To summarize the preparation for vaginal examination or delivery:
1. Trim nails and scrub hands with soap and hot water.
2. Shave vulva.
3. Scrub and soak hands.
4. Scrub vulva, inner surface of thighs and lower abdomen with green soap and sterile water, alcohol, 70%, and lastly bichloride 1–1000 or lysol 1% or 2%, using sterile sponges and _taking care not to contaminate vulva from surrounding fields_.
5. Cover vulva with sterile towel or pad.
This may be taken as a description of a fairly typical method of preparing a patient for vaginal examination or for delivery, which is widely employed and with satisfactory results. But it is by no means the only satisfactory procedure, for many other and different methods of preparation also are followed by excellent results, as measured by the patient’s temperature during the puerperium.
The details of preparation vary so greatly, even among different doctors in the same hospital, that the nurse will simply have to bear in mind the general principles of asepsis and antisepsis, and adjust herself to the practices of the individual doctor. And she must remember that in spite of the best planning, there will be emergencies and precipitate labors, when the preparation will necessarily be modified, and sometimes so curtailed that even the bath and enema are omitted.
But in all cases the nurse can, and must, bear in mind that on one point there is virtually no difference of opinion among obstetricians of to-day; and that is the imperative necessity of having everything sterile that is brought to the perineal region or used in any way in connection with the delivery, or as nearly sterile as is possible under the circumstances.
By many doctors this is considered the most important factor, as to surgical cleanliness, in the entire preparation. In their opinion the local preparation of the patient may, with safety, be restricted to clipping the pubic hairs (instead of shaving), and scrubbing the vulva with only soap and water. But these doctors believe at the same time that the patient is dangerously susceptible to infection which may be conveyed to her from without, and accordingly they do not permit vaginal examinations to be made during labor, and make the most exacting demands concerning the maintenance of perfect surgical technique, by all who assist with the delivery.
In this connection, much depends upon the actual sterilization of the rubber gloves, either by boiling or by steam under pressure; and the method of putting on the gloves, in order that once having been sterilized, they may be kept so. It is useless to attempt to sterilize gloves by boiling, if they are thrown loosely into a kettle of water. There will practically always be enough air in the fingers to keep at least a part of the gloves out of the water, and consequently unaffected by its heat. They should be put into a covered wire basket that will be entirely submerged, or they may be wrapped in a towel, the weight of which will carry them below the surface of the water (Fig. 76), and insure their being completely covered while boiling, which should continue for ten to fifteen minutes. The doctor will usually want boiled gloves placed in a large basin of bichlorid solution, 1–1,000, or lysol 2 per cent., from which he may remove them after scrubbing his hands. If dry gloves are used, there should be in readiness a sterile towel and powder with which to dry and powder the hands before putting on the gloves. (Fig. 77.)
Whether boiled or steamed, the cuffs of the gloves should first be turned up toward the hand, to make it possible to put them on without touching the glove fingers with ungloved hands. (Fig. 78.) For no matter how long and carefully the hands are scrubbed and soaked, they cannot be made absolutely sterile, and therefore, in relation to the gloves which are sterile, the bare hands must always be regarded as unclean. Too much thought and attention cannot be given to the sterilization and handling of the gloves, for the patient’s very life may depend upon their aseptic condition.
After the doctor has seen the patient, the nurse will make observations and communicate with him in accordance with instructions which she must make sure to obtain from him at that time. Many doctors wish to be with a primipara continuously from the time the cervix is completely dilated, and with multiparæ after it is half dilated. But that, of course, is a matter which each doctor decides for himself. The nurse’s responsibility is to learn his wishes.
_Watchfulness_, then, is of extreme importance; watching for symptoms of complications or change in the patient’s condition, and watching the progress of labor in order to keep the doctor fully informed about his patient’s condition. Nurses are very frequently taught to make rectal examinations for the sake of increasing the value of their assistance in this respect.
Although unexpected symptoms do not, as a rule, develop suddenly during the first stage, the nurse must be none the less vigilant for them. The doctor should be notified if the pains suddenly grow either more or less frequent, or more or less severe; if there is any bulging of the perineum; if the membranes rupture; if there is any bleeding or a prolapsed cord; if there is extreme restlessness or any evidence of unusual distress; a rising temperature or pulse; a temperature of 100° F. or a pulse of more than 100 or less than 60; a fetal heart rate of more than 150 or less than 116, or any marked change of any kind in the patient’s condition.
During the latter part of the first stage, and during the second stage, the patient has an almost continuous desire to empty her bowels, because of pressure made upon the rectum by the descending head. This is another point which the nurse explain to her patient, in assuring her that frequent attempts to use the bed-pan will give no relief.
The end of the first stage is reached when the cervix is fully dilated, at which time the pains occur about every two minutes, are stronger and more severe, and the patient begins to feel like bearing down. The membranes frequently rupture at this point and the vaginal discharge is blood tinged. The patient should remain in bed and not be left alone from this time on.
To sum up the nurse’s duties during the first stage of labor, when the patient is almost entirely in the nurse’s care:
1. She must be a sympathetic, encouraging friend to the patient.
2. She must help the patient to preserve her strength by giving her light nourishment about every four hours; by advising her not to bear down; not to exhaust herself by walking about too much but to lie down when tired.
3. She must watch the progress of labor and watch for symptoms of complications.
4. She must employ strictest aseptic and antiseptic methods.
5. She must prepare for the birth of the baby.
SECOND STAGE
The second stage is shorter, harder and more perilous than the first. The uterine contractions are stronger; more frequent and more expulsive, and the baby steadily curves and rotates its way down through the birth canal.
With the onset of the second stage the nurse should complete the preparations for the baby’s birth, bearing in mind that with a primipara the baby probably will not come for an hour and a half or two hours, but may come in half an hour or less if the patient is a multipara. Everything which is to be used should be conveniently placed, but the packages are not necessarily opened at this time.
In addition to the sterile dressings, basins, gloves, instruments and various other articles which have been enumerated, the nurse must remember that there should be for the baby a box or basket lined with a blanket and containing one, or preferably two, hot-water bottles at 125° F.; in hospitals, an adhesive strip for the baby’s name or a name necklace; a binder of flannel or sterile gauze, according to the custom of the doctor; sterile olive oil or albolene for the first oiling and one or two tubs, in case the baby needs to be resuscitated.
There will be needed, also, a covered basin for the placenta; chloroform and an inhaler; Wassermann tubes, for those doctors who make this test as a routine; hypodermic syringe and needles, with pituitrin, ergotole and drugs for stimulation which the doctor may specify. (Figs. 79, 80.)
In the meantime, the force and frequency of the pains should be noted, and some doctors require a record of both the fetal and maternal pulse rate every half hour, and notification if the baby’s is over 150 or below 116, or the mother’s over 100 or below 60. Extreme restlessness, distress, vaginal bleeding, prolapsed cord, a temperature of 100° F., or any marked change must be communicated to the doctor immediately, if it occurs before he has started for his patient.
The patient may complain of intense pain in her back and cramps in her legs during the second stage. Pressure made by the nurse’s hand, or a small pillow slipped under the small of the back will frequently relieve the backache, while cramps in the legs may be relieved by straightening, and slightly elevating the leg, and rubbing it while in that position. As these pains are usually due to pressure they have no serious significance and subside as soon as the child is born.
_On table by bed_: Sterile: cover. towels, 6. bag of sponges. delivery pad. pair of leggings. delivery sheet. doctor’s gown. perineal pads. cord ligatures. _Lower shelf_: douche pan.
_Window sill_: Baby box with hot-water bag at 125° F., and blanket. Chloroform dropper and inhaler. Sterile albolene for baby. Alcohol. Baby band. Wassermann tubes.
_Second table_: Basin of instruments. Basin of bichloride, 1–1,000 with pair of gloves. Sponge sticks in alcohol. Hypo, tray: pituitary liquid. ergotole. syringe and needles. alcohol. pledgets. _Lower shelf_: 2 tubs for resuscitating baby. Covered placenta basin. Dressing basin.
_Head of bed_: Nightgown. Sheet. Stockings. Towel.
The nurse may find herself in any one of three situations during the second stage. The doctor may arrive in ample time to conduct the delivery; he may be slightly delayed and the nurse endeavor to retard labor, according to instructions; or the baby may be born, with or without the expulsion of the placenta, before his arrival.
When the doctor arrives at the onset of, or during the second stage of labor, the nurse acts solely under his direction, the nature of her offices depending somewhat upon the condition and surroundings of the patient, and whether or not the nurse is the only person at hand to give assistance. In any case, the gloves, and instruments for repairing a tear should be boiled and in readiness; the dressings and other articles to be used are to be conveniently arranged upon the tables and opened at the proper time.
After having everything ready and at hand for the delivery, the nurse may be called upon to clean up and act as an assistant, or to give the anesthetic. If she cleans up, she should wear a sterile gown and gloves, and if it is the doctor’s custom, a cap and mask as well, having prepared her hands somewhat as follows:[6]
1. Scrub hands and arms with hot water and green soap for five minutes, paying especial attention to the fingers and nails.
2. Clean and trim nails and scrub again for five minutes.
3. Soak and scrub hands and forearms in alcohol, 70%, for two minutes.
4. Soak in bichloride solution, 1–1000, for five minutes.
5. Put on gloves out of second bichloride solution, avoiding contact with fingers of ungloved hand. (See Fig. 78.)
The patient is given a final scrubbing with green soap and sterile water and an antiseptic solution, by some one with clean hands, and is further protected by means of sterile leggings, a sterile towel across the abdomen and one covering the inner surface of each thigh, held in place by sterile clips or safety pins. The lower half of the bed is covered with a sterile sheet while a sterile delivery pad is slipped under the patient’s hips. (Fig. 82.)
If the delivery is made with the patient lying on her side, the sterile dressings are so arranged as to cover all but the perineal region after she is placed in the desired position.
This brings up the question of the nurse’s obligation to protect her patient from the embarrassment of unnecessary exposure at any time during labor. The field which is prepared must be uncovered temporarily, and while the patient is being draped for examination or delivery a certain amount of exposure is unavoidable; but there are many little ways in which the nurse may show her consideration for the patient in this connection and the patient always appreciates the protection.
During the second stage, the preservation of asepsis, watching the progress of labor and watching for unfavorable symptoms, are of even greater importance than during the first stage. After the patient has been prepared and draped with sterile dressings, neither they nor the perineal region should be touched with anything unsterile.
If for any reason it has not been possible to sterilize sheets and towels, or more are needed after the prepared supply has been exhausted, the inner surfaces of towels and sheets that have been ironed either by hand or machinery, and folded with the ironed surfaces inside without being touched, may be regarded as practically sterile.
As the second stage advances, the patient may greatly aid the progress of labor by voluntarily bearing down during pains, and the nurse in turn may be called upon to help by encouraging her and explaining just what she should do. At the beginning of a pain the patient should take a deep breath, close her lips, brace her feet and strain with all her strength. If she opens her mouth and cries out, she fails to use her pains to the best advantage. The effect of this bearing down may be increased by providing the patient with straps, attached to the foot of the bed, upon which she may pull during the contractions, as she bears down. (Fig. 83.) Or, what is often a great comfort to her, she may pull upon the nurse’s hands as the latter braces herself so as to offer strong resistance. If the nurse can be spared from other duties to give this kind of assistance, it is indeed a comfort to the patient, who appears to derive from it both a moral and physical sense of being helped in her struggle. It is also important to assure the patient, between pains, that she is doing well, and that her efforts are advancing the baby, if this is true; and if not, she may under ordinary conditions be urged to make greater effort.
Before the head can be seen at the outlet or its advance noted by perineal bulging, the stage of its descent is often ascertained by palpating through the perineum, the fingers of a gloved hand pressing upward, on one side of the vulva. (Fig. 84. See Figs. 85, 86, 87, and 88 for appearance, advance and birth of head during normal delivery.)
Immediately after the birth of the head, and before the birth of the body, the nurse is frequently asked to wipe the baby’s mouth and eyes and sometimes to drop nitrate of silver into the eyes. In such a case she should wipe out the mouth very gently with a bit of sterile gauze, wet with boric, wrapped about her little finger, reaching well back into the throat; the eyes should be wiped from the nose outward, a separate wipe being used for each eye. The purpose of these maneuvers, when they are employed, is to favor respiration from the beginning by removing mucus that might impede it and to remove possible infective material from the lashes before it is spread to the conjunctivæ by the baby’s winking. The silver solution is to destroy germs that may have gotten into the eye.
As soon as the baby is completely born a sterile douche pan should be slipped under the patient or a small sterile basin placed close to the perineum, to receive the blood which escapes during the third stage. This is partly to protect the bed, but chiefly that the blood may be measured, as in no other way can it be ascertained how much the patient loses. A loss of 600 cubic centimetres or more is regarded as a hemorrhage.
=Immediate Care of the Child.= After the baby has been brought safely into the world, it is of greatest possible importance to make sure that it begins its separate existence by crying lustily, in order fully to expand its lungs. This provides for oxygenation of its blood, which has taken place, until now, through the placental circulation. In many cases the baby cries satisfactorily without aid, but not infrequently must be stimulated to do so. In all instances the first step is to clear the air passages of the mucus lodged in the mouth and throat, by some one of the many approved methods. One is by means of a piece of wet sterile gauze wrapped about the little finger, and wiped gently about in the back part of the baby’s mouth (Fig. 89), though many doctors object to this procedure for fear of abrading the very delicate mucous membrane, no matter how lightly it is done. They prefer to hold the baby by its feet, with the head hanging down and the neck sharply curved backward, when by gravity the mucus will drop out of the mouth; or, holding the baby by the feet, to run the thumb and forefinger along the neck on either side of the trachea, toward the mouth, and force out the mucus in that way. If the baby does not cry well after the mucus is removed, it may usually be stimulated to do so if held by the feet, head downward, and the back gently rubbed (Fig. 90) or the face stroked or the buttocks spanked two or three times. When holding the baby in this position the nurse should slip one finger between the ankles and grasp them firmly.
After the baby has cried well it may be laid on the foot of its mother’s bed. At this juncture it seems pertinent to stress two points which must be remembered throughout the entire routine of the baby’s care, namely: the importance of protecting it from infection and from being chilled. As the baby lies on the mother’s bed, before the cord is cut, it finds itself in a room which is many degrees cooler than the very warm habitat from which it has just emerged; it is struggling to establish its functions, which are suddenly deprived of the mother’s help, chief of which at the moment are respiration and the circulation. Body warmth is one of the most valuable aids in promoting an even circulation, and accordingly the baby should be kept warm from the beginning. For this purpose there should be a small sterile blanket, or piece of flannel, in readiness to protect the little body as it lies on the bed, awaiting further developments. The hands and feet of the newborn baby that lies uncovered for even a quarter of an hour, or more, are nearly always cold, and as this must be guarded against in an older, more securely established baby, it cannot be desirable for the newly born.
As soon as the cord ceases to pulsate, it is usually clamped with two clamps about two inches apart (Fig. 91) and cut between the clamps. The scissors should have blunt points, in order not to scratch or cut the baby, who may be wriggling vigorously by this time. The cord is tied tightly with a sterile cord ligature, in a square knot that will not slip (Fig. 92), about an inch from the abdominal wall. It is considered a safe precaution, after removing the clamp, to bend the cord back upon itself and tie it a second time with the same ligature, as the danger of hemorrhage from a loosely tied cord is serious when the baby is kept sufficiently warm. The placental end of the cord is also tied, or it remains clamped until the placenta is expelled, because of the possibility of there being another child in the uterus and the danger of its bleeding to death through the open cord.
Some doctors do not tie the cord, but crush the vessels with a clamp which is left on the cord for about half an hour and then permanently removed, but this should not be done by a nurse upon her own responsibility.
Very often the person who performs the delivery removes the blood, mucus and vernix from the baby’s body, as soon as the cord is tied, by sponging it thoroughly with albolene or olive oil; wraps the cord stump with a sterile, dry or alcohol sponge and applies the abdominal binder while an assistant holds the baby by the feet, head down. It is also very common simply to oil the baby with unsterile lard, oil or vaseline, cover the cord with sterile gauze and leave the bath, cord-dressing and binder to be attended to later.
If the delivery takes place in a hospital the baby must be marked _before it is taken from the delivery room_, with adhesive plaster, upon which its mother’s name is plainly printed, or with the name necklace, now so frequently used.
The baby is once more wrapped in a warm blanket and placed, with a hot-water bottle, at 125° F., in the basket or box, which was prepared for it. Although the baby should be well covered, care must be taken to leave the face fully exposed as a young baby is easily suffocated. It was formerly customary to lay the new baby on its right side, but with the present fuller knowledge of the fetal circulation and the changes which take place after birth, this practice has been largely done away with.
=Resuscitation of the Newborn Baby.= If the baby breathes feebly, or even if it does not cry vigorously, the effort to stimulate the respirations may have to be continued for an hour or more after the cord is tied. In addition to the simple methods, previously described, which are very commonly employed at the time of labor, such as stroking the baby’s back or holding him by the feet and spanking him (Fig. 93), the following measures are sometimes resorted to if the baby’s condition demands it:
One method is to hold the baby with its chest resting on the palm of one hand, with head, legs and arms hanging forward, thus compressing the chest wall and favoring expiration (Fig. 94), and then turning it over on its back, in the other hand, in which position the head, legs and arms hang backward, thus expanding the chest and favoring an inspiratory movement. (See Fig. 95.) Alternate repetitions of these positions, about twelve times a minute, will often stimulate the child to breathe satisfactorily.
Another method is alternately to plunge the baby into tubs of hot and cold water. But as there is doubt about the wisdom of chilling the entire surface of the baby’s body, the cold plunge is forbidden by many doctors, who, instead, dash a little cold water upon the face and chest, while the body is immersed in water at about 110° F.
A widely used and efficacious method is to hold the baby continuously in a tub of water at about 110° F., and alternately extend and fold its body, thus keeping it warm while stimulating inspiration and expiration. (Figs. 96, 97.)
Direct insufflation may be employed while the baby is in the warm water, by protecting its face with clean dry gauze and blowing directly into its mouth at intervals corresponding to those of normal inspiration. (Fig. 98.)
Another procedure is to hold the baby by the shoulders, with its body hanging down, thus expanding the chest, and then to toss it quickly upwards, folding the legs upon the chest to compress it. This method is objected to by many obstetricians on the ground that it both exhausts and chills the baby.
The outstanding requirements in resuscitating a baby are to stimulate its respiratory movements, by alternately expanding and contracting the chest; to promote its circulation by keeping it warm, and to avoid exhausting the very frail little body. Gentle handling, therefore, is important.
THIRD STAGE
After the birth of the baby, some doctors request the nurse to rest one hand on the mother’s abdomen in order to feel the fundus as it rises while expelling the placenta, and to keep him informed concerning its consistency. Others regard this as a dangerous practice and forbid it.
As a rule, there is little bleeding until the placenta has separated. If bleeding does occur, it is the practice of some doctors to have the uterus gently massaged through the abdominal wall, to stimulate contractions, while others consider this inadvisable.
After the placenta separates and descends into the lower uterine segment, it produces a bulging just above the symphysis, while the fundus may be felt as a firm, hard mass above the umbilicus. Since the placenta is entirely separated from the uterus at this time, its complete expulsion is usually aided, when it does not occur spontaneously, by gentle pressure upon the fundus. The accoucheur holds his hand just below the vaginal outlet, to receive the placenta (Fig. 99), which he turns over and over in his hands, thus twisting the membranes, and gradually draws it away from the mother, the membranes trailing after in the form of a tapering cord. (Fig. 100.) It is important that the placenta and membranes be carefully examined to make sure that they are intact, for if fragments of either are retained within the uterus they will prevent its firm contraction and thus may be a cause of post-partum hemorrhage. For this reason, only very gentle pressure and traction are used in expressing the placenta and withdrawing the membranes, for the use of force might leave small particles adhering to the uterine lining, which would otherwise separate with the rest, in due time, as a result of the uterine contractions.
Having been inspected, the placenta should be placed in a covered receptacle to be disposed of as the doctor directs, as many physicians make a routine laboratory examination of the placenta and wish to have it kept for this purpose.
With the birth of the placenta comes a gush of blood, as the uterine vessels, some of which are as large as a lead pencil at this time, are left wide and gaping. The bleeding usually subsides very shortly, however, as the blood vessels are closed by involuntary contraction of the network of uterine muscle fibres in which they are enmeshed, and which are sometimes referred to as “living ligatures.” If the bleeding continues, these contractions should be stimulated by massage. This is done by grasping the uterus through the abdominal wall firmly with one hand and kneading vigorously. Rubbing the top of the fundus with the fingers usually is not enough. The fundus should be grasped by the entire hand; the thumb curved across the anterior surface and the fingers, directed deep into the abdomen, behind it. (Fig. 101.)
Pituitrin or ergot, or both, are frequently given to further stimulate contractions of the uterine muscles. Since the action of pituitrin is quick, but evanescent, and the effect of ergot is slower and more lasting, both a quick and lasting effect is obtained by giving them together.
The expulsion of the placenta ends the third stage and completes the process of labor.
=Immediate After-care of the Patient.= The patient should be bathed and dried about the thighs and buttocks, the vulva being bathed with alcohol or an antiseptic solution, and a sterile perineal pad applied. The douche-pan, wet towels, delivery pad and draw sheet are replaced by a dry draw-sheet and a towel or pad slipped under the patient’s hips, while a fresh nightgown is put on if the one worn during labor is wet or soiled. The perineal pad is very commonly held in place by a T. binder, with which all nurses are familiar, but some doctors prefer an abdominal binder to which a perineal strap is attached. This abdominal support may be a straight swathe or a Scultetus bandage, varying with the wishes of the doctor, and it may or may not be used in conjunction with a pad, so applied as to make pressure over the fundus. Other doctors forbid the application of any kind of a perineal dressing from the time of delivery, but instead, have a large, sterile pad slipped under the patient to receive the discharge.
The patient is usually tired and cold at the conclusion of labor, and may even have a nervous chill. Although this chill is not serious, the patient is none the less uncomfortable, and she should be warmly covered, be given something hot to drink, and a hot-water bag placed at her feet.
All possible effort must now be made to secure for her rest, quiet, and an opportunity to sleep. Every one but the doctor and the nurse had better be excluded from the room, which should be absolutely quiet, somewhat darkened and well ventilated. In addition to this, the majority of doctors now require that either they or the nurse shall stay with the patient and keep one hand resting on the fundus for at least an hour after delivery as a safeguard against post-partum hemorrhage. As long as the fundus is felt through the abdominal wall as a firm, hard mass, its irregularly arranged muscle fibres are contracted upon the blood vessels, and will prevent an escape of blood. But if the fundus feels soft and boggy, its muscles are relaxed, the constrictions are somewhat released from the open vessels, and serious bleeding may occur unless they are stimulated to contract again.
=If the Doctor Is Delayed.= It sometimes happens that labor progresses with unexpected rapidity, or that the doctor is delayed in his arrival and the nurse is accordingly confronted with the emergency of being alone with the patient during part or all of the delivery.
When the baby is making such rapid descent that the nurse fears it may be born before the doctor’s arrival, she may somewhat retard labor by covering her hand with a folded, sterile towel, if she has not had time enough to put on gloves, and hold back the head by pressing against the perineum during pains, at the same time instructing the patient to open her mouth, breathe deeply and try not to bear down. It is sometimes easier for the patient not to bear down if she lies on her side.
If by mischance, or in spite of her efforts, the baby so far descends that the brow appears before the doctor’s arrival, the nurse cannot safely hold it back longer because of the danger of the baby becoming asphyxiated. She should, up to this point, hold the head back during pains in order that the perineum may be stretched slowly, with the hope of preventing a tear. (See Fig. 87.) It is the sudden distension of the perineum and expulsion of the baby’s head at the height of a pain that frequently causes lacerations. If fecal matter is expressed during pains, the field should be wiped, downward, with sterile sponges and bathed with the antiseptic solution at hand.
After the brow is born, the nurse may gradually release the pressure and allow the head to emerge, and remembering the position of the child and the mechanism of its birth, assist Nature in its complete delivery. After the head is born, it drops down toward the mother’s rectum, after which external rotation, or restitution, takes place. (See Fig. 88.) A finger should be slipped around the neck in search of coils of cord, which, if felt, should be slipped over the baby’s head. Otherwise, pressure upon the cord in that unnatural position might so interfere with the circulation as to asphyxiate the baby.
The shoulders may be born spontaneously or the nurse may grasp the head with both hands, curving the fingers of one hand under the baby’s chin, and of the other, under the occiput, and make gentle, downward traction (See Fig. 69.) in order to slip the anterior shoulder from under the symphysis; and then pull gently upward, to deliver the lower or posterior shoulder (see Fig. 70.), after which the rest of the body follows easily.
This description of how a nurse may conduct a normal delivery by fairly typical and generally approved methods is only intended to guide her in an emergency, when there has been no understanding between her and the doctor about what she should do in event of his absence; or when he has authorized her to use her best judgment in safeguarding the lives of mother and baby.
It is obviously of extreme importance for the nurse to ascertain definitely the doctor’s wishes in this connection, as he sometimes will be unwilling to have the nurse give any attention to either mother or baby, even to tie the cord, before his arrival.
=Prolapsed Cord.= If the umbilical cord should prolapse at any time during labor, in the absence of the doctor, or lacking instructions, the nurse should elevate the patient’s hips, in order that gravity may lessen the pressure on the cord as it lies between the presenting part and the pelvic brim. Otherwise, the interference with the placental circulation may result in asphyxiation of the baby. (Fig. 102.)
The elevated Sims position is often effective. Or, a straight chair may be upturned and pushed under the mattress, from the foot toward the head, in such a way that the patient will be lying on an incline which slopes upward from the head of the bed toward the foot. Or the chair may be placed in the same position on top of the mattress, with the top of the chair-back under the patient’s shoulders. The chair should be padded with pillows in order to minimize the patient’s discomfort as she lies in this trying position.
=Post-partum Hemorrhage.= Should a post-partum hemorrhage occur, in the absence of the doctor, the nurse should massage the fundus, unless she has been instructed not to, and have some one elevate the foot of the bed on blocks or the seat of a firm, straight chair. The use of ice bags or cold compresses on the abdomen is sometimes helpful and some physicians advise placing the baby at the mother’s breast immediately, since the suckling stimulates the uterine muscles to contract.
In anticipation of a post-partum hemorrhage, the nurse must have a clear understanding of the doctor’s wishes, particularly in regard to the administration of pituitrin and ergot which are so widely and efficaciously used to check post-partum bleeding.
ANESTHETICS
Those of us who are accustomed to seeing anesthetics used to relieve patients of the worst of their pain, during labor, find it hard to realize that until comparatively recent years women went through this suffering without mitigation.
The use of anesthesia was introduced into obstetrical practice, in 1847, by Sir James Y. Simpson of Scotland, who first used ether but later adopted chloroform when he learned that it also had anesthetic properties. Its use in America was subsequently introduced by Dr. Channing of Boston.
In the early days, the idea of using anesthesia during labor was greeted with a storm of protest, both from the clergy and the laity, because of their belief that the relief of women in childbirth was contrary to the teachings of the Bible, as set forth in God’s curse on Eve, when He said, “In sorrow thou shalt bring forth children.”
There is to-day practical unanimity of opinion concerning the advantages which are derived from the use of anesthesia when any operative procedures are employed; but there is still some objection to its use in spontaneous deliveries. This is partly on medical grounds because of the possible ill effects of anesthetics and is partly a persistence of the early religious protest. However, in the vast majority of cases, some kind of an anesthetic, or analgesic, is administered to the woman in labor because the advantages of its use are generally conceded.
The agents used are chloroform, ether and nitrous oxid gas, while what is popularly called “twilight sleep” is produced, completely or in a modified degree, by the hypodermic administration of scopolamin and morphine.
=Chloroform.= Of these various drugs chloroform is apparently the anesthetic most widely used in normal obstetrics. Its advantages are that it is easy to give; quick in its action and is followed by little or no nausea or other ill effects. For some reason, as yet not explained, the woman in labor enjoys a certain amount of immunity against chloroform poisoning, but this tolerance exists only during labor as the puerperal woman is subject to the same dangers as any other individual.
Chloroform is not usually administered until the patient is well along in the second stage, or until the head may be felt through the perineum, or is in sight. The patient’s face should be oiled and protected with a towel or gauze folded across her brow, mouth and chin to prevent burns that might follow the inadvertent dropping of chloroform on her face. With the beginning of a pain, a few drops are poured on the inhaler which is held about an inch from the face to give a free admixture of air, and the patient is told to breathe in deeply. (Fig. 103.) The inhaler is removed as soon as the pain subsides, but reapplied as soon as another pain begins. The patient retains consciousness and is able to talk under this degree of anesthesia, but her suffering is greatly relieved. It has the advantage, also, of lessening the danger of perineal tears, as the accoucheur has better control of the delivery when the patient lies quietly than when she tosses violently about the bed, and a tear resulting from the sudden delivery of the head at the height of a pain may in this way be averted.
This light, intermittent anesthesia, now so widely used, is called obstetrical anesthesia or anesthesia _à la reine_, after Queen Victoria, upon whom it was first employed at the birth of her seventh child, in 1853.
When the perineum is distended to its maximum, obstetrical anesthesia is not always sufficient, and complete anesthesia may be employed; but even this requires very little chloroform. Under ordinary conditions, the anesthesia is discontinued as soon as the child is born, for unless there is an extensive tear, the patient is sufficiently anesthetized to permit of a perineal repair and the delivery of the placenta.
Chloroform is not often given early in labor because of the general belief that its free or prolonged use lessens the force and frequency of uterine contractions, thus prolonging labor, and also may unfavorably affect the child. But small doses seem to stimulate rather than retard contractions, and by having her pain relieved, the patient is prompted to make greater effort to use her abdominal muscles, an end greatly to be desired.
If complete anesthesia is needed for more than a few moments, after the child is born, ether usually replaces the chloroform, being considered more satisfactory for prolonged anesthesia, but many obstetricians prefer not to give it until after delivery because of its possible effect upon the child.
As chloroform poisoning is likely to produce degenerative changes in the liver, and eclampsia also causes a liver necrosis, chloroform is not used for an eclamptic patient.
=Ether=, also, is used widely in normal obstetrics and is almost always preferred for continuous anesthesia, because of its being safer than chloroform. Unlike chloroform, ether is sometimes given in the first stage after the pains have become severe and frequent. About a dram of ether is poured into the cone which is held just off the patient’s face (Fig. 104.) until the beginning of a contraction, at which time it is lowered and held close to her face (Fig. 105.) As the action of ether is slower than chloroform, it should be poured into the cone in advance of a pain, which the nurse anticipates by feeling the uterus begin to grow hard under the hand which she keeps upon the patient’s abdomen. If the ether is not poured into the cone until a pain begins, its anesthetic effect may be lost because of the delay in its administration.
At the Cleveland Maternity Hospital, where ether is used during normal labor, the nurses are taught to give it as has just been described, with further instructions from Miss MacDonald, as follows: “A patient will vaporize about one dram of ether per pain during the early first stage, gradually vaporizing a greater amount until she will vaporize two or three drams per pain near the end of the second stage. Should the patient reach the excitement stage of ether before she is in the second stage of labor, discontinue the ether for from five to fifteen minutes, then give a lessened amount.
“Should it be necessary to control the descent of the presenting part, light anesthesia may be given. This may be managed by putting about two drams of ether in the cone at intervals frequent enough to sufficiently retard the descent of the presenting part. This procedure almost obliterates contractions. Lift the cone from the face for a few moments at frequent intervals to admit air. Keep the ether vapor of such concentration as avoids choking, coughing or vomiting. This may be done by administering a small amount frequently, rather than a large amount at longer intervals. When the desired stage is reached, try to keep the patient at this degree of anesthesia by giving a few drams of anesthetic at regular intervals.”
=Nitrous Oxid Gas Analgesia.= The effect of this drug is termed analgesia rather than anesthesia, because the patient does not lose consciousness but is unconscious of pain. From a medical standpoint it is considered practically ideal for use in obstetrics. If given skillfully it seems to have no bad effects upon the child; it tends to stimulate, rather than diminish uterine contractions; it may be started, with safety; as soon as the patient begins to suffer severely, and continued for several hours if necessary.
Its disadvantages are that it is very expensive; it can be given safely only by a skillful, trained person; the apparatus necessary for its administration is expensive, heavy and difficult to transport. But when these difficulties can be overcome, its use is attended with very satisfactory results.
“=Twilight Sleep=,” so called, or _Dämmerschlaf_, as it is termed in Germany, has been and still is discussed so widely, that the nurse should know something of it, whether or not she aids in its administration. It may be described as a state of amnesia, or forgetfulness, produced by the hypodermic injection of morphin and scopolamin. The patient, therefore, is conscious of pain at the time but speedily forgets it.
This treatment was first used widely in Freiburg. Following an enthusiastic report from there upon a large number of cases in which it had been used, there was such a clamor for it by American women, that its temporary use was practically forced upon obstetricians in this country. It was given what appears to have been a fair trial, but its continued use in this country has not been widespread. Those obstetricians who object to its use describe its disadvantages as follows: It cannot be used outside of a well-conducted hospital; it requires the constant attendance of a well-trained obstetrician or obstetrical nurse throughout the entire course of labor; it is suitable for use in certain selected normal cases only; it prolongs the second stage and increases the percentage of cases in which operative interference is necessary; it has an asphyxiating effect upon the child and increases the percentage of fetal deaths.
On the other hand, the use of scopolamin and morphin is a routine in certain excellent maternity hospitals, and by many obstetricians of the first rank, who maintain that with a nurse in attendance and the observance of ordinary precautionary measures, the advantages far outweigh the disadvantages of a modified “twilight sleep.” An anesthetic is usually administered during the second stage, after the use of the scopolamin-morphin treatment.
COMPLETE ANESTHESIA. If an emergency should arise and the nurse be required to change from the light anesthesia _à la reine_, and to give complete anesthesia, her responsibilities increase, for she must watch carefully the patient’s pulse, respirations, color and pupils. The flat pillow which is ordinarily left under the patient’s head during normal labor, should be removed and the inhaler should be held closely over her face with the nurse’s fingers so placed as to hold it in position and also to hold the patient’s jaw forward and up. (Fig. 106.)
The ether should be dropped in clean drops, not poured, upon the inhaler. The dripping should be steady, but slow at first, gradually increased as the patient becomes accustomed to the fumes.
With the average, normal patient who is taking ether well the _respirations_ become somewhat stertorous and more rapid, increasing to possibly 36 or 40 per minute; the _pulse_ starts at a little above the normal rate and increases to 116 or 120 and then drops to normal, which is slightly below the rate at which it started; the _color_ is normal at first and then may become crimson, or it may change very little; the _pupils_ first dilate, and then contract almost to a pin point.
Unfavorable signs are: _respirations_ that are rapid and shallow, then possibly slow, but still shallow; increasing _pulse_ rate, this being so serious that the ether is usually stopped if the pulse approaches 140, and stimulation is promptly given; _cyanosis_ which is slight at first and then extreme, and dilated _pupils_.
It is obviously not wise nor possible to attempt, by means of a few paragraphs and illustrations to teach a nurse so technical and important a procedure as the administration of an anesthetic, but it is hoped that these general suggestions may be helpful, particularly to the nurse who is unexpectedly confronted by an emergency.
Under all conditions the nurse must remember that no matter what anesthetic is given, nor by whom it is administered, she must guard against the very prevalent tendency to talk freely while the patient is going under, in the belief that she is unaware of what is going on about her. Many patients suffer great mental distress because of hearing, or partly hearing conversation not intended for their ears, which takes place in their hearing while they are incompletely anesthetized.