CHAPTER XV

NURSING CARE DURING THE NORMAL PUERPERIUM

In general, the nursing care during the puerperium is much the same as that which is given to a surgical patient, with special attention to the breasts and perineum and a sustained effort to prevent complications and restore the mother to a normal state of health in due time.

As the nurse doubtless realizes by this time, the principal complications to guard against during the puerperium are hemorrhage from the still raw area, where the placenta was attached to the inner surface of the uterus; infection of the birth canal; breast abscesses; displacement of the uterus and subinvolution, or failure of the uterus to return to its normal size and condition in the usual length of time.

In addition to guarding against these definite complications, the nurse must help to save her patient from the less tangible, but perhaps equally injurious effects of fatigue of mind and body. As many young mothers are in a more or less unstable, excitable condition after the baby’s birth, the beneficial effect of promoting a tranquil and contented state of mind can scarcely be overestimated.

The doctor may be ever so tactful and cheering and sustaining, but his contacts with the patient are short and infrequent as compared with the nurse’s constant companionship. She can, therefore, by her attitude, manner and conduct practically create or destroy the atmosphere that is necessary to her patient’s welfare.

In order to give the best and most helpful service the nurse must try from the very beginning to understand her patient as an individual and adapt herself to the patient’s temperament. Some women are rested and soothed by being talked with, read to, diverted and amused in one way or another, during most of the time, and will grow nervous and depressed if left to their own devices. Others, who have greater resources within themselves are happier and better off when left to themselves a good deal, and given an opportunity to think things over. Some women are much subdued as the consciousness of their motherhood grows upon them, and they feel a kind of awe and wonder about this baby that they begin to realize is their own. It is a big experience, this one of motherhood, full of promise and responsibilities, and the young mother herself very often wants to think it out. She will enjoy talking when she wants to talk, but may be irritated and exhausted by a nurse who tries to entertain her all of the time.

For this reason, the most conscientious and painstaking nurse imaginable may destroy her usefulness, by adopting the wrong attitude toward her patient during this period of enforced intimacy. Some women want, and even need to be indulged and petted; but, on the other hand, a certain type of reserved and dignified woman is affronted by such attention or by the easy air of familiarity that another courts; one patient is exhausted by the unvarying punctuality and precision of a conscientious, but unadaptable nurse, while that very punctuality and precision is satisfying and restful to another.

It is not a simple matter to sound the depths of a patient’s personality, for they are all complex and each one is peculiar to herself. That fact must not be overlooked for each patient is an entirely new and different problem and not like any other that the nurse has had before. But the nurse who is sincere and sympathetic and who earnestly tries to put herself in her patient’s place and see things from her standpoint, will, by virtue of that very attitude, accomplish much toward sensing the patient’s temperament and establishing harmonious relations. Moreover, the patient, herself, will all unconsciously make something of an adjustment to the nurse when she feels the nurse’s sincerity and her eagerness to be of service.

One factor in shaping the young mother’s state of mind, which the nurse must take into account is that the entire scheme and purpose of her patient’s life have been changed. She has been plunged very suddenly into a wholly new condition and her reaction to this change will depend upon her temperament, disposition and habits of adjustment.

She has spent nine months looking forward to an event that has been consummated; she has spent nine months in a state of more or less apprehension and suspense that have been abruptly ended, and we know that it is quite natural for any one to experience a letting down, or something akin to collapse, when long-continued uncertainty is ended, even though it ends happily.

And as recovery progresses the patient becomes aware, perhaps only vaguely, of another change which is not always a welcome one. For nine months she has been the centre of interest in her immediate circle; she has been the object of unremitting concern and solicitude, and much as she and her family may have tried to keep her life normal, she and her needs have constantly been given the first consideration. The very mystery of the child developing within her has created an attitude of respect, almost of reverence, which was never her portion before. In every way she has been shielded, protected and cared for, and all eyes, including her own, have steadily looked forward to the event for which this care has been preparing her—her ordeal of childbirth and the coming of her baby.

And now her ordeal is over. Her baby is here. Every one may be said to be breathing easily at last and they are no longer apprehensive and absorbingly interested in her. As a result the young mother will soon become simply one of the family and the community, and will cease to be the centre of reverential interest and solicitude.

It is scarcely human to welcome such a change in one’s state, and though in all probability very few mothers are conscious of resenting it, very many actually do. And for this reason very many unwittingly cling to a rôle of semi-invalidism. It is entirely unconscious on their part and it is also very human and natural.

To aid in the process of bracing up such a young woman to resume her former life and to meet the demands which it imposes; or to protect another patient of the eager, buoyant type from exposing herself too early to the onslaughts made by everyday life, is far from being a simple task, and to meet it no one rule can be laid down. There are all of the variations and degrees between the timid or self-indulgent woman, who must be encouraged and spurred on, and the too active, ambitious patient, who must be steadied and held back for a time.

But here, again, this is simply a part of the nurse’s duty; one aspect which makes nursing the gratifying service that it is.

Fortunately the majority of young mothers are happy and normal in their outlook and may be kept so by the exercise of an average amount of tact and amiability on the part of the nurse. The actual physical care of the patient during the puerperium is a fairly simple matter for the well trained nurse. She will find, however, that in hospitals, private practice and public-health work alike there will be wide differences in the treatment given by different doctors, during this period, just as there were during pregnancy and labor, and she will have to carry out the prescribed directions enthusiastically and loyally no matter how they vary from those of the doctors who helped in her training.

The details of the care will be indicated by the individual doctor, but the general, underlying principles—cleanliness, watchfulness, adaptability and sympathetic understanding will apply to the nursing of all patients. The most notable differences of opinion relate to the care of the breasts, the perineum and the use of abdominal binders, the accepted routine for the general nursing of average, normal cases being fairly uniform the country over.

NURSING CARE

As has been stated, the general nursing care of the puerperal patient is much the same as that given to any surgical patient, with such adaptations as are indicated by the condition and needs of the young mother.

=Position in Bed.= The question of the patient’s position in bed is probably the first one that presents itself to the nurse after that first hour when the patient must be kept flat on her back and the fundus closely watched. She should continue to lie quietly on her back for a few hours, with only a small pillow under her head, as moving about may cause hemorrhage. Some doctors permit the patient to turn from side to side at will after a few hours of quiet, while others do not allow this for two or three days particularly if the patient has perineal stitches, unless her knees are tightly bound together. Their reason for this precaution is fear that the stitches may be torn out if the thighs are separated and also that air may gain access to the uterine vessels, through the relaxed and gaping birth canal, and produce air embolism. It is a routine in some hospitals to keep the head of the patient’s bed elevated during the first week, to promote drainage, but as a rule it is in the usual position.

Quite commonly the patient is encouraged to lie first on one side and then on the other, after she begins to move about in bed unassisted, and then face downward at intervals, in order to change the position of the uterus and thus tend to prevent backward displacement.

In many hospitals, it is part of the daily routine to measure and record the height of the fundus (Fig. 116) above the symphysis, in addition to noting the character, amount and odor of the lochia, in order to judge if involution is progressing normally. A uterus that does not remain firm and does not steadily shrink in size and descend into the pelvis is not involuting properly, and the usual remedy is more rest and a longer stay in bed, with an icecap over the fundus.

=Sitting Up.= Except when there are perineal stitches or the temperature has been elevated at some time following delivery, the patient is ordinarily allowed to sit up in bed about the sixth or eighth day. If the lochia is normal, the uterus firm and in the proper position in the abdomen and her general condition satisfactory, she is allowed to sit up in a chair for a little while about the ninth or tenth day. Some patients are able to sit up for an hour the first time without being tired, but it is often better for them to sit up for a few moments morning and afternoon on the first day, than for a longer time at one stretch. The patient is usually allowed to sit up an hour longer on each successive day and to walk a few steps on the third or fourth day after getting up.

A patient with stitches does not usually sit up in bed until the ninth or tenth day, when the stitches are removed, sitting up in a chair for an hour, two or three days later. If she has had fever, the time at which she may sit up will of necessity depend upon her condition.

The return to normal life must be very gradual and this also must be regulated by the patient’s general condition and her recuperative powers. A pinkish or red discharge or backache should be taken as warnings against standing or walking or working. The possible consequences of ignoring these warnings and being up and about too soon, may be displacement, even prolapse of the uterus; hemorrhage, from dislodgment of clots in the uterine vessels; metritis or endometritis.

It is not a good plan, as a rule, for the patient to go up and down stairs until the baby is about four weeks old, nor wholly to resume her normal activities within six or eight weeks after delivery.

In addition to this sustained, general care, it is a customary preventive measure for the doctor to make a thorough pelvic examination from four to six weeks after delivery. A slight abnormality, if detected at this time may usually be corrected with little difficulty, but if allowed to persist may result in chronic invalidism or necessitate an operation. If the uterus is not properly involuted, for example, or the perineum is found to be flabby, more rest in bed is indicated; while a uterine displacement, which seems to be present in about a third of all cases, usually may be corrected by the adjustment of a pessary.

The time of sitting up, of getting up and of walking about varies so with the individual, therefore, that it is not possible to describe a definite routine, for some patients recover slowly and would be injured by getting up and about at a period which would be entirely safe and normal for the majority. It must be determined in each case by the condition of the uterus, the appearance and amount of the lochia and the patient’s general condition.

Quite evidently, then, much ill health and many gynecological operations may be prevented by caution, prudence and good care during the first few days and weeks after the baby’s birth, while the patient returns to a normal mode of living.

=The Daily Bath.= During the first week or two the patient’s skin must aid in excreting fluids from the edematous tissues throughout the body and broken down products from the involuting uterus. Therefore she should have a bath of warm water and soap every day, to remove material already on the surface and stimulate the skin to further activity, and an alcohol rub at night, if possible. It is important for the nurse to remember, while bathing her patient, that she is perspiring freely and therefore may be easily chilled if not well protected.

It is often a good plan to have the patient, without stitches, begin to bathe herself in bed, after the third or fourth day, for the sake of the exercise, and also the encouragement that it offers. When all is going well, tub-bathing is usually resumed by the third or fourth week.

=Diet.= Opinions as to diet vary slightly with different doctors and in different hospitals, but in general, a patient in good condition is given liquid food during the first twelve to twenty-four hours after delivery; then a soft diet for a day or two, a nourishing, light diet being resumed by the third or fourth day, or after the bowels have moved freely.

The patient will usually have little appetite, at first, and will have to be tempted by small amounts of invitingly served food. The factors which the nurse must bear in mind when arranging the patient’s dietary are the general nutrition of the mother; the desirability of minimizing her loss of weight during the puerperium; increasing her strength and, particularly, of promoting the function of her breasts, in order to produce milk of a quality and quantity adequate to nourish the baby.

The best producer of such milk is a diet consisting largely of milk, eggs, leafy vegetables and fresh fruits, taken with an appetite that is made keen by constant fresh air. The nurse will do well to convince her patient of this, in addition to bearing it in mind herself, and to place little reliance on so-called milk producing foods.

The young mother’s dietary may well be made up from the groups of foods that are suitable for the expectant mother. (See Chapter VI). At this time, as during pregnancy, she must avoid all food which may produce any form of indigestion, but for the baby’s sake, now, as well as her own. While it is not generally believed, to-day, that there are many, if any articles of diet which in themselves affect the mother’s milk unfavorably, it is generally conceded that a derangement of her digestion may, and usually does, have a deleterious effect upon her milk, and therefore upon the baby.

The old, and widespread, belief that certain substances from such highly flavored vegetables as onions, cabbage, turnips and garlic are excreted through the milk, to the baby’s detriment, is not given general credence to-day. On the other hand, it is known, however, that certain protective substances in certain foods are excreted through the milk, to the baby’s distinct advantage, and it is therefore, important that the mother’s diet should regularly contain those articles of food which contain them. These foods are milk; egg yolk; glandular organs, such as sweet-breads, kidneys and liver; the green salads, such as lettuce, romaine, endive and cress and the citrus fruits, or oranges, grapefruit and lemons.

These are called “protective foods” because they protect the body against the so-called deficiency diseases known as scurvy, beri-beri, xerophthalmia, which with rickets and pellagra are discussed in the chapter on Nutrition. It is possible for a baby who nurses at the breast of a woman whose diet is poor in protective foods, to be so insufficiently nourished, in some particular, as to be on the border line of one of these diseases, or even to develop the disease itself. This is one reason for the statement that the nursing mother must “eat for two.”

Certain drugs are excreted through the milk and may affect the baby in the same way as though they were administered directly, for example: salicylic acid, potassium iodid, lead, mercury, iron, arsenic, atropine, chloral, alcohol and opium.[9]

In addition to her food the nursing mother should have an abundance of water to drink, and to facilitate this it is a good plan to keep a pitcher or thermos bottle of water on the bedside table, and replenish it regularly, every four hours.

In general, the young mother should have light, nourishing, easily digestible food, with little, if any meat; an abundance of cereals, creamed dishes, creamed soups, eggs, salads and the fresh fruits and vegetables which ordinarily agree with her; at least a quart of milk, daily, in addition to that which is used in preparing her meals, and an abundance of water to drink.

=The Bowels.= The puerperal patient is almost always constipated, and needs assistance in regaining regularity in the movements of her bowels.

The routine use of cathartics and enemata varies, but it is very common to give an enema on the second morning after delivery or castor oil or Rochelle salts, followed by an enema if necessary. After this, a mild cathartic or a low enema is given often enough to produce a daily movement when this is not accomplished by means of the diet.

Some doctors, however, prefer that the bowels shall not move for four or five days after delivery, believing that this delay reduces the danger of infection from the intestinal contents, which are swarming with organisms, particularly the colon bacillus.

In cases of third degree tears, catharsis is practically always delayed for four to six days in order that the torn edges of the rectal sphincter may become well united before being strained by a bowel movement. In these cases an enema of six or eight ounces of warm olive oil is often given and the patient encouraged to retain it over night, in order to soften the contents of the rectum and lessen the strain and irritation of evacuation.

=The Bladder.= The question of helping the patient to void after delivery is one of extreme importance, because she will almost certainly have difficulty in emptying her bladder, and yet catheterization is not to be resorted to unless absolutely necessary. As a rule the patient should be encouraged to try to void from four to eight hours after delivery. If she is unable to do so at first there are several aids which the nurse should employ before admitting the patient’s inability to empty her bladder. Inducing her to drink copious amounts of hot fluids is the first step. Very often she will then void if placed upon a bedpan containing water hot enough to give off steam, and more warm, sterile water is poured directly upon the urethral outlet; or hot and cold sterile water may be dashed, alternately, upon the meatus.

The sound of running water is often helpful as well as the application of hot stupes over the supra-pubic region. When everything else fails, success frequently follows the application of a partly filled hot-water bottle over the bladder, held in place by a tight binder, particularly if the patient rests upon a pan of steaming water at the same time.

The danger of infecting the bladder, by carrying lochia into it upon the catheter, is so great that some doctors choose what they regard as the lesser of two evils, and allow the patient to be assisted to the sitting position, if she has not a serious tear. Not infrequently the patient’s inability to void is due to the fact that she is unaccustomed to using a bedpan, and would have difficulty in using one under any conditions, but is able to void while sitting up. As the danger of infection is greater two or three days after delivery than at first, because of the beginning decomposition of the lochia, it is very evidently important to help the patient to establish the habit of voiding from the beginning, for if she is catheterized once there is great likelihood that she will need to have it continued for some days.

If the first attempts are unsuccessful, therefore, but the patient thinks that she may be able to void later, if the efforts are repeated, catheterization is sometimes delayed for as long as sixteen to eighteen hours after delivery in the hope that it may be avoided altogether.

When the most persistent and painstaking efforts fail, and catheterization is necessary, the nurse must remember the extreme gravity of her responsibility and preserve asepsis throughout the procedure. Although there is extreme danger of infection, it can be prevented as a rule, and its occurrence is therefore regarded as almost inexcusable.

In preparing for catheterization, the nurse should drape the patient as for a vaginal examination, making sure that she is warmly covered, and place her on a sterile douche- or bedpan. If it is done at night she should place the light in a position at once safe and advantageous. She should have at hand on a tray: sterile forceps; cotton pledgets; two glass catheters (in case one should be broken or become contaminated); a disinfecting solution such as bichlorid, 1–4,000 or lysol 1 per cent.; a sterile receptacle in which to receive the urine; sterile towels and a dressing basin or paper bag for the used pledgets.

The preparation of the nurse’s hands, at this point, varies in different hospitals, but always the greatest care is taken to bring nothing unsterile in contact with the vulva and meatus.

According to one method, the nurse scrubs her hands for three minutes and prepares the patient as for a vaginal examination, removes the douche pan and places a sterile towel over the vulva. She then scrubs and soaks her hands as described in Chapter XII, puts on sterile gloves, places a sterile towel over the patient’s abdomen and slips one under her hips. She should then separate the labia with the gloved fingers of the left hand, drawing the fingers upward a little to make the meatus more prominent. The inner surface of the labia is then bathed with pledgets soaked with the disinfecting solution, with downward strokes, each pledget being used but once. Five or six pledgets should be used, one after the other, to sponge the meatus, each pledget being placed squarely against the orifice, without touching the adjacent tissues, and given a slight, downward twisting motion and discarded. The bowl may then be placed in position to receive the urine, and the catheter picked up with the fingers, by its open end. The rounded end must be carefully inspected to insure against using one that is cracked or broken, after which it is slowly and gently introduced into the urethra for two or three inches. If the urine does not flow freely the catheter may be slightly withdrawn and light pressure made upon the bladder.

Before removing the catheter the nurse must locate the fundus and assure herself that it is in a proper position. If it is pushed up or to one side she will know that the bladder is still distended, and that more urine must be withdrawn. After the bladder has been emptied the nurse should place one finger over the open end of the catheter and remove it slowly.

Another method of catheterization differs from the one just described, in the preparation of the nurse’s hands. In this instance she simply washes her hands well with soap and hot water and wears neither gloves nor finger cots.

She bathes the vulva with pledgets and an antiseptic solution, using forceps, and then separates the labia with two dry pledgets, one each under forefinger and thumb of the left hand, and proceeds as above. It will be observed that the nurse avoids touching the inner surface of the labia or the meatus with anything but sterile pledgets and the sterile catheter. The advantage of this procedure is that it is accomplished quickly and with the minimum of disturbance to the patient.

A distended bladder may so easily occur unless the patient is carefully observed during the puerperium that the nurse should charge herself to watch for this complication. She should give the patient a bedpan every four hours, note the contour of the abdomen and measure the urine during the first week, remembering that the patient should void considerably more than the average amount, both because of the amount of milk and water that she is taking, and the fluid which she is eliminating from her tissues. The importance of measuring the urine lies in the fact that though the patient may void fairly regularly she may not empty her bladder, and thus enough urine may accumulate to distend it.

=The temperature, pulse and respirations= are usually taken and recorded every four hours for the first five or six days and then two or three times daily, if normal. If the temperature is above normal at any time, the nurse should take it every two hours until it becomes normal and notify the doctor immediately if it goes as high as 100.4° F., or if the pulse reaches 100.

=Care of the Perineum.= The best way of caring for the perineum, during the first week or ten days after delivery, is a moot question, and the nurse may find herself sorely perplexed by the widely divergent instructions of different doctors who have excellent results, unless she goes back of the details themselves and recognizes their purpose. She will then see that there is entire agreement about the importance of protecting the patient against infection, at this time, when infection may so easily occur. And so far as the nurse is concerned, this means cleanliness as to methods and appliances, when making perineal dressings, and extreme precaution against conveying infection to her patient. The minimum requisites for this are that the bedpan shall be sterilized, by steam or boiling, at least once a day, and well scrubbed and scalded after each time that it is used, and that the nurse shall at least scrub her hands with soap and hot water before making each perineal dressing, and apply only sterile pads.

After the perineum is bathed, immediately following delivery, the usual practice is to apply a sterile pad, after which a fresh one is applied as often as necessary at first, every four hours during the first week and subsequently every eight hours. When the dressing is changed, and after each voiding and defecation, the perineum is bathed with sterile pledgets and some such antiseptic solution as bichlorid 1–2,000 or lysol ½ per cent. or 1 per cent. (Figs. 117 and 118.) The soiled pad must always be removed from above downward and the bathing also directed toward the rectum, each pledget being used for one stroke only. The rectum is bathed last, a fresh sterile pad applied and the patient’s hips and back thoroughly dried.

The nurse may be required to scrub and soak her hands, wear sterile gloves and hold the pledgets in forceps when bathing the perineum, the object of such precautions being, quite clearly, to avoid infecting the patient from without, for the inner surface of the uterus is still regarded as an open wound.

Some obstetricians believe that the perineal pad is a menace, since it slips and moves about, and thus may transfer infective material from the anus to the vagina. Accordingly, they forbid the use of all perineal dressings and instead have large, sterile, absorbent pads slipped under the patient’s hips to receive the lochia, the pads being changed as often as necessary. This is the practice at the Brooklyn Hospital, for example, where the nurse bathes the vulva with lysol 1 per cent., placing the patient on a sterile bedpan, using sterile forceps and cotton swabs and wearing sterile gloves while making the dressing.

Another method is to place the patient on a sterile bedpan, remove the pad and with gloved hands pour from a sterile pitcher a warm antiseptic solution over the groin and outside of the vulva; then to separate the labia and pour the solution between them, in some instances pressing a dry, sterile pledgets to the vaginal orifice during the irrigation.

When the urine is being measured, as it frequently is during the first week, the solution which is used for irrigating the vulva should be measured beforehand and the contents of the bedpan measured after the dressing, in order that the amount of urine passed, if any, may be ascertained.

Another method of bathing the perineum, that employed at Johns Hopkins Hospital, is simply to bathe the perineum with soap and warm water, without separating the labia, using a clean wash cloth and afterwards applying a sterile pad, the pads being changed every four hours, or oftener if necessary. The theory upon which this procedure is based is that the steady outward flow of the lochia constantly carries material, infective and otherwise, away from the generative tract, and that if nothing is introduced between the labia or into the vagina the patient will not be infected.

In caring for the perineum, the nurse must remember also the real danger of the patient infecting herself with her own fingers and should caution her against taking this risk. The patient should be told that if she feels uncomfortable, or thinks she is bleeding, she must lie quietly and summon a nurse, but on no account to try to find out for herself what is wrong. There is little doubt that cases of severe infection have been caused by the introduction of organisms into the vagina by means of the patient’s own fingers, after the most scrupulous precautions had been taken by doctors and nurses to avoid that very disaster.

In most instances the care of the perineum is the same whether or not there are stitches, and in any case the method employed will be specified by the doctor. The nurse’s responsibility is to appreciate the object of the care, whatever form it may take, and bring intelligence to bear in giving it.

When there are perineal stitches, it is a wise and harmless precaution to fasten a towel or bandage about the patient’s knees for a few days, to prevent her pulling apart the uniting edges of the tear as she moves about in bed.

=Douches.= In connection with perineal dressings, it may be well to caution the nurse against giving douches without explicit orders. Douches are seldom given early in the puerperium, for fear of carrying infective material up into the uterus, except occasionally in cases of hemorrhage, in which case they are given by the doctor.

Sometimes, however, a low vaginal douche is given daily for some time after the patient gets up, with the idea of increasing her comfort and promoting involution. About two quarts of some weak antiseptic solution at 110° F. is given with the nozzle introduced just within the vaginal outlet, and the container of the solution placed only slightly above the level of the patient’s hips, in order that the stream may be very gentle.

=The Care of the Breasts.= There is a wide difference of opinion about the proper care of the breasts, also, but here again, although the details vary, the ultimate objects of the care are always the same, namely: to facilitate the baby’s nursing, promote the mother’s comfort and prevent breast abscesses. These ends are usually accomplished by keeping the nipples clean and intact and by giving support and rest to heavy, painful breasts.

The patient who has cared for her nipples during the latter part of pregnancy will usually have little or no trouble with them during the period of lactation, if the care is continued. But this attention is imperative.

It is very generally customary to have the nipples bathed before and after each nursing with a saturated solution of boracic acid, in either water or alcohol, using sterile pledgets and forceps, and to keep them clean between nursings by applying sterile gauze. This gauze may be held in place by means of a breast binder or by tapes tied through the ends of narrow strips of adhesive plaster, four being applied to each breast. (Fig. 119.) Strips of adhesive plaster about five inches long are folded over at one end, two adhesive surfaces being in contact for about an inch. Through a hole in the folded end a narrow tape or bobbin is tied and the strips applied to the breast, beginning at the margin of the areola and extending outward. The free ends of the tapes are tied over squares of sterile gauze, between nursings, and untied to expose the nipple at nursing time.

Lead shields are sometimes used to protect the healthy nipple and not infrequently are applied to cracked nipples, being held in place by means of a breast binder. The secretion of milk which escapes into the shield is acted upon by the metal and the result is a lead wash which continuously bathes the nipple. The shields should be scrubbed with sapolio and boiled once daily.

Another method, and one widely employed, is to anoint the nipple after nursing with sterile albolene or a paste of sterile bismuth and castor oil, and apply squares of sterile paraffin paper. These bits of paper are pressed into place and held for a moment by the nurse’s hand, the warmth of which softens and moulds them to the breast after which they remain in place. In some instances the bismuth and castor oil paste is wiped off, with a sterile pledget, before nursing and in others it is not.

In some hospitals, neither gauze nor paper is used, the nipples being protected by putting sterile night-gowns on the patients.

The purpose of all of these methods is to keep the nipples clean, and here again the patient must be cautioned against infecting herself. No amount of care on the nurse’s part will protect the patient if she touches her nipples with her fingers.

The nurse will appreciate the reason for all of this painstaking care if she calls to mind the fact that the breast tissues are highly vascular and excessively active at this time and therefore very susceptible to infection, and also that the baby’s suckling is often very vigorous and accompanied by a good deal of chewing and gnawing of the nipples. Unless the nipples have been toughened, and sometimes even when they have, the skin becomes abraded or cracked as a result of the baby’s suckling, thus creating a portal of entry for infecting organisms, in addition to the milk ducts which lead back into the breast tissues. Unless the nipples are kept clean, constantly, they may become infected by organisms from the baby’s mouth or on the patient’s hands, bedding or gown with a breast abscess as a result. The important thing, then, is to keep the nipples clean and not allow anything unsterile, excepting the baby’s mouth, to come in contact with them at any time.

It is sometimes the practice to swab the baby’s mouth with boric soaked cotton or gauze before each nursing, but many doctors hold that this is injurious to the delicate mucous lining of the baby’s mouth. The opinions for and against this routine seem to be about equally prevalent.

If the nipples become painful or cracked, one can easily understand that continued suckling would only aggravate the condition and increase the danger of infection. But the baby must nurse, if possible, and so in the majority of cases a nipple shield is used (Figs. 120–121) as a protection, and after nursing the fissures or abraded areas are painted with bismuth and castor oil paste; compound tincture of benzoin; balsam of Peru; argyrol, silver nitrate or sometimes only alcohol. The application is made with sterile swabs prepared by twisting a wisp of cotton about the end of a toothpick. If the crack or abrasion is extensive enough to cause bleeding, even nursing through a shield is sometimes, but not necessarily discontinued, while the other treatment is the same as for a nipple that does not bleed.

Sound, uninjured nipples, then, are to be kept clean and protected from infection and those which are abraded or cracked are to be kept clean and also protected against further injury.

=Lactation.= About the third or fourth day after delivery, when milk replaces colostrum, the breasts become swollen, engorged and often very painful, and not infrequently, a hard, sensitive lump or “cake” may be felt. The growing tendency, now, is merely to support these heavy breasts by means of a binder which has straps passing over the shoulders, in order to hold them up without making pressure (Fig. 122) and to apply ice caps or hot compresses to the painful areas. It used to be customary to massage and pump caked breasts, to apply pressure and various kinds of lotions or ointments. Though one, or all of these measures are still employed, in some cases, the general practice is to avoid manipulating the breasts but to empty them regularly by the baby’s nursing; support them and allow Nature to make an adjustment between the amount secreted and the amount withdrawn.

Free purging is sometimes employed and the amount of fluids reduced until the engorgement and discomfort subside. This happy issue is practically always reached if the baby nurses regularly and satisfactorily, as there is a spontaneous adjustment between the amount secreted by the mother and that withdrawn by the baby. But as abscesses may follow in the wake of caked breasts, particularly if the nipples are sore, it is of great importance that the nurse watch closely for the first evidence of painful lumps. The prompt application of a supporting bandage and ice bags (Fig. 123) or hot compresses will, in the majority of cases, give speedy and complete relief. So widely is this believed that many doctors regard the care of the breasts, including the prevention of breast abscesses, as a nursing question, entirely, and conversely are likely to regard the occurrence of a breast abscess as an evidence of careless nursing.

Certain it is that breast abscesses are almost never seen where the nurses have this sense of responsibility, and habitually watch the breasts closely and promptly use support and either heat or cold when the breasts become heavy and sensitive.

There are innumerable bandages and methods for supporting heavy breasts, any one of which is efficacious so long as it meets the two chief requirements: to lift the breasts, suspending their weight from the shoulders, and, while fitting snugly below to avoid making pressure at any point, particularly over the nipples. One of the most satisfactory and widely used supports is the Y-bandage, (Figs. 124, 125, 126), another, the Indian binder (Fig. 127.)

The nurse must on no account massage or pump engorged breasts on her own responsibility, for there is a good deal of evidence to show that any such manipulation tends to increase the amount of the secretion and this in turn increases the engorgement and pain. It is possible, too, that massage may bruise the breasts and thus make them more susceptible to infection.

=Mastitis.= When infection occurs, the swollen, painful breasts may grow hot and red, the patient may complain of chilliness and have a slight fever, with or without there being an abscess. Even then the general treatment is most frequently found to consist of support; ice or heat; catharsis and restricted fluids, though in some cases the breasts are pumped and nursing is discontinued.

When the inflammation so far progresses as to require that the breast be opened and drained, the subsequent nursing care will be outlined by the doctor to meet the needs of each case. It is a painful operation and often a serious one, for the destruction of breast tissue may be extensive enough to render the breasts valueless as milk-producing organs. The healing is slow and altogether the occurrence is a most lamentable one.

The nurse’s part in preventing this complication is cleanliness and gentleness in her attentions; unremitting watchfulness; immediate application of a suspensory bandage and either heat or cold, upon the first sign of engorgement and prompt reporting to the doctor.

If the patient’s nipples have not been toughened during pregnancy or if flat or retracted nipples have not been satisfactorily brought out, it may be necessary for the nurse to employ the treatment to these ends which were described in the chapter on pre-natal care. In the meantime the baby may have to nurse through a shield until the nipple is brought out prominently enough for him to grasp it well.

=Stripping.= Sometimes in cases of depressed nipples, which the baby cannot grasp, or when the baby is too feeble, to nurse at the breast, milk is withdrawn from the breast by means of so-called “stripping.” The nurse should scrub her hands thoroughly with hot water and soap and dry them on a sterile towel before beginning. The breast is grasped by placing the thumb and forefinger of the right hand on the areola on opposite sides of the nipple but well below it. The nipple is then raised from the breast by a quick, lifting and rolling motion of the thumb and finger, accompanied by slight pressure. A sterile medicine glass should be held in position to receive the milk which spurts from the nipple, but the glass should not touch the breast. (Fig. 128.)

There is a knack about stripping and it requires practice, but those doctors who advocate it feel that it empties the breast, when this is necessary, with less disturbance than that caused by pumping, and as the milk is projected directly from the nipple into the sterile glass, without any of it running over the nipple or breast as may happen in pumping, it has the additional advantage of always being sterile.

Extreme gentleness must be used; the openings of the milk ducts must not be touched by the fingers, and the thumb and finger must not press deeply enough to reach the glandular tissue itself. If done properly stripping neither stimulates nor bruises the breast tissue nor does it cause the patient even temporary discomfort.

=Abdominal Binders and Bed Exercises.= There is considerable difference of opinion about the advantage of using abdominal binders upon the puerperal patient while she is in bed, and the nurse will accordingly care for the patients of some doctors who use them and for those of others who do not.

The application of a moderately snug binder for the first day or two is a fairly common practice, for multiparæ, particularly, are often made very uncomfortable by the sudden release of tension on their flabby abdominal walls; a discomfort which a binder will relieve. And during the first few days after the patient gets up and walks about, she is sometimes given great comfort by a binder that is put on as she lies on her back, and is adjusted snugly about her hips and the lower part of her abdomen.

But the continued use of a binder after the first day or two, while the patient is still in bed, is not as general as it formerly was. Many women ask for binders in the belief that they help to “get the figure back” to its original outline, and some doctors feel that the use of the binder is helpful in restoring the tone to the abdominal muscles, which amounts to about the same thing. Both the straight swathe and the Scultetus binder are used for this purpose and they are put on in the usual manner; snugly and with even pressure, but not tight enough to bind.

Those doctors who disapprove of the binder believe that it interferes with involution and, by making pressure, tends to push the uterus back and cause a retro-position, in addition to retarding instead of promoting a return of normal tone to the abdominal muscles.

Accordingly, they instruct their patients to take exercises, instead of wearing binders, and they have these exercises started while the patient is still in bed. Their adoption, and the rate at which they are increased, are entirely dependent upon the individual patient’s condition, for they must never be continued to the point of fatigue. There are, therefore, no definite rules laid down, concerning these exercises, beyond a description of the positions and movements themselves, and their sequence.

Those which are taught to the patients at the Long Island College Hospital are so simple, and evidently productive of such happy results that they offer excellent examples of this form of treatment. They are, of course, taken only by the doctor’s order, but the nurse’s intelligent supervision increases their effectiveness.

The general purpose of these exercises is to strengthen the abdominal muscles, thus helping to prevent a large, pendulous abdomen; to increase the patient’s general strength and tone, just as exercise benefits the average person; to promote involution; to prevent retro-version and in a measure, increase intestinal tone and thus relieve constipation. To accomplish these much to be desired ends the exercises must be taken with moderation and judgment; started slowly; increased very gradually and constantly adapted to the strength of the individual patient. Otherwise they may do more harm than good. In the average, uncomplicated case in which the patient is doing well, she usually starts the chin-to-chest exercise from twelve to twenty-four hours after delivery. She should lie flat on her back and raise her head until her chin rests upon her chest. (Fig. 129.) If she rests her hand upon her abdomen, she will feel for herself that the abdominal muscles contract, and accordingly will be disposed to continue the exercises with more interest and confidence than she otherwise might. The movement is repeated twenty-five times, morning and evening, every day, and continued as long as the patient is in bed.

The familiar, deep-breathing exercise is ordinarily started on the third or fourth day. The patient should lie flat, with her arms at her sides, then extend them straight out from the shoulders (Fig. 130), raise them above her head (Fig. 131) and return them to the original position. This is repeated ten times morning and evening, daily, as long as the patient is in bed.

The one-leg-flexion exercises are not done by patients with perineal stitches, but in other cases they are usually started about the fifth day. The thigh is flexed sharply on the abdomen and leg on thigh (Fig. 132), then extended and lowered to the bed. This is repeated ten times, with each leg, morning and evening for one, or possibly two days.

The next exercise replaces the one-leg-flexion and is started after the latter has been done for one or two days, according to the strength of the patient, and it in turn is continued for only one or two days. Both thighs are sharply flexed on abdomen and legs on thighs (Fig. 133), then extended and lowered but not far enough for the heels to rest upon the bed before being flexed again. This is repeated ten times morning and evening.

Next is the exercise for which the leg-flexion exercises prepare the patient, and which are discontinued when this one is adopted. It is started, as a rule, about the seventh day, or three or four days before the patient gets up. Both legs are slowly lifted to a position at right angles to the body (Fig. 134) and slowly lowered, but not far enough for the heels to touch the bed (Fig. 135), and the movement repeated. As this exercise requires a good deal of effort, it must be taken up very gradually, as follows: The legs should be raised on the first day, once in the morning and twice in the evening; second day, three times in the morning and four times in the evening; third day, five times in the morning and six times in the evening and so on, if the patient is not fatigued, until the exercise is repeated ten times each morning and evening. It is continued for several months.

The knee chest position (Fig. 136) is intended to counteract the tendency toward retroversion, from which so many women suffer after childbirth. It is usually started about the seventh day and the patient begins by remaining in that position for a moment or two, gradually lengthening the time to about five minutes each morning and evening for about two months.

Walking on all fours is violent exercise and has to be taken up very gradually. Some patients are able to attempt it on the first day out of bed, if they have been taking the other exercises, but as a rule it is not started until the second or third day. The patient’s clothes should be free from all constrictions; the knees should be held stiff and straight with the feet widely separated, to allow a rush of air into the vagina, and the entire palmar surface of the hands should rest flat on the floor. (Fig. 137.) The patient should start by taking only a few steps each morning and evening, gradually lengthening the walk to five minutes twice daily and continuing it for about two months.

It is believed that as the patient walks in this position the uterus and rectum rub against each other producing something the same result as would be obtained by massage. The effect of the exercise is to promote involution and diminish the tendency toward constipation and retroversion, apparently preventing malposition entirely in a large percentage of cases. Though not widely used, its beneficial effects are unquestioned by those doctors who employ it.

In taking a general survey of the young mother and her needs, we realize that in a broad sense she is not ill, in so far as no pathological condition exists. But she is in a transitional state and may become acutely or chronically ill if not carefully watched and nursed. In general her mental, physical and nervous forces must be conserved and increased, and this requires thoughtful and devoted attention from the nurse. She must be scrupulously clean in her care of the nipples and perineum, and in order to be able promptly to inform the doctor of any departure from the normal in the patient’s condition, the nurse’s watchfulness should embrace regular observations upon the following:

1. The patient’s general condition; the amount and character of her sleep; her appetite; her nervous and mental condition.

2. The temperature, pulse and respiration.

3. The height and consistency of the fundus.

4. The quantity, color and odor of the lochia.

5. The persistence and severity of the after-pains.

6. The condition of the perineum.

7. The condition of the nipples and breasts.

8. The functions of the bladder and bowels.

If all goes well and there are no complications, the patient will usually be able to assume full charge of her baby by the sixth or eighth week, and practically return to her customary mode of living, with the difference that she now has the care of a baby which she did not have before. The care of that baby requires certain, definite care of herself, as a nursing mother, which will be described in detail in the next chapter.

To sum up the general principles of nursing the young mother during the puerperium, we find that just as during pregnancy and labor, the nurse must first be familiar with the normal changes that occur in order that she may recognize the abnormal. Then, as before, the nurse’s care of the individual patient must rest unfailingly upon a foundation of cleanliness in order to prevent infection; watchfulness, which implies ability to recognize normal changes and unfavorable symptoms; adjustment to the methods of the attending physician and to all of the circumstances surrounding the patient, and the wisest and tenderest consideration for her patient as an individual.