CHAPTER XVIII

COMPLICATIONS OF THE PUERPERIUM

The most important of the complications of the puerperium are subinvolution and malpositions of the uterus; breast abscesses; hemorrhage and infection.

The importance of these to the nurse lies in their preventability, by means of the clean and efficient care which she helps to give during pregnancy, labor and the early weeks after the baby is born.

The nurse’s part in prevention and treatment of subinvolution, malpositions of the uterus and breast abscesses is so bound up in the daily care of the young mother that it was described in the preceding chapter.

=Hemorrhage.= Under ordinary conditions, a patient may lose as much as 500 cubic centimetres of blood during or immediately after labor, without serious results, but a loss of 600 cubic centimetres or more is regarded as a hemorrhage and as requiring speedy attention.

According to Dr. Williams, severe hemorrhage occurs only once in every few hundred labors, and with proper treatment, should not result fatally in more than one out of every 2000 or 2500 cases.

The severe hemorrhage due to a partially separated placenta occurs during the third stage of labor and was discussed in that connection. As the danger of hemorrhage, after labor is completed, is greatest during that critical hour immediately following, it is practically routine the country over to watch the patient closely during this period, both for the sake of preventing bleeding and detecting its early evidence, should hemorrhage occur, thus making prompt treatment possible.

The causes of post-partum hemorrhage are: Deep cervical tears, retained portions of the placenta, and atony of the uterus.

The treatment of hemorrhage due to tears of the generative tract is suturing the torn edges.

Since the retention of even a small piece of placental tissue will prevent the uterus from contracting firmly, the treatment of hemorrhage from this cause is immediate removal of the retained fragment. It is to obviate this occurrence that the placenta is carefully inspected after its expulsion. If it is not intact, the obstetrician may introduce his finger and remove the retained portion, thus making it possible for the uterus to contract properly and close off the open blood vessels.

Atony, or impaired tone of the uterine muscles, may result in hemorrhage because of failure of the muscle fibres to constrict the vessels. Quite evidently, the first step toward controlling hemorrhage from this cause is to stimulate the muscles to contract; this is done by means of massage and the administration of pituitrin and ergot. Elevation of the foot of the bed and application of ice-bag to the abdomen are also employed.

In severe cases, the doctor may give an intra-uterine douche of hot, sterile salt solution and if this fails he may pack the uterus tightly with sterile gauze. The douche and pack represent operative maneuvers and, therefore, are never to be undertaken by the nurse. Her assistance is important, however, as strictest asepsis is imperative and she will have to prepare the patient and the necessary articles with the greatest care.

Should bleeding become profuse during the doctor’s absence _the nurse must stay with the patient and massage the fundus_ and have some one else elevate the foot of the bed on the seat of a straight chair or upon firm blocks and summon the doctor. In anticipation of such an emergency the nurse must always have an understanding with the doctor about the administration of pituitrin and ergot. If there has been no understanding, and the doctor is delayed or the bleeding becomes alarmingly profuse, the nurse will usually be upheld if she gives 1 cubic centimetre of pituitrin, hypodermically and a dram of ergot by mouth.

It is, of course, definitely understood that nurses do not give medicines without orders, but a single dose of pituitrin and ergot upon the occurrence of a profuse hemorrhage can scarcely do harm and may actually save the patient’s life. Such a situation is an emergency fortunately a rare one, and the nurse will have to be quick-witted and use the best judgment she is capable of.

The patient is usually more or less shocked by the time the bleeding has been controlled and needs the rest, quiet and stimulation that are ordinarily employed in such cases. She should be well wrapped in blankets and surrounded with hot water bottles _placed outside the blankets, watched constantly and moved frequently_; salt solution or strong coffee are sometimes given by enema, or saline infusions or intra-venous injections may be given. The patient must be kept warm and quiet and pressed to drink large amounts of fluids.

But above all the nurse must remember that severe hemorrhage from a relaxed uterus can almost always be prevented if the fundus is kept hard, by massage when necessary, during the first hour or so after delivery.

=Puerperal infection= is usually regarded as a condition which results from the entrance of infective bacteria into the female generative tract during labor or the puerperium, to distinguish it from other infections which may occur coincidently with the puerperal state, but not necessarily be related to it.

Puerperal infection is one of the most destructive and most dreaded of the complications which may overtake the obstetrical patient, and has evidently been so considered since the days of Hippocrates. Until recent years this veritable scourge was so utterly baffling that it was regarded as more or less of a dispensation of a Divine Providence and therefore to be accepted with the same philosophical resignation as earthquakes and cyclones.

In dramatic contrast to this unresisting attitude is the present knowledge concerning the cause and prevention of this disease, and the general belief that it is a wound infection and therefore practically preventive; that it is to be ascribed to the carelessness of mankind rather than to the indifference of Providence.

This change is due very largely to the devoted work of three men who were deeply stirred by the tragic frequency with which young women laid down their lives in so-called “child bed fever.” These men were Ignaz Semmelweiss, Oliver Wendell Holmes, better known to Americans as poet and humorist, and Louis Pasteur, each contributing his own special observations to the sum of knowledge which was to mean so much to mothers of the future. Also the theories of Lister concerning antisepsis and the inauguration of the use of sterile rubber gloves by Dr. Halsted, of Johns Hopkins Hospital, has had the same life-saving effect upon obstetrical patients as upon all surgical patients.

In 1843, Oliver Wendell Holmes read a paper before the Boston Society for Medical Improvement, entitled “The Contagiousness of Puerperal Fever.” In this paper he presented striking evidence that in many instances, something was conveyed by doctor or nurse, from an ill person to a maternity patient with puerperal fever as a result. He was attacked and ridiculed for his theories and some of the leading obstetricians declared that it was an insult to their intelligence to expect them to believe that creatures too small to be seen by the naked eye could work such havoc.

In 1847 Ignaz Semmelweiss, of the Vienna Lying-in Hospital, decided as a result of some of his investigations that puerperal infection was a wound infection, and that the infecting organisms were introduced into the birth canal on the examining finger of the doctor or nurse, after contact with an infected patient or cadaver. Accordingly he required that all vaginal examinations be preceded by washing the hands in chloride of lime, after which precautions the mortality from infection dropped from 10 per cent. to less than 1 per cent. In 1867 Semmelweiss offered his theories and conclusions in a masterly work on this subject, the title of which may be translated as “The Etiology, Conception and Prophylaxis of Child-Bed Fever,” but the actual cause of the disease was still unknown.

But about 1879 Pasteur demonstrated what is now known as the streptococcus, in certain patients suffering from puerperal fever.

“Pasteur,” wrote M. Roux, “does not hesitate to declare that that microscopic organism (a microbe in the shape of a chain or chaplet) is the most frequent cause of infection in recently delivered women. One day, in a discussion on puerperal fever at the Academy, one of his most weighty colleagues was eloquently enlarging upon the causes of epidemics in lying-in hospitals; Pasteur interrupted him from his place. ‘None of those things cause the epidemic; it is the nursing and medical staff who carry the microbe from an infected woman to a healthy one.’ And as the orator replied that he feared that microbe would never be found, Pasteur went to the blackboard and drew a diagram of the chain-like organism, saying: ‘There, that is what it is like!’ His conviction was so deep that he could not help expressing it forcibly. It would be impossible now to picture the state of surprise and stupefaction into which he would send the students and doctors in hospitals, when, with an assurance and simplicity almost disconcerting in a man who was entering a lying-in ward for the first time, he criticised the appliances, and declared that the linen should be put into a sterilizing stove.”[13]

Slowly, but very slowly, the teachings of these earnest men were adopted by the medical profession, with the result that in well-conducted, modern hospitals the precautions which have been described in preceding chapters are rigidly observed. And to-day, one woman in about 1,000 in such hospitals dies of puerperal infection, instead of one in ten, as in the early days. In the year 1864, 23 per cent. of the patients at the Maternité, in Paris, died of puerperal infection.

But unhappily, the decline in the occurrence of puerperal infection, in this country is largely confined to the hospitals, for in the homes throughout the land the disease is almost as common as it was in the days of our fathers, or even grandfathers. Of approximately 20,000 deaths from childbirth in this country during 1920, about one-half, or possibly 10,000 were from puerperal infection.

To the nurse there is considerable significance in Pasteur’s characterization of the infected young mother as an “invaded patient,” for the nurse’s preparation for labor and her care of the patient during the puerperium should be enormously influential in preventing this “invasion.” In this connection she may well ponder Miss Nightingale’s assertion that “The fear of dirt is the beginning of good nursing.” Certainly the obstetrical patient cannot be well cared for unless the nurse has this fear in her heart.

Puerperal infection, then, in the light of present information, is regarded as a wound infection caused by the streptococcus, gonococcus, colon bacillus, gas bacillus or any other pus producing organism. Of these, the streptococcus infection is the most frequently seen and is also the most serious, about 10 per cent. of such infections resulting fatally; while the gonorrheal infection, though seldom ending in death, usually causes sterility.

Infection during the puerperium occurs most often in the uterus, and, if mild, may amount to nothing more than endometritis, or inflammation of the uterine lining. In more serious cases, the inflammation may spread to the tubes and ovaries; may cause abscesses in the broad ligament and general peritonitis. A streptococcus infection may spread through the lymphatics and cause general septicemia.

Infection of the raw and bleeding placental site may occur at any time during labor or the ten days following, though the danger of infection decreases steadily after the first day postpartum.

=Symptoms.= The symptoms vary greatly according to the infecting organism and according to the site and extent of the inflammation. In mild types of infection, the patient may be entirely normal for the first three or four days and then complain of chilliness or even have a chill; her temperature will be slightly above normal, finally reaching about 101° F., where it hovers for ten days or two weeks, after which it drops again to normal and the patient recovers.

The severe type, which is so dreaded, is the one in which the patient is normal until the third or fourth day when she complains of tenderness, chilliness, weariness, and of being generally wretched. She may complain of chilliness but more often has a chill.

The pulse is usually rapid and the temperature goes up somewhat abruptly. (Chart 3.) The condition of the lochia depends upon the infecting organism. In streptococcal infection the lochia is often greatly decreased in amount and almost odorless, while in colon bacillus infections the lochia is profuse and foul-smelling. The attack may be very acute and result fatally in a few days, or it may gradually subside and the patient recover.

In gonorrheal infections the temperature does not go up until later, from the sixth or to the tenth day, as a rule. (Chart 4.) The patient is not usually very ill and generally recovers. But the gonococcus is very likely to produce an inflammation of the tubes and to close up the fimbriated opening. Thus it is impossible for ova thereafter to enter the tube and gain access to the uterus and accordingly the patient cannot again become pregnant. Unlike other infections, gonorrhea is not conveyed to the patient during or soon after labor on instruments or examining fingers, but is already present in the vulvo-vaginal glands and from them may travel to the uterine cavity and to the tubes.

=Treatment and Nursing Care. Preventive.= There is so little that can be done toward curing a patient suffering from puerperal infection that the greatest effort should be made to prevent the disease. The nurse’s part in preventing this complication is an important one and consists of making such preparation for labor that it may be conducted with absolute cleanliness; maintaining the same asepsis during delivery as she would throughout a major surgical operation and protecting the perineum from infection after delivery.

=Curative.= The curative treatment for puerperal infection resolves itself largely into good nursing care. The patient should be kept warm and quiet and as comfortable as possible; elimination is promoted, her strength is saved and her general resistance increased in every way possible. The head of the bed is frequently elevated, to promote drainage; the windows are kept open to provide plenty of fresh air; the diet is light and nourishing and the patient is encouraged to drink an abundance of water. Ice caps to the head and abdomen are frequently used to make the patient more comfortable; also cold sponge baths when the temperature is high.

A patient suffering from puerperal infection should be conscientiously isolated. If the nurse who cares for her is forced to come in contact with other patients, she should wear gloves and a gown while attending the infected woman and thoroughly scrub and soak her hands after each attention.

It was formerly the practice to curette the patient suffering from puerperal infection, and give intra-uterine douches, but it is now pretty generally believed that neither of these procedures does any appreciable good, but on the other hand may do harm. The objection to curettage is on the ground that by this means the protective wall which Nature has developed to prevent the further invasion of bacteria into the uterine tissues, is removed and a new bleeding area is provided for further and easy development of the inflammation.

Antiseptic douches seem to be useless, for if they are strong enough to be germicidal they are likely to injure the tissues and also do harm by being absorbed into the system; while weaker solutions will not destroy the organisms but are likely to carry more infective material up into the uterus. In cases of putrid endometritis, however, if the doctor cleans out the uterus with his finger, a douche of sterile salt solution is often given for the purpose of removing any putrefactive material which may have been left behind.

=Phlegmasia alba dolens or “milk leg.”= In some cases of puerperal infection, thrombi are formed in the veins of the pelvis, from which particles may be broken off and carried to various parts of the body and cause phlebitis or even abscesses. If thrombi lodge in the large vessels of the thigh, the interference of the venous circulation results in swelling and tenderness of the leg which is often referred to as “milk leg.” This condition is rather rare and does not usually appear until the second or third week after delivery.

The swelling ordinarily starts at the foot and gradually extends up to the thigh. The patient complains of pain in the calf of her leg and she may have an elevated temperature, rapid pulse and the general wretchedness associated with an infection.

The main feature of the treatment is rest in bed; the patient should be kept there for at least a week after her temperature becomes normal; her leg should be elevated, wrapped in cotton batting and the bedclothes held from it by means of a bed cradle or some sort of a light frame. The nurse should never rub the affected leg, and the patient should also be cautioned against this for fear of dislodging a particle of the thrombus and causing an embolism elsewhere, possibly in the lungs. For the same reason, the patient must be warned not to make sudden or violent movements for some time after she is allowed to be up and about, but to walk and move rather slowly. The swelling and discomfort may subside in a few weeks or they may persist for months.

=Puerperal Mania.= A word about extreme mental unbalance during the puerperium is worth while at this point because the nurse will frequently hear of this distressing condition, and will almost inevitably come in contact with it at some time. It was formerly believed that there were certain mental disorders which were peculiar to pregnancy and the puerperium, but this belief has given way before the present knowledge of psychiatry.

The puerperal patient is sometimes delirious and violent for longer or shorter periods of time, but apparently these conditions are due to toxemia or fever, or a mental unbalance has resulted from her reaction to the idea of motherhood, just as it would have resulted from an equal strain of some other character.

In other words, the young mother may suffer mental derangement from the same causes that would produce this state in any other person, but not from causes or conditions which are peculiar to the puerperium.

If the excitement or delirium are due to a toxemia, they are relieved by treating the cause, while from the nurse’s standpoint the care would be the same as for any delirious patient. The patient should not be left alone and she should be protected against doing herself any injury.

A mental disturbance which is due to the patient’s inability to adjust herself to the state of motherhood, and all that that implies to her, is a different matter, and is discussed in the chapter on mental hygiene.

“Sympathy with, interest in the poor so as to help them, can only be got by long and close intercourse in their own houses—not patronizing—not ‘talking down’ to them—not ‘prying about’—sympathy which will grow in insight and love with every visit.”—FLORENCE NIGHTINGALE.