CHAPTER XX
CARE OF THE MOTHER AND BABY BY VISITING NURSES
The preventive value of post-partum care is now so generally recognized that maternity care by visiting nurses is given not only in the larger cities, but is being extended even to rural communities. The routine of the Visiting Nurse Society of Philadelphia, under the direction of Miss Katharine Tucker, may be taken as an example of effective post-partum care, in which daily visits by a nurse bring to large numbers of patients the minimum of necessary attention. As the same kind of work is effective and possible in smaller communities, the routines and instructions used by the Philadelphia Society are reproduced on pp. 439 to 445. These include
1. The equipment of the nurse’s bags.
2. Delivery routine.
3. Routine technique in caring for mother and baby.
In normal maternity cases, a visit is made once a day for eight days. After that time, if the mother is up and about and the baby is in good condition, the nurse visits at least once a week for supervision until the fifth week, when the case is transferred automatically to the Child Welfare Nurses under the City. If, however, there is any complication with either the mother or baby, the nurse continues daily visits or twice daily as indicated by the condition, until both mother and baby are normal. Instruction to the mother in the care of the baby is one of the important phases of the maternity nurse’s program.
The points observed and recorded on the bedside cards are: condition of breasts, urination, condition of bowels, character of lochia, position of uterus, T.P.R. or any abnormality. If there is any rise in temperature or other abnormality noted, the physician is called by telephone and the situation reported.
Any one can call the nurse—children, husband, neighbor, doctor, social worker,—and a nurse is sent out on every call. A doctor must be in charge of every case, and if one has not been engaged when the nurse gets there, she sees to it that one is procured. The only exception is in cases delivered by midwives, in which instances the nurse gives any necessary care and supervision, having it clearly understood that if any abnormality occurs, she will first notify the midwife and then the midwife or the nurse will immediately call a doctor.
The doctor ordinarily brings his own equipment for delivery. The contents of the nurse’s bag is the same for delivery as for post-partum care, except for the addition of the nurse’s gown, extra towels and silver nitrate. Perineal pads, cotton, boric solution, etc., are supplied at cost, or free of charge if the patient is unable to pay. Bed linen, nightgowns, layettes, etc., are provided for patients who cannot procure them.
The cost per visit to maternity patients averages one dollar and the cost for services at the time of confinement averages five dollars. Miss Tucker says of the maternity work:
“A complete maternity service which includes prenatal work, service at time of confinement, post-partum care and subsequent supervision of mother and baby is essential if adequate results are to be accomplished. Anything less than this complete service does not give full protection to the life of the mother and the baby. The Philadelphia Visiting Nurse Society has found that the inclusion of service at time of confinement has given a tremendous stimulation to both their prenatal and postnatal service. In the branches where a delivery service has been added, the prenatal service has increased fourfold. Both doctors and patients are enthusiastic and see far more reason for instruction and supervision from a nurse who is going to see the case through than from one who drops out at the crucial moment. It certainly has strengthened our whole maternity service, both as to results accomplished and in our relationship to the doctor and to the community.”
FORMS AND ROUTINES FOR MATERNITY WORK, VISITING NURSE SOCIETY PHILADELPHIA
EQUIPMENT FOR BAGS
Bottles containing:
1. Alcohol.
2. Licreolisis.
3. Green soap.
4. Mouth wash.
Jar with boric acid crystals.
Jar with cord powder.
Jar containing vaseline.
1. Hypodermic syringe.
2. Tongue depressors.
3. Two thermometers: rectal and mouth.
4. Toothpicks.
5. Adhesive plaster.
6. Fountain syringe or funnel and tube in linen bag.
7. Gauze and bandages in linen bag, cord dressing and cord tape.
8. Cotton and p.p. pads in linen bag.
9. Paper napkins on which to lay articles.
10. Granite pan.
11. Two towels.
12. One apron.
13. Hand-brush.
Instrument case containing:
Scissors, forceps, 2 artery clamps, glass catheter, rubber catheter, colon tube, connecting tube, glass nozzle, medicine dropper.
Folder containing:
Records.
Fee slips.
Literature.
ROUTINE TECHNIQUE
=1. Uniforms.=
Except in the case of substitutes during their first six months and staff nurses during their probation period, all the nurses are required to wear the uniform of the Society.
Prescribed hat and coat. Sensible black shoes. Plain dress of prescribed material.
=2. Bags.=
Lining to be changed once in two weeks. Bottles to be kept neatly labelled.
Lost articles to be replaced at the expense of the nurse.
New equipment may be obtained only in exchange for the worn-out one.
Notebooks, charts, other papers, and pencils to be kept in the long pocket.
Instruments to be boiled before and after dressings.
Brush to be boiled twice a week and after all infectious cases.
=3. Thermometer Disinfection.=
To be washed before and after using in running water if possible.
After using wrap in cotton soaked in alcohol and leave until the work is finished. Then wash with green soap under running water.
=4. Routine in the Home.=
=General Care=:
A. Remove hat and coat, folding coat right side out and placing on chair away from wall. Place bag on chair or on table with newspaper underneath.
B. Ask nature of illness, doctor’s orders, etc.
Ask family for a kettle of boiling water; pitcher of cold water; basin, soap and soap dish; pail for the waste; tumbler; towels and wash cloth; bath blanket or sheet; clean gown and necessary bed linen; newspapers; comb and brush.
C. Open the bag; put on apron; roll up sleeves; take from bag necessary articles, placing on clean newspaper or napkin. Wash hands and thermometer. Take everything needed from the bag at once to prevent unnecessary handling. Take and record T.P.R. of all cases except chronics of long standing.
D. Place newspapers-one on chair, one under edge of bed for soiled linen, one for utensils (kettle, pitcher, etc.)
Make cornucopia of newspaper for waste and pin to the side of bed.
E. Bath. Cover patient with blanket or sheet.
Remove upper bed clothes, fold and place on chair.
Soiled linen should be placed on paper with the stains turned in.
Avoid unnecessary exposure of the patient at all times.
Give thorough bath, using plenty of soap and rinsing carefully.
Change water at least once.
Bathe upper half of body, give local bath, change water and bathe lower half.
Put on nightdress before completing bath.
Clean teeth and nails.
Comb hair, protecting pillow with towel.
In making the bed be sure that there are no wrinkles under the patient and that the bed clothes are neatly tucked in.
F. Clear room of articles used. Empty basin. Wrap soiled linen in paper.
Burn cornucopia before leaving the house.
Wash hands.
Complete bedside record, sign receipt for fees, and place in an envelope.
Instruct the family to give it to the doctor.
G. Instruct the Family
1. To have hot water and necessary articles ready for the next visit.
2. To keep room clean and well ventilated and emphasize the importance of damp dusting and sweeping.
3. To have table cleared for patient’s use.
4. About the care to be given between visits.
Choose most suitable member of the family and instruct carefully.
H. Observe general health of other members of family and the hygienic conditions of the home.
=Partial Care=:
Prepare as for general care.
Bathe the patient’s hands, face, neck, axilla, and breasts, and give local bath. With maternity cases do post-partum dressing.
Cleanse the mouth.
Make bed as in general care.
DELIVERY ROUTINE
Extra articles to be carried in bags: gown, 2 towels, clamps, 2% silver nitrate solution.
The doctor should be called at the same time as the nurse. This should be ascertained when call is taken over telephone.
If the nurse arrives first, she should judge from the progress of labor whether an urgent call should be sent for the doctor and how much time she will have to spend in preparation for the delivery. Unless directed otherwise by doctor, the nurse should proceed as follows:
Have a supply of boiled water and pour some in covered vessel to cool.
Take necessary articles from bag, wash hands, put on gown.
Prepare patient by giving enema, sponge bath, braiding the hair, putting on clean white stockings and a gown which can be rolled up around waist.
Make bed with tight sheet, oilcloth and draw sheet, protect with pads made of many thicknesses of newspaper, covered with old muslin.
Protect floor with newspapers, and place basin for placenta. On bedside table, place alcohol, green soap, glass of boric acid solution, silver nitrate, basin containing scissors, clamps, catheter, medicine dropper, cotton gauze, cord tape and dressing, perineal pads, hypodermic, thermometer. Basin of lysol within reach. Prepare a place for baby by covering pillow with blanket and placing hot water bottle. Have olive oil (warmed). Get baby clothes, also gown and binder for mother.
Scrub hands and cleanse patient locally with green soap and water and put on sterile pad.
Assist doctor in any way possible during delivery.
Ask doctor whether he wishes to instill silver nitrate into baby’s eyes. This should be followed by normal salt solution and boric acid.
After delivery, cleanse vulva with warm lysol, put on fresh pad and binder, and make patient as comfortable as possible, giving her something hot to drink.
Weigh, oil, cleanse, dress baby. Unless doctor orders otherwise, instruct mother to nurse every three hours and to cleanse nipples with boric acid solution before and after nursing. The following additional information is to be written on the medical history card of patient attended at delivery:
1. Time nurse arrived.
2. Time baby was born and sex and weight.
3. Presentation.
4. Instrumental—high or low.
5. Laceration.
6. Repair, kind and number of sutures.
7. Hemorrhage.
8. Prophylactic used for the eyes.
9. Number of hours in labor.
10. Condition on discharge—fundus and lochia.
This technique is given as a general standard but the nurse is expected to use her own discretion in adapting it to the condition of patient, the home surroundings and the wishes of the doctor.
ROUTINE AFTER DELIVERY
=Care of the Baby=:
=A.= Make preparations as for general care.
Have everything ready before the baby’s bath.
Have separate basin for the baby whenever possible.
Test temperature of water with the elbow.
If the room is cold bathe in the kitchen.
Use table whenever possible for the baby’s bath.
If not possible sponge on lap beside the mother’s bed so that she can observe technique.
When cord is off, tub.
Place on paper napkin on third chair, table, or corner of dresser, glass of boracic acid sol., olive oil, warmed, cord powder, and dressings, safety pins, band, absorbent cotton, rectal thermometer, vaseline and alcohol. Have baby’s clothes within easy reach. Protect lap with blanket or bath towel.
Remove clothing.
To protect cord dressing, unpin but do not remove band.
Take temperature first and last visit, and when indicated.
Weigh baby on first and last visit.
Examine carefully for any abnormalities and note when found.
=B. Eyes.=
Unless there is a secretion, let the eyes alone.
When secretion or redness, wash eyes gently with 2% Boric acid sol. using separate pledget for each eye.
=C. Mouth.=
Examine mouth.
No treatment unless required.
If necessary to cleanse use cotton wrapped around little finger and dipped in boracic acid.
=D. Nose.=
No treatment unless required.
If necessary use piece of twisted cotton and boracic acid sol.
Never use toothpicks.
=E.= Wash face and ears gently with wash cloth or absorbent cotton and dry.
Soap head with hands, rinse with cloth and dry carefully. Soap body with hands, rinse with cloth and pat dry with soft towel. Fold binder across abdomen, protect with hand and turn baby on stomach. Bathe the back. Fold diaper and place under buttocks.
=F.= Genitals should be carefully cleansed.
In the case of boys, the foreskin should be gently pushed back once in every two or three days, and the parts underneath bathed carefully with absorbent cotton and boracic acid sol., removing the white pasty material which causes irritation.
In the case of girl babies, carefully bathe genitalia. If deposit is difficult to remove, soften with olive oil.
=G.= On first visit wash umbilicus with 70% alcohol and apply dry sterile dressing. Do not remove this dressing except when soiled. After the first time dress with cord powder. Put on clean binder, pinning on side with safety pins. Oil under arms, buttocks and all creases.
Put on shirt.
Pin diaper.
Petticoat and dress should be drawn on over the feet.
Use hot water bottle filled with warm, not hot, water.
If necessary beer bottle, tightly corked, is a good substitute.
Clear away articles used for the baby.
=H.= Points to be observed, recorded and reported to the physician if urgent:
1. Condition of cord.
2. Eyes; discharge, swelling or redness.
3. Urination and stools.
4. When foreskin is very tight and in every case when it cannot be easily pushed back.
=I. Instruct the Mother=:
1. To nurse every three hours unless otherwise ordered.
2. To cleanse nipples with boracic acid sol. before and after nursing, and to keep the breasts covered with clean cloth.
3. To give cooled, boiled water at least twice a day between feedings.
4. If fluid appears in the baby’s breasts, caution the family not to touch.
=J.= Do not discharge the baby until cord is off, umbilicus is in good condition and no further nursing care required. Premature babies should be oiled and wrapped in cotton. Premature jackets can be secured from the V.N.S. for 35 cents.
=Care of Mother=:
Make preparations as for general care.
Extra articles needed:
1. Pitcher for solution.
2. Glass for boracic acid.
3. Absorbent cotton.
4. Dressings.
5. Binder.
Take T.P.R.
Give complete bath.
Post-partum dressing:
1. Make sol. of lysol in pitcher (or glass jar) which has been washed and scalded.
Directions for lysol Sol.: Use ½ teaspoon lysol to 1 quart hot water.
2. Place paper napkin on table or chair at side of bed and on it pledgets of cotton, and clean pads.
3. Arrange sheet or bath blanket to avoid exposure.
4. Place soiled pad in cornucopia.
5. Place clean douche pan or basin under patient.
6. Scrub hands with green soap and brush under running water.
7. Pour sol. over vulva. Use pledgets for cleaning vulva, wiping always towards rectum.
Dry thoroughly with pledgets.
8. Remove pan.
Turn patient on side and wipe from perineum back over rectum with pledget. Dry.
Dry back and put on pad.
While in this position place binder and draw sheet.
9. Wash hands.
10. Binder.
Locate fundus.
Draw edges of binder together and begin pinning from fundus down.
Then pin from fundus up, taking dart in either side.
Fasten pad to binder, front and back.
Unless especially ordered the binder may usually be replaced by a T-binder on the fourth day.
11. Complete as in general care.
Points to be observed and recorded on bedside notes if necessary:
1. Condition of the breasts.
2. Urination.
3. Condition of bowels.
4. Lochia.
5. Position of uterus.
Record any abnormal conditions.
Do not massage breasts unless ordered.
Full post-partum care to be given on first visit if possible.
Give general care every other day.
=Douche.=
When douche is ordered boil nozzle before and after using.
Boil douche bag before using and wash afterwards—use boiled water.
When sutures, instruct the family how to irrigate after urination and movement of the bowels.
Normal maternity cases should be visited daily until after the 8th day of puerperium and at least once a week for supervision until the 5th week. The case is then transferred to Child Welfare nurse.
Additional visits should be made if the patient is still in bed and there is no intelligent adult to give care, or if the baby’s condition is not satisfactory.
A SUGGESTION FROM MONTREAL
Ingenuity, resourcefulness, and quick wit on the part of an intelligent nurse can almost always apply hospital ideals to circumstances which would at first seem hopeless. It is the nurse’s knowledge of obstetrical nursing and principles, rather than her equipment, that counts in saving lives. The following directions given to visiting nurses, by Cecil A. K. Dawkins, R.N., Supervisor of the Outdoor Department of the Montreal Maternity Hospital, indicate the possibility of clean, efficient care in conditions far from ideal:
“MATERNITY CASE CONDUCTED IN A HOUSE WHERE THERE IS VERY LITTLE TO WORK WITH
“=Appliances You Are Likely to Find in Any House=:
“Bed, table, chair, two boxes, basin, pail, kettle, saucepan, plate, two cups, spoon, several fair sized bottles, sheet, two towels, pillow, pillow case, handkerchief, newspapers, old clean rags, small package boracic powder, small bottle vaseline, soap, baby clothes.
“Doctor’s bag will usually contain towel, clamps, scissors, ergot, chloroform, creolin, rubber apron, hypodermic syringe, nail brush.
“1. I would take a look at the fire. Put on the kettle to boil, also saucepan containing scissors, clamps, hypo (cord ligatures), clean rags to use as sponges, if absorbent is not available. I would put several pieces of clean rag (some small for cord dressings, others large for vulva pads) on a plate in the oven to bake. This will only take a minute.
“2. Attack the bed. Strip it, place a good pad of newspapers where the patient is to lie. Then the sheet. Cover this all over with newspapers, particularly where the patient lies. Here I would form a Kelly pad, rolling the paper up at the top and bottom and left side, the right side falling over the edge of the bed into the pail. Cover with clean rag. Paper under the pail.
“3. Place basin, towel, soap and nail brush on table. Wash up and prepare patient. Braid her hair. Put on a clean nightdress.
“4. Clip away the pubic hair with scissors, if razor not available to shave. Give S.S. enema, provided you have the time to do it in, and the syringe to do it with. Wash the vulva well with soap and water. Put on pad, rag wet with disinfectant.
“5. The instruments, swabs, etc., should be boiled by this time. Place scissors and clamps on plate, and swabs in basin. Get hypo ready. Water for ergot. Boracic for baby’s eyes. Baby’s clothes together,—also warm cloth to wrap baby in. Fold handkerchief crosswise, and make funnel for chloroform mask.
“6. When baby comes, wrap him up warmly, and place on the right side in a safe place. If no other place available, pull bureau drawer half open and put him in, but be careful not to close it again.
The plate that has held the scissors and clamps may be used for the placenta.
“7. To clean up the bed and make the patient comfortable, roll her on her right side, rolling the paper up to her back. Wash her and turn her on her left side, removing paper. Put on a clean pad and “T” binder.
“8. A jug of boiled water left to cool would be useful in emergency,—as also several glass bottles filled with hot water for case of shock. The boxes may be used for raising the foot of the bed.”
Yet it is but a little human babe, Given at last into his reaching arms And carried to the hollow of her breast! MARGUERITE WILKINSON.